Left ventricular remodelling in masters athletes

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): I have received a research fellowship grant from the UK based charity Cardiac Risk in the Young

Objectives

We investigated the effect of long-term exercise and sex on left ventricular (LV) geometry in a large group of female and male masters athletes.

Background

Studies assessing LV geometry in masters athletes are scarce.

Methods

Different types of LV geometry were identified according to echocardiography-derived relative wall thickness (RWT) and left ventricular mass (LVM) values as per international guidelines. 4 groups were formed: normal (normal LVM/normal RWT), concentric hypertrophy (increased LVM/increased RWT), eccentric hypertrophy (increased LVM/normal RWT), and concentric remodeling (normal LVM/increased RWT).

Results

A total of 277 healthy, elite, caucasian endurance masters athletes (65% female; mean age54.8 ± 7.7 years) were assessed. The athletes were exercising for a mean 32 ± 11.7 years and have completed a median 70 competitions including a median 13 marathon-type competitions. Females exhibited lower absolute LVM (127.7 ± 30.31g vs 196.57 ± 45.0g, p < 0.001), indexed LVM (76.8 ± 18.0 g/m2 vs. 103.6 ± 22.7 g/m2; p < 0.001), RWT (0.36 ± 0.07 vs. 0.42 ± 0.08; p < 0.001) and absolute LV end-diastolic dimension (LVEDD) (46.3 ± 4.1 mm vs 50.1 ± 5.11 mm, p < 0.001) but greater indexed LVEDD (27.7 ± 2.7mm/m2 vs 26.5 ± 2.7 mm/m2, p < 0.001) compared with male athletes. Most female athletes showed normal LV geometry (72% vs 38% in male athletes, P < 0.001) and significantly less concentric remodeling (12% vs 35%, p < 0.001) and concentric hypertrophy (5% vs 13%, p = 0.01) (table & figure).

Conclusions

A sex-specific response to chronic exercise is observed. Male masters athletes exhibit significantly more frequently abnormal LV geometry with concentric LV remodeling and/or concentric hypertrophy.

Cohort characteristics Male masters athletes N = 97 Female masters athletes N = 180 P value Age (years) 55.0 ± 9.0 54.7 ± 6.9 0.68 Years of exercise 32.0 ± 12.8 33.3 ± 11.1 0.14 LV Mass (g) 127.7 ± 30.31 196.57 ± 45.0 <0.001 LV Mass Indexed (g/m2) 76.8 ± 18.0 103.6 ± 22.7 <0.001 LVEDD (mm) 46.3 ± 4.1 50.1 ± 5.11 <0.001 LVEDD Indexed (mm/m2) 27.7 ± 2.7 26.5 ± 2.7 <0.001 Normal Remodeling 36 (37) 130 (72) <0.001 Eccentric Hypertrophy 14 (14) 18 (10) 0.27 Concentric Remodeling 34 (35) 23 (13) <0.001 Concentric Hypertrophy 13 (13) 9 (5) 0.01 LV Left Ventricular, LVEDD: Left Ventricular End Diastolic Dimension Abstract Figure. Patterns of left ventricular remodeling

Morphological, Chemical, and Genetic Characteristics of Korean Native Thyme Bak-Ri-Hyang (Thymus quinquecostatus Celak.)

Bak-ri-hyang (Thymus quinquecostatus Celak.) is an important medicinal and aromatic plant in Korea. T. quinquecostatus population and is always mixed with other thyme cultivars during cultivation and marketing. Hence, this study aimed to determine the genetic variability and the essential oil composition of three Korean native thyme, T. quinquecostatus cultivars collected from the Wolchul, Jiri, and Odae mountains, in comparison with six commercial thyme cultivars (T. vulgaris), to distinguish Bak-ri-hyang from other thyme cultivars. The composition of essential oils obtained from nine individuals was analyzed by gas chromatography–mass spectrometry (GC–MS). The random amplified polymorphic DNA (RAPD) analysis was accomplished using 16 different primers. The GC–MS analysis revealed that Wolchul, creeping, golden, and orange cultivars belong to the geraniol chemotype. Whereas the Odae, lemon, and silver cultivars belong to the thymol chemotype. Further, linalool was the most abundant component in carpet and Jiri cultivars. The RAPD analysis demonstrated that all thyme cultivars showed characteristic RAPD patterns that allowed their identification. In total, 133 bands were obtained using 16 primers, and 124 bands were polymorphic, corresponding to 93.2% polymorphism. Cluster analysis of RAPD markers established the presence of clear separation from nine thyme cultivars. The highest dissimilarity and similarity coefficient of the RAPD markers were 0.58 and 0.98, respectively. According to the RAPD patterns, the nine thyme cultivars could be divided into two major clusters. Among three Korean cultivars, the Wolchul and Odae cultivars were placed into the same cluster, but they did not show identical clustering with their essential oil compositions. The findings of the present study suggest that RAPD analysis can be a useful tool for marker-assisted identification of T. quinquecostatus from other Thymus species.

623 Short-term reversed remodeling post aortic valve intervention

Background

LV remodeling in AS can cause LV hypertrophy, interstitial fibrosis and reduced contractility. SAVR or TAVI are the mainstay treatment for symptomatic severe AS. Speckle tracking has the potential to detect early signs of reverse cardiac remodeling but such LV deformation data post-SAVR/TAVI is currently lacking.

Aim

To assess the early impact of LV unloading post-TAVR/SAVR using STE.

Methods

This prospective single-center study recruited 122 patients with varying degrees of AS who underwent resting transthoracic echocardiography with offline speckle-tracking. During the follow-up period, 50 patients underwent TAVI and 15 had SAVR.

Results

Patients were followed-up for a period of 4 ± 2 weeks post-intervention. Table 1 summaries the echocardiographic findings of patients pre- and post-intervention. AV peak velocity and mean pressure gradient dropped significantly immediately after intervention in both groups. AV intervention resulted in early improvements in all myocardial deformation parameters (Figure 1). There was a significant improvement in GLS and GRS irrespective of the intervention type. While SAVR led to a significant early improvement in GCS.

Conclusion

AV Intervention in severe symptomatic AS translates into an immediate and measurable improvement in LV deformation parameters. To our knowledge this is the first echocardiographic evidence of reverse remodeling early after SAVR and TAVI.

Table 1 TAVI (n = 50) SAVR (n = 15) Variables Pre Post P* value Pre Post P* value P value┼ AV vel.(m/s) 4.4 ± 0.8 2.2 ± 0.5 <0.001 4.5 ± 0.8 2.2 ± 0.5 <0.001 NS AV mPG (mmHg) 44.3 ± 16.2 9.7 ± 3.9 <0.001 44.6 ± 19.2 9.8 ± 4.8 <0.001 NS GLS (%) -10.9 ± 3.6 -13.9 ± 3.1 <0.001 -13.7 ± 4.5 -17.7 ± 3.9 0.002 NS GCS (%) -29.2 ± 9.1 -32 ± 9.5 NS -28.6 ± 9.8 -34.9 ± 5.1 0.032 NS GRS (%) 42.0 ± 15.1 47.2 ± 13 0.024 34.7 ± 12.5 41.4 ± 9.9 0.04 NS EDV (ml) 87.29 ± 55.3 89.8 ± 38.6 NS 104.3 ± 25.1 83.2 ± 41.9 NS NS ESV (ml) 45.1 ± 39.4 36.6 ± 29.1 NS 42.8 ± 17.7 28.6 ± 18.6 0.03 NS SV (ml) 59.7 ± 23.6 55 ± 19.3 NS 65.5 ± 17.9 57.2 ± 22.7 NS NS SVi (ml/m2) 33.1 ± 12.7 30.4 ± 9.6 NS 34.1 ± 8.3 29.8 ± 11.1 NS NS LV mass (g) 185.7 ± 53.6 183.3 ± 48. NS 177.5 ± 48.4 169.5 ± 52.2 NS NS LVMi (g/m2) 103.6 ± 30 102.1 ± 25.9 NS 93.8 ± 29.9 89.4 ± 24.2 NS NS Biplane EF (%) 58 ± 15 62 ± 13 0.013 60 ± 9 66 ± 6 <0.05 NS AV: Aortic valve; EDV: end diastolic volume; EF: ejection fraction; ESV: end systolic volume; GCS: Global circumferential strain; GLS: Global longitudinal strain; GRS: Global radial strain; LV: left ventricle; LVMi: left ventricular mass index; mPG: mean pressure gradient; SV: stroke volume; SVi: stroke volume index; Vel: velocity Data are expressed as mean ± SD. Comparisons were performed using paired Student"s t tests(parametric) or Wilcoxon paired test (non-parametric). *Pre and post intervention. ┼Comparison of pre/post-intervention measurement difference between the two intervention groups done using unpaired t-test

Abstract 623 Figure.

618 Adaptive myocardial mechanics in aortic stenosis patients

Introduction

Left ventricular (LV) hypertrophy in aortic stenosis (AS) becomes maladaptive over time, leading first to a reduction in global longitudinal strain (GLS) and in a later stage a reduction in ejection fraction (EF). The myocardial state of impaired GLS but preserved EF is a key remodeling turning point in AS, yet little is known about the coping mechanics of the LV at or around this sensitive juncture.

Aim

1) To study the relationship between LV mass index (LVMi) increase and measures of LV function, including strain in AS; 2) To investigate whether augmentation of global myocardial radial and circumferential strain (GRS, GCS) compensates for the GLS reduction in AS patients with preserved EF.

Methods

One-hundred and eleven patients with varying degrees of AS, and 20 age- and gender-matched healthy volunteers were prospectively enrolled. transthoracic echocardiography with offline strain analysis was performed using TomTec software. Intra- and inter-observer variability of linear LV internal dimensions/thickness, EF and strain indices was tested on 20 randomly selected patients.

Results

Clinical and demographic characteristics of cases and controls are shown in Figure 1. GLS was impaired in AS patients compared to controls. In AS with preserved EF (>50%), as LVMi increased, GLS progressively improved up to a point, beyond which any further increase in LVMi appeared counter-productive with impairment of GLS (Figure 1). EF preservation in these AS patients was mediated by a compensatory supernormal augmentation of GRS and a smaller augmentation of GCS (Figure 1). We observed a significant inverse correlation between GRS and GLS (r = 0.3, p = 0.002), and a similar trend between GCS and GLS (r = 0.275, p = 0.004). Intraclass correlation coefficient was high for all measurements (0.7-0.9).

Conclusion

In patients with AS and preserved EF, progressive myocardial hypertrophy improves GLS up to a point beyond which GLS drops and GRS increase to compensate. This plasticity of myocardial mechanics, in particular the supranormal augmentation of GRS is what enables the pathologically hypertrophied AS ventricle to delay the otherwise inexorable decline in its global systolic function.

Abstract 618 Figure 1

Making MRI available for patients with cardiac implantable electronic devices: growing need and barriers to change

Abstract

More than half of us will need a magnetic resonance imaging (MRI) scan in our lifetimes. MRI is an unmatched diagnostic test for an expanding range of indications including neurological and musculoskeletal disorders, cancer diagnosis, and treatment planning. Unfortunately, patients with cardiac pacemakers or defibrillators have historically been prevented from having MRI because of safety concerns. This results in delayed diagnoses, more invasive investigations, and increased cost. Major developments have addressed this—newer devices are designed to be safe in MRI machines under specific conditions, and older legacy devices can be scanned provided strict protocols are followed. This service however remains difficult to deliver sustainably worldwide: MRI provision remains grossly inadequate because patients are less likely to be referred, and face difficulties accessing services even when referred. Barriers still exist but are no longer technical. These include logistical hurdles (poor cardiology and radiology interaction at physician and technician levels), financial incentives (re-imbursement is either absent or fails to acknowledge the complexity), and education (physicians self-censor MRI requests). This article therefore highlights the recent changes in the clinical, logistical, and regulatory landscape. The aim of the article is to enable and encourage healthcare providers and local champions to build MRI services urgently for cardiac device patients, so that they may benefit from the same access to MRI as everyone else.

Key Points

• There is now considerable evidence that MRI can be provided safely to patients with cardiac implantable electronic devices (CIEDs). However, the volume of MRI scans delivered to patients with CIEDs is fifty times lower than that of the estimated need, and patients are approximately fifty times less likely to be referred.

• Because scans for this patient group are frequently for cancer diagnosis and treatment planning, MRI services need to develop rapidly, but the barriers are no longer technical.

• New services face logistical, educational, and financial hurdles which can be addressed effectively to establish a sustainable service at scale.

A rice really interesting new gene H2-type E3 ligase, OsSIRH2-14, enhances salinity tolerance via ubiquitin/26S proteasome-mediated degradation of salt-related proteins

Salinity is a deleterious abiotic stress factor that affects growth, productivity, and physiology of crop plants. Strategies for improving salinity tolerance in plants are critical for crop breeding programmes. Here, we characterized the rice (Oryza sativa) really interesting new gene (RING) H2-type E3 ligase, OsSIRH2-14 (previously named OsRFPH2-14), which plays a positive role in salinity tolerance by regulating salt-related proteins including an HKT-type Na⁺ transporter (OsHKT2;1). OsSIRH2-14 expression was induced in root and shoot tissues treated with NaCl. The OsSIRH2-14-EYFP fusion protein was predominately expressed in the cytoplasm, Golgi, and plasma membrane of rice protoplasts. In vitro pull-down assays and bimolecular fluorescence complementation assays revealed that OsSIRH2-14 interacts with salt-related proteins, including OsHKT2;1. OsSIRH2-14 E3 ligase regulates OsHKT2;1 via the 26S proteasome system under high NaCl concentrations but not under normal conditions. Compared with wild type plants, OsSIRH2-14-overexpressing rice plants showed significantly enhanced salinity tolerance and reduced Na⁺ accumulation in the aerial shoot and root tissues. These results suggest that the OsSIRH2-14 RING E3 ligase positively regulates the salinity stress response by modulating the stability of salt-related proteins.

A rice really interesting new gene H2-type E3 ligase, OsSIRH2-14, enhances salinity tolerance via ubiquitin/26S proteasome-mediated degradation of salt-related proteins

Salinity is a deleterious abiotic stress factor that affects growth, productivity, and physiology of crop plants. Strategies for improving salinity tolerance in plants are critical for crop breeding programmes. Here, we characterized the rice (Oryza sativa) really interesting new gene (RING) H2-type E3 ligase, OsSIRH2-14 (previously named OsRFPH2-14), which plays a positive role in salinity tolerance by regulating salt-related proteins including an HKT-type Na⁺ transporter (OsHKT2;1). OsSIRH2-14 expression was induced in root and shoot tissues treated with NaCl. The OsSIRH2-14-EYFP fusion protein was predominately expressed in the cytoplasm, Golgi, and plasma membrane of rice protoplasts. In vitro pull-down assays and bimolecular fluorescence complementation assays revealed that OsSIRH2-14 interacts with salt-related proteins, including OsHKT2;1. OsSIRH2-14 E3 ligase regulates OsHKT2;1 via the 26S proteasome system under high NaCl concentrations but not under normal conditions. Compared with wild type plants, OsSIRH2-14-overexpressing rice plants showed significantly enhanced salinity tolerance and reduced Na⁺ accumulation in the aerial shoot and root tissues. These results suggest that the OsSIRH2-14 RING E3 ligase positively regulates the salinity stress response by modulating the stability of salt-related proteins.

2395LGE CMR predicts sudden death and VT in adults with repaired tetralogy of Fallot - a prospective study with 3500 patient follow up years

Background

Adults with repaired tetralogy of Fallot (rtoF) are at risk of ventricular arrhythmia and sudden cardiac death (SCD). Cross-sectional data suggest association of late gadolinium enhancement (LGE) cardiovascular magnetic resonance imaging (CMR) with adverse clinical risk factors

Purpose

We sought to determine prognosis related to LGE CMR.

Methods

In this prospective cohort study the primary composite outcome comprised the first of cardiovascular death (SCD or heart failure-related), aborted SCD (successfully resuscitated cardiac arrest or appropriate AICD shock for ventricular fibrillation), and clinical sustained ventricular tachycardia (VT>30 seconds duration).

Results

In 531 rtoF patients (median age 32; 23–42, 296 (56%) male, NYHA≥II 17%) followed up after LGE CMR for median 5 (1.7–8.9) years, there were 39 primary composite outcomes: 10 SCD, 11 heart failure related deaths (2 perioperative RV failure), 2 aborted SCD and 16 clinical sustained VT events. At study end, there were 28 ventricular arrhythmic events in 28 rtoF patients (10 SCD, 16 clinical sustained VT, 2 aborted VF) that were significantly predicted by RV LGE extent (HR 1.45 CI: 1.3–1.6; P<0.001).

Univariable predictors of the primary outcome were RV LGE score; HR: 1.44 (1.31–1.57; p<0.001), (Figure) together with older age; HR: 1.05 (1.02–1.07; P<0.001), late repair; HR: 1.04 (1.02–1.07; p<0.001), lower RV ejection fraction; HR: 0.92 (0.89–0.95; p<0.001), larger RVOT akinetic length; HR: 1.04 (1.02–1.06; p<0.001) larger right atrial area; HR: 1.2 (1.12–1.29; p<0.001); higher BNP levels; HR: 1.01 (1–1.02; p<0.001), lower peak VO2; HR: 0.89 (0.83–0.96; p=0.001), prior atrial arrhythmia; HR: 5.3 (2.8–10.07; p<0.001), and non-sustained VT; HR: 4.1 (2.1–7.7; p<0.001). Inducible VT did not predict the primary outcome; HR: 2.1 (0.57–8; p=0.25)

In multivariable analysis both RV LGE score and indexed right atrial area (RAAi) only, remained predictive of the primary outcome (HR 1.29 CI: 1.12–1.49; p<0.001 and HR 1.1 CI: 1.02–1.12; p=0.01, respectively). Patients could accordingly be stratified such that supramedian RV LGE score (≥5) and RAAi ≥16cm2/m2 had 5-year event free survival 84% vs 94% for supramedian RV LGE score (≥5) and RAAi <16cm2/m2 or 98% for inframedian RV LGE score with RAAI<16cm2/m2. Figure.

Conclusions

For every unit increase in CMR defined RV fibrosis score there is a 44% increased risk of sudden cardiac death and VT. LGE CMR and maximal right atrial area should therefore be incorporated into risk stratification for sudden death in adults with rTOF.

Acknowledgement/Funding

British heart foundation

P340Inflammatory cardiomyopathy in Fabry disease

Background

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations in α-galactosidase A. Cardiovascular magnetic resonance (CMR) has helped unveil the pathogenesis of Fabry cardiomyopathy: sphingolipid storage (low T1 mapping values), left ventricular hypertrophy (LVH) and myocardial fibrosis with late gadolinium enhancement (LGE) characteristically present in the basal inferolateral (BIFL) wall. Recent evidence has suggested that the LGE may be inflammation and oedema as part of this pathogenic process.

Purpose

To assess the presence of inflammation in patients with FD using T2 mapping (for oedema/inflammation) supported by blood troponin levels (showing myocyte death and by inference inflammation).

Methods

A multi-centre international study in gene positive FD patients using CMR and blood biomarkers. All participants underwent CMR at 1.5 T. Native T1 and T2 mapping were performed. The T1 mapping sequence was MOLLI with sampling scheme in seconds. LGE used a phase sensitive inversion recovery sequence. Global longitudinal 2D strain (GLS) values were obtained using feature tracking analysis. Blood high-sensitivity troponin T (hsTnT) was measured on the same day.

Results

100 FD patients (age 43.8±1.3 years, 42% male) were included. 45% had LVH, 35% LGE. Low T1 mapping (normal <943ms) was found in 49% and 33% had high hsTnT values (normal <15ng/L). Mean T2 mapping values were 52.6±0.6ms in the BIFL wall and 49.5±0.3ms in the remote myocardium/septum (p<0.001, normal <53ms). T2 values in the BIFL wall were significantly higher among patients with LGE (58.2±6.1ms vs 49.2±3.1ms, p<0.001, Figure 1). In a per-segment analysis of 1600 segments, higher T2 values correlated positively with percentage of LGE per segment (r=0,262, p<0.001), T1 values (r=0,205, p<0.001), maximum wall thickness (r=0,253, p<0.001) and GLS values (r=0,212, p<0.001). HsTnT values were higher among patients with LGE (median of 31 vs 3ng/L in patients without LGE, p<0.001). There was a strong positive correlation between T2 values in the BIFL wall and ln(hsTnT) (r=0.776, p<0.001, Figure 2). The strongest predictor of increased hsTnT in multivariate analysis (age, sex, LVH, septum T1, T2 in the BIFL, GLS, LGE) was T2 in the BIFL wall (β=0.4, p=0.001).

Conclusions

Cardiac involvement in FD goes beyond storage (low T1 values). When LGE is present, this is almost always associated with a high T2 and troponin elevation supporting FD as a chronic inflammatory cardiomyopathy. Initial reports of LGE being fibrosis are too simplistic – LGE in FD appears to have a significant chronic inflammation/oedema component.