Left ventricular longitudinal shortening at cardiac base as a determinant of left atrial reservoir function in cardiac amyloidosis

Objective

To investigate a mechanistic determinant of left atrial (LA) reservoir function in patients presenting left ventricular (LV) hypertrophy, and clarify diagnostic and prognostic values of LA reservoir strain in patients with cardiac amyloidosis (CA).

Methods

Three-hundred sixty patients (median age: 68 years, male gender: 65%) with left ventricular hypertrophy (LVH) assessed by echocardiography were retrospectively included. The LVH etiologies were diagnosed by any of biopsy, cardiac magnetic resonance imaging or 99mTc-PYP scintigraphy. LV segmental longitudinal strain was estimated from apical three views, and LA reservoir strain was measured from an apical 4-chamber view.

Results

The LVH etiologies were confirmed with CA in 81 patients, hypertensive heart disease in 87 patients, hypertrophic cardiomyopathy in 143 patients, and miscellaneous disorders in 49 patients. The median (25th, 75th percentile) value of LV ejection fraction was 59% (48–67). LV basal longitudinal strain and LA reservoir strain were significantly reduced in patients with CA compared with those with other etiologies; LV basal strain: 5.4% (3.9–8.7) vs. 11.9% (9.3–14.6), LA reservoir strain: 9.2% (6.3–12.3) vs. 17.5% (11.3–24.1), p<0.01 respectively. LV basal strain was significantly correlated with LA reservoir strain in patients with CA (r=0.57, p<0.01) and in those with other etiologies (r=0.45, p<0.01). The area under the receiver-operating characteristic curves of LA reservoir strain and E/e' (0.78 and 0.74) to identify CA etiology were significantly larger than that of LA volume index (0.62) (p<0.01). During the follow-up period (median 2.9 years), 53 patients experienced heart failure hospitalization. The Cox regression model including age, gender, LV ejection fraction, E/e' and LA reservoir strain showed that male gender (hazard ratio: 0.46, p=0.03), E/e' (hazard ratio: 1.04, p<0.01) and LA reservoir strain (hazard ratio: 0.94, p<0.01) independently predicted heart failure hospitalization.

Conclusions

The decrease of LV longitudinal shortening at cardiac base could worsen LA reservoir function especially in patients with CA. LA reservoir strain might be an alternative measure to identify CA etiology and have a predictive value of heart failure hospitalization in patients with LV hypertrophy.

Funding Acknowledgement

Type of funding sources: None.

Differences in quality of life improvement with pulmonary vein isolation alone vs. more extensive ablation of persistent atrial fibrillation: insights from the EARNEST-PVI trial

Background

Improving the quality of life (QoL) is one of the main purposes of catheter ablation (CA) of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus).

Purpose

To investigate the QoL change after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy.

Methods

In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n=512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS).

Results

In the EARNEST-PVI trial, the PVI alone strategy was associated with higher recurrence rate compared with the PVI plus additional ablation strategy. After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 222 patients were evaluated respectively. Overall, significant improvements in PCS (46.2±11.4 to 48.7±11.4]), MCS (50.1±8.8 to 54.3±8.6) and RCS (44.6±13.3 to 48.6±11.3) occurred 12 months after ablation (P<0.001, respectively). Although significant QoL improvement occurred in both PVI alone and PLI plus strategies, the changes in PCS was greater in the PVI-plus than that in PVI-alone (3.5±10.3 vs 1.5±10.6, P=0.04).

Conclusions

Ablation for persistent atrial fibrillation improved both physical and mental quality of life. The PVI-plus strategy showed greater improvement in physical QoL.

Funding Acknowledgement

Type of funding sources: None. QoL improvement

Hue-Preserving Saturation Improvement in RGB Color Cube

This paper proposes a method for improving saturation in the context of hue-preserving color image enhancement. The proposed method handles colors in an RGB color space, which has the form of a cube, and enhances the contrast of a given image by histogram manipulation, such as histogram equalization and histogram specification, of the intensity image. Then, the color corresponding to a target intensity is determined in a hue-preserving manner, where a gamut problem should be taken into account. We first project any color onto a surface in the RGB color space, which bisects the RGB color cube, to increase the saturation without a gamut problem. Then, we adjust the intensity of the saturation-enhanced color to the target intensity given by the histogram manipulation. The experimental results demonstrate that the proposed method achieves higher saturation than that given by related methods for hue-preserving color image enhancement.

Gender differences in self-perceived changes among Japanese workers with depression

BACKGROUND

The number of patients living with depression continues to increase in Japan. The economic effects of depression include loss of productivity due to both absenteeism and presenteeism. Gender differences have been reported in prevalence, onset pathways and subjective symptoms of depression.

AIMS

To understand how workers with major depressive disorder (MDD) perceive problems in the workplace and examine gender differences in their self-perceived levels of functioning at work, noticed during the initial stages of depression.

METHODS

This is a cross-sectional study of Japanese workers with MDD. Participants' self-perceived changes in the level of functioning at work were surveyed after the diagnosis during the first visit. The relationship between gender and changes in the level of functioning at work as initially perceived by the participants themselves was analysed using the chi-square test, supplemented by a residual analysis.

RESULTS

We administered the survey to 147 workers with MDD. In terms of gender differences in initial self-perceived changes in the level of functioning at work, the proportion of men reporting reduced work efficiency was significantly higher than that of women, while the proportion of women reporting deterioration in relationships with colleagues and superiors was significantly higher than that of men.

CONCLUSIONS

The findings suggest that greater attention to reduced work efficiency by men and to deterioration in work relationships by women with MDD should be essential components of self-care. Managers need to pay attention to the level of functioning and provide adequate social support for employees.

Gefitinib induction followed by chemoradiotherapy in EGFR-mutant, locally advanced non-small-cell lung cancer: LOGIK0902/OLCSG0905 phase II study

Background

The role of epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) induction coupled with standard concurrent chemoradiotherapy (CRT) is unclear in unresectable, stage III, EGFR-mutant non-small-cell lung cancer (NSCLC). Therefore, a phase II trial was conducted to evaluate the efficacy and safety of gefitinib induction followed by CRT in this disease setting.

Patients and methods

Patients with unresectable, EGFR-mutant, stage III NSCLC were administered gefitinib monotherapy (250 mg/day) for 8 weeks. Subsequently, patients without disease progression during induction therapy were administered cisplatin and docetaxel (40 mg/m² each) on days 1, 8, 29, and 36 with concurrent radiotherapy at a total dose of 60 Gy. The primary endpoint was the 2-year overall survival (OS) rate, which was hypothesized to reach 85%, with a threshold of the lower limit of 60%.

Results

Twenty patients (median age: 66 years; male/female: 9/11; histology: 20 adenocarcinoma; stage IIIA/IIIB: 9/11; and exon 19/21: 10/10) were enrolled. The 2-year OS rate was 90% (90% confidence interval: 71.4% to 96.8%), indicating that this trial met the primary objective. The overall response rate and 1- and 2-year progression-free survival rates were 85.0%, 58.1%, and 36.9%, respectively. Grade ≥3 adverse events (>10%) included hepatic toxicity during the induction phase and neutropenia and febrile neutropenia in the CRT phase. Radiation pneumonitis grade ≥3 or treatment-related death did not occur.

Conclusions

This is the first prospective study to demonstrate the favorable efficacy and safety of EGFR-TKI induction followed by standard CRT in EGFR-mutant, stage III NSCLC. Further confirmatory studies are needed.

•

This is the first prospective study evaluating gefitinib induction followed by CRT in EGFR-mutated, locally advanced NSCLC.

•

The 2-year OS rate was 90% (90% confidence interval: 71.4% to 96.8%), indicating that this trial met the primary objective.

•

The objective response rate throughout the treatment protocol was 85.0% (17 of 20).

•

The safety findings were consistent with the known safety profiles of all agents administered.

•

Our results might raise a critical point that needs to be evaluated in further studies to improve the cure rate.

Case of de novo cerebral microbleeds in ischemic-type pediatric moyamoya disease

Background:

Studies on pediatric patients with moyamoya disease who presented with de novo cerebral microbleeds (CMBs) are extremely rare.

Case Description:

Herein, we report a 7-year-old boy with moyamoya disease who had de novo CMBs during treatment. He presented with transient left-side motor weakness and was diagnosed with moyamoya disease. He underwent revascularization surgery on the right cerebral hemisphere. Six months after the surgery, he presented with transient right-side motor weakness and MRA revealed progression of stenosis in the left middle cerebral artery. After another 3 months, three de novo CMBs were identified. He underwent revascularization surgery on the left side. The symptom disappeared completely after surgery and no additional de novo CMBs were identified 1 year after surgery.

Conclusion:

This is the first report on de novo CMBs in pediatric patients. Although the significance of de novo CMBs in pediatric patients is completely unknown, attention should be paid to not only ischemic stroke but also hemorrhagic stroke. Although the short-term course is good in the current case, follow-up period is too short to assess for rebleeding and long-term follow-up is still important. Further, more cases should be collected.

Geochemical characterization of monazite sands based on rare earth elements, thorium and uranium from a natural high background radiation area in Tamil Nadu, India

The Kanyakumari coastal area in the southernmost part of Tamil Nadu, India is a well-known natural high background radiation area due to the abundance of monazite in beach placer deposits. In the present study, the concentrations of major oxides, rare earth elements (REEs), Th and U were measured to understand geochemical characteristics of these monazite sands. Based on the ambient dose rate, 23 locations covering an area of about 60 km along the coast were selected for sample collection. The concentrations of U and Th ranged from 1.1 to 737.8 μg g^-1 and 25.2-12250.6 μg g^-1, respectively. The Th/U ratio ranged from 2.2 to 61.6, which clearly indicated that Th was the dominant contributing radionuclide to the enhanced natural radioactivity in this coastal region. The chondrite-normalized REEs pattern of the placer deposits showed enrichment in light REEs and depletion in heavy REEs with a negative Eu anomaly that indicated the monazite sands were derived from granite, charnockite, and granitoid rocks from the Nagercoil and the Trivandrum Blocks of the Southern Granulite Terrain.

Evaluation of left ventricular filling pressure by echocardiography: incremental diagnostic information from left atrial strain

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Background

Elevated left ventricular (LV) filling pressure is an important diagnostic feature of heart failure.

Objectives

To investigate determinants of left atrial (LA) reservoir and pump strain and if these parameters may serve as markers of LV filling pressure.

Methods

In a multicenter study of 322 patients with cardiovascular disease of different etiologies, LA strain by speckle tracking echocardiography was compared to conventional echocardiographic markers using invasive pressure as reference.

Results

Left ventricular filling pressure correlated well with LA reservoir and pump strain (r-values

‑0.52 and ‑0.57, respectively) (Figure). However, LV global longitudinal strain (GLS) was the strongest determinant of LA reservoir strain (r = 0.64), and correlated well with LA pump strain (r = 0.51).  For both LA strains, association with filling pressure was strongest in patients with reduced LV ejection fraction. In patients with normal GLS (≥18%), atrial strains provided no information regarding filling pressure (Figure). Reservoir strain <18% and pump strain <8% predicted elevated LV filling pressure better (p < 0.05) than the conventional indices LA volume, ratio of mitral early filling velocity/annular velocity and tricuspid regurgitation velocity. Accuracy to classify filling pressure as normal or elevated was 75% for both LA strains . When any one of the conventional indices were missing, and were replaced by LA strains, the combination of indices had accuracy 82% to correctly classify filling pressure.

Conclusions

Left atrial reservoir and pump strain may serve as clinical markers of LV filling pressure, but will be useful predominantly in patients with reduced systolic function.  Due to limited diagnostic accuracy, LA strain should be used in combination with other indices.

Abstract Figure

The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (<120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (>150 ms): 14 ± 7% (p <0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p <0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.

A case of pediatric moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an intraventricular hemorrhage

Reports on patients with moyamoya disease presenting cerebral ischemic complications after the onset of intraventricular hemorrhage (IVH) and/or intracerebral hemorrhage (ICH) are limited. Herein, we report a case of a 7-year-old girl with moyamoya disease with severe cerebral vasospasm and delayed cerebral infarction following an IVH. Although the case is rare, the potential for vasospasm-induced cerebral infarction should be carefully considered and thus, intensive treatment should be immediately initiated.

SURG-24. NOVEL MALLEABLE FORCIPES FOR ENDOSCOPIC ASSISTED TECHNIQUE IN PEDIATRIC BRAIN TUMORS

Recent advances in optical devices and surgical instruments have been applied to neurosurgery. Even with modifications, one of the most serious risks is injury of neuronal and vascular structure caused by operation of surgical instruments in a narrow surgical field. Fixed instruments are not practical for pediatric brain tumor surgeries because the length of the curved or angled tip portion is limited because of the narrow entrance. We developed a novel malleable forceps to resolve the difficulties related to microsurgical procedures. The malleable forceps has two shafts with a sharp cup at the tip. The entire forceps was made of stainless steel, with a silver and nickel alloy inserted between 10 and 40 mm from the tip. In the alloy part, the surgeon can flex the forceps freely using a special cylinder. The special cylinder is useful to prevent from slipping of the cups of tip. The maximum angle that can be bent is 70 degrees vertically. We also developed a monoshaft malleable forceps. We used these flexible forcipes in the case of various pediatric brain tumors including craniopharyngioma. We performed tumor resection by anterior interhemispheric trans-lamina terminalis approach. After procedure of tumor resection using microscope, endoscope inserted around the pituitary stalk. The piece of calcified tumor could be easily removed without any complications. These forcipes can be deformed to an appropriate angle and can be applied to various cases, especially pediatric brain tumors.

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p<0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p<0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Clinical significance of the relative apical sparing pattern of longitudinal strain in patients with cardiac amyloidosis

Background

The relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis (CA). However, some patients with CA do not show the RASP, and their clinical characteristics have not been fully clarified. We sought to investigate the clinical significance of RASP in patients with CA.

Methods

One hundred consecutive CA patients who were diagnosed by biopsy or myocardial pyrophosphate scintigraphy and evaluated for RASP (mean age: 76 years, male: 77%, LV mean wall thickness: 13.5 mm, light-chain [AL] type: 33 cases, transthyretin [TTR] type: 67 cases) were retrospectively enrolled. The RASP was semi-quantitatively and quantitatively assessed. Semi-quantitative RASP was defined as reduction of LS (≥−10%) in ≥5 (of 6) basal segments relative to preserved LS (<−15%) in ≥1 apical segment. Quantitative RASP was calculated according to the following formula: Quantitative RASP = [Average apical LS] / [Average basal LS + Average mid LS]. We adapted three validated thresholds (>1.00, >0.90, and >0.87) according to the literature.

Results

Semi-quantitative and binalized quantitative RASP (>1.00, >0.90, and >0.87) were observed in 55, 55, 63, and 65 patients, respectively. RASP in each definition was more prevalent in the TTR group than in the AL group. Additionally, RASP was significantly associated with higher LV wall thickness even after adjustment for the CA subtypes (all, p<0.05, Figure). After the RASP assessment, 35 all-cause deaths and 26 cardiac deaths were observed during the follow-up period (median, 1.1 years). Although these events were significantly associated with poor nutrition, lower blood pressure, higher New York Heart Association class, and the AL group, no association was found with RASP and LV wall thickness.

Conclusions

The incidence of RASP is low in the case of thin LV wall thickness in CA patients, which may indicate the difficulty of early diagnosis of CA using RASP in patients with mild LV hypertrophy. The prognostic prediction using RASP may be challenging in this cohort.

Figure 1

Funding Acknowledgement

Type of funding source: None

Alpelisib plus fulvestrant for PIK3CA-mutated, hormone receptor-positive, human epidermal growth factor receptor-2-negative advanced breast cancer: final overall survival results from SOLAR-1

BACKGROUND

Activation of the phosphatidylinositol-3-kinase (PI3K) pathway via PIK3CA mutations occurs in 28%-46% of hormone receptor-positive (HR+), human epidermal growth factor receptor-2-negative (HER2-) advanced breast cancers (ABCs) and is associated with poor prognosis. The SOLAR-1 trial showed that the addition of alpelisib to fulvestrant treatment provided statistically significant and clinically meaningful progression-free survival (PFS) benefit in PIK3CA-mutated, HR+, HER2- ABC.

PATIENTS AND METHODS

Men and postmenopausal women with HR+, HER2- ABC whose disease progressed on or after aromatase inhibitor (AI) were randomized 1 : 1 to receive alpelisib (300 mg/day) plus fulvestrant (500 mg every 28 days and once on day 15) or placebo plus fulvestrant. Overall survival (OS) in the PIK3CA-mutant cohort was evaluated by Kaplan-Meier methodology and a one-sided stratified log-rank test was carried out with an O'Brien-Fleming efficacy boundary of P ≤ 0.0161.

RESULTS

In the PIK3CA-mutated cohort (n = 341), median OS [95% confidence interval (CI)] was 39.3 months (34.1-44.9) for alpelisib-fulvestrant and 31.4 months (26.8-41.3) for placebo-fulvestrant [hazard ratio (HR) = 0.86 (95% CI, 0.64-1.15; P = 0.15)]. OS results did not cross the prespecified efficacy boundary. Median OS (95% CI) in patients with lung and/or liver metastases was 37.2 months (28.7-43.6) and 22.8 months (19.0-26.8) in the alpelisib-fulvestrant and placebo-fulvestrant arms, respectively [HR = 0.68 (0.46-1.00)]. Median times to chemotherapy (95% CI) for the alpelisib-fulvestrant and placebo-fulvestrant arms were 23.3 months (15.2-28.4) and 14.8 months (10.5-22.6), respectively [HR = 0.72 (0.54-0.95)]. No new safety signals were observed with longer follow-up.

CONCLUSIONS

Although the analysis did not cross the prespecified boundary for statistical significance, there was a 7.9-month numeric improvement in median OS when alpelisib was added to fulvestrant treatment of patients with PIK3CA-mutated, HR+, HER2- ABC. Overall, these results further support the statistically significant prolongation of PFS observed with alpelisib plus fulvestrant in this population, which has a poor prognosis due to a PIK3CA mutation. CLINICALTRIALS.

GOV ID

NCT02437318.

High incidence of left atrial dysfunction and low voltage zone in patients requiring multiple atrial fibrillation ablation

Background

While multiple catheter ablation for recurrent atrial fibrillation (AF) is effective for the maintenance of sinus rhythm, some of patients have ablation-refractory AF. Left atrial (LA) dysfunction and the presence of low voltage zone (LVZ) are associated with recurrence after AF ablation. The association between recurrence and LA dysfunction/ LVZ among patients undergoing multiple AF ablation remains unclear.

Purpose

We aimed to compare (i)LA function, (ii)the prevalence of LVZ among patients undergoing first, second and third or more AF ablation procedures. Further, we investigated whether LA dysfunction and LVZ are associated with recurrence after multiple procedures.

Methods

We retrospectively analyzed 460 patients undergoing AF ablation procedures including first, second and third or more sessions from January 2017 to October 2019 in our institute. Before each session, 256-slice MDCT was performed under sinus rhythm to measure pre-ablation LA emptying fraction (LAEF) as the representative of LA function. At the end of each session, we checked the presence of LVZ, which was defined as regions where bipolar peak-to-peak voltage was <0.5mV. All patients underwent pulmonary vein isolation (PVI). If necessary, additional ablation (e.g. linear ablation, non-PV foci ablation and LVZ ablation) was performed.

Results

Out of 460 sessions, 295 were first (follow-up years: 1.5 [0.8, 2.0]), 134 were second (1.0 [0.5, 1.8]), and 31 were third or more sessions (1.2 [0.7, 2.0]). As the number of sessions increased, the recurrence rate was increased (19% vs. 31% vs. 61%, first vs. second vs. ≥third, P<0.0001), LAEF decreased (39.7±10.5% vs. 32.6±10.1% vs. 25.3±11.8%, P<0.0001) and the incidence of LVZ increased (18% vs. 34% vs. 68%, P<0.0001) (Figure 1). In patients with recurrence (N=104) after multiple ablation (second or more sessions), LAEF was lower and the prevalence of LVZ was higher than those without recurrence (N=61) (LAEF: 27.3±10.3% vs. 33.5±10.5%, with vs. without, P=0.0003; LVZ: 57% vs. 31%, P=0.0014).

Conclusions

As the number of sessions increased, the recurrence rate was increased. The prevalence of LA dysfunction and LVZ was high in patients requiring multiple ablation procedure. LA dysfunction and LVZ possibly reflect arrhytmogenic substrate causing recurrence of ablation-refractory AF. We should carefully consider repeated AF ablation in patients with severe LA dysfunction and extensive LVZ.

Figure 1

Funding Acknowledgement

Type of funding source: None

Assessment of left ventricular filling pressure: left atrial reservoir strain is an excellent replacement for missing tricuspid regurgitation velocity

Background

When evaluating left ventricular filling pressure (LVFP) according to current guidelines, tricuspid regurgitation (TR) velocity is often not available.

Purpose

In the present study we investigate if left atrial (LA) reservoir strain may be used instead of TR velocity for evaluation of LVFP.

Methods

We performed a prospective, multicenter, multinational and multivendor study in an all comer population of 322 patients with suspected heart failure or other cardiovascular disease where LVFP was measured by right- or left heart catheterization, as pulmonary capillary wedge pressure or pre-A LV diastolic pressure, respectively. Echocardiography was performed within 1 day of catheterization.

101 patients classified as special populations in the 2016 ASE/EACVI recommendations (i.e. non-cardiac pulmonary hypertension, atrial fibrillation, hypertrophic and restrictive cardiomyopathies) were excluded. Of the remaining 221 patients, 118 patients had EF ≥50% and 103 patients had EF <50%. Regression analysis was performed for LA reservoir strain and TR velocity against LVFP. LA reservoir strain at a cut-off value of <18% was applied instead of TR velocity in the 2016 ASE/EACVI algorithm and compared with the current algorithm.

Results

LA reservoir strain correlated better with LVFP than TR velocity, r=0.62 vs 0.40 (p<0.01) (Figure 1). When replacing TR velocity with LA reservoir strain, the feasibility of the ASE/EACVI 2016 algorithm increased from 91.8% to 98.1%. The accuracy of the algorithm was not significantly altered (80% vs 79%).

An accuracy of 80% for the algorithm is lower than what has been reported in earlier publications, this may be due to inclusion of patients without suspected heart failure and no assessment of clinical data, which in turn may have influenced the accuracy of the algorithm.

Conclusion

LA reservoir strain has better correlation to LVFP than TR velocity, and can be used in the ASE/EACVI 2016 algorithm for estimation of LVFP as a replacement when TR velocity is missing.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Utility of scoring system including relative apical sparing pattern for screening cardiac amyloidosis in patients with left ventricular hypertrophy

Background

Cardiac amyloidosis (CA) is an infiltrative disease mimicking left ventricular hypertrophy (LVH), although its prognosis is poorer than other diseases with LVH. Moreover, because CA is treatable, appropriate screening for CA is an important area of study for clinicians to prevent and treat the disease. Several imaging predictors of CA have been reported so far;. in particular, deformation parameters such as relative apical sparing patterns of longitudinal strain (RASP) may diagnose CA with better precision than conventional parameters. Accordingly, we hypothesized that the inclusion of deformation parameters into the established diagnostic parameters would permit derivation of a risk score for CA screening in patients with LVH. Thus, we aimed to 1) investigate the incremental benefits of deformation parameters over established diagnostic parameters for CA screening in patients with LVH; 2) determine the risk score to screen CA patients with LVH using all of these variables; and 3) externally validate the score.

Methods

We retrospectively studied 295 consecutive non-ischemic patients with LVH who underwent echocardiography as well as the detailed work-up for LVH (biopsy, technetium pyrophosphate scintigraphy (99mTc-PYP) or cardiac magnetic resonance imaging) (median age, 67 years; MWT, 12 mm). CA was diagnosed by biopsy or 99mTc-PYP. The base model consisted of age (≥65 [male], ≥70 [female]), low voltage in electrocardiography, and posterior wall thickness ≥14 mm in reference to previous studies. Continuous echocardiographic variables were binarized by the use of generally accepted external cutoff points to avoid best clinical scenario. Incremental benefits were assessed using receiver operating characteristic curve analysis and area under the curve (AUC) comparison. Multiple logistic regression analysis was performed to determine the risk score. The score was then validated in the external validation sample (N=178, median age, 70 years; MWT, 12 mm).

Results

CA was observed in 54 patients (18%) and of the several echocardiographic parameters studied, only RASP demonstrated a significant incremental benefit for the screening of CA over the base model (Figure A). After multiple logistic regression analysis in the prediction of CA with 4 variables (RASP and basal model components), each was assigned a numeric value based on its relative effect (Figure B). The incidence rate of CA clearly increased as the sum of the risk score increased (Figure C). The score had good discrimination ability, with an AUC of 0.87, a total score of ≥2 with 70% sensitivity and 90% specificity. Similarly, the discrimination ability of the score in the validation cohort was sufficient (AUC = 0.87).

Conclusion

Overall, we determined a simple risk score including RASP to screen CA. This score takes into account 4 common parameters used in daily practice, and therefore, has potential utility in risk stratification and management of patients with LVH.

Figure 1

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Kitaishikai

One-year outcome of the rule-out group according to the 0-h /1-hour algorithm with suspected myocardial infarction in Asian countries

 

Background/Introduction; A rapid rule-out or rule-in protocol based on the 0-h/1-hour algorithm using high-sensitivity cardiac troponin T (hs-cTnT) is recommended by the European Society of Cardiology (ESC). Around 40–50% were stratified into “rule-out” group, and their 30-days prognosis was excellent. However, the one-year prognosis is uncertain. We aimed to better characterize these patients.

Methods

This study was a prospective, multi-center, observational study of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS) admitted to 5 hospitals in Japan and Taiwan from 2014 November to 2018 December, respectively.

All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, standard blood test, chest radiography. Exclusion criteria were ST elevated myocardial infarction, chronic kidney disease (serum creatinine more than 3 mg/dL) and congestive heart failure, arrhythmia, or infection disease. The patients were divided into three groups according to the algorithm; “rule-out”, “observe” and “rule-in”. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, stress electrocardiography and follow-up data. The presence of acute myocardial infarction (AMI) was defined according to the Fourth Universal Definition of Myocardial Infarction. After hospital discharge patients were follow after one-year b telephone or in written form. Major adverse cardiovascular events (including death myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention (PCI)) were recorded by establishing contact with the patient and the family physicians. The primary prognosis end point was all-cause mortality.

Results

Of the 1,187 patients were analyzed after exclusion. The prevalence rate of AMI was 16.1%. According to the algorithm, 42% (n=493) of patients were assigned to “rule-out” group and had no AMI nor death. The most common final adjudicated diagnoses were atypical chest pain (80%), gallstone attack (3%) and vasospastic angina pectoris (2%). All patients with unstable angina (4.7%) underwent PCI.

Conclusion(s)

Our findings suggest that the “rule-out” group patients according to ESC 0-h/1-hour algorithm provides very high safety and efficacy for the triage toward AMI.

Funding Acknowledgement

Type of funding source: None

Pre-ablation left atrial function predicts the presence of low voltage zone in patients undergoing paroxysmal atrial fibrillation ablation: OLAF-LVZ predictive score

Background

Preoperative left atrial (LA) function is associated with paroxysmal atrial fibrillation (PAF) ablation outcome. The presence of left atrial low voltage zone (LVZ) is also associated with recurrence. We hypothesized that reduced pre-ablation LA function reflects the presence of LVZ.

Purpose

We investigated the association between baseline LA function and the presence of LVZ in patients undergoing initial PAF ablation. Further, we sought to create the new predictive scoring for the presence of LVZ.

Methods

Consecutive 305 patients who underwent LA voltage mapping during initial PAF ablation from January 2017 to October 2019 in our institute were retrospectively analyzed. We performed 256-slice MDCT at baseline. As the representative of LA function, we calculated LA emptying fraction (LAEF), where LAEF = {[(maximum LAV) − (minimum LAV)]/(maximum LAV)} x 100. LVZ was defined as regions where bipolar peak-to-peak voltage was <0.5mV. We performed the univariate and multivariate analysis to assess the association between LAEF and the presence of LVZ. Second, we performed receiver operating characteristic (ROC) analysis for the prediction of LVZ. We combined multivariate predictors and created the predictive scoring for LVZ.

Results

Out of 305 pts, 56 pts (18%) had LVZ in LA. In univariate analysis, low body mass index, higher percentage of female sex, higher age, higher E/e', larger maximum LA volume and lower LAEF (29.3±11.8% vs. 41.2±9.7, P<0.0001) was associated with the presence of LVZ. In multivariate logistic regression analysis, Low LAEF revealed the strongest predictor for LVZ (LAEF; Odds ratio [OR]/10% increase: 0.54, 95% CI: 0.39–0.82, P=0.0016). High age and female sex also remained as the independent predictors (Age; OR/10 y.o. increase: 1.80, 1.23–3.03, P=0.0042, Female; OR: 2.51, 1.15–5.49, P=0.0213). In ROC analysis, LAEF had moderate predictive accuracy for the presence of LVZ. (Area under the ROC curve: 0.77, Best cut-off value: 31%, P<0.0001) (Figure 1). We created OLAF-LVZ predictive score by combining Old age (1 point, ≥65), LAEF (2 points, LAEF ≤31%) and Female sex (1 point). OLAF score had gradient effect on the incidence of LVZ (2%, 11%, 25%, 45%, 71%, OLAF score; 0, 1, 2, 3, 4, respectively, P<0.0001) (Figure 2).

Conclusions

In PAF patients, preoperative LAEF was strongly associated with the presence of LVZ. LVZ might reflect the myocardial injury causing LA dysfunction. OLAF-LVZ predictive score: combination of Old age (≥65), Female sex, and LAEF (≤31%) could be useful to stratify the risk of the presence of LVZ.

Funding Acknowledgement

Type of funding source: None

Which single echo parameter is the best marker of left ventricular filling pressure?

Background

Estimation of left ventricular filling pressure (LVFP) is highly relevant in clinical practice. Invasive pressure remains the gold standard, but a number of echocardiographic parameters that correlate with LVFP are used as non-invasive markers of pressure.

Purpose

We investigated how different echocardiographic parameters correlated with invasively measured LVFP, and how accurately those parameters could differentiate between normal or elevated LVFP.

Method

We performed a prospective, multicenter, multinational and multivendor study in an all comer population of 322 patients with suspected heart failure or other cardiovascular disease. 194 patients had EF ≥50% and 129 had EF <50%. LVFP was measured by right- or left heart catheterization, as pulmonary capillary wedge pressure or pre-A LV diastolic pressure, respectively.

When excluding all special patient populations defined in the 2016 recommendations for echocardiographic evaluation of LV diastolic function, 213 patients remained. Of these 135 had EF ≥50% and 74 had EF <50%.

Echocardiography was performed within 1 day of catheterization. Previously recommended cut-off values for established parameters were used to determine the accuracy of classifying LVFP as normal or elevated. For left atrial (LA) reservoir strain, based on ROC analysis, a cut-off value of <18% was used as marker of elevated LVFP.

Results

LA reservoir strain and the ratio of peak mitral early flow velocity (E) and LA reservoir strain (E/LA strain) showed the best correlations to LVFP (Table 1, Figure 1). They also had the highest accuracy, 75% for both, in classifying LVFP as normal or elevated in the whole patient population. E/LA reservoir strain provided no additional diagnostic value to using LA reservoir strain alone.

In HFpEF patients accuracy was essentially similar for LA strain, E/LA strain and E/e', whereas in HFrEF patients the two former tended to be better than E/e'.

Conclusion

Parameters containing LA reservoir strain showed the best correlation to LVFP. This indicates that LA reservoir strain may have a role in evaluation of LVFP.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Diagnostic reliability of quantitative flow ratio for detection of myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices

Background

Quantitative flow ratio (QFR) is an image-based virtual fractional flow reserve (FFR) computed by three dimensional quantitative coronary angiography (3D-QCA) and estimated flow velocity. Several studies have reported that QFR had a good diagnostic performance as compared with wire-based FFR or instantaneous wave-free ratio (iFR).

Purpose

We compared the diagnostic reliability of QFR for detection of myocardial ischemia with other angiographic and visual predicted indices.

Methods

In 301 coronary lesions (263 patients) from our QFR database for previously-reported two studies, the diagnostic reliability of QFR, several angiographic and visual predicted indices were investigated using ROC analysis as reference of FFR≤0.8 or iFR≤0.89. Visual predicted FFR were estimated by 3 physicians (25-year experienced expert, 10-year experienced senior physician and 3-year experienced trainee) blinded to other indices.

Results

Area under the curve (AUC) of each index in ROC analysis is shown in Table.

Conclusion

QFR was reliable index detecting myocardial ischemia compared with other angiographic and experience-dependent visual predicted indices.

Funding Acknowledgement

Type of funding source: None

Predictive factors of recurrent atrial tachyarrhythmia after multiple procedures of radiofrequency catheter ablation for paroxysmal atrial fibrillation: Kansai Plus Atrial Fibrillation Registry (KPAF)

Background

The predictors of arrhythmia recurrence after radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) have not yet been fully evaluated.

Purpose

The aim of this study was to develop and validate a risk scoring system to predict the incidence of recurrence of atrial tachyarrhythmia after the final RFCA for PAF.

Methods

The study population consisted of 3223 consecutive patients undergoing first-time RFCA for PAF from November 2011 to March 2014 in 26 cardiovascular centers in Japan who were enrolled in the Kansai Plus Atrial Fibrillation (KPAF) registry. We developed a scoring system in a derivation cohort with 2149 patients and assessed its reproducibility in a validation cohort with 1074 patients. The primary endpoint was recurrent atrial tachyarrhythmia lasting for ≥30 seconds after 91 days post the final ablation.

Results

During a median follow-up period of 3.1 years, 404 (18.8%) patients of the derivation cohort had AF recurrence after the final RFCA. The baseline patient characteristics of the derivation cohort were as follows: mean age 64.7 years, male 1480 (68.9%), mean body mass index (BMI) 23.6 kg/m2, hypertension 1122 (52.2%), prior heart failure 182 (8.5%), diabetes mellitus 203 (9.5%), prior stroke and/or transient ischemic attack 21 (1.0%), prior vascular disease 209 (9.7%), prior valvular disease 105 (4.9%), median CHADS2 score 1.1, median CHA2DS2-VASc score 2.1, mean number of ineffective antiarrhythmic drugs (AAD) 0.80, median duration of history of AF episodes 2.1 years, mean left atrial diameter (LAD) 38.2 mm, mean left ventricular ejection fraction (LVEF) 65.3%, and mean eGFR 68.7 mL/min/1.73m2. There was no significant difference in the baseline characteristics between derivation and validation cohorts. The results of the multivariate logistic regression models identified 5 independent variables of recurrent atrial tachyarrhythmia after the final RFCA: female (odds ratio (OR) = 1.45, p=0.0017), BMI <25 kg/m2 (OR=1.40, p=0.0081), duration of AF history 3 years≤ (OR=1.39, p<0.0034), chronic kidney disease (CKD) (OR=2.1, p=0.005, for stage 2/3CKD, OR=2.6, p=0.018 for stage 4/5 CKD), and LVEF (OR=2.1, p=0.039 for LVEF <50%, OR=1.5, p=0.022 for LVEF 50–60%). The predictive score for each factor was 3 points for CKD stage 4/5, 2 for CKD stage2/3 and LVEF <50%, and 1for the others (11 points in total). The arrhythmia-free rates after the final RCFA in the derivation cohort according to the score were as follows: 0–2 points = 91.7%, 3–4 = 80.7%, 5< = 72.6%, respectively. The similar results were reproduced in the validation cohort (Figure 1).

Conclusion

Our newly developed scoring system, composed of female, BMI, AF duration, CKD, and LVEF, could reproducibly predict arrhythmia recurrence after the final RFCA for PAF.

Funding Acknowledgement

Type of funding source: None