Myocardial work impairment in children with Wolff-Parkinson-White syndrome

Background

Wolf-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardium deformation during systole. According to guidelines, when the left ventricle (LV) dysfunction is present catheter ablation of the accessory pathway may be required, even in asymptomatic patients.

Purpose

The study aimed to assess the diagnostic value of non-invasive myocardial work in predicting subtle myocardial abnormalities in children with WPW.

Methods

Eighty pediatric patients (age 7.91±3.2 years) were included in the study: 20 cases with manifest WPW and 60 age- and sex-matched controls (CTR). Global myocardial work index (MWI) was measured as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated. In addition, standard echocardiographic parameters of LV function were evaluated.

Results

Patients characteristics are summarized in the table. Despite normal LV EF and GLS, children with WPW had worse MWI (WPW 1292.90±307.67 mmHg% vs CTR 1658.73±241.74 mmHg%, p=0.0000005), MCW (WPW 1844.15±267.96 mmHg% vs CTR 2104.90±237.85 mmHg%, p=0.00009), MWW (WPW 101.5 [85–148.25] mmHg% vs CTR 72 [54.75–109.25] mmHg%, p=0.004) and GWE (WPW 94 [91.75–95] mmHg% vs 96 [95–97] mmHg%, p=0.00012) (table). In the WPW group, MWE (r=−0.6, p=0.009) and MWW (r=0.6, p=0.01) was found to correlate with a prolonged QRS (figure).

A multiple regression model was generated to identify the relation between abnormal myocardial work indices (worst interquartile range as dependent variable) and several independent variables. QRS was the best independent predictor of impaired myocardial work. In particular, a QRS>110 msec showed an 86% sensibility and 85% specificity for abnormal MWE (AUC of 0.85), and a 75% sensibility and 83% specificity for abnormal MWW (AUC of 0.83) (figure).

Conclusion

In children with WPW, myocardial work indices were found significantly reduced, even in presence of normal LV EF and GLS. Prolonged QRS independently predicted myocardial impairment. In pediatric patients with WPW, myocardial work may represent a sensitive measure of LV dysfunction and help in the decision-making.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 vaccination in adults with congenital heart disease: results of 1-year prospective study

Background

Adults with congenital heart disease (ACHD) are a vulnerable population. Routine vaccination is the only strategy to prevent a life-threatening infection. However, concerns on the cardiac safety and efficacy of COVID-19 vaccines have been raised.

Aim

To assess safety and efficacy of available COVID-19 vaccines in ACHD patients.

Methods

Data on COVID-19 infection and vaccines including booster doses and any suspected or confirmed adverse events were prospectively collected for all ACHD patients attending our tertiary centre from the beginning of the vaccination campaign (March 2021). A group of 75 healthy volunteers, matched per age and sex, was included for comparison. Antispike IgG titre was routinely obtained at the ACHD clinic. Patients' attitude towards COVID-19 was explored with a questionnaire.

Results

As of February 2022, 498 ACHD patients (36.7±16 years, 54% male,69% with moderate-complex defects, 48% with advanced physiological stage) were enrolled. Four hundred and sixty-one (92%) were fully vaccinated: the type of vaccine was Pfizer-BioNTech for 399 (86%) patients, Moderna for 20 (4%) and AstraZeneca for 26 (6%), 9 received a mixed vaccine regimen (2%). Forty-two (9%) had a history of previous COVID-19 infection and therefore received only one dose. Two-hundred and sixty-nine (58%) patients received a booster dose. Adverse events were mainly mild and transient. One patient complaining of chest pain following administration of mRNA-based vaccination was diagnosed with acute pericarditis, which made full remission after appropriate therapy. Two patients reported a non-specific increment of inflammatory markers. No other severe adverse events were reported. Thirty-seven (7%) refused COVID-19 vaccination being scared of potential cardiac/extra-cardiac adverse events. Among those not-vaccinated, 9 (24%) had a history of previous mild COVID-19 infection. IgG titre was measured in 243 patients at 1915 [835–5934] BAU/ml, which was significantly higher compared to controls (1196 [827–2048] BAU/ml, p=0.002). Three ACHD patients contracted COVID-19 infection after the first dose, while 65 (14%) fully vaccinated patients tested positive for COVID-19, all with mild to moderate symptoms. COVID-19 symptoms duration was significantly longer in case of infection before vaccination (10 [2.7–15] vs 3 [1.2–7], p=0.03). One Fontan patient was tested positive for COVID-19 twice, before and after COVID-19 vaccination, requiring hospitalization in both cases. Four hundred and seven patients completed the questionnaire: 128 (31%) declared to be scared of potential cardiac effects of the vaccine and that the discussion with the ACHD cardiologist was crucial to decide to undergo COVID-19 vaccination.

Conclusions

Our data provide real-world evidence on COVID-19 vaccines safety and efficacy in ACHD patients. Patients' education from the ACHD team may play a key role in vaccine acceptance in this vulnerable population.

Funding Acknowledgement

Type of funding sources: None.

Effects of sacubitril/valsartan in patients with a systemic right ventricle

Background

Sacubitril/valsartan has been proved to reduce mortality in heart failure and reduced ejection fraction (EF) and is currently recommended as first-line therapy. However, effects in patients with a systemic right ventricle (sRV) have not been systematically investigated yet.

Purpose

We aimed to assess safety and efficacy of sacubitril/valsartan in patients with a sRV

Methods

From September 2020 to April 2021, all patients with congenitally corrected transposition of the great arteries (TGA) or TGA after Senning/Mustard repair attending our tertiary centre were prospectively enrolled. Inclusion criteria were: age ≥18 years, 3-months of optimal medical therapy including ACEi/ARB and sRV EF≤40%. Patients with univentricular physiology, systolic blood pressure (SBP) <90 mmHg, glomerular filtration rate (GFR) <30 ml/min or K >5.5 mEq/L were excluded. SBP and blood samples were obtained at 1-month of treatment. Other clinical and echocardiographic variables were reassessed at 6 and 12-month follow-up and the medication was progressively up-titrated to the highest tolerated dose.

Results

Fifty-one patients (38±11 years, 60% male, 34% ccTGA) were included. Up to March 2022, 48 (92%) patients were reviewed after 6 months of therapy and 35 (68%) completed the first year of follow-up. Baseline patients' characteristics are summarized in Table 1. At 1 month, treatment did not impact on the serum potassium values (4.5±0.3 vs 4.4±0.3 mEq/L, p=0.9) and GFR (112±33 vs 112±31 ml/min, p=0.3), while SBP dropped significantly (119±13 vs 108±18 mmHg, p=0.003). Two patients ceased the treatment due to symptomatic hypotension during the first month. One patient developed a nephrotic syndrome at 4 months of follow-up, which was likely unrelated to the treatment. No other major adverse events were reported. One patient was lost to follow-up after 3 months. Despite no significant change in the NYHA class (p=0.9), the 6-minute walking distance increased significantly at 6-month (Table 2). Nt pro BNP values were significantly decreased at 6-month, and returned to baseline at 12-month. Improved sRV systolic function was demonstrated at 6 and 12-month by significant increase in fractional area change, RV global longitudinal strain and sRV EF measured with 3D echocardiography.

Conclusions

Our mid-term results showed that sacubitril/valsartan is well tolerated in patients with a sRV and leads to signficant improvement of sRV systolic function, supporting its use in this complex population.

Funding Acknowledgement

Type of funding sources: None.

P156 TRANSCATHETER CLOSURE OF ATRIAL SEPTAL DEFECT IN OVER 60 YEARS OLD PATIENTS

Background

Ostium secundum ASD (ASDII) is the most common type of congenital heart disease in adults. Percutaneous closure has emerged as the first–line treatment for the majority of ASDII. However, the occurrence of Pulmonary Hypertension (PH) with combined pre– and post–capillary component may render ASD management challenging in elderly patients.

Methods

We report the hemodynamic data and clinical findings of elderly patients (> 60 years old) undergoing transcatheter closure of an ASDII at our department.

Results

From 2000 to 2021, 82 elderly patients were scheduled (mean age 65,4+ 4,4) of which 60 (73%) were female. Systemic arterial hypertension and supraventricular arrhythmias were the most common comorbidities accounting respectively 51% and 38% of cases. The right ventricular overload supported the ASD closure in 76 cases (93%) and paradoxical embolism in the remaining 6 (7%). 17 patients (21%) were in NYHA class III– IV. At right heart catheterization, 33 patients had normal pulmonary arterial pressure and 49 patients showed a mean pulmonary artery pressure > 20 mmhg. In the latter cohort, 33 showed a pulmonary artery wedge pressure (PAWP) < 15 mmHg (Group I) and 16 > 15 mmHg (Group II). The device implantation was completed in all patients except one with elevated pulmonary vascular resistance (PVR) of the Group I. For 14 patients of Group II, balloon occlusion test was required during the catheterization. ASD closure was achieved promptly in 10 patients. However, to reduce the risk of acute pulmonary oedema, in one case we created a small fenestration in the occluder device and in other case we retained the patency of additional defect (both patients exhibiting slightly PAWP increase during balloon occlusion test). In one patient showing significantly PAWP increase during balloon test, delayed ASD closure was performed ensuring the improvement of hemodynamic parameters at 3 months initiation of medical therapy with angiotensin–converting enzyme inhibitor and loop diuretic diuretics. For the remaining 4 patients, the percutaneous closure was not been done because of prohibitive hemodynamic parameters. Overall, ASD closure was performed successfully in 94% of cases.

Conclusions

Age and comorbidities are not absolute contraindications to ASDII percutaneous closure. In the complex cases, both medical therapies and balloon occlusion test may be use to support the decision–making process.

C84 PERCUTANEOUS TREATMENT OF INTERATRIAL MULTIFENESTRATE ANEURYSM IN PAEDIATRIC POPULATION: INFLUENCE OF THE LAYOUT DURING MID–TERM AND LONG–TERM FOLLOW–UP

Background

Multifenestrate aneurysms of interatrial septum (ISA) are a challenge in paediatric age, not only for the complex anathomy, but also for small body surface and small dimensions of cardiac chambers of the patients, that may limit the use of large and multiple devices. Aim of the study: to evaluate the efficacy of percutaneous closure of multifenestrate aneurysms during mid–term and long–term follow–up; to evaluate if the morphological characteristics of interatrial septum may influence the success of the procedure.

Materials and Methods

We retrospectively analyzed 63 patients (mean–age 9,12±3,12 years) undergone to cardiac catheterism from 2000 to 2021, for percutaneous closure of interatrial aneurysm in our division of Cardiology, subdivided into 3 groups on the basis of side and morphological characteristics of the interatrial aneurysm: Group I (2 o more defects DIA>5 mm); Group II (one defect >5 mm and more than one further fenestrations); Group III (multiple fenestrations).

Results

Percutaneous closure was efficacy in 60 patients (95%), while in 3 patients (5%) surgery closure was necessary. In half of the treated patients (30) we used 2 devices. Complications occurred in 4 patients (6%). Only in 2 patients occurred major complications (Atrio–Ventricular Block that needed PMK implantation and partial displacement of device, treated by removal and percutaneous replanting). Residual shunts, not emodynamically significant appear in the immediate post–operative period in 26% and during the follow–up in 18%. The group I was associated with greater risk of failure of the procedure (P < 0.01) and need of implantations of more than one devices (P < 0.01).

Conclusions

Percutaneous closure of multifenestrate aneurysm of interatrial septum in paediatric age are effective and shows low incidence of failure and complications. If is present residual shunt is not significant. The anathomy of interatrial septum influences procedural outcome.

Blood flow vortices adapt their behaviour to the presence of kent accessory pathway

Funding Acknowledgements

Type of funding sources: None.

Background

Blood speckle imaging (BSI) is a new speckle-tracking-based technique for the evaluation of blood flow. Ventricular flow vortices have been studied in sinus rhythm in normal and dysfunctional hearts, however, data are lacking in patients with Kent accessory pathway (KAP) and short atrio-ventricular (AV) conduction.

Purpose

We aimed to evaluate the characteristics of left ventricle blood vortices in children with KAP.

Methods

Nineteen paediatric patients (age 7 ± 2.9 years) were included in the study: 13 patients with manifest KAP (KAP group) and 6 age and sex -matched controls with normal AV conduction (CTR group). A thorough echocardiographic evaluation with 2D, color doppler and BSI was performed in all the included patients. BSI was recorded in apical 3-chamber view with a 6S-D probe. Vortices characteristic were analysed during filling phase of the left ventricle. We focused on the anterior vortex generated by mitral valve, which persisted longer during the cardiac cycle and is assumed to contribute to optimizing cardiac function. A standard 12-lead ECG was also recorded for each child in KAP group to esteem KAP localization.

Results

According to Arruda criteria for KAP localization, all patients in KAP group manifested the accessory pathway in the septal region. All patients in CTR group presented one major anterior vortex during filling phase, while in KAP group 10 patients out of 13 (p= 0.009) lacked of this main anterior vortex, showing instead fragmented different vortices. There were no differences in term of left ventricle function (KAPg 59.8 ± 4.02% vs CTRg 59.0 ± 2.5%, p= 0.6) and global longitudinal strain (KAPg -18.6 ± 1.0% vs CTRg -19.6 ± 3.1%, p= 0.5) between the two groups.

Conclusion

In our preliminary analysis, in patients with septal KAP, blood vortices adapted their diastolic traces to the septal dyssynchrony showing a fragmented pattern. We speculate this fragmentation may contribute to impair the performance of the left ventricle. Abstract Figure. BSI in control vs patient with WPW

Myocardial work indices and ventricular dyssynchrony in adults with aortic coarctation

Funding Acknowledgements

Type of funding sources: None.

Background

Adults with coarctation of the aorta (CoA) may present residual aortic obstruction and develop arterial vasculopathy and subclinical left ventricular (LV) dysfunction. Myocardial work (MW) is a novel non-invasive index of myocardial efficiency calculated from echocardiographic LV pressure-strain loops, which yields incremental information over ejection fraction and global longitudinal strain. (GLS)

Purpose

Aim of the present study is to analyze LVMW in a cohort of adult patients with operated aortic CoA

Methods

CoA patients aged > 18 years who underwent transthoracic echocardiography between September 2020 and July 2021 at our tertiary centre were included. Exclusion criteria were significant recoarctation, impaired LVEF, significant valvular disease and suboptimal image quality. A group of healthy individuals with no cardiac abnormalities. GLS and peak strain dispersion(PSD) were measured. MW indices were calculated using the blood pressure measured in the right arm at the time of the exam.

Results

Sixty patients (26[22-33]years, 66%male) were included. Data on previous medical history, clinical status at last assessment and Coa-related echocardiographic findings are showed in table 1. No significant differences in traditional parameters of LV systolic and diastolic function were found between groups (EF 60[57-64] vs 57[53-61],p = 0.6), however Coa patients had higher LVmass (84[75-97] vs 68[56-75]g). GLS and MW indices in the study population and in the control group  are reported in table 2. Coa group showed lower GLS values and higher PSD (p < 0.0001 for both). Global work index(GWI) and global constructive work(GCW) values were not significantly different between groups, whereas CoA group showed significant increase of global wasted work(GWW) and impaired global work efficiency(GWE,p = 0.003 and 0.0005 respectively). Spearman’s linear method illustrated that both GCW and GWI had a moderate positive relation with mean gradient across the descending aorta at continuous wave Doppler. PSD was positively related to GWW and inversely related to GWE(Figure 1). Using linear regression model with the log of GWE values as dependent variable,PSD,age(β:-0.002,p = 0.03) and LVmass(β:-0.06,p = 0.004)were related to GWE. However, only PSD retained a significant relation on multivariable analysis(β:-0.002,p > 0.0001).

Conclusion

MW indices assessment is feasible in Coa patients may provide a more comprehensive understanding of the overall myocardial mechanics and performance. In particular, MW demonstrated impaired LV efficiency, which was strongly related to increased mechanical dispersion in Coa patients. Abstract Figure.  Abstract Figure.

Impaired myocardial work in paediatric patients with wolff-parkinson-white syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Wolff-Parkinson-White Syndrome (WPW) has been associated with reduced local myocardium deformation during systole. Left ventricle (LV) dysfunction due to electrical dyssynchrony may require catheter ablation of the accessory pathway, even in asymptomatic patients.

Purpose

The study aimed to assess the diagnostic value of non-invasive myocardial work in predicting subtle myocardial abnormalities in patients with WPW.

Methods

Forty-four paediatric patients (age 8.2 ± 4.3 years) were included in the study: 12 cases with manifest WPW and 32 age-, sex- and arterial pressure- matched controls (CTR). LV ejection fraction (EF) and global longitudinal strain (GLS) were evaluated. Global myocardial work index (MWI) was measured as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated.

Results

Despite normal LV systolic function by standard echocardiographic parameters, patients with WPW had lower MWI (1233.5 ± 281.6 mmHg% in WPW vs 1624.0 ± 305.8 mmHg% in CTR, p = 0.0004), MCW (1833.4 ± 257.9 mmHg% in WPW vs 2069.0 ± 319.9 mmHg% in CTR, p= 0.03), MWW (187.6 ± 117.7 mmHg% in WPW vs 90.9 ± 58.9 mmHg% in CTR, p= 0.0008) and GWE (90.5 ± 4.8% in WPW vs 95.2 ± 2.2% in CTR, p= 0.00006). There were no significant differences in GLS and EF between patients with WPW and controls.

Conclusion

Myocardial work indices were found significantly reduced in patients with WPW, even in presence of normal LV EF and GLS. In patients with WPW, MWI may represent a sensitive measure of myocardial dysfunction and help in the decision-making for catheter ablation. Abstract Figure. Myocardial work in WPW  Abstract Figure. Myocardial work in control patient

The adding value of fluid challenge and balloon occlusion tests in patients with atrial septal defect

Background

Careful, step-wise assessment is required in all patients with an atrial septal defect (ASD) to exclude pre-existing pulmonary vascular disease or left ventricular disease. Fluid challenge test (FCT) and balloon occlusion testing (BOT) may unmask left ventricular disease and challenge the pulmonary circulation, but their complementary role in the evaluation of patients with “operable” ASD is not well established.

Aim

To evaluate the haemodynamic changes of the pulmonary circulation by FCT and BOT in ASD patients undergoing percutaneous closure according to the current guidelines.

Methods

Consecutive patients selected for percutaneous ASD closure underwent invasive hemodynamic assessment at baseline and after BOT, FCT and both.

Results

Fifty patients (mean age 47.3±11.7 years, 72% female) were included. All patients had a pulmonary-to-systemic flow ratio (QP/QS) ≥1.5, pulmonary vascular resistance (PVR) <5 WU and pulmonary arterial wedge pressure (PAWP) <15 mmHg. Individuals with a PVR ≥2 WU at baseline were older, more symptomatic, with a higher baseline systemic vascular resistance compared to the lower PVR group (PVR <2 WU; p<0.0001). The response of Qp/Qs to FCT was different between groups (p<0.0001, Figure 1). Patients with a lower baseline PVR experienced an increase in Qp/Qs, which remained above 1.5 in all patients, whereas in almost all (90%) patients with a higher baseline PVR, the Qp/Qs fell to below 1.5.

FCT caused a marked increase in pulmonary blood flow of almost 2 liters (p<0.0001) accompanied by increases in PAWP (p<0.0001). BOT led to a modest increase in PAWP (Δ1.5 [−1.0–7.0] mmHg, p<0.0001). FCT added to BOT caused a further increase in PAWP and Qs (both p<0.0001), while PVR was unchanged (p>0.1).

No difference was observed in the PAWP response to FCT, BOT or both between groups; no patients reached a PAWP ≥18 mmHg following FCT or BOT alone, but 4 (8%) patients did following the addition of FCT to BOT. No acute clinical adverse events were experienced by any patients.

Conclusions

None of the reported ASD patients presented with FCT criteria of post-capillary PH (that is a PAWP >18 mmHg). Even small rises in PVR may have significant implications on cardiovascular haemodynamics. In fact, patients with PVR <2 WU showed an increase in Qp/Qs, which remained above 1.5 in all patients, suggesting that they still had a distensible pulmonary circulation, whereas in almost all patients with a PVR ≥2 WU, the Qp/Qs fell to below 1.5.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Effects of sacubitril/valsartan in patients with a systemic right ventricle: early evidence of exercise tolerance and systolic function improvement

Background

Sacubitril/valsartan has been shown to reduce mortality and morbidity inpatients with heart failure and reduced systolic function. However, the effects of this novel association in patients with congenital heart disease and a systemic right ventricle (sRV) have not been investigated yet.

Purpose

We aimed to assess tolerability and efficacy of sacubitril/valsartan in patients with a sRV

Methods

From September 2020 to March 2021, 38 patients with congenitally corrected transposition of the great arteries or transposition of the great arteries after Senning or Mustard repair were prospectively enrolled. Inclusion criteria were: age ≥18 years, optimal medical therapy including ACEi/ARB for at least 6 months and EF of the sRV ≤40%. Patients with univentricular physiology, systolic blood pressure (SBP) <90mmHg, glomerular filtration rate (GFR) <30ml/min or K >5.5mEq/L were excluded. RV systolic function was assessed on echocardiography using a multiparametric evaluation. The study protocol contemplates serial assessments at 1, 3, 6 and 12 months after treatment initiation.

Results

Up to March 31th, 23 patients completed 1-month and 15 completed 3-month assessment after treatment initiation. Baseline patients' characteristics are summarized in table 1. The medication dose was up-titrated to the highest tolerated dose during follow-up. During early follow-up, no major adverse events were reported. Treatment did not impact significantly on the values of serum potassium (basal K+ 4.4 [4.2–4.6] mEq/L, K+ at 3 months 4.4 [4.3–4.6] mEq/L, p=0.7) and GFR (basal GFR 113.9±35ml/min, GFR at 3 months 107.8±21 ml/min, p=0.7). Although SBP did not change significantly (114±12 vs 113.9±19 mmHg at 1-month and 117.3±12 mmHg at 3 months; p=0.9 for both), 2 (5%) patients ceased the treatment due to symptomatic hypotension during the first month of treatment. There was no significant change in the NYHA class. However, the 6-minute walking distance increased significantly after 3 months (365±120 vs 498.3±71 min; p=0.01). Furthermore, while traditional echocardiographic parameters of RV systolic function (TAPSE, s wave and FAC) did not change significantly, RV global longitudinal strain (GLS) and RV free wall GLS demonstrated subclinical improvement in right ventricular systolic function (table 2).

Conclusions

Our short-term results from an ongoing prospective study showed that sacubitril/valsartan is well tolerated in patients with a sRV with early evidence of improvement in exercise tolerance and sRV systolic function. Longer follow-up is warranted to confirm these data.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

Prognostic relevance of thyroid disease in adults with congenital heart disease

Background

Adults with congenital heart disease (ACHD) are frequently affected by thyroid diseases (TD). However, the clinical relevance of TD in ACHD remains unknown.

Purpose

We aimed to describe the prevalence of TD in the ACHD population and to ascertain whether TD are associated with worse outcome.

Methods

Clinical data on all consecutive patients aged >18 years attending our ACHD unit for a day-case between 2014 and 2019 were retrospectively collected. For statistical analysis, a composite endpoint was created combining the following events at follow-up: hospitalization for heart failure, new-onset tachyarrhythmic or bradyarrhythmic events and death.

Results

Four hundred ninety-five ACHD patients with a median age of 32.2 [24.5–45.6] years (46% male) were included. There was an overall prevalence of patients with moderate or complex lesions (414=84%). Compared to the group with no history of TD, patients in the TD were older, (41.9 [29.7–53.5] vs 30.2 [24.3–39] years; p<0.0001) and mainly female (77% vs 46%; p<0.0001) and more likely to have undergone at least two cardiac catheterization procedures (29 vs 13%; p<0.0001). Genetic disorders including Down syndrome were more prevalent in the group with TD (p<0.0001). Moreover, at last follow-up, those with TD had higher pro-BNP-nt values (243.5 [96.5–523] pg/ml Vs 94 [45–207] pg/ml; p<0.0001) and were in a more advanced NYHA class (27% vs 13% in class III-IV; p=0.0002). Echocardiography showed lower EF in the TD group (55 [55–60]% vs 60 [55–65]%; p=0.0002).

Median follow-up was 9.4 [4.5–13.1] years. Patients with TD had a higher unadjusted mortality rate, with a trend towards statistical significance (p=0.07). Sixty-four (42%) patients in the TD group and 43 (12.5%) met our composite endpoint, leading to a 10-year survival free from events of 53.7% Vs 86.5%, respectively (p<0.0001, Figure1). Multivariate analysis showed that age, ejection fraction, previous surgical palliation, advanced physiological stage and TD were independent predictors of our composite endpoint, even after stratification for genetic disorders as reported in table1. After adjustment for baseline differences between groups with propensity matching score using age, sex, disease complexity, physiological stage, previous palliative or reparative surgery, normal or reduced systemic ventricle ejection fraction, pulmonary arterial hypertension, cyanosis and presence of systemic right ventricle as independent variables, TD remained a strong predictor of cardiac events at follow-up with an hazard ratio of 4.47 (95% CI 2.42–8.28; p<0.0001).

Conclusion

TD is a strong predictor of adverse outcome in the ACHD population after exclusion of potential confounding factors, being related to a fourfold increased risk of events at follow-up.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Response to fluid challenge in patients with atrial septal defect

Background

A fluid challenge test (FCT) with a rapid infusion of saline allows for discrimination between pre- and post-capillary pulmonary hypertension (PH) and may unmask hidden post-capillary PH. Patients with atrial septal defect (ASD) may develop pre- or post-capillary PH after shunt closure respectively in case of pulmonary vascular disease or left ventricular disease.

Aim

To evaluate the haemodynamic changes of the pulmonary circulation in ASD patients undergoing percutaneous closure with indicated according to the current ESC guidelines.

Methods

Twenty-three patients (mean age 42.9±12.4 years; 15 female) underwent right heart catheterization in basal conditions and after FCT (volume loading with rapid saline infusion of 7 ml/kg in 10 min) before percutaneous closure of the ASD.

Right atrial pressure (RAP), systolic, mean and diastolic pulmonary arterial pressure (sPAP, mPAP and dPAP), pulmonary arterial wedge pressure (PAWP), cardiac output (CO), pulmonary vascular resistance (PVR), systemic vascular resistance (SVR) and the ratio between pulmonary and systemic flow (QP/QS) were calculated four times: before and after inflating the sizing balloon both at baseline and immediately after FCT (Fig. 1).

Results

The patients had an increase in pressures and flows after FCT with open ASD: mPAP (18.7±4.4 vs 16.7±4.6 mmHg, p<0.001), PAWP (11.3±3.1 vs 9.2±3.0 mmHg, p<0.001), QP (12.5±2.3 vs 10.3±2.0 l/min, p<0.001), and QS (6.6±1.4 vs 5.9±1.2 l/min, p<0.001) but RAP remained unchanged (8.7±3.0 vs 8.3±2.4 mmHg, p=0.35). PVR (0.2±0.4 vs 0.8±0.3 Wood Units, p<0.001) and SVR (11.2±3.2 vs 12.5±3.2 Wood Units, p=0.02) decreased, and PVR/SVR (0.06±0.02 vs 0.06±0.3, p=0.25) remained unchanged. QP/QS increased in all patients after FCT (mean±SD: 2.0±0.4 vs 1.8±0.4, p<0.001).

During a temporary ASD closure by sizing balloon, the patients had increases of RAP (9.0±2.6 vs 7.6±2.6 mmHg, p<0.001) mPAP (19.5±4.0 vs 17.4±3.7 mmHg, p<0.001), PAWP (13.2±2.1 vs 11.2±2.9 mmHg, p<0.001), and CO (7.7±2.7 vs 6.8±2.3 l/min, p<0.001) after FCT. PVR remained unchanged (0.9±0.4 vs 1.1±0.6, p=0.12) and SVR reduced (9.8±2.7 vs 11.3±2.9, p<0.001) after FCT.

Conclusions

None of the reported ASD patients presented with FCT criteria of post-capillary PH (that is a PAWP >18 mmHg). The FCT was associated with an increase in QP/QS suggesting that the patients still had a distensible pulmonary circulation. Further studies are needed to explore the relevance of a FCT in ASD patients, particularly those with higher PVR values.

Figure 1

Funding Acknowledgement

Type of funding source: None

1107 An unusual vegetation on a prosthetic pulmonary valve

Conclusion

Differential diagnosis of cardiac vegetations is a challenging process including microbological tests, multi modality imaging and clinical reasoning. It is always necessary to consider alternative diagnosis, even when traditional imaging tests seem to suggest infective endocarditis.

Non infective thrombotic endocarditis are a rare form of negative blood culteres endocarditis related to systemic hypercoagulable state (i.e. antiphospholipid syndrome, systemic lupus, behcet syndrome, cancer). Malignancies can be considered an unusual cause of cardiac vegetation and they must be taken into account on differential diagnosis.

Abstract 1107 Figure. FDG uptake in pulmonary position

P781 Role of serum biomarkers combined with two-dimensional speckle tracking echocardiography for screening of immunotherapy-induced cardiotoxicity

Background

Immune checkpoint inhibitors (ICIs) are a novel class of antineoplastic drugs which have dramatically changed the management of non-small cell lung cancer. ICI-associated cardiotoxicity is rare, but potentially fatal, presenting in most of cases as autoimmune acute myocarditis during the first phase of treatment. However, since an extensive cardiac monitoring is not routinely performed in most immunotherapy trials, the true incidence of ICIs related cardiac effects is largely unknown.

Aim

Aim of our study is to ascertain a possible subclinical cardiac involvement in patients with non-small cell lung cancer treated with ICIs.

Methods

We prospectively recruited 40 patients (13 males; mean age 64.3 ± 8.3 years) starting immunotherapy with PD-1/PDL-1 inhibitors for non-small lung cancer between January and August 2018. Demographic and clinical data were recorded and all patients underwent a standard 12-lead ECG and a transthoracic echocardiogram with assessment of left ventricular global longitudinal strain (LV GLS). Furthermore, blood samples for pro BNP-nt and high sensitivity Troponin T (hsTnT) measurements were collected. Serial assessments were performed before and 1 and 3 months after initiation of immunotherapy.

Results

A history of previous coronary artery disease was documented in eight cases (20%). At follow-up no cardiovascular events were recorded. Compared with baseline, echocardiographic parameters of ventricular function did not significantly changed at 1 and 3 months (LVEF 61 ± 6% at baseline, 61 ± 5% at 1 month, 60,2 ± 5% at 3 months, p =0.1; E/E’at baseline 9.2 ± 3, 9.2 ± 2.8 at 1 month, 9.1 ±3,5 at 3 months, p = 0.2;TAPSE 20 ± 3.4 mm at baseline, 21.3 ± 2.8 mm at 1 month, 20 ± 3.8 mm at 3 months, p =0.1; LV GLS -20.3 ± 3.6% at baseline, -20.8 ± 2.3% at 1 month, -20.6 ± 3% at 3 months; p = 0.4). Analogously, no significant increase in circulating levels of cardiac biomarkers was found with hsTnT <0.015 ng/ml in all patients at baseline, 1 month and 3 months and median proBNP-nt 118 pg/ml (IQR 47-200) at baseline, 171 pg/ml (IQR 91-520) at 1 month, and 182 pg/ml (IQR 78-470) at 3 months, p = 0.9.

Conclusions

In our study no significant clinical or subclinical evidence of myocardial involvement was detected during treatment with ICIs in patients with non-small cell lung cancer, thus suggesting the potential cardiovascular safety of this promising class of antineoplastic drugs.

P4160Safety and efficacy of triple combination therapy with parenteral prostanoids in patients with Eisenmenger physiology

Aim

While combination therapy is currently strongly advocated for idiopathic pulmonary arterial hypertension (PAH) patients, evidence to support its use in patients with PAH related to congenital heart disease (CHD), especially patients with Eisenmenger syndrome, is lacking. We evaluated the efficacy and safety of sequential triple combination therapy with parenteral prostanoids after failure of double oral therapy in patients with PAH-CHD and Eisenmenger physiology.

Methods

This is an international, multicentre, retrospective cohort study conducted in adult patients with Eisenmenger physiology on double oral PAH therapy in whom intravenous or subcutaneous prostanoid treatment was added due to clinical deterioration or failure to reach the treatment goals. Clinical status, 6-minute walk test distance (6MWD), biomarkers and haemodynamics were assessed at baseline and during the follow-up.

Results

A total 28 patients with Eisenmenger syndrome (6 [21%] male, age 37.6±14.3 years) were included. A post-tricuspid shunt was present in 16 (57%), 86% of whom had a ventricular septal defect. The majority (89%) were treated with subcutaneous treprostinil. At 27±14 months follow-up, WHO functional class improved in 18 (64%), remained unchanged in 8 (29%), and deteriorated in 2 (7%) patients. There was also an increase in 6MWD (mean 339±145 versus 233±140m, p=0.0001, fig 1A) and a reduction in NT-proBNP levels (median 1125 [123–5882] versus 3087 [234–7428] pg/mL, p<0.0001, fig 1B). On follow-up cardiac catheterization, an improvement in right atrial pressure (8±2 versus 11±5 mmHg, p=0.01), mean pulmonary artery pressure (68±12 versus 72±17 mmHg, p=0.005), cardiac index (2.3±0.3 versus 2.0±0.5 l/min/m2, p=0.005, fig 1C), and pulmonary vascular resistance (17±7 versus 21±10, p=0.008, fig 1D), was observed compared to baseline. No patients discontinued treatment. Five (18%) patients died during follow up.

Figure 1

Conclusions

Triple combination therapy with subcutaneous treprostinil or endovenous epoprostenol in patients with Eisenmenger syndrome is safe and well tolerated at 2 years follow-up, resulting in a significant improvement in clinical status, exercise tolerance and haemodynamics.

4972Upfront triple combination therapy with ambrisentan, tadalafil and subcutaneous treprostinil in incident patients with severe pulmonary arterial hypertension

Aim

Current treatments strategies for high-risk patients with pulmonary arterial hypertension (PAH) are based on the use of parenteral prostanoids. The evidence to support triple upfront combination therapy remains largely based on expert consensus or small studies. Aim of this study was to evaluate the efficacy and safety of an upfront triple combination therapy with ambrisentan, tadalafil and subcutaneous (sc) treprostinil in patients with severe PAH.

Methods

This is a multi-center retrospective analysis of patients with newly diagnosed severe PAH treated with upfront triple combination therapy with ambrisentan, tadalafil and sc treprostinil between 2014 and 2018. Clinical evaluations, WHO functional class (FC), 6-min walk distance, biomarkers and right heart catheterization were collected from the patients' medical records at baseline and during the follow-up.

Results

Overall, 20 patients (mean age 44±15 years, 15 female) were included.

Over a median follow-up of 12 months, all patients were still alive on triple combination therapy. At baseline 11 patients were in WHO-FC 3 and 9 patients in WHO-FC 4. At follow-up, WHO-FC (2.0±0.5 vs 3.5±0.5, p<0.001, improved in all: 2, 16, and 2 patients in FC 1, 2 and 3, respectively), exercise capacity (431±67 vs 152±130 m, p<0.001), NT-proBNP (423±260 vs 3492±1864 pg/ml; p<0.001), and haemodynamics (right atrial pressure 5±2 vs 13±3 mmHg, p<0.001; mean pulmonary artery pressure 42±5 vs 60±9 mmHg, p<0.001; cardiac index 3.5±0.8 vs 1.8±0.3 l/min/m2, p<0.001; pulmonary vascular resistance 5.5±1.3 vs 16.4±4.4 Wood units, p<0.001; pulmonary arterial compliance 2.5±0.9 vs 0.8±0.3 ml/mmHg, p<0.001) significantly improved compared with baseline. No patient discontinued the therapy due to serious adverse events.

Conclusions

Triple upfront combination therapy with ambrisentan, tadalafil and sc treprostinil is safe and offers clinical and heamodynamics benefits in incident patients with severe PAH.

Efficacy and safety of dabigatran in a "real-life" population at high thromboembolic and hemorrhagic risk: data from MonaldiCare registry

OBJECTIVE

Dabigatran is a novel target specific oral anticoagulant for stroke prevention in non valvular atrial fibrillation. Little is still known about its real-world effectiveness and safety in the italian population. Aim of our study was to evaluate the efficacy and safety of dabigatran in a large single-center cohort of "real-life" italian population with non-valvular AF and to compare the results with those obtained from the RE-LY trial and the Medicare study.

PATIENTS AND METHODS

We studied a prospective cohort of 2108 patients (1119 male; mean age 69.4 ± 9.4 years) who started the oral anticoagulant treatment with dabigatran 110 mg twice-daily (DAB 110; N = 1075; 51%) or 150 mg twice-daily (DAB 150; N = 1033; 49%). Follow-up data were obtained trough outpatients visits each 3-6 months for assessing the clinical status, adherence to treatment, occurrence of side effects and major cardiovascular complications.

RESULTS

In DAB 150 group the mean age was 64.9 ± 8.8 years, 56.8% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 94.3% and HAS-BLED was ≥ 3 in 59.7%. In DAB 110 group (N = 1075) the mean age was 73.9 ± 7.5 years; 49.5% of patients was male. CHA2DS2Vasc Score was ≥ 3 in 73.4% and HAS-BLED was ≥ 3 in 87.4% of DAB 110 patients. One patient taking Dabigatran 110 mg bid had ischemic stroke without significantly neurological sequelae. In both groups, no patient experienced hemorrhagic stroke during the follow-up period. 147 patients (6.9%) of MonaldiCare population reported adverse effects from treatment with dabigatran, of whom 121 patients (5.7%) discontinued therapy. We reported one case of subarachnoid hemorrhage (0.05%) in a patient with high thrombo-embolic and high hemorrhagic risk score who was taking dabigatran 150 mg bid and one case (0.05%) of bladder bleeding in a patient who was taking dabigatran 110 mg bid. No major gastrointestinal bleeding was observed in the MonaldiCare population.

CONCLUSIONS

MonaldiCare registry showed a safety profile of both dosages of dabigatran regarding major of fatal bleeding in a "real life" single center italian population at high thromboembolic and hemorrhagic risk. The majority of MonaldiCare patients tolerated dabigatran treatment without significant side effects. The efficacy of dabigatran was demonstrated by very low prevalence of ictus/TIA, also when patients underwent electrical AF cardioversion independently of the transesophageal examination.

The effect of aortic coarctation surgical repair on QTc and JTc dispersion in severe aortic coarctation newborns: a short-term follow-up study

Sudden death is a possible occurrence for newborns younger than 1 year with severe aortic coarctation (CoA) before surgical correction. In our previous study, we showed a significant increase of QTc-D and JTc-D in newborns with isolated severe aortic coarctation, electrocardiographic parameters that clinical and experimental studies have suggested could reflect the physiological variability of regional and ventricular repolarization and could provide a substrate for life-threatening ventricular arrhythmias. The aim of the current study was to evaluate the effect of surgical repair of CoA on QTc-d, JTc-d in severe aortic coarctation newborns with no associated congenital cardiac malformations. The study included 30 newborns (18M; 70+/-12 h old) affected by severe congenital aortic coarctation, without associated cardiac malformations. All newborns underwent to classic extended end-to-end repair. Echocardiographic and electrocardiographic measurements were performed in each patient 24 h before and 24 h after the interventional procedure and at the end of the follow-up period, 1 month after the surgical correction. All patients at baseline, 24 h and one month after CoA surgical repair did not significantly differ in terms of heart rate, weight, height, and echocardiographic parameters. There were no statistically significant differences in QTc-D (111.7+/-47.4 vs 111.9+/-63.8 ms vs 108.5+/-55.4 ms; P=0.4) and JTc-D (98.1+/-41.3 vs 111.4+/-47.5 vs 105.1+/-33.4 ms; P=0.3) before, 24 h and 1 month after CoA surgical correction. In conclusions, our study did not show a statistically significant decrease in QTc-D and JTc-D, suggesting the hypothesis that the acute left ventricular afterload reduction, related to successful CoA surgical correction, may not reduce the ventricular electrical instability in the short-term follow-up.

Prolonged corrected QT dispersion

The anthracyclines are antibiotics effective in the treatment of many malignancies. However, their usefulness is limited by the development of potentially acute or chronic cardiotoxicity. No definitive guidelines exist for monitoring cardiac function during and after anthracyclines although methods have been suggested. Electrocardiograms and echocardiograms are routinely utilized for noninvasive assessment of myocardial function. The aim of the study was to assess the effects of doxorubicin on ventricular repolarization time indexes, as they have been shown to be effective in the identification of electrical myocardial instability and hence in the identification of the risk for either arrhythmia or heart failure. Electrocardiographic parameters were compared in 27 cancer patients before and after chemotherapy including doxorubicin. The data of the present study show that after only a short period of treatment with doxorubicin there is a significant increase in ventricular recovery time indexes (QTc dispersion and 'Adjusted' QTc dispersion). The relation between the electrophysiological response to doxorubicin and the potential cardiotoxic effect of this drug remains to be established through prospective studies.

Electrophysiologic significance of leftward QRS axis deviation in bifascicular and trifascicular blocks

BACKGROUND

Intraventricular conduction disturbances determine complete impairment of impulse propagation along the right or left bundle branch or the two left fascicles.

HYPOTHESIS

This study was undertaken to investigate the electrophysiologic significance of QRS axis (QRSA) orientation in bifascicular and trifascicular blocks.

METHODS

A group of 76 subjects, 43 with right bundle-branch block (RBBB) and left anterior hemiblock (LAH) (Group A), and 33 with left bundle-branch block (LBBB) (Group B), was submitted to electrophysiologic evaluation.

RESULTS

In Group A, QRSA was inversely related only to intraventricular conduction, while in Group B, QRSA inversely related to infrahisal conduction times. A value of < -60 degrees was considered the cut-off point for determining subjects with a considerable leftward QRSA deviation. Of the 27 Group A patients with a QRSA < -60 degrees, 38.5% developed an infrahisal second-degree atrioventricular (AV) block during incremental atrial stimulation (IAS) in comparison with 11.1% of those with QRSA > -60 degrees. Of the 9 Group B patients with a QRSA < -60 degrees, 44.4% exhibited severe impairment of infrahisal conduction at baseline and 66.6% developed an infrahisal second-degree AV block during IAS, whereas among the remaining 24 with a QRSA > -60 degrees, in only 8.3% were both infrahisal (HV1 and HV2) intervals dangerously prolonged, and 23.8% encountered an infrahisal second-degree AV block during IAS. In Group A, atrioventricular conduction time > 200 ms exhibited a better predictive accuracy than QRSA < -60 degrees for the development of an infrahisal second-degree AV block during IAS, whereas the latter appeared the best noninvasive predictor in Group B with a slightly lesser predictive accuracy than HV > 80 ms.

CONCLUSION

The degree of leftward QRSA deviation seems to reflect the entity of intraventricular conduction delay in patients with RBBB + LAH, while it appears to be directly related to infrahisal conduction prolongation in those with LBBB.

Long term effects of bosentan treatment in adult patients with pulmonary arterial hypertension related to congenital heart disease (Eisenmenger physiology): safety, tolerability, clinical, and haemodynamic effect

BACKGROUND

Oral bosentan is an established treatment for pulmonary arterial hypertension (PAH).

OBJECTIVE

To evaluate safety, tolerability, and clinical and haemodynamic effects of bosentan in patients with PAH related to congenital heart disease (CHD).

PATIENTS

22 patients with CHD related PAH (8 men, 14 women, mean (SD) age 38 (10) years) were treated with oral bosentan (62.5 mg x 2/day for the first 4 weeks and then 125 mg x 2/day).

MAIN OUTCOME MEASURES

Clinical status, liver enzymes, World Health Organisation (WHO) functional class, resting oxygen saturations and 6-min walk test (6MWT) were assessed at baseline and at 1, 3, 6, and 12 months. Haemodynamic evaluation with cardiac catheterisation was performed at baseline and at 12 month follow-up.

RESULTS

12 patients had ventricular septal defect, 5 atrioventricular canal, 4 single ventricle, and 1 atrial septal defect. All patients tolerated bosentan well. No major side effects were seen. After a year of treatment, an improvement was seen in WHO functional class (2.5 (0.7) v 3.1 (0.7); p<0.05), oxygen saturation at rest (87 (6%) v 81 (9); p<0.001), heart rate at rest (81 (10) v 87 (14) bpm; p<0.05), distance travelled in the 6MWT (394 (73) v 320 (108) m; p<0.001), oxygen saturation at the end of the 6MWT (71 (14) v 63 (17%); p<0.05), Borg index (5.3 (1.8) v 6.5 (1.3); p<0.001), pulmonary vascular resistances index (14 (9) v 22 (12) WU m(2); p<0.001), systemic vascular resistances index (23 (11) v 27 (10) WU.m(2); p<0.01), pulmonary vascular resistances index/systemic vascular resistances index (0.6 (0.5) v 0.9 (0.6); p<0.05); pulmonary (4.0 (1.3) v 2.8 (0.9) l/min/m2; p<0.001) and systemic cardiac output (4.2 (1.4) v 3.4 (1.1) l/min/m2; p<0.05).

CONCLUSIONS

Bosentan was safe and well tolerated in adults with CHD related PAH during 12 months of treatment. Clinical status, exercise tolerance, and pulmonary haemodynamics improved considerably.

Prognostic value of intra-left ventricular electromechanical asynchrony in patients with mild hypertrophic cardiomyopathy compared with power athletes

OBJECTIVES

We sought to assess the indexes of myocardial activation delay, using Doppler myocardial imaging (DMI), as potential diagnostic tools and predictors of cardiac events in patients with hypertrophic cardiomyopathy (HCM) compared with power athletes.

BACKGROUND

the distribution and magnitude of left ventricular (LV) hypertrophy are not uniform in patients with HCM, which results in heterogeneity of regional LV systolic function.

METHODS

The study population comprised 70 young patients with HCM (mean (SD) age 29.4 (5.9) years) with mild septal hypertrophy (15-19 mm) and 85 age and sex matched athletes with septal thickness >12 mm, followed up for 44.4 (10.8) months. Using pulsed DMI, myocardial peak velocities, systolic time intervals, and myocardial intraventricular and interventricular systolic delays were measured in six different basal myocardial segments.

RESULTS

DMI analysis showed in HCM lower myocardial both systolic and early diastolic peak velocities of all the segments. Patients with HCM also showed significant interventricular and intraventricular delay (p<0.0001), whereas athletes showed homogeneous systolic activation of the ventricular walls. During the follow up, seven sudden deaths occurred in the HCM group, while no cardiovascular event was observed in the group of athletes. In patients with HCM, intraventricular delay on DMI was the most powerful independent predictor of sudden cardiac death (p<0.0001). An intraventricular delay >45 ms identified with high sensitivity and specificity patients with HCM at higher risk of ventricular tachycardia and cardiac events (test accuracy 90.6%).

CONCLUSIONS

DMI may be a valid supporting tool for the differential diagnosis between HCM and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up. Accordingly, such patients may benefit from early intensive treatment and survey. MINIABSTRACT: Doppler myocardial imaging may represent a valid supporting tool for the differential diagnosis between mild hypertrophic cardiomyopathy (HCM) and "athlete's heart". In patients with HCM, DMI indexes of intraventricular delay may provide additional information for selecting subgroups of patients with HCM at increased risk of ventricular arrhythmias and sudden cardiac death at follow up.

Right ventricular myocardial dysfunction in adult patients late after repair of tetralogy of fallot

AIM OF THE STUDY

To detect in adult patients late after repair of Tetralogy of Fallot (TOF) possible correlation between myocardial parameters assessed at rest by Tissue Doppler (TD) and cardiac performance during physical effort.

METHODS

Doppler echo, treadmill test and pulsed TD of both mitral and tricuspid annulus were performed in 25 healthy subjects and in 40 adult patients who had undergone surgery for TOF at a mean age of 1.4+/-0.5 years. Exclusion criteria were echocardiographic evidence of residual pulmonary, either stenosis or regurgitation. By use of TD, the following parameters were assessed: systolic peak velocities (Sm), pre-contraction time, contraction time, early (E(m)) and late (A(m)) diastolic velocities, E(m)/A(m) ratio, relaxation time. By treadmill test, we measured: maximal heart rate (HR), systolic blood pressure (SBP), rate-pressure product, maximal workload, time duration of the exercise.

RESULTS

the two groups were comparable for left ventricular measurements and for all transmitral and transtricuspid Doppler indexes, while tricuspid ring diameter was increased in TOF. TD analysis showed in TOF lower S(m), E(m) and E(m)/A(m) ratio and prolonged PCT(m) and Rt(m) at tricuspid annulus level, despite comparable TD mitral annulus indexes. By treadmill test, TOF showed reduced time of exercise, number of METS reached and rate-pressure product. Multiple linear regression models evidenced in TOF independent positive association between tricuspid Em velocity and time of exercise (p<0.0001), achieved METS at peak effort (p<0.001) and rate-pressure product (p<0.001). An E(m) peak velocity of tricuspid annulus lower than 0.13 m/s showed 90% sensitivity and 93% specificity in identifying TOF patients unable to perform maximal exercise test.

CONCLUSIONS

despite normal Doppler parameters, adult patients late after correction of TOF showed impaired right ventricular myocardial function. In these patients pulsed TD may be taken into account as a valuable supporting tool to predict the effort response and possibly to assess long-term follow-up of cardiac functional reserve.

Right ventricular myocardial activation delay in adult patients with right bundle branch block late after repair of Tetralogy of Fallot

Electromechanical interaction, with prolonged QRS duration due to right ventricular (RV) overload, has been described as a predictor of unfavorable outcome in patients late after correction of Tetralogy of Fallot (TOF). Aim of our study was to evaluate myocardial function and activation delay of both left and right ventricles in TOF patients. Doppler echo, treadmill test and pulsed Tissue Doppler (TD) were performed in 25 healthy subjects and in 30 adult patients who had undergone surgery for TOF, all with right bundle branch block on ECG. Exclusion criteria were evidence of residual pulmonary either stenosis or regurgitation. By use of TD, the level of both LV mitral and RV tricuspid annulus were measured: systolic (Sm), early- and late-diastolic (Em and Am) regional peak velocities. The indexes of myocardial systolic activation were calculated: precontraction time (PCTm) and interventricular activation delay (InterV-del) (difference of PCTm between RV and LV segments). The two groups were comparable for LV diameters and for Doppler indexes, while QRS duration was prolonged and RV end-diastolic diameter was increased in TOF. By TD analysis, only at the level of tricuspid annulus TOF patients had lower Sm and Em, and increased RV PCTm ( p<0.001 ) and InterV-del ( p<0.0001 ), even after adjustment for heart rate (HR) and QRS duration. By treadmill test, TOF showed reduced cardiac functional reserve. In seven patients non-sustained ventricular tachycardia was documented during physical effort. By multivariate analysis, RV Em ( p<0.001 ), and InterV-del ( p<0.01 ) were independently associated to maximal workload at peak effort. The same InterV-del was an independent determinant of risk of ventricular arrhythmias during effort ( p<0.01 ). A cut-off point of Em peak velocity of tricuspid annulus <0.13 m/s at rest showed a sensitivity of 91% and a specificity of 88% in identifying TOF patients with submaximal exercise test. A cut-off point of InterV-del >55 ms showed 87% sensitivity and 88% specificity to detect increased risk of ventricular arrhythmias during effort. In TOF patients, TD analysis at rest may be taken into account as a non-invasive and easy-repeatable tool to predict cardiac performance during physical effort, and to select subgroups of patients at increased risk of ventricular arrhythmias.

Risk factors for pacemaker implantation following aortic valve replacement: a single centre experience

OBJECTIVE

To identify perioperative clinical predictors of permanent pacemaker implantation following aortic valve replacement.

DESIGN AND PATIENTS

Prospective cohort study on 276 patients submitted for aortic valve replacement: 267 patients (mean (SD) age, 57.5 (14) years) with no conduction disturbances, and nine patients (67.7 (5) years) with severe conduction disturbances requiring permanent pacing; 65 perioperative variables (38 preoperative, eight intraoperative, and 19 postoperative) were considered.

RESULTS

Nine patients (3.2%) had irreversible second or third degree atrioventricular (AV) block requiring permanent pacing. Risk factors for permanent pacing identified by univariate analysis were: preoperative: additional valvar disease, aortic regurgitation, myocardial infarction, pulmonary hypertension, anaemia, use of digitalis; intraoperative: cardiac arrest; postoperative: cardiac arrest, conduction disturbances, electrolytic imbalance, angiotensin converting enzyme inhibitor use. Multivariate logistic regression analysis identified preoperative aortic regurgitation (p < 0.005; odds ratio (OR) 6.6, 95% confidence interval (CI) 1.6 to 12.2), myocardial infarction (p < 0.0005; OR 15.2, 95% CI 6.3 to 19.9), pulmonary hypertension (p < 0.005; OR 12.5, 95% CI 3.2 to 18.3), and postoperative electrolyte imbalance (p < 0.01; OR 4.5, 95% CI 1.3 to 6.4).

CONCLUSIONS

Irreversible AV block requiring permanent pacemaker implantation is an uncommon condition following aortic valve replacement. Previous aortic regurgitation, myocardial infarction, pulmonary hypertension, and postoperative electrolyte imbalance should be considered in order to identify patients at increased risk for advanced AV block.

Usefulness of Doppler tissue imaging for the assessment of right and left ventricular myocardial function in patients with dual-chamber pacing

The aim of the study was to evaluate by Doppler tissue imaging (DTI) the combined effects of atrio-ventricular (AV) delay and heart rate (HR) changes on global and segmental right (RV) and left (LV) ventricular diastolic function in 15 patients with dual-chamber pacemakers paced in the DDD mode. RV and LV inflow velocities and regional systolic and diastolic pulsed-wave (PW) DTI parameters were analyzed at four different pacing modes: (1) HR 70 beats/min, AV delay 125 ms; (2) HR 70 beats/min, AV delay 188 ms; (3) HR 89 beats/min, AV delay 125 ms; (4) HR 89 beats/min, AV delay 188 ms. For each pacing mode selected, RV diastolic filling velocities always prevailed over LV ones. As for RV and LV adaptation to the four different stimulation protocols, a higher paced rate and a prolonged AV delay caused across both the AV valves a decrease of E wave and of E/A ratios. The intersegmental comparison of PW-DTI parameters outlined that RV free wall exhibited significantly higher peak systolic (Sm) and early-diastolic (Em) wall velocities, and longer systolic ejection time. Considering separately RV and LV segmental physiology at the four programmed pacing modes, an increase in HR determined a progressive shortening of systolic ejection times in all the segments analyzed. Moreover, in each region the Em/Am ratio decreased with higher HR and longer AV delay. Conversely, Em encountered a progressive reduction in RV free wall, while remaining quite unchanged in all the LV regions. Both ventricles shared a similar pattern of global and regional adaptation to programmed HR and AV delay modifications, consisting in a progressive greater contribution of late diastole to ventricular filling at higher HR and more prolonged AV delay. However, at a regional level the right ventricle exhibited higher systolic and diastolic wall velocities than all left ventricular regions.

Left ventricular outflow tract obstruction in the transposition of great arteries defined by transthoracic three-dimensional echocardiography

We assessed the feasibility of transthoracic three-dimensional reconstruction of the pulmonary valve and subpulmonary left ventricular outflow tract in two patients with transposition of great arteries, ventricular septal defect, and obstruction to the left ventricular outflow tract. Three-dimensional reconstruction of the pulmonary valve could be displayed as "en face" through a three-dimensional generated "pulmotomy view," allowing an overview of the pulmonary aspect of the valve from a surgeon's perspective. In similar fashion, reconstruction of the subpulmonary outflow tract could be displayed along its longitudinal axis as seen through a left ventriculotomy. Unique views could be obtained equivalent to surgical or autopsy dissections, allowing more complete understanding of the morphology and severity of left-sided obstructive lesions.

Risk predictors of paroxysmal atrial fibrillation following aortic valve replacement

BACKGROUND

Atrial fibrillation (AF) is the most frequently encountered arrhythmic complication associated with cardiac surgery. The aim of this paper was to identify the clinical predictors of AF occurrence following aortic valve replacement.

METHODS

Three hundred and two patients were included in this study and divided into two groups according to the absence (SR group, 243 patients, mean age 55.6 +/- 15 years) or the evidence (AF group, 59 patients, mean age 63.8 +/- 11 years) of post-aortic valve replacement AF. Sixty-five perioperative variables (37 preoperative, 8 intraoperative and 20 postoperative) were considered.

RESULTS

Post-aortic valve replacement paroxysmal AF occurred in 59 out of 302 patients (19%). At univariate analysis, post-aortic valve replacement AF was associated with advanced age, left atrial enlargement, preoperative episodes of paroxysmal AF, the use of a warm blood cardioplegic solution and normothermia, administration of inotropic agents, prolonged assisted ventilation but also with postoperative acidosis, electrolyte imbalance and atrioventricular and intraventricular conduction disorders. Stepwise forward multivariate logistic regression analysis identified age (p = 0.002, odds ratio--OR 1.04), left atrial enlargement (p = 0.004, OR 2.6), a prior history of paroxysmal AF (p = 0.0003, OR 10.9), and postoperative electrolyte imbalance (p = 0.01, OR 2.3) as independent correlates of AF, whereas the use of hypothermia appeared to be a protective factor (p = 0.0004, OR 0.26).

CONCLUSIONS

According to our findings, post-aortic valve replacement AF seems to be associated with well-defined anatomical and electrical substrates generated by advanced age, increased left atrial dimensions, and a possible electrical remodeling consequent to prior repetitive episodes of paroxysmal AF. On these grounds, external factors such as postoperative electrolyte imbalance might enhance atrial ectopic activity and trigger postoperative sustained tachyarrhythmias, while the use of hypothermia might allow for better protection of the atrial myocardium against intraoperative ischemia.

Left ventricular remodeling and mechanics after successful repair of aortic coarctation

Forty normotensive patients (mean age 12.3 +/- 6.5 years) followed up after a successful repair of aortic coarctation (mean age at coarctectomy 5.1 +/- 4.8 yrs) were studied by echo-Doppler to (1) evaluate left ventricular (LV) remodeling and endocardial and midwall mechanics, and (2) identify factors that might predispose to persistent abnormalities. Sex- and age-specific cutoff levels for LV mass/height2.7 and relative wall thickness were defined to assess LV geometry. To adjust for age-and growth-related changes in ventricular mechanics, all echocardiographic variables were expressed as a Z-score relative to the normal distribution. In addition, the smallest diameter of the aorta was assessed by magnetic resonance imaging and calculated as percent narrowing compared with the diameter of the aorta at the diaphragmatic level. In the study group, 24 of 40 patients (60%) had normal LV geometry. Among the 16 patients (40%) with abnormal LV geometry, 5 (12.5%) had a pattern of concentric remodeling and 11 (27.5%) an eccentric hypertrophy. LV hypertrophy was marked (LV mass index >51 g/m2.7) in 5 of these patients. No patient had a pattern of concentric hypertrophy. LV contractility was increased (Z-score >95th percentile) in 28 patients (70%) as assessed using the endocardial stress-velocity index. In contrast, LV contractility assessed using midwall stress-velocity index remained elevated (Z-score >95th percentile) in 15 patients (37.5%). The stepwise multiple logistic regression analysis was not able to detect any significant independent predictor of abnormal LV remodeling, including sex, age at surgical repair, length of postoperative follow-up, heart rate, body mass index, systolic and diastolic blood pressure, and smallest diameter of the aorta, as well as indexes of LV geometry (shape, mass, volume, mass/ volume ratio) and function (preload, afterload, pump function, and myocardial contractility). Thus, normotensive patients after surgical repair of aortic coarctation may be in an LV hyperdynamic cardiovascular state (more frequent in those who have undergone late repair) and have multiple patterns of LV geometry.

Atrial and ventricular electromechanical function in 1-ventricle hearts: influence of atrial flutter and Fontan procedure

OBJECTIVE

Echocardiography was used to study electromechanical atrial and ventricular function in adult patients with a 1-ventricle heart who were in sinus rhythm to better understand the recurrence of atrial flutter in these conditions. Patients who had recent atrial flutter, with and without the Fontan procedure, were compared with those who had no arrhythmia.

METHODS

This was a prospective study that used M-mode and 2-dimensional Doppler echocardiography and electrocardiography. Conventional measurements were used to evaluate ventricular long-axis function. Basic data were drawn from case notes. The setting was a designated quaternary service for grown-up congenital heart patients (GUCH) in a tertiary referral center for cardiology and cardiac surgery. From January 1997 to February 1998, 26 consecutive adult patients (aged >16 years) with a heart with one functioning ventricle and a history of atrial flutter were studied: group 1, with non-Fontan palliative surgery or no surgery (10 patients), and group 2, with Fontan-type repair (16 patients). Also studied were 20 patients with a 1-ventricle heart but no history of atrial flutter. These 20 patients were divided into 2 groups: control 1, which comprised 14 patients with previous shunts or no surgery, and control 2, which consisted of 6 patients with Fontan repair.

RESULTS

P-wave duration on the electrocardiogram was similar in the 4 patient groups, but the amplitude was reduced in group 2 and control 2 (patients with Fontan surgery) (P <.016). Bifid P wave was seen in 5 (50%) of 10 patients in group 1 and in 6 (43%) of 14 patients in control 1, but it was not seen in patients with Fontan (P <.01). Ventricular systolic and diastolic dimensions and fractional shortening were not different between patients and controls. Right atrial transverse dimensions were greater in group 2 patients compared with those in controls. Significant atrioventricular valve regurgitation was seen in 9 of 10 group 1 patients but in none of the others. Right-sided total long-axis excursion and atrial A-wave amplitude were depressed in group 2 patients compared with the values in the others. The onset of right atrial shortening was delayed by 50 ms in group 2 compared with control 2, whereas the left atrial shortening was delayed by 30 ms in group 1 compared with control 1. This particular disturbance remained 6 months after cardioversion.

CONCLUSION

In 1-ventricle hearts, significant atrioventricular valve regurgitation is commonly associated with atrial flutter in patients who did not undergo the Fontan procedure, and with electromechanical disturbances in those who did. Recognition of disturbances in ventricular long-axis function may thus assist in the identification of patients with a 1-ventricle heart who are prone to atrial flutter.