Distal radial secondary access for transcatheter aortic valve implantation: The minimalistic approach

BACKGROUND

Although not yet recommended by the guidelines, distal radial access, a new site for cardiovascular interventions, has been rapidly acknowledged and adopted by many centers due to its high rate of success, safety and fewer complications. We present our experience using secondary distal radial access during transcatheter aortic valve implantation (TAVI), proposing a new, even more minimal approach.

METHODS

As of November 2020, a systematic distal radial approach as secondary access site for TAVI was adopted in our center. Primary endpoints were technical success and major adverse events (MAEs). Secondary endpoints: the access site complication rate, hemodynamic and clinical results of the intervention, procedural related factors, crossover rate to the femoral access site, and hospitalization duration (in days).

RESULTS

From November 2020, 41 patients underwent TAVI using this strategy. Patients had a mean age of 76 ± 11.2 years, 41% were male. Six (14.63%) patients received a balloon-expandable valve and 35 (85.37%) received a self-expandable valve. TAVI was successful in all cases. No complications occurred due to transradial access. Puncture success, defined as completed sheath placement was maximum (N = 41/41,100%) and emergent transfemoral secondary access was not required in any case. Primary transfemoral vascular access site complications occurred in 7 cases (17%) of which 4 (13.63%) were resolved through distal radial access: one occlusion, two flow-limiting stenoses and four perforations of the common femoral artery. There were no additional major vascular complications at 30 days. Overall MACE rate was 2.4%.

CONCLUSION

The use of the distal radial approach for secondary access in TAVI is safe, feasible and has several advantages over old access sites.

Left Ventricular Rotational Abnormalities in Treated Hypopituitarism: Insights From the Three-Dimensional Speckle-Tracking Echocardiographic MAGYAR-Path Study

Introduction: Hypopituitarism is a rare, often underdiagnosed, complex hormonal disease caused by the decreased secretion of one or more hormones in the pituitary gland. The present study was designed to assess left ventricular (LV) rotational mechanics in patients with treated hypopituitarism. It was also aimed to find possible differences in these parameters according to the origin of hypopituitarism (congenital vs. acquired). Methods: The present prospective study involved 35 treated patients with hypopituitarism; however, 4 patients had to be excluded due to inferior image quality. The mean age of the remaining 31 cases was 56.3 ± 13.2 years (18 males). The control group consisted of 29 age- and sex-matched healthy volunteers (mean age: 55.3 ± 4.8 years, 14 males). In all cases a complete two-dimensional echocardiography examination was performed followed by three-dimensional speckle-tracking echocardiography. Results: No significant differences could be found in LV volumes between the controls and patients with hypopituitarism and hypopituitary subgroups. LV apical rotation (8.1 ± 5.1° vs. 10.6 ± 3.5°, p < 0.05) and LV twist (11.9 ± 5.3° vs. 15.1 ± 3.8°, p < 0.05) were impaired in the hypopituitary group with normally directed LV rotational mechanics as compared to the healthy controls. However, 13% of patients showed a near absence of LV twist called LV "rigid body rotation" (LV-RBR). There were no significant differences regarding LV apical and basal rotations and twist between acquired and congenital hypopituitary subgroups. Conclusions: Impaired LV apical rotation and twist could be demonstrated in hypopituitarism regardless of its origin. In the present study with small number of patients with hypopituitarism, LV-RBR was present in 13% of cases.

Mitral and tricuspid annular abnormalities in hypereosinophilic syndrome – a three-dimensional speckle-tracking echocardiographic study

Introduction

Peripheral eosinophilia with absolute eosinophil count more than 1.500 cells/uL and eosinophilic tissue and end-organ damage are typical features in hypereosinophilic syndrome. In the present study it was hypothesized that hypereosinophilic syndrome-related atrial and ventricular abnormalities are associated with changes in size and function of mitral and/or tricuspid annuli.

Methods

The study comprised 17 patients with hypereosinophilic syndrome who were recruited, prospectively, 2 patients had to be excluded due to suboptimal image quality (mean age: 61.7±11.2 years, 10 males). The control group consisted of 24 healthy volunteers (mean age: 55.2±7.9 years, 12 males). Complete two-dimensional Doppler echocardiography was performed, mitral and tricuspid annuli were measured by three-dimensional speckle-tracking echocardiography.

Results

Only interventricular septum proved to be significantly thickened in patients with hypereosinophilic syndrome, other parameters did not differ between the groups examined. Increased end-diastolic and end-systolic mitral annular diameter (2.6±0.3 cm vs. 2.4±0.3 cm, p&lt;0.05 and 2.2±0.2 cm vs. 1.7±0.3 cm, p&lt;0.05, respectively), area (9.5±2.3 cm2 vs. 7.5±1.9 cm2, p&lt;0.05 and 6.7±2.0 cm2 vs. 3.8±1.1 cm2, p&lt;0.05, respectively), and perimeter (11.6±1.7 cm vs. 10.4±1.3 cm, p&lt;0.05 and 9.9±1.9 cm vs. 7.4±1.1 cm, p&lt;0.05, respectively) together with reduced mitral annular fractional area change (29.6±13.0% vs. 47.7±15.8%, p&lt;0.05) and fractional shortening (16.6±11.9% vs. 28.9±12.7%, p&lt;0.05) could be detected in patients with hypereosinophilic syndrome as compared to that of matched controls. From tricuspid annular morphological parameters, only end-diastolic tricuspid annular area (9.1±2.4 cm2 vs. 7.5±1.9 cm2, p&lt;0.05) and end-systolic tricuspid annular perimeter (9.9±1.2 cm vs. 9.3±1.4 cm, p&lt;0.05) proved to be significantly increased in patients with hypereosinophilic syndrome as compared to controls with preserved tricuspid annular functional parameters.

Conclusion

Mitral annular dilation is more pronounced compared to that of tricuspid annulus in hypereosinophilic syndrome. Mitral annular functional impairment is present in hypereosinophilic syndrome.

Funding Acknowledgement

Type of funding sources: None.

Tricuspid annular abnormalities in isolated left ventricular noncompaction – a three-dimensional speckle-tracking echocardiographic study

Introduction

Left ventricular (LV) noncompaction (LVNC) is a rare cardiomyopathy due to arrest of the normal maturation process of the myocardium. It is characterized by prominent LV trabecularization with deep intratrabecular recesses. In most of cases LVNC is isolated, but biventricular forms are also known. The tricuspid valve is a complex anatomical structure which incorporates the three-dimensional (3D) saddle-shaped fibrosus annulus (TA). 3D speckle-tracking echocardiography (STE) is a novel non-invasive imaging method with capability of not only measuring volumetric, strain and rotational parameters of heart chambers, but with finding optimal valvular planes in the 3D space evaluation of TA dimensions respecting cardiac cycle is allowed. The present study was designed to assess TA morphological and functional abnormalities by 3DSTE in LVNC patients without right ventricular (RV) involvement.

Methods

The present study consisted of 15 patients with LVNC (mean age: 52.1±11.4 years, 9 males). LVNC was defined according to the Jenni's criteria. Their results were compared to 21 age- and gender-matched healthy controls (mean age: 52.4±3.9 years, 14 males). Complete routine 2-dimensional Doppler echocardiographic examination with 3DSTE was performed in all LVNC patients and healthy controls.

Results

Enlarged left atrial and LV dimensions with reduced LV ejection fraction could be seen in LVNC patients. The mean number of noncompacted segments proved to be 6.9±2.0. Grade 1 and 2 mitral regurgitation (MR) could be demonstratred in 5 and 5 LVNC patients, respectively. Higher grade of MR could not be found. Grade 1 and 2 tricuspid regurgitation (TR) could be demonstrated in 4 and 1 LVNC patients, respectively. Only one LVNC patient has grade 4 TR. Tricuspid annular plane systolic excursion (TAPSE) and RV fractional area change (RV-FAC) proved to be 13.9±3.9 mm and 34.1±2.7%, respectively. LVNC patients showed significantly dilated end-diastolic and end-systolic TA diameter (2.6±0.3 cm vs. 2.2±0.3 cm, p&lt;0.05 and 2.2±0.2 cm vs. 1.8±0.3 cm, p&lt;0.05, respectively), area (8.4±1.7 cm2 vs. 7.0±1.5 cm2, p&lt;0.05 and 6.5±1.7 cm2 vs. 5.3±1.4 cm2, p&lt;0.05, respectively) and tendentiously larger perimeter (11.2±1.4 cm vs. 10.5±1.2 cm, p=ns and 9.8±1.5 cm vs. 8.9±1.0 cm, p=ns, respectively), which was accompanied with tendentiously lower TA functional properties represented by TA fractional area change (TAFAC, 22.2±12.3% vs. 23.7±11.7%, p=ns) and TA fractional shortening (TAFS, 15.9±5.6% vs. 18.8±8.0%, p=ns). TAPSE and RV-FAC showed mild correlations with TAFAC (r=0.39, p=0.05; r=0.36, p=0.05, respectively) and TAFS (r=0.37, p=0.05; r=0.38, p=0.05). Extent of LV noncompaction did not correlate with any echocardiographic parameters.

Conclusions

TA is dilated in LVNC patients without obvious RV involvement. Longitudinal (TAPSE) and sphincter-like (TAFAC, TAFS) TA motions correlate with each other.

Funding Acknowledgement

Type of funding sources: None.

The tricuspid annulus in cardiac amyloidosis – a three-dimensional speckle-tracking echocardiographic study

Introduction

Amyloidosis is a rare condition due to extracellular deposition of excessive amount of protein in parenchymal tissues including the heart. The present study aimed to test whether cardiac amyloidosis (CA) is associated with morphological and functional abnormalities of the tricuspid annulus (TA). For this aim, the results of patients having CA were compared to age- and gender-matched healthy controls by three-dimensional speckle-tracking echocardiography (3DSTE). Moreover, differences in TA parameters between light-chain CA (AL-CA) and transthyretin CA (TTR-CA) were studied as well.

Methods

The study comprised 27 CA patients (mean age: 62.7±9.1 years, 21 males), their results were compared to those of 20 age- and gender-matched healthy volunteers (59.3±3.8 years, 13 males). Current consensus criteria were used for the definition of CA. Biopsy was carried out in all patients to confirm the diagnosis of CA. The first positive biopsy site was the myocardium in 7 cases, bone marrow in 6 cases, duodenum and rectum in 5 cases, salivary gland in 1 case, skin and subcutaneous tissue in 2 cases and kidney in 10 cases in the CA patients. In 5 CA patients, biopsy samples were collected from more than one organ. CA proved to be AL-CA in 21 subjects and TTR-CA in 6 patients. Complete two-dimensional Doppler echocardiography and 3DSTE were performed in all CA patients and controls.

Results

CA patients had significantly higher left atrial diameter, left ventricular (LV) end-diastolic diameter, thicker interventricular septum and LV posterior wall and increased E/A ratio compared to the results of healthy controls. None of the 27 CA patients and their matched controls had atrial fibrillation in their medical history. Dilated 3DSTE-derived end-diastolic and end-systolic TA diameter (3.0±0.6 cm vs. 2.1±0.2 cm, p&lt;0.05 and 2.6±0.6 cm vs. 1.6±0.2 cm, p&lt;0.05, respectively), area (10.7±3.5 cm2 vs. 6.1±1.1 cm2, p&lt;0.05 and 8.0±3.2 cm2 vs. 4.1±1.0 cm2, p&lt;0.05, respectively) and perimeter (12.5±2.0 cm vs. 9.8±1.0 cm, p&lt;0.05 and 10.6±2.1 cm vs. 8.0±1.0 cm, p&lt;0.05, respectively) could be detected in all CA patients and in the AL-CA and TTR-CA subgroups, as well. Although only a few TTR-CA patients were involved, morphologic TA parameters proved to be tendentiously higher as compared to those of AL-CA patients. Functional parameters of TA represented by TA fractional area change (TAFAC, 26.1±11.2% vs. 32.0±11.1%, p=0.07) and TA fractional shortening (TAFS, 12.8±10.3% vs. 21.6±7.4%, p&lt;0.05) were found to be reduced in CA patients, which were more enhanced in TTR-CA patients (TAFAC for TTR-CA: 27.1±14.3% vs. TAFAC for AL-CA:25.7±10.5%, p=ns; TAFS for TTR-CA: 16.0±9.8% vs. TAFS for AL-CA: 11.9±10.4%, p=ns).

Conclusions

Dilated TA is associated with its functional deterioration in CA. Patients with TTR-CA have tendentiously more dilated TA with more enhanced TA functional parameters.

Funding Acknowledgement

Type of funding sources: None.

Additive prognostic value of coronary flow and heart rate reserve during vasodilator stress echocardiography in hypertrophic cardiomyopathy

Background

Coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) during vasodilator stress echocardiography (SE) assess coronary microvascular function and cardiac sympathetic reserve respectively. Both CFVR and HRR can be impaired in hypertrophic cardiomyopathy (HCM).

Objectives

To evaluate the prognostic value of CFVR and HRR during vasodilator SE in HCM.

Methods

We enrolled 244 HCM patients (age=51±15 years, 116 men) studied with vasodilator SE from 1999 to 2019 in 5 certified centers. Stress modality was either adenosine (Ado, 0.14 mg/kg/min in 2', n=171) or dipyridamole (Dip, 0.84 mg/kg in 6', n=73). Left ventricular outflow tract obstruction was present at rest in 80 patients (33%). We assessed CFVR in left anterior descending coronary artery (by TTE in 225, and TEE in 19 patients) and HRR (peak/rest heart rate). Abnormal values of HRR were based on receiver operating characteristics for Ado and Dip separately calculated. All patients completed the follow-up.

Results

CFVR was 2.17±0.46 for Dip and 2.13±0.43 for Ado (p=ns); HRR was 1.36±0.19 for Dip and 1.10±0.16 for Ado (p&lt;0.001). An abnormal CFVR (&lt;2.0 for both Ado and Dip) was present in 28 patients for Dip and 73 for Ado (38% vs 43%, p=ns). An abnormal HRR (≤1.34 for Dip and ≤1.03 for Ado) was present in 39 patients for Dip and in 70 patients for Ado (53% vs 41%, p=ns). During a median follow-up of 67 months (interquartile range: 29–103 months), 97 spontaneous events occurred in 71 patients: 29 all-cause deaths, 32 new hospital admission for acute heart failure, 3 sustained ventricular tachycardias, 32 atrial fibrillations and 1 heart transplantation. Event rate was 2.5%/year in patients with normal CFVR and HRR, 4.7%/year in patients with only one abnormal criterion and 10.9%/year in patients with abnormal responses of both criteria (see figure). At multivariate analysis, abnormality of both CFVR and HRR (Hazard ratio 4.033, 95% CI 1.863–8.729, p&lt;0.001) was independent predictor of events.

Conclusions

A reduced CFVR and blunted HRR during vasodilator SE identify distinct phenotypes and show independent value in predicting outcome in HCM patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier spontaneous event-free survival curves based on HRR and CFVR. Kaplan-Meier survival curves (considering spontaneous events) in patients stratified with the abnormal HRR and/or CFVR. Number of patients at risk per year is shown.

Detailed analysis of left ventricular deformation in athletes doing high dynamic sports – a three-dimensional speckle-tracking echocardiographic study

Background

Physiologic remodeling due to repetitive overload induced by exercise training is a known feature in the athletes' heart including significant changes in left ventricular (LV) deformation mechanics. The aim of the present study was to investigate three-dimensional speckle-tracking echocardiography- (3DSTE-)derived LV strains in elite athletes doing high dynamic sports with different grades of static components of their training.

Methods

The athlete group comprised 67 subjects (mean age: 23.6±6.4 years, 50 men). The following groups were created regarding their physical activity: Group C. I. (high dynamic/low static) (n=12, mean age: 23.1±4.0 years, Group C. II. (high dynamic/moderate static) (n=22, mean age: 24.8±7.8 years) and Group C. III. (high dynamic/high static) (n=33, mean age: 23.0±6.1 years). Their results were compared to 83 age- and gender-matched non-athletic healthy controls (mean age: 23.6±3.2 years, 50 men). All athletes and non-athletes underwent a complete two-dimensional Doppler echocardiography examination with 3DSTE.

Results

None of the healthy subjects or athletes had any known cardiovascular risk factors or received drugs and ECG showed no significant alterations. Athletes spent 10.8±3.3 years, 10.1±5.9 years and 6.9±4.2 years in elite sport in Groups C. I., C. II. and C. III., respectively. No significant differences could be seen in the ratio of athletes being in an actual race period between Groups C. I., C. II. and C. III. [n=3 (25%), n=11 (50%) and n=11 (32%), respectively]. Enlarged LV dimensions and thickened posterior wall and interventricular septum were found in all athletes compared to the non-athlete healthy control group by 2-dimensional echocardiography. Increased 3DSTE-derived LV end-diastolic and end-systolic volumes could be seen in all athletes, the largest values were seen in the C. III. group. Global LV-LS (−18.5±3.0% vs. −16.3±2.3%, p&lt;0.05), LV-CS (−29.9±5.2% vs. −28.1±4.8%, p&lt;0.05) and LV-AS (−43.7±5.4% vs. −40.9±4.8%, p&lt;0.05) were increased as compared to those of non-athlete controls. All apical regional LV strains proved to be increased in all athletes with enhanced basal LS and midventricular LS, AS and 3DS. Global LV strains did not differ between the athlete groups based on static component of their training. No significant regional differences in LV strains could be detected between C. I., C. II. and C. III. groups (except in midventricular LV-LS).

Conclusions

Enhanced LV contractility represented by LV strains in longitudinal and circumferential directions could be demonstrated in elite athletes doing high dynamic sports, which does not depend on the grade of the static component of their training.

Funding Acknowledgement

Type of funding sources: None.

Left atrial volumes changes are associated with changes in mitral annular dimensions and functional properties in healthy adults – a three-dimensional speckle-tracking echocardiographic study

Introduction

Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a novel echocardiographic method with capability of 3D assessment of heart chambers and valvular annuli making an opportunity to compare cyclic changes of left atrial (LA) volumes and mitral annular (MA) dimensions in physiological healthy circumstances. The present study was designed to examine correlations between LA volume changes and MA dimensions and functional properties in healthy adult subjects by 3DSTE.

Methods

The study population consisted of 199 healthy adults (mean age: 33.5±12.7 years, 104 males), who had no symptoms, conditions or diseases, which could affect results. None of subjects received any medication. The group of subjects was divided according to their maximum LA volume (Vmax) into three groups using 30 ml and 50 ml as cut-off values. All subjects underwent complete two-dimensional Doppler echocardiography extended with 3DSTE.

Results

All LA volumes and stroke volumes increased with end-systolic Vmax. Early diastolic passive atrial emptying fraction (PAEF) was significantly reduced in patients with Vmax&gt;50 ml. End-systolic total atrial emptying fraction (TAEF) and late diastolic active atrial emptying fraction (AAEF) was not accompanied with increased end-systolic Vmax. Both end-diastolic and end-systolic MA dimensions were dilated in subjects with increased Vmax, which was accompanied with reduction of MA function. Only end-systolic MA dimensions showed further increase, when end-systolic Vmax was larger than 50 ml compared to cases with Vmax between 30 ml and 50 ml. When prognostic value of MA dimensions and functional properties were analyzed, several MA dimensions and MA fractional area change (MAFAC) were found to have prognostic value to predict Vmax&gt;50 ml. The cut-off values for end-diastolic MA diameter (MAD-D), end-systolic MA diameter (MAD-S) and area, end-diastolic and end-systolic MA perimeter and MAFAC to predict Vmax&gt;50 ml proved to be 2.3 cm, 1.5 cm, 3.4 cm2, 10.2 cm, 7.4 cm and 50.93%, respectively. While increased LA volumes were associated with both dilated MAD-D and MAD-S, only increased diastolic LA volumes were associated with reduced MAFAC. While dilated MAD-D was associated with increased total and active atrial stroke volumes, similar relationship with MAD-S could not be detected. Increased passive atrial stroke volume was associated with augmented MAFAC. While dilated MAD-D was associated with increased AAEF, dilated MAD-S was found to be related to reduced TAEF and PAEF. Increased MAFAC was associated with increased values regarding all emptying fractions. End-diastolic MA dimensions increased with dilation of end-systolic MA dimensions and vice versa. Increased MAFAC was associated with dilated MAD-D and reduced MAD-S.

Conclusions

Strong relationship exists between LA volumes and MA dimensions and functional properties in healthy subjects.

Funding Acknowledgement

Type of funding sources: None.

Correlations between left atrial volumes and strains in healthy adults: Detailed analysis from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

INTRODUCTION

Little is known about the relationship between left atrium (LA) volumes and contractility features along the cardiac cycle. The present study aimed to assess, by three-dimensional speckle-tracking echocardiography (3DSTE), correlations between LA volumes, volume-based functional properties, and strains during the cardiac cycle in healthy adults.

METHODS

We included 217 healthy adult volunteers (mean age 33.4 ± 12.7 years, 112 males) who underwent complete two-dimensional Doppler echocardiography with 3DSTE.

RESULTS

LA stroke volumes were greater in subjects with the greater maximum LA volume (V_max ) in reservoir, conduit, and booster pump phases of LA function. While LA emptying fraction in LA reservoir phase was not different between subjects depending in their V_max value, a significantly lower LA emptying fraction could be detected in LA conduit phase in subjects whose V_max was >50 mL. In booster pump function, LA emptying fraction was not significantly different whatever the V_max . Only global and mean segmental peak LA radial strain (RS) and 3D strain (3DS) and the same strains at atrial contraction appeared greater in subjects with greater V_max , whereas the other strain parameters were not different.

CONCLUSIONS

In healthy subjects, LA-RS and LA-3DS, objective features of LA contractility, are greater in subjects with greater LA volumes up to a point beyond which this association disappears.

The effects of lower body compression on left ventricular rotational mechanics in lymphoedema (from the MAGYAR-Path Study)

Aims

Lower body half compression of bilateral secondary leg lymphoedema (LE) without relevant cardiac insufficiency gives rise to whether external leg compression may influence left ventricular (LV) function. Patients with LE were subjected to baseline two‐dimensional transthoracic echocardiography (2DTTE) for general assessment then three‐dimensional speckle‐tracking echocardiography (3DSTE) before and 1 h after lower body half external compression for LV torsion analysis.

Methods and results

Baseline 2DTTE was performed in the cohort of 25 LE patients, and the results were compared with those of age‐ and gender‐matched 52 healthy controls (mean age: 47.8 ± 12.8 vs. 40.7 ± 14.0 years, 24 women/1 man vs. 49 women/3 men, respectively). 3DSTE was conducted for the assessment of LV rotational mechanics where apical (AR), and basal rotations (BR) were measured before and 1 h after the use of compression class 2 (ccl 2) flat‐knitted medical compression pantyhoses (pressure range: 23–32 mmHg). 2DTTE showed significantly larger LV end‐diastolic volume and ejection fraction among LE patients compared with control subjects (108.3 ± 20.1 vs. 98.5 ± 21.7 mL, 69.8 ± 4.8 vs. 65.5 ± 4.3%, respectively) and notably smaller LV end‐systolic diameter and posterior wall thickness (28.9 ± 3.5 vs. 31.2 ± 3.4 mm, 8.1 ± 1.0 vs. 9.0 ± 1.7 mm, respectively). The results of 20 patients with LE were considered in 3DSTE examinations due to the drop‐out of five probands with technical failures. The data of four LE patients showing significant LV rotational abnormalities were managed separately, and the rotational parameters of the remaining sixteen patients did not differ significantly from those of matched controls except significant reduction of LV BR following the application of medical compression stockings (MCS) (−2.70 ± 1.26 degrees after 1 h use of pantyhose in patient group vs. −4.28 ± 2.18 degrees of the control group; P < 0.05).

Conclusions

The application of compression pantyhoses moderately but significantly decreased LV BR without a remarkable impact on twisting mechanism in LE patients in the absence of LV rotational abnormalities.

Prognosis of the non-ST elevation myocardial infarction complicated with early ventricular fibrillation at higher age

Early ventricular fibrillation (EVF) predicts mortality in ST-segment elevation myocardial infarction (STEMI) patients. Data are lacking about prognosis and management of non-ST-segment elevation myocardial infarction (NSTEMI) EMI with EVF, especially at higher age. In the daily clinical practice, there is no clear prognosis of patients surviving EVF. The present study aimed to investigate the risk factors and factors influencing the prognosis of NSTEMI patients surviving EVF, especially at higher age. Clinical data, including 30-day and 1-year mortality of 6179 NSTEMI patients, were examined; 2.44% (n=151) survived EVF and were further analyzed using chi-square test and uni- and multivariate analyses. Patients were divided into two age groups below and above the age of 70 years. Survival time was compared with Kaplan-Meier analysis. EVF was an independent risk factor for mortality in NSTEMI patients below (HR: 2.4) and above the age of 70 (HR: 2.1). Mortality rates between the two age groups of NSTEMI patients with EVF did not differ significantly: 30-day mortality was 24% vs 40% (p=0.2709) and 1-year mortality was 39% vs 55% (p=0.2085). Additional mortality after 30 days to 1 year was 15% vs 14.6% (p=0.9728). Clinical characteristics of patients with EVF differed significantly from those without in both age groups. EVF after revascularization—within 48 h—had 11.2 OR for 30-day mortality above the age of 70. EVF in NSTEMI was an independent risk factor for mortality in both age groups. Invasive management and revascularization of NSTEMI patients with EVF is highly recommended. Closer follow-up and selection of patients (independent of age) for ICD implantation in the critical first month is essential.

Normal reference values of left ventricular strain parameters in healthy adults: Real-life experience from the single-center three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

INTRODUCTION

A number of studies defined normal reference values of three-dimensional (3D) speckle-tracking echocardiography (3DSTE)-derived left ventricular (LV) strains. The present study aimed to quantify normal reference values of LV strains in healthy adult population in real clinical world settings in different age groups, and to determine age- and gender-dependence of these variables in a high volume single center.

METHODS

The present prospective study included 296 healthy adult subjects. Among them, 124 were excluded due to inferior image quality during the 6-year recruitment period (2011-2017). The remaining population was further divided into four subgroups based on age decades.

RESULTS

While global radial (RS) strain showed an increase-decrease-increase pattern with age, circumferential, longitudinal, and area strains (CS, LS, AS, respectively) were nonsignificantly lower in older ages. Only global LV-LS showed gender-dependency with higher values in females. Although moderately higher RS and 3DS and lower LS, and AS were observed in males, clear gender-dependency could not be detected in different age decades.

CONCLUSIONS

This study provides normal reference values of 3DSTE-derived global, segmental, mean segmental, and regional LV strains in healthy adult subjects based on real-life clinical experience. Age-, gender-, and functional nonuniformity of LV strains were also defined.

Normal reference values of left ventricular volumetric parameters in healthy adults-real-life single-center experience from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Background

The left ventricle (LV) is the pump of the peripheral circulation, therefore its non-invasive accurate volumetric and functional assessment is essential. Three-dimensional (3D) speckle-tracking echocardiography (STE) is a new tool with capability of quantification of LV volumes and ejection fraction (EF). In the present study, age- and gender-dependency of 3DSTE-derived LV volumetric parameters were aimed to be quantified in healthy adults.

Methods

The present study involved 298 healthy adults. Data acquisition took place over a 6 year period (2011-2017), during which 123 adults had to be excluded due to inferior image quality. The study population was further divided into 4 groups based on age decades. In every case, a complete two-dimensional echocardiography was performed followed by 3DSTE examination.

Results

No significant differences were detected between the different age groups regarding 3D end-diastolic volume (EDV) and 3D end-systolic volume (ESV) and their body surface area (BSA)-indexed counterpart. 3DEF differed significantly between the 30-39-year-old males and 40-49-year-old males (P=0.04). Between the youngest and oldest patient group, only 3D left ventricular mass (LVM) was significantly different (P=0.02). The 18-29-year-old females had a significantly different 3DLVM (P<0.001) compared to that of the 50+ year-old females. Between the 40-49-year-old and 50+ year-old females 3DLVM (P=0.02) and BSA-indexed 3DLVM (P=0.05) proved to be significantly different.

Conclusions

3DSTE seems to be a reasonably viable tool for the quantification of LV volumetric parameters.

Left ventricular rotational abnormalities in adult patients with corrected tetralogy of Fallot following different surgical procedures (Results from the CSONGRAD Registry and MAGYAR-Path Study)

Background

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease (CHD). Abnormal aortic dimensions and elasticity parameters have been long described for corrected TOF (cTOF) together with left ventricular (LV) rotational abnormalities, but results are conflicting. The present study focuses on investigating LV rotational mechanics in cTOF, and possible correlation of these parameters with aortic elasticity. It was also aimed to be examined whether different surgical strategies have any effect on these results.

Methods

The study involved 26 adult cTOF patients, from which 14 had palliative surgery first and a late total correction (pcTOF), while early total correction was the treatment of choice in 12 patients (etrTOF). Their results were compared to those of 37 age- and gender-matched healthy adults. Routine transthoracic two-dimensional Doppler echocardiography extended with assessment of aortic elastic properties and three-dimensional speckle-tracking echocardiography (3DSTE) was performed in all cTOF patients and controls.

Results

Sixteen out of 26 cTOF patients showed normally directed LV rotational mechanics, while apical or basal LV rotations were in the same clockwise or counterclockwise directions in 7 and 3 cTOF cases, respectively (LV 'rigid body rotation', RBR). Significantly reduced LV apical rotation and twist could be demonstrated in all cTOF patients with preserved LV basal rotation regardless of previous procedure. pcTOF patients showed significantly reduced LV apical rotation as compared to that of etrTOF cases. Significant correlations could be demonstrated between LV apical rotation and aortic stiffness index (r=-0.55, P=0.03) and aortic distensibility (r=0.52, P=0.04).

Conclusions

Significant LV rotational abnormalities could be demonstrated in cTOF with the high prevalence of LV-RBR. pcTOF patients showed significantly reduced LV apical rotation as compared to that of etrTOF cases. Unexpected abnormal physiologic response of LV rotational mechanics to increased aortic stiffness can be detected in cTOF patients without LV-RBR.

Left ventricular strains correlate with aortic elastic properties in adult patients with corrected tetralogy of Fallot (Results from the CSONGRAD Registry and MAGYAR-Path Study)

Background

Aortopathy is a common phenomenon in tetralogy of Fallot (TOF). The current study was designed to detect left ventricular (LV) deformation abnormalities and its relation to aortic stiffness in corrected TOF (cTOF) using the novel three-dimensional (3D) speckle-tracking echocardiography (3DSTE). Detailed comparative analysis between patients with early palliation-late correction (pcTOF) and early total reconstruction (etrTOF) was also performed.

Methods

The present study consisted of 28 cTOF patients (35.0±15.7 years, 11 males) from which 15 and 13 proved to be pcTOF and etrTOF, respectively. Their clinical parameters were compared to those of 39 matched healthy adults (35.5±6.0 years, 16 males).

Results

cTOF patients showed significantly lower global LV longitudinal, circumferential and area strains as compared to controls. In etrTOF patients, global LV 3D strain was higher than in controls. In pcTOF patients, all LV strains proved to be significantly lower as compared to those of etrTOF patients and controls. In all cTOF patients, several moderate correlations could be detected between LV strain parameters and aortic elastic properties.

Conclusions

Significant LV deformational abnormalities could be demonstrated in cTOF patients. etrTOF patients have beneficial LV strain parameters as compared to those of pcTOF patients. LV strains show correlations with aortic elastic properties.

Provision of medical health care for adults with congenital heart disease associated with aortic involvement

Background

All patients with congenital heart disease (CHD) are chronically ill from their cardiac disease. Despite the increasing evidence that aortic alterations are becoming relevant, the importance of aortopathy in CHD has long been underestimated. This study was conducted to determine the health status of patients and/or the provision of health services of adults with CHD (ACHD) with manifest aortopathy or at risk thereof.

Methods

In a questionnaire-based cross-sectional survey, the "real life"-care of ACHD was analysed, comparing patients with risk of developing aortopathy and/or manifest aortopathy.

Results

Of the 563 enrolled ACHD (49.6% female, mean age 35.8±12.1, 18-86 years) 56.8% (n=320) had a risk of developing aortopathy and/or manifest aortopathy. Of the 320 patients at risk, 187 (33.2% of the total number) had a proven aortopathy. Within this subgroup, the basic medical care for CHD-independent medical problems was given by primary medical care providers [family doctors/general practitioners (GP) in 89.4% (n=286), internists in 13.4% (n=43), physicians of another specialty in 2.5% (n=8)]. Almost all primary medical care providers knew about the CHD of their patients. Even for CHD-specific health problems, the basic medical care of risk patients was provided by a family doctor or GP in 56.6% (n=181) and by an internist in 18.4% (n=59). 30.0% (n=96) primarily consulted another specialist, including cardiologists. Only 32.8% of ACHD at risk had ever been referred to a CHD specialist by a GP for cardiac problems related to their CHD. In contrast, the need for advice was high for ACHD with aortopathy and related mainly to physical activity, employment and education, pregnancy, rehabilitation or health and life insurance. Only 35.5% of patients at risk indicated that their information on specific care structures for ACHD was sufficient, and a further 38.1% of patients were aware of patient organizations.

Conclusions

Even today, aortic involvement in ACHD is an often-overlooked condition, although considerable negative effects on morbidity and mortality exist. As aortopathy gains in importance with increasing age and complexity of CHD, almost all affected ACHD need lifelong medical advice and access to modern, scientifically based care concepts. According to the study-results, primary care providers and also patients are mostly insufficiently informed about the specialized ACHD facilities. The future goal is therefore to create a better awareness of CHD problems among both primary care physicians and the patients concerned.

Correlations between left ventricular rotational mechanics and parasympathetic autonomic function-results from the three-dimensional speckle-tracking echocardiographic MAGYAR-Healthy Study

Left ventricular (LV) twist is calculated from the net difference of counterclockwise apical and clockwise basal rotation during systole. The current study was designed to evaluate correlations between autonomic function and LV rotational mechanics in healthy subjects. The present study comprised 18 healthy subjects (mean age: 36±12 years, 12 men). Three-dimensional speckle tracking echocardiography (3DSTE) could be used for non-invasive evaluation of LV rotation and twist. Autonomic function was assessed by means of 5 standard cardiovascular reflex tests. During 3DSTE, basal LV rotation proved to be -3.24±2.02 degree, while apical LV rotation was 9.08±3.04 degree, therefore LV twist was 11.70±6.80 degree. Valsalva test showed significant correlations with LV basal (r=0.529, P=0.019) and apical rotations (r=-0.534, P=0.022), and LV twist (r=-0.467, P=0.044). Heart rate response to deep breathing significantly correlated with LV twist, as well (r=-0.452, P=0.052). The other tests had no any relationship with rotational characteristics. Correlations exist between parasympathetic autonomic function and 3DSTE-derived LV rotation and twist in healthy subjects.

Normal reference values of three-dimensional speckle-tracking echocardiography-derived mitral annular dimensions and functional properties in healthy adults: Insights from the MAGYAR-Healthy Study

INTRODUCTION

There is a limited number of echocardiographic studies determining mitral annular (MA) dimensions in healthy subjects. The present study aimed to establish normal reference values of three-dimensional speckle-tracking echocardiography-derived MA dimensions and functional properties in healthy adults in relation with age and gender.

METHODS

The present study comprised 298 healthy adult subjects. From this population, 94 subjects were excluded due to inadequate image quality. Therefore the remaining group consisted of 204 subjects with the mean age of 33.88 ± 12.97 years (107 males). The population sample was further divided into age categories: 18-29 years (n = 105; mean age: 24.11 ± 2.98 years, 51 males), 30-39 years (n = 44; mean age: 33.80 ± 2.39 years, 31 males), 40-49 years (n = 19; mean age: 43.47 ± 3.18 years, 11 males) and ≥50 years of age (n = 36, mean age: 57.42 ± 6.11 years, 14 males).

RESULTS

End-diastolic MA dimensions did not change significantly during the decades. End-systolic MA diameter, area, and perimeter were larger over the age of 50 years than in the 18-29 year-old group. MA fractional area change was found smaller over the age of 50 years than in 18-29-year-old group. While end-diastolic MA variables did not show gender-differences, end-systolic MA area and perimeter were lower in females in the 18-29-year-old group.

CONCLUSIONS

End-systolic MA dimensions change over decades, resulting in a special pattern of MA functional properties with significant reduction over the age of 50 years.

Mitral annulus is dilated with preserved function in acromegaly regardless of its activity: Insights from the three-dimensional speckle-tracking echocardiographic MAGYAR-Path Study

INTRODUCTION AND OBJECTIVE

Acromegaly is a rare, chronic and slowly developing endocrine disorder caused by hypersecretion of human growth hormone and consequently of insulin-like growth factor-1 during adulthood. The present study was conducted to assess mitral annular (MA) size and function between acromegalic patients and age- and gender-matched healthy controls by three-dimensional speckle-tracking echocardiography (3D-STE). It also aimed to examine whether activity of the disease has any effect on MA parameters.

METHODS

This study included 27 patients with acromegaly, three of whom were excluded due to inferior image quality. The mean age of the remaining 24 patients was 55.7±14.0 years and seven were male. Complete two-dimensional Doppler echocardiography and 3D-STE were performed in all cases.

RESULTS

Significantly increased end-diastolic and end-systolic MA diameter (2.81±0.36 cm vs. 2.44±0.34 cm and 2.00±0.32 cm vs. 1.65±0.37 cm, respectively), area (9.67±2.33 cm² vs. 7.38±1.93 cm² and 5.14±1.62 cm² vs. 3.74±1.19 cm², respectively) and perimeter (11.76±1.42 cm vs. 10.27±1.33 cm and 8.61±1.23 cm vs. 7.36±1.10 cm, respectively) were demonstrated in acromegalic patients compared with control subjects. MA functional parameters were not significantly altered compared to those of healthy individuals.

CONCLUSIONS

MA dilation could be seen in acromegaly regardless of its activity. Acromegaly is not associated with MA functional impairment.

Correlations between left atrial volumes and strains in healthy adults - a three-dimensional speckle-tracking echocardiographic study

Funding Acknowledgements

Type of funding sources: None.

Introduction. Left atrium (LA) is a dynamic structure, which can be characterized by several volumetric and functional properties. Not only volumetric changes could be detected during cardiac cycle, but contractility of its walls have also special quantitative properties. Three-dimensional (3D) speckle-tracking echocardiography (3DSTE) is a new imaging technique with capability of featuring changes in both LA volume and function by several parameters based on a virtual 3D LA model respecting cardiac cycle at the same time. This ability of 3DSTE makes an opportunity to examine correlations between LA volumes and contractility features. Due to the limited number of studies assessing these physiologic relationships, the present study aimed to test correlations between LA volumes, volume-based functional properties and strains respecting cardiac cycle in healthy adults by 3DSTE. 

Methods. The present study comprised 217 healthy adult volunteers (mean age: 33.4 ± 12.7 years, 112 males) without any symptoms, known diseases or other states, which could affect results. None of them received any medication at the time of examination. Complete two-dimensional (2D) Doppler echocardiography and 3DSTE have been performed in all cases. 

Results. LA stroke volumes increased with maximum LA volume (Vmax) in reservoir, conduit and booster pump phases of LA function. LA emptying fraction (EF) remained unchanged in LA reservoir phase (total atrial EF, TAEF) with the increase in Vmax (TAEF at Vmax &lt; 30 ml = 51.9 ± 13.7% vs. TAEF at Vmax &gt; 50 ml = 50.9 ± 10.9%, p = ns). Significant reduction in LA-EF could be detected in LA conduit phase (passive atrial EF, PAEF), if Vmax proved to be larger than 50 ml (PAEF at Vmax &lt; 30 ml = 34.0 ± 13.2% vs. PAEF at Vmax &gt; 50 ml = 27.5 ± 12.6%, p &lt; 0.05). In booster pump function LA-EF (active atrial EF, AAEF)  did not show significant alterations with the increase of Vmax (AAEF at Vmax &lt; 30 ml = 26.9 ± 14.7% vs. PAEF at Vmax &gt; 50 ml = 31.7 ± 11.7%, p = ns). Global peak LA radial strain (RS) (at Vmax &lt; 30 ml = -11.7 ± 8.9% vs. at 30 ml ≤ Vmax ≤ 50 ml = -15.4 ± 7.7% and at Vmax &gt; 50 ml = -14.7 ± 6.8%, p &lt;0.05 and p &lt; 0.05, respectively) and 3D strain (3DS) (at Vmax &lt; 30 ml = -5.5 ± 5.7% vs. at 30 ml ≤ Vmax ≤ 50 ml = -7.5 ± 5.6% and at Vmax &gt; 50 ml = -8.0 ± 5.0%, p &lt; 0.05 and p &lt; 0.05, respectively) increased with Vmax only until a point. LA-RS and LA-3DS at atrial contraction similarly increased with Vmax. The other strain parameters did not show any changes.

Conclusions. LA-RS and LA-3DS, objective features of LA contractility do not increase beyond a point in parallel with an increase in maximum LA volume in healthy subjects.

Left ventricular rotational mechanics in elite athletes with high dynamic component of their training - a three-dimensional speckle-tracking echocardiographic study

Funding Acknowledgements

Type of funding sources: None.

Introduction. In normal circumstances left ventricular (LV) apex and base rotate different directions during cardiac cycle, while LV apex rotates counterclocwise, LV base has a clockwise movement at the same time. This sort of towel-wringing-like movement is called LV twist. Three-dimensional speckle-tracking echocardiography (3DSTE) is a new, promising, easy-to-perform and reproducible modality for the evaluation of LV apical and basal rotations. Although cardiac adaptation is a known feature seen in highly trained athletes, there are conflicting results according to sport activity-related changes in LV rotational mechanics. The present study was designed to test whether differences in LV rotational mechanics could be detected in elite athletes with high dynamic, but different grade of static components of their training by 3DSTE.

Methods. The subjects group comprised 80 elite sportmen, which group of athletes was further divided according to the task force classification of the American College of Cardiology considering dynamic and static components of their training. The following groups were created regarding to their physical activity: Group C1 (high dynamic/low static)(n = 13, mean age: 24.0 ± 5.1 years, Group C2 (high dynamic/moderate static)(n = 23, mean age: 24.6 ± 7.7 years) and Group C3 (high dynamic/high static)(n = 34, mean age: 22.8 ± 6.0 years). Their results were compared to 67 age- and gender-matched non-athletic healthy controls (mean age: 24.0 ± 5.1 years, 33 men). 3DSTE was used for the evaluation of LV rotational abnormalities.

Results. Increased LV end-diastolic and end-systolic volumes could be detected in Groups C2 and C3 subjects as compared to controls. No changes in LV volumes and rotational mechanics could be detected in Group C1 cases. Reduced LV basal rotation was seen in Group C2 and C3 subjects compared to that of controls (-3.17 ± 2.81 degree and -2.88 ± 1.88 degree vs. -4.31 ± 1.82 degree, p &lt; 0.05 and p &lt; 0.05, respectively). It was accompanied with LV twist reduction in Groups C2 and C3 subjects compared to that of controls (11.3 ± 4.3 degree and 11.5 ± 4.1 degree vs. 14.0 ± 3.4 degree, p &lt; 0.05 and p &lt; 0.05, respectively). None of elite athletes showed absence of LV twist called as LV ‘rigid body rotation’ (LV-RBR).

Conclusions. Significant LV basal rotation and twist reduction could be detected in elite athletes with high dynamic and moderate/high static components of their training.