Impact of dapagliflozin on cardiac remodelling in patients with chronic heart failure: The DAPA-MODA study

AIMS

Dapagliflozin improves the prognosis of patients with heart failure (HF), regardless of left ventricular ejection fraction (LVEF). However, its effect on cardiac remodelling parameters, specifically left atrial (LA) remodelling, is not well established.

METHODS AND RESULTS

The DAPA-MODA trial (NCT04707352) is a multicentre, single-arm, open-label, prospective and interventional study that aimed to evaluate the effect of dapagliflozin on cardiac remodelling parameters over 6 months. Patients with stable chronic HF receiving optimized guideline-directed therapy, except for any sodium-glucose cotransporter 2 inhibitor, were included. Echocardiography was performed at baseline, 30 and 180 days, and analysed by a central core-lab in a blinded manner to both patient and time. The primary endpoint was the change in maximal LA volume index (LAVI). A total of 162 patients (64.2% men, 70.5 ± 10.6 years, 52% LVEF >40%) were included in the study. At baseline, LA dilatation was observed (LAVI 48.1 ± 22.6 ml/m2 ) and LA parameters were similar between LVEF-based phenotypes (≤40% vs. >40%). LAVI showed a significant reduction at 180 days (-6.6% [95% confidence interval -11.1, -1.8], p = 0.008), primarily due to a decrease in reservoir volume (-13.8% [95% confidence interval -22.5, -4], p = 0.007). Left ventricular geometry improved with significant reductions in left ventricular mass index (-13.9% [95% confidence interval -18.7, -8.7], p < 0.001), end-diastolic volume (-8.0% [95% confidence interval -11.6, -4.2], p < 0.001) and end-systolic volume (-11.9% [95% confidence interval -16.7, -6.8], p < 0.001) at 180 days. N-terminal pro-B-type natriuretic peptide (NT-proBNP) showed a significant reduction at 180 days (-18.2% [95% confidence interval -27.1, -8.2], p < 0.001), without changes in filling Doppler measures.

CONCLUSION

Dapagliflozin administration in stable out-setting patients with chronic HF and optimized therapy results in global reverse remodelling of cardiac structure, including reductions in LA volumes and improvement in left ventricular geometry and NT-proBNP concentrations.

Pregnancy-related aortic complications in women with bicuspid aortic valve

OBJECTIVES

To describe the aortic-related risks associated with pregnancy in women with bicuspid aortic valve (BAV) and to evaluate changes in aortic diameter in pregnancy.

METHODS

Prospective observational study of patients with BAV from a single-site registry of pregnant women with structural heart disease between 2013 and 2020. Cardiac, obstetric and neonatal outcomes were studied. An assessment of aortic dimensions was performed during pregnancy by two-dimensional echocardiography. Aortic diameters were measured at the annulus, root, sinotubular junction and maximum ascending aorta diameter, and the largest diameter was used. Measurements of the aorta were made using the end-diastolic leading edge-to-leading edge convention.

RESULTS

Forty-three women (32.9 years, IQR 29.6-35.3) with BAV were included: 9 (20.9%) had repaired aortic coarctation; 23 (53.5%) had moderate or severe aortic valve disease; 5 (11.6%) had a bioprosthetic aortic valve; and 2 (4.7%) had a mechanical prosthetic aortic valve. Twenty (47.0%) were nulliparous. The mean aortic diameter in the first trimester was 38.5 (SD 4.9) mm, and that in the third trimester was 38.4 (SD 4.8) mm. Forty (93.0%) women had an aortic diameter of <45 mm; 3 (7.0%) had 45-50 mm; and none had >50 mm. Three women (6.9%) with BAV presented cardiovascular complications during pregnancy or the postpartum period (two prosthetic thrombosis and one heart failure). No aortic complications were reported. There was a small but significant increase in aortic diameter during pregnancy (third trimester vs first trimester, 0.52 (SD 1.08) mm; p=0.03). Obstetric complications appeared in seven (16.3%) of pregnancies, and there were no maternal deaths. Vaginal non-instrumental delivery was performed in 21 (51.2%) out of 41 cases. There were no neonatal deaths, and the mean newborn weight was 3130 g (95% CI 2652 to 3380).

CONCLUSIONS

Pregnancy in BAV women had a low rate of cardiac complications with no aortic complications observed in a small study group. Neither aortic dissection nor need for aortic surgery was reported. A low but significant aortic growth was observed during pregnancy. Although requiring follow-up, the risk of aortic complications in pregnant women with BAV and aortic diameters of <45 mm at baseline is low.

Influence of initial clinical suspicion on the diagnostic yield of laboratory enzymatic testing in lysosomal storage disorders. Experience from a multispecialty hospital

Lysosomal storage disorders (LSD) are a group of inherited metabolic diseases mainly caused by a deficiency of lysosomal hydrolases, resulting in a gradual accumulation of non-degraded substrates in different tissues causing the characteristic clinical manifestations of such disorders. Confirmatory tests of suspected LSD individuals include enzymatic and genetic testing. A well-oriented clinical suspicion can improve the cost-effectiveness of confirmatory tests and reduce the time expended to achieve the diagnosis. Thus, this work aims to retrospectively study the influence of clinical orientation on the diagnostic yield of enzymatic tests in LSD by retrieving clinical, biochemical, and genetic data obtained from subjects with suspicion of LSD. Our results suggest that the clinical manifestations at the time of diagnosis and the initial clinical suspicion can have a great impact on the diagnostic yield of enzymatic tests, and that clinical orientation performed in specialized clinical departments can contribute to improve it. In addition, the analysis of enzymatic tests as the first step in the diagnostic algorithm can correctly guide subsequent confirmatory genetic tests, in turn increasing their diagnostic yield. In summary, our results suggest that initial clinical suspicion plays a crucial role on the diagnostic yield of confirmatory enzymatic tests in LSD.

Prognostic value of cardiac magnetic resonance in elderly patients soon after ST-segment elevation myocardial infarction

Background

Elderly patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce.

Purpose

We aim to study the prognostic value of an early (1-week) CMR in elderly patients after STEMI and to create a simple risk score including clinical and CMR variables.

Methods

The registry comprised 247 patients over 70 years of age discharged for a first STEMI treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

Results

During a 4.8-year mean follow-up, 66 (26.7%) first major adverse cardiac events (MACE) occurred (27 all-cause deaths and 39 re-admissions for acute heart failure). Higher GRACE score (HR 1.03 [1.02–1.04], p&lt;0.001), more depressed CMR-LVEF (HR 0.97 [0.95–0.99] per increased %, p=0.006) and more extensive MVO (HR 1.24 [1.09–1.4] per segment, p=0.001) predicted MACE occurrence. The addition of CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694–0.824] vs. 0.685 [0.613–0.756], NRI=0.6, IDI=0.08, p&lt;0.001). The best cut-offs for independent variables were GRACE score &gt;155, LVEF &lt;40%, and MVO ≥2 segments. A simple score (0, 1, 2, and 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (p&lt;0.001).

Conclusions

CMR data contribute valuable prognostic information in elderly patients submitted to undergo CMR soon after STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Sex-based differences on adverse left ventricular remodeling and clinical outcomes after an ST-segment elevation myocardial infarction in the PCI era

Background

There is conflicting evidence regarding sex-based differences in myocardial salvage and clinical outcome in patients after an ST-segment elevation myocardial infarction (STEMI) in the contemporary era of primary percutaneous coronary intervention (PCI) and optimal medical treatment.

Adverse left ventricular remodelling (LVR) after a STEMI worsens outcomes, however, the influence of sex is not yet clear.

Aim/Purpose

To analyze whether there are sex differences in clinical outcomes and adverse LVR in patients after a STEMI.

Methods

Patients with STEMI who underwent primary PCI were included and a cardiac magnetic resonance (CMR) was performed during hospitalization (6.2±2.6 days) and after 6 months (6.1±1.8 months). LVR, myocardial salvage (MS), infarct size (IS), microvascular obstruction (MVO), and area at risk (AAR) were quantified. Adverse LVR was defined as a 15% increase in LV end-diastolic volume and a relative fall in LV ejection fraction of 3% at 6 months. The primary outcome was a composite of cardiovascular death, admission for heart failure, or ventricular arrhythmia.

Results

A total of 1046 patients were included (mean age: 59.8±9 years; 16.6% women), and a second CMR was completed in 589 patients. Women were older (58.8±8 years vs 65.0±10 years, p&lt;0.0001) and presented more cardiovascular risk factors (Table). The primary outcome occurred in 310 patients during follow-up of 75 months (range: 36–112 months) and was more frequent in women than in men (35.8% vs 22.3%, p&lt;0.001). After adjusting for baseline differences (age, diabetes, hypertension, Killip class, and time to reperfusion), female sex was not an independent predictor of major adverse cardiac events (Fig. 1A & B).

Although adverse LVR was a strong independent predictor for the primary outcome, no interaction was present between sex and LVR (women 6.4% vs men 8%, p=0.46) (Fig 1B), nor did we find significant differences between sex and other CMR derived variables such as MS, IS, MVO and AAR.

Conclusions

After a STEMI, women present worse clinical outcomes than men. However, these differences are related to their clinical characteristics and higher incidence of cardiovascular risk factors, and not to a higher incidence of adverse left ventricular remodeling.

Funding Acknowledgement

Type of funding sources: None.

A novel clinical and cardiac magnetic resonance risk score for early risk prediction after ST-segment elevation myocardial infarction

Background

Cardiac magnetic resonance (CMR) performed early after ST-segment elevation myocardial infarction (STEMI) can improve major adverse cardiac event (MACE) risk prediction. However, predictive models including clinical and CMR variables are scarce and not routinely implemented in clinical practice.

Purpose

We aimed to create a simple clinical-CMR risk score for early MACE risk stratification in STEMI patients.

Methods

We performed a multicenter prospective registry in three Spanish university hospitals of reperfused STEMI patients (n=1118) in whom early (1-week) CMR-derived left ventricular ejection fraction (LVEF), infarct size and microvascular obstruction (MVO) were quantified. MACE was defined as a combined clinical endpoint of cardiovascular (CV) death, non-fatal myocardial infarction (NF-MI) or re-admission for acute decompensated heart failure (HF), whichever occurred first. Univariate and multivariate analyses were performed and a risk score was computed using the variables which independently predicted the risk of MACE.

Results

During a median follow-up of 5.52 [2.63–7.44] years, 216 first MACE (58 CV deaths, 71 NF-MI and 87 HF) were registered. Mean age was 59.3±12.3 years and most patients (82.8%) were male. Based on the four variables independently associated with MACE, we computed an 8-point risk score: time to reperfusion &gt;4.15h (1 point), GRACE risk score &gt;155 (3 points), CMR-LVEF &lt;40% (3 points), and MVO &gt;1.5 segments (1 point). This score permitted MACE risk stratification: MACE per 100 person-years was 1.96 in the low-risk category (0–2 points), 5.44 in the intermediate-risk category (3–5 points), and 19.7 in the high-risk category (6–8 points): p&lt;0.001 in multivariable Cox survival analysis.

Conclusions

A novel risk score including clinical (time to reperfusion &gt;4.15h and GRACE risk score &gt;155) and CMR (LVEF &lt;40% and MVO &gt;1.5 segments) variables allows for simple and straightforward MACE risk stratification early after STEMI. External validation should confirm the applicability of the risk score.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) and Sociedad Española de Cardiología.

Impact of persistent MVO late after STEMI on adverse left ventricular remodelling: a CMR study

Background

Despite successful revascularization at the epicardial level, microvascular obstruction (MVO) appears soon after reperfusion in up to 50% of cases. Early MVO has been solidly associated with adverse resulting cardiac structure and heightened risk of future cardiovascular events. Although clinical and experimental studies demostrated the spontaneous repair of MVO, little is known about the occurrence and implications of persistent MVO late after infarction.

Purpose

We used cardiovascular magnetic resonance (CMR) to characterize the impact of persistent MVO late after reperfused ST-segment elevation myocardial infarction (STEMI) on adverse left ventricular (LV) remodelling (ALVR).

Methods

A prospective registry of 471 STEMI patients underwent CMR 7 [5–10] and 198 [167–231] days post infarction, and MVO (&gt;1 segment) and ALVR (relative increase &gt;15% at follow-up CMR) of LV end-diastolic (LVEDVI) and end-systolic volume indices (LVESVI) were determined.

Results

One-week MVO occurred in 209 patients (44%) and persisted in 30 of these (6%). Most patients with persistent MVO (22/30, 73%) displayed extensive (&gt;2.5% of LV mass) MVO at 1 week. Compared with patients without MVO (n=262, 56%) or with MVO only at 1 week (n=179, 38%), those with persistent MVO at follow-up (n=30, 6%) showed higher rates of ALVR-LVEDVI (22%, 27%, 50% p=0.003) and ALVR-LVESVI (20%, 21%, 53% p&lt;0.001). After adjustment, the extent (% of LV mass) of MVO at follow-up was independently associated with ΔLVEDVI (relative increase, %) (p=0.01) and ΔLVESVI (p=0.03). Compared to a 1:1 matched population of 30 patients with MVO only at 1 week, patients with persistent MVO more frequently displayed ALVR-LVEDVI (12% vs. 50%, p=0.003) and ALVR-LVESVI (12% vs. 53%, p=0.001).

Conclusion

MVO persists in a small percentage of patients in chronic phase after STEMI and exerts deleterious effects in terms of LV remodelling. These findings fuel the need for further research on microvascular injury repair.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” [grant numbers PI20/00637, PI15/00531, FI18/00320, and CIBERCV16/11/00486] and by Conselleria de Educaciόn – Generalitat Valenciana (PROMETEO/2021/008).

Aortic flow patterns by 4D flow CMR in Marfan and Loeys-Dietz patients before and after valve sparing aortic root replacement: a comparison with healthy volunteers

Introduction

Abnormal aortic flow patterns in patients with a connective tissue disorder (CTD), such as Marfan or Loeys-Dietz syndrome, may contribute to aortic root dilation [1,2]. Valve sparing aortic root replacement, which is effective in reducing the risk of aortic dissection in case of severe dilation, may also normalize flow patterns beyond the replaced aorta and potentially slow its progressive aortic dilation.

Purpose

To assess aortic flow dynamics in patients with a CTD by 4D flow cardiovascular magnetic resonance (CMR) before and after valve sparing aortic root replacement, and to compare the results with those of healthy volunteers (HV).

Methods

Patients with Marfan or Loeys-Dietz syndrome underwent two non-contrast enhanced 4D flow CMR, one before and another after undergoing valve sparing aortic root replacement. Healthy volunteers matched for age, sex and BSA were also included for comparison. Maximum velocity, in-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) and wall shear stress (WSS) magnitude and its axial and circumferential components were obtained at 24 planes covering the thoracic aorta from the sinotubular junction to the descending aorta at the diaphragmatic level [3–5].

Results

Sixteen patients and 21 healthy volunteers were included. Demographic and clinical data is presented in Table. The mean time between the CMR prior and posterior to surgery was 15 months. Compared to HV, patients with CTD before intervention presented lower maximum velocity at the proximal ascending aorta (Fig. 1A), lower IRF and circumferential WSS at the arch and the proximal descending aorta (Fig. 1B and F), lower magnitude and axial WSS at the proximal ascending and descending aorta (Fig. 1E and D), and increased SFRR at the proximal descending aorta (Fig. 1C). The intervention completely restored maximum velocity and partially-restored physiological helical flow and circumferential WSS, but barely improved axial WSS and SFRR.

Conclusion

Valve sparing aortic root replacement in patients with Marfan or Loeys-Dietz syndrome partially restore to physiological level both in-plane rotational flow and circumferential wall shear stress in the descending aorta. This flow normalization may contribute to prevent progressive dilation after the surgery.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III (Spain) (PI17/00381)Spanish Society of Cardiology (SEC/FEC-INV-CLI 20/015)

Cardiac magnetic resonance predictors of readmission for heart failure in elderly vs not elderly patients after ST-segment elevation myocardial infarction

Background

Patients with ST-segment elevation acute myocardial infarction (STEMI) have an increased risk of re-admission for acute heart failure (AHF). However, identification of patients at higher risk of AHF is challenging, especially in elderly individuals. The implications of cardiac magnetic resonance (CMR) imaging soon after the acute event for this specific purpose are unknown.

Purpose

We aim to study the clinical and CMR predictors of AHF in elderly and not elderly patients after STEMI.

Methods

STEMI patients treated with percutaneous coronary intervention and discharged from three university hospitals were included in a multicenter registry. We registered baseline clinical characteristics, echocardiographic parameters and early (1-week) CMR parameters - left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments). Univariate and multivariate comparisons were performed in elderly (&gt;70 years) and not elderly (≤70 years) patients to predict AHF during follow-up.

Results

The cohort was comprised of 759 patients, of which 177 (23.3%) were elderly (&gt;70 years). During a mean follow-up of 5.23±3.54 years, 79 (10.4%) patients presented AHF. In not elderly patients, Killip class at admission (HR 2.05 [1.32–3.17], p=0.001), anterior infarction (HR 3.43 [1.13–10.36], p=0.03) and CMR-LVEF (HR 0.94 [0.91–0.98] per increased %, p=0.001) independently predicted AHF. However, a combined risk score comprising these variables was not superior to CMR-LVEF alone to predict AHF during follow-up (AUC 0.81 [0.74–0.88] vs. 0.81 [0.73–0.88], p=NS). In elderly patients, CMR-LVEF was the only predictor of AHF in the final multivariable model (HR 0.94 [0.91–0.97], p&lt;0.001), although its predictive power was moderate (AUC 0.68 [0.56–0.80], p=0.001). Most AHF events in the not elderly subgroup occurred in patients with reduced (≤40%) CMR-LVEF (71%), while in the elderly subgroup AHF occurred more frequently in patients with preserved (≥50%, 30%) or mildly reduced (40–49%, 32%) CMR-LVEF than reduced (≤40%) CMR-LVEF (38%).

Conclusions

LVEF quantified by CMR soon after STEMI can accurately predict the risk of AHF in not elderly (≤70 years) patients and identify those individuals at higher risk (i.e. CMR-LVEF ≤40%). However, in elderly (&gt;70 years) patients most AHF occur in patients with CMR-LVEF &gt;40%, emphasizing the need for better predictive strategies in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Mapping of thoracic aorta growth rate on serial self-navigated 3D whole-heart magnetic resonance angiographies by image registration

Introduction

Accurate and reproducible assessment of aortic diameters and their growth rate is of key importance for the management of patients with thoracic aortic aneurysms [1,2]. It has been recently shown that image registration permits the assessment of progressive aortic dilation on ECG-gated contrast-enhanced CT angiography, outperforming manual quantification and allowing for 3D aortic size and growth mapping [3]. However, exposure to radiation makes it convenient to limit the use of CT for serial follow-up, especially in young patients. Self-navigated 3D whole-heart CMR acquisitions provides excellent image quality overcoming these limitations [4].

Purpose

To evaluate the accuracy and reproducibility of registration-based assessment of aortic dilation using self-navigated 3D whole-heart CMR acquisitions.

Methods

Fifteen patients with two self-navigated 3D whole-heart CMR images obtained at least 1 year apart were included. Aortic root and thoracic aorta diameters were measured by 2 independent observers both manually (multiplanar reconstruction) and with the registration-based technique. To perform registration-based assessment, the aorta was semi-automatically segmented and typical anatomical landmarks were placed by each observer at baseline [3]. Geometrical mapping between baseline and follow-up acquisitions was obtained using deformable image registration, and applied to the baseline aortic surface points to obtain their location at follow-up. Finally, aortic diameters and their growth rate were automatically measured and used to calculated 3D aortic dilation maps. Agreement between techniques and their inter-observer reproducibility were calculated.

Results

Patients age was 27.2±14.5 years and 40% were male. Mean follow-up duration was 2.7±1.6 years. Compared to manual assessment, the registration-based technique presented low bias and excellent agreement for aortic diameters (Table 1), and low bias and moderate agreement for growth rates both in the aortic root and the thoracic aorta (Table, Fig. 1A). The techniques presented similar inter-observer reproducibility in the assessment of aortic diameters (Table 1), while the registration-based method demonstrated much higher inter-observer reproducibility in the assessment of growth rates in the aortic root and the thoracic aorta (Table 1, Fig. 1A and B). Three-dimensional mapping of thoracic aortic diameters and growth was highly reproducible (mean regional ICC=0.90 for diameters; 0.82 for growth rate).

Conclusion

The assessment of the dilation rate of the thoracic aorta via registration of serial self-navigated 3D whole-heart CMR acquisitions is accurate and reproducible in the aortic root and the thoracic aorta. Thus, it allows to assess local aortic growth without the drawbacks of CT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Ministerio de Ciencia e Innovaciόn (Spain)

Importance of genotype for risk stratification in arrhythmogenic right ventricular cardiomyopathy using the 2019 ARVC risk calculator

AIMS

To study the impact of genotype on the performance of the 2019 risk model for arrhythmogenic right ventricular cardiomyopathy (ARVC).

METHODS AND RESULTS

The study cohort comprised 554 patients with a definite diagnosis of ARVC and no history of sustained ventricular arrhythmia (VA). During a median follow-up of 6.0 (3.1,12.5) years, 100 patients (18%) experienced the primary VA outcome (sustained ventricular tachycardia, appropriate implantable cardioverter defibrillator intervention, aborted sudden cardiac arrest, or sudden cardiac death) corresponding to an annual event rate of 2.6% [95% confidence interval (CI) 1.9-3.3]. Risk estimates for VA using the 2019 ARVC risk model showed reasonable discriminative ability but with overestimation of risk. The ARVC risk model was compared in four gene groups: PKP2 (n = 118, 21%); desmoplakin (DSP) (n = 79, 14%); other desmosomal (n = 59, 11%); and gene elusive (n = 160, 29%). Discrimination and calibration were highest for PKP2 and lowest for the gene-elusive group. Univariable analyses revealed the variable performance of individual clinical risk markers in the different gene groups, e.g. right ventricular dimensions and systolic function are significant risk markers in PKP2 but not in DSP patients and the opposite is true for left ventricular systolic function.

CONCLUSION

The 2019 ARVC risk model performs reasonably well in gene-positive ARVC (particularly for PKP2) but is more limited in gene-elusive patients. Genotype should be included in future risk models for ARVC.

Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION 

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

PURPOSE 

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up. 

METHODS 

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF &lt; 50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF CMR values were considered 50-57% according to current recommendations. Cox-regression analysis was used for MACE and logistic regression was used for progressive systolic dysfunction (only first and last TTE were available).

RESULTS 

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38 ± 19 years and 165 (54%) were men. LVEF was 62 ± 8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1-7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.73 (95% CI 2.00-3.72) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by CMR (HR 0.95, 95% CI 0.91-0.99, p = 0.0048) and hypertension (HR 2.30, 95% CI 1.08-4.89, p = 0.031) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). LGE was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF &lt; 50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (OR 0.93, 95% CI 0.89-0.98, p = 0.008). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 10.69, 95% CI 1.97-58.13, p = 0.006).

CONCLUSIONS 

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored. Abstract Figure. Kaplan Meier cuves for MACE  Abstract Figure. Risk of progressive systolic dysfunction

Mitral valve prolapse but no mitral annular disjunction is related to mitral regurgitation progression in patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1,2). It has been associated with mitral valve prolapse (MVP). Limited data is available regarding the impact of the presence of MVP on the evolution of mitral regurgitation in these syndromic entities.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS), and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at the first echocardiogram were evaluated. Electronic medical records were reviewed to register the need for mitral surgery. The last echocardiogram available was also assessed to evaluate MR progression. 

Results

A total of 295 patients were included (235 MFS, 42 LDS, and 18 vEDS). The mean age at baseline was 39.0+-14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3 %) of LDS and was not present in vEDS (p&lt; 0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt; 0.001).

In MFS, MAD was significantly associated with MVP (p= &lt;0.001) (Table 1). Concretely, 73 (31.1%) of the MFS patients had the concurrence of MAD and MVP and 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 30 (12.8%) of the MFS and in 18 (24.7%) of patients with concurrent MAD and MVP. Interestingly, significant MR was absent in patients with isolated MAD (Figure 1). MVP (OR 16.85 CI 4.43 – 64.07) but not MAD (p = 0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at &gt; = 1 year (mean 4.1 +- 1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p = 0.007).

After a mean clinical follow-up of 7.5 +- 3.2yrs, 10 patients required mitral surgery (6 prostheses, 4 valvuloplasties).

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p= 0.529) but MVP was (OR 5.2 IC 1.70 - 15.93). Similarly, MVP (OR 5.6 CI 1.23 - 25.86)  but not MAD  (P= 0.096) was associated with the  need for mitral surgery ., 

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MVP but not MAD was associated with mitral regurgitation evolution and the need for mitral surgery. Abstract Table 1  Abstract Figure 1

Multi-Centre, Multi-Vendor and Multi-Disease Cardiac Segmentation: The M&Ms Challenge

The emergence of deep learning has considerably advanced the state-of-the-art in cardiac magnetic resonance (CMR) segmentation. Many techniques have been proposed over the last few years, bringing the accuracy of automated segmentation close to human performance. However, these models have been all too often trained and validated using cardiac imaging samples from single clinical centres or homogeneous imaging protocols. This has prevented the development and validation of models that are generalizable across different clinical centres, imaging conditions or scanner vendors. To promote further research and scientific benchmarking in the field of generalizable deep learning for cardiac segmentation, this paper presents the results of the Multi-Centre, Multi-Vendor and Multi-Disease Cardiac Segmentation (M&Ms) Challenge, which was recently organized as part of the MICCAI 2020 Conference. A total of 14 teams submitted different solutions to the problem, combining various baseline models, data augmentation strategies, and domain adaptation techniques. The obtained results indicate the importance of intensity-driven data augmentation, as well as the need for further research to improve generalizability towards unseen scanner vendors or new imaging protocols. Furthermore, we present a new resource of 375 heterogeneous CMR datasets acquired by using four different scanner vendors in six hospitals and three different countries (Spain, Canada and Germany), which we provide as open-access for the community to enable future research in the field.

Clinical, laboratory, electrocardiogaphic and multimodality imaging outcome predictors in cardiac amyloidosis

Background

Cardiac affectation in amyloidosis is presented among 50% patients what implies worse prognostic. Early diagnosis and prognostic stratification is mandatory after the appearance of new therapies that could modify the course of the disease.

Purpose

The aim of the present study was to evaluate the main outcome predictors with multiparametric approach including clinical, laboratory, electrocardiographic and imaging parameters in patients with cardiac amyloidosis (CA).

Methods

We recruited patients (p) prospectively followed in our cardiomyopathy unit, for a mean period of 10 years (from 2010 to 2020) who were diagnosed with CA. Baseline clinical, laboratory and echocardiographic data were obtained. We collected cardiovascular risk factors and previous events. We performed a multimodality imaging study including echocardiogram (TTE) and cardiac magnetic resonance (CMR). TTE hallmarks of CA were recorded, as well as CMR parameters of cardiac function, myocardial mass and tissue characterization. Finally we evaluated the parameters related with mortality in the follow-up.

Results

A total of 98 p were included, with a mean age of 67.5±16.9 years old. Mean follow-up was 42,2±32 months. 22 p (24,4%) had light-chain amyloidosis (AL), 34 p (37,8%) wild type transthyretin amyloidosis (ATTRwt) and 34 p (37,8%) familiar transthyretin amyloidosis (ATTRm). 43p (47.78%) died in the follow-up. Factors related with mortality in the the follow-up where the age (HR 1.08, ppresence of hypertension (HR 2.81, p=0,002) diabetes (HR 3.12, p=0,001) and previous stroke (HR 2.69, p=0,01); NYHA class at diagnosis (HR 2.49, p&lt;0.001), low voltage (HR 2.31, p=0,008) and pseudoinfarct pattern at ECG (HR 1.9, p=0,003); elevated BNP (HR 10.29, p&lt;0.001) and creatinine (HR 1.42, p=0,02); septum (HR 1.09, p=0,001) and posterior wall (HR 1,14, p&lt;0,001)thickness, left ventricular ejection fraction (HR 0.96, p=0,0031) global longitudinal strain (HR 1.18, p&lt;0.001), ratio E/A (HR 2.29, p&lt;0,001) and E/e' (HR 1.13, p=0,003) and left atrium size (HR 1,05, p=0,006) at echo; and the presence of left atrium fibrosis (HR 4.17, p&gt;0,001) and extension of late gadolinium enhancement (HR 1,06, p=0,03) at CMR. When evaluated within a multivariate analysis in a Cox regression model, the independent variables associated with mortality were NYHA class at diagnosis (p=0.002) and amyloidosis type (p=0.002) ATTRm had a better prognosis than ATTRwt and AL (Log-rank p&lt;0.001).

Conclusion

Mortality in cardiac amyloid patients is high. Clinical parameters like hypertension, diabetes, previous stroke and NYHA class at diagnosis; laboratory parameters like BNP and creatinine, main systolic and diastolic function at TTE, presence of auricular fibrosis and extension of late gadolinium enhancement at CRM are related with mortality in the follow-up. Among different types of CA, patients with ATTRm had a better prognosis, which may have therapeutic implications with the appearance of new therapies.

Funding Acknowledgement

Type of funding sources: None. Mortality

Mitral annular disjunction in patients with syndromic hereditary aorthopaties

Background

Mitral annular disjunction (MAD) is a structural abnormality of the mitral annular fibrosus characterized by a separation between the atrial wall-mitral valve junction, and the left ventricular attachment (1). It has been associated with mitral valve prolapse (MVP) (2) but also, with arrhythmias and sudden cardiac death (SCD) (3). There is no evidence of its prevalence and clinical significance in patients with syndromic hereditary aortopathies.

Purpose

To evaluate the prevalence of MAD, PMV, and the combination of both in patients with syndromic hereditary thoracic aortic disease (HTAD) including Marfan (MFS), Loeys-Dietz (LDS) and vascular Ehlers-Danlos syndromes (vEDS), and its relationship with arrhythmias, SCD, mitral regurgitation (MR) severity and the need for mitral surgery at the follow-up.

Methods

Adult patients with syndromic HTAD seen at our specialized unit were retrospectively included. The presence of MAD, MVP, and significant MR at first echocardiogram were evaluated. Electronic medical records were reviewed to register the occurrence of arrhythmic events and the need of mitral surgery. Last echocardiogram available was also assessed to evaluate MR progression.

Results

A total of 295 patients were included (235 MFS, 42 LDS and 18 vEDS). Mean age at baseline was 39.0±14.4 and 52.9% were female. MAD was present in 87 (37.0%) of MFS, 6 (14.3%) of LDS and was not present in vEDS (p&lt;0.001). MVP was found in 105 (44.7%) of MFS, 6 (14.3%) of LDS and 0 in vEDS (p&lt;0.001).

In MFS, the presence of MAD was significantly associated with MVP (p≤0.001) (Table 1). However, 14 (6.0%) of patients had isolated MAD (Table 2). At baseline, significant MR was observed in 18 (24.7%) of patients with concurrent MAD and MVP and was not present in patients with isolated MAD (Table 2). MVP (OR 16.85 IC 4.43 – 64.07) but not MAD (p=0.607), was associated with significant MR in the multivariate analysis.

A second echocardiogram was available in 220 patients at ≥1 year (mean 4.1±1.4 years). Overall, 25 (11.4%) presented significant progression of MR, 0 in the isolated MAD group, 13 (19.4%) in the MAD/MVP group and 6 (20.0%) of the isolated MVP (p=0.007).

After a mean clinical follow-up of 7.5±3.2 years, 10 patients required mitral surgery (6 prosthesis, 4 valvuloplasty), 22 (9.4%) presented atrial fibrillation, flutter or supraventricular tachycardia (SVT), and 2 (0.9%) SCD.

After adjustment for the presence of MVP and time of follow-up, MAD was not associated with progression of MR (p=0.529) need for mitral surgery (p=0.096), atrial fibrillation-flutter or SVT (p=0.510) nor SCD. (p=0.997).

Conclusions

The prevalence of MAD in syndromic HTAD is high, especially in Marfan syndrome, and absent in vEDS. In this retrospective observational study, the presence of MAD in Marfan was not associated with mitral regurgitation evolution or arrhythmic events.

Funding Acknowledgement

Type of funding sources: None. Characteristics of MFS patientsPresence of significant MR by groups.

Prognosis of left ventricular noncompaction with preserved ejection fraction

Introduction

Left ventricular noncompaction (LVNC) is a poorly defined entity with heterogeneous prognosis. LV ejection fraction (LVEF) is one of the main predictors of major adverse cardiovascular events (MACE). However, outcomes of LVNC patients with preserved LVEF (pEF) remain uncertain.

Purpose

The aim of our study was to determine the incidence and predictors of MACE in LVNC patients with pEF as well as to assess the evolution of LVEF throughout follow-up.

Methods

We conducted a retrospective, longitudinal, multicentre cohort study. Consecutive patients with transthoracic echocardiography (TTE) and/or cardiac magnetic resonance (CMR) diagnostic criteria for LVNC and initially pEF (LVEF≥50%) were recruited. MACE were defined as a composite of heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and/or all-cause mortality. Progressive systolic dysfunction was defined as an LVEF&lt;50% at last TTE and/or an absolute ≥10-point decrease in LVEF from first to last TTE. Lower limit of LVEF values were considered 50–53% for TTE and 50–57% for CMR, according to current recommendations.

Results

A total of 305 patients from 12 centres were included from 2000 to 2018. Age was 38±19 years, 165 (54%) were men and 185 (61%) were probands. LVEF was 62±8% and 8% had late gadolinium enhancement (LGE). During a median follow-up of 4.7 (IQR 2.1–7.4) years, MACE occurred in 40 (13%) patients with an incidence rate of 2.96 (95% CI 2.17–4.04) events per 100 person-years: 8 HF, 27 VA, 3 SE and 5 deaths. LVEF by TTE (HR 0.95, 95% CI 0.90–0.99, p=0.035) and age (HR 1.02, 95% CI 1.01–1-04, p=0.04) were the only variables independently associated with the endpoint. Patients with lower limit LVEF values showed an increased risk of MACE (Figure 1). Among probands, those with family aggregation presented a higher incidence of MACE compared to nonfamilial cases (HR 2.74, p=0.043). A positive genotype was not associated.

Sixty-one (21%) patients experienced progressive systolic dysfunction: 31 (11%) had an LVEF&lt;50% and 48 (17%) an absolute ≥10-point decrease in LVEF at last follow-up. On multivariate analysis, LVEF by CMR was the only independent predictor (HR 0.96, 95% CI 0.92–0.99, p=0.031). Patients with lower limit LVEF values had an increased risk (Figure 2). In this subgroup, LGE was also associated with the endpoint (HR 3.52, p=0.011). Family aggregation was not associated, while a positive genotype correlated with lower risk (HR 0.52, p=0.029).

Conclusions

Patients with left ventricular noncompaction and preserved ejection fraction carry a moderate risk of major adverse cardiovascular events and progressive systolic dysfunction. LVEF remains the main predictor of outcomes in this subgroup. Patients with lower limit LVEF values are at increased risk, probably suggesting subclinical systolic dysfunction. Therefore, they should be carefully monitored.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Evaluation of myocardial strain assessed by CMR tissue-tracking to predict adverse cardiovascular events in patients with cardiac amyloidosis

Background

Cardiac affectation in amyloidosis is presented among 50% patients what implies worse prognostic. Early diagnosis and prognostic stratification is mandatory after the appearance of new therapies that could modify the course of the disease.

Purpose

The aim of our study was to assess the prognostic value of cardiac magnetic resonance parameters, including Tissue deformation, in cardiac amyloidosis patients.

Methods

We recruited patients (p) prospectively followed in our cardiomyopathy unit, for a mean period of 10 years (from 2010 to 2020) who were diagnosed with CA. Baseline clinical, laboratory and echocardiographic data were obtained. Contrast-enhanced CMR was performed on a 1.5 T clinical scanner. Routine analysis was performed with a semi-automatic software for volumetric analysis. When late gadolinium enhancement was present, percentage of area of enhancement (LGE) was calculated.All strain parameters were measured off-line using dedicated software. Left ventricular circumferential strain (CS) measurements were obtained using mid-ventricular level short-axis cine views. Longitudinal strain (LS) derived from cine SSFP of 2-, 3-, and 4-chamber long axis views.Finally we evaluated the CMR parameters related with the combined event of mortality and heart failure in the follow-up.

Results

A total of 98 p were included, with a mean age of 67.5±16.9 years old. Mean follow-up was 42,2±32 months. 22 p (24,4%) had light-chain amyloidosis (AL), 34 p (37,8%) wild type transthyretin amyloidosis (ATTRwt) and 34 p (37,8%) familiar transthyretin amyloidosis (ATTRm). 59p (60,8%) died or present heart failure during the follow-up. Patients who died or present heart failure in the follow-uo had lower left ventricular ejection fraction (48,25±12,2% vs 56,13±11,03%, p=0,003), higher myocardial mass (156,05±54,8g vs 120,84±56,1g, p=0,007), higher LGE (8,6±6,8% vs 4,4±2%), worst GLS (−14,76±6,1% vs −18,67±6,2%) and worst GCS (−23,3±9,7% vs −30,04±9,1%). Both, GLS and GCS were independently associated with the combined event of dead or heart failure when evaluated within a multivariate analysis in a Cox regression model, but GCS was the stronger predictor of events in the follow-up over other CMR parameters like LGE an myocardial mass (p&lt;0,001). Tertile distribution for GCS identified subgroups with different adverse events, particularly for the lowest-risk tertile: GCS &lt;−34%, who had a combinated event in 13,6% of cases, significantly lower than patients in the mid-risk tertile (41,5%) and highest-risk tertile (53,8%) (Log-rank p=0,02)

Conclusion

Mortality and appearance of heart failure in cardiac amyloid patients is high. The assessment of myocardial strain parameters by CMR tissue-tracking in this population is useful to predict adverse outcomes in the follow-up. Particularly, GCS, stratify patients in subgroups with different risk of events, with added value to classical CMR parameters.

Funding Acknowledgement

Type of funding sources: None. Death & Heart Failure by GCS

Prognostic value of baseline versus 6-month follow infarct size in patients with reperfused STEMI

Background

Acute infarct size is a predictor of clinical outcomes in acute ST segment elevation myocardial infarction (STEMI) patients, although its prognostic value has differed between studies. In acute STEMI, infarct size is often overestimated due to the presence of extensive myocardial oedema, a confounder that is no longer present at a 6-month follow-up study. It was our purpose to assess whether infarct size in the acute phase or at 6-months follow-up provided superior prognostic information in STEMI patients.

Methods

STEMI patients who underwent successful primary percutaneous revascularization were included and a cardiac magnetic resonance (CMR) was performed between 5–7 days after STEMI and at 6 months to study infarct size (as a % of myocardial mass). The primary endpoint was a composite of cardiovascular mortality, hospitalization for heart failure and ventricular arrhythmia.

Results

A total of 796 patients were included (mean age 58.3±11.5 years, 82.4% male, 52.3% anterior infarction). During a mean follow-up of 59 months, 59 patients (7.4%) presented with the primary end-point (cardiovascular death n=7, hospitalization for heart failure n=52, ventricular arrhythmia n=1). ROC curve analysis (figure 1) showed a non-significant difference between baseline and 6-month infarct size for the prediction of the primary endpoint (baseline AUC 0.685 95% CI 0.610–0.760, 6-month AUC 0.713 95% CI 0.643–0.782, p=0.60). Optimal cut-off values for baseline and 6-months follow-up infarct size for prediction of outcomes, respectively 22% and 17.5%, were used for Kaplan-Meier curve analysis (figure 2).

Conclusion

Infarct size estimated during the first week after STEMI and at 6-months follow-up showed similar predictive value and with similar cut-off values. Therefore, the prognostic information provided by infarct size can be obtained during initial STEMI admission and does not require a waiting period for infarct size stabilization.

Funding Acknowledgement

Type of funding sources: None. ROC curve analysisKaplan-Meier analysis

Do morphological, haemodynamic and biomechanical parameters relate to aortic growth rate in chronic type B aortic dissection? A 4D flow CMR study

Background

Aortic dissection (AD) is the most devastating complication of thoracic aortic disease (1). In the chronic phase, yearly clinical and imaging follow-up of the maximum aortic diameter is recommended, since indication for thoracic endovascular aortic repair or surgery is suggested by guidelines in case of thoracic aortic enlargement or false lumen (FL) aneurysms (2). Most of the reported parameters related adverse events in chronic AD are focused on morphological variables (3) and not on the haemodynamics and biomechanics of the FL.

Purpose

To evaluate the relationship between aortic growth rate and anatomical variables, flow patterns and aortic stiffness in patients with chronic type B AD.

Methods

Forty-one patients with chronic type B aortic dissection, no connective tissue disorders and with an imaging follow-up including two computed tomography angiograms (CTA) acquired at least 3 years apart underwent contrast-enhanced 4D-flow CMR and MR angiography (MRA). The FL volume was segmented from MRA, and velocity data inside the 3D volume of the FL was extracted from 4D-flow CMR and used for parameter quantification. Retrograde systolic and diastolic flow, wall shear stress (WSS) and in-plane rotational flow (IRF) were calculated at 8 equidistant planes in the distal descending aorta (DAo), from the pulmonary bifurcation to the diaphragmatic level, and averaged values were used [4]. Aortic stiffness in the FL was assessed in terms of pulse wave velocity (PWV), which was calculated from the third supraortic trunk to the diaphragmatic level on 4D-flow CMR [5]. The percentage of thrombus in the FL was calculated as the ratio of thrombus and FL volumes on MRA. Dominant entry tear area was quantified on the baseline CTA (Figure 1). Aortic growth rate (GR) was defined as the difference between final and baseline aortic diameters as measured on CTA divided by follow-up duration.

Results

Anatomical, haemodynamic and biomechanical parameters are shown in Table. Twenty-five patients have repaired type A AD with residual entry tear and 16 have type B AD. Mean follow-up duration was of 4.9±2.7 years. In bivariate analysis, WSS, IRF and PWV were positively related to GR, whereas dominant entry tear area and percentage of thrombus in the FL showed a positive tendency with GR (Table) (Figure). In multivariate analysis IRF, PWV, dominant entry tear area and thrombus in the FL were positively and independently associated with GR (Table). Retrograde systolic and diastolic flow were not related to GR while WSS tended to statistical significance.

Conclusions

In-plane rotational flow, regional aortic stiffness, dominant entry tear area and percentage of thrombus in the false lumen are positively and independently related to aortic growth rate in patients with chronic type B aortic dissection. Further prospective studies are needed to confirm if the assessment of these parameters may help to identify patients at higher risk of adverse clinical events.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Aortic rotational flow patterns and stiffness by 4D flow CMR in patients with Loeys-Dietz syndrome compared to healthy volunteers and patients with Marfan syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató de TV3, Instituto de Salud Carlos III through the project and Spanish Ministry of Science, Innovation and Universities.

BACKGROUND

Loeys-Dietz (LDS) and Marfan (MFS) syndromes are rare genetic connective tissue disorders associated with progressive aortic dilation, however, aortic dissections have been observed at lower aortic root diameters in LDS than in MFS. Recent CMR studies in MFS patients reported increased aortic stiffness (1–3) and altered rotational flow (4), but research on aortic flow dynamics and biomechanics in LDS is lacking.

PURPOSE

The aim of this study was to assess rotational aortic flow and aortic stiffness in LDS compared to healthy volunteers (HV) and MFS patients, using 4Dflow CMR.

METHODS

Twenty-one LDS and 44 MFS patients, without previous aortic dissection or surgery, and 43 HV underwent a non-contrast-enhanced 4D flow CMR. Aortic stiffness was quantified at the AAo and DAo using pulse wave velocity (PWV). In-plane rotational flow (IRF), systolic flow reversal ratio (SFRR) (5) and local aortic diameters were obtained at 20 equidistant planes from the ascending (AAo) to the proximal descending aorta (DAo).

RESULTS

LDS patients had lower IRF at the distal AAo and proximal DAo compared to HV (p = 0.053 and 0.004, respectively), once adjusted for age, stroke volume and local aortic diameter; but no differences were found with respect to MFS (Figure). Although SFRR at the proximal DAo was increased in LDS patients compared to both HV (p = 0.037) and MFS populations (p = 0.015), once adjusted for age and aortic diameter, the difference in magnitude was small (Figure). On the other hand, AAo and DAo PWV revealed stiffer aortas in LDS patients compared to HV but no differences versus MFS patients (Table).

CONCLUSIONS

Patients with Loeys-Dietz syndrome showed decreased in-plane rotational flow and abnormally-high regional aortic stiffness compared to healthy controls, and similar hemodynamics and aortic stiffness with respect to patients with Marfan syndrome.

Prognostic role of cardiac magnetic resonance in left ventricular noncompaction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Purpose

Describe prognostic role of CMR on long term outcomes of LVNC patients. 

Methods

 

Retrospective multicentric longitudinal cohort study of consecutive patients fulfilling imaging diagnostic criteria for LVNC (Jenni echo criteria and Petersen and Jacquier CMR criteria). Demographic, ECG, genetic, family and treatment variables were recorded. Baseline CMR was used for the analysis. LV ejection fraction (LVEF) was categorized according to heart failure (HF) guidelines and late gadolinium enhancement (LGE) was visually assessed in a binary way. End points were HF, ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) were the combination of the four previous end points. In patients with initially preserved LVEF (≥ 50%), LV adverse remodelling (LVAR) was defined as an LVEF &lt; 50% and/or absolute decrease of ≥10% in LVEF at last follow-up.

Results

585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented LGE. During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.

LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p &lt; 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p &lt; 0.001) and was associated with higher HF and VA risk in patients with an LVEF &gt; 35% (HR 2.69 and 2.48 respectively, p &lt; 0.05) (Figure 1). No MACE (0%) occurred during long-term follow-up in patients with preserved LVEF, no LGE as well as no ECG abnormalities and no family aggregation.

305 (52%) patients presented with initially preserved LVEF, and 230 (75%) of those had LVEF available at last follow-up. LVAR occurred in 50 (22%) patients: 22 (10%) had an LVEF &lt; 50% and 41 (18%) an absolute ≥ 10% decrease in LVEF. LGE was independently associated with LVAR (HR 3.51, p = 0.045) (Figure 2). 

Conclusions

Cardiac magnetic resonance has an important prognostic role in LVNC. LVEF is the most powerful predictor of events. Myocardial fibrosis is associated with worse outcomes in patients without severe systolic dysfunction, as well as with left ventricular adverse remodelling in those with initially preserved LVEF. Besides, CMR may identify a low-risk subgroup of LVNC patients. Therefore, CMR should be used in risk stratification in LVNC.

Sequential cardiovascular magnetic resonance assessment of left ventricular ejection fraction for prediction of subsequent events in a large multicenter STEMI registry

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER”

Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain.

Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE.

Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: &lt;40%; mid-range [mr]: 40-49%; preserved [p]: ≥50%) was sequentially quantified by CMR at 1 week and after &gt;3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR.

Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF &lt; 40% at follow-up CMR (r-LVEF 22%, mr-LVEF 7%, p-LVEF 6%; p-value &lt; 0.001). Based on LVEF dynamics from 1-week to follow-up CMR, incidence of MACE was 5% for sustained LVEF³40% (n = 783), 13% for improved LVEF (from &lt;40 to ³40%, n = 96), 21% for worsened LVEF (from ³40% to &lt;40%, n = 34) and 22% for sustained LVEF &lt;40% (n = 100), p-value &lt; 0.001. Using a Markov approach that considered all studies performed, transitions towards improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to higher incidence of subsequent MACE.

Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (&lt;40%) by CMR at any time during follow-up identifies a small subset of patients at high risk of subsequent events.

Biomarkers in Fabry Disease. Implications for Clinical Diagnosis and Follow-up

Fabry disease (FD) is a lysosomal storage disorder caused by deficient alpha-galactosidase A activity in the lysosome due to mutations in the GLA gene, resulting in gradual accumulation of globotriaosylceramide and other derivatives in different tissues. Substrate accumulation promotes different pathogenic mechanisms in which several mediators could be implicated, inducing multiorgan lesions, mainly in the kidney, heart and nervous system, resulting in clinical manifestations of the disease. Enzyme replacement therapy was shown to delay disease progression, mainly if initiated early. However, a diagnosis in the early stages represents a clinical challenge, especially in patients with a non-classic phenotype, which prompts the search for biomarkers that help detect and predict the evolution of the disease. We have reviewed the mediators involved in different pathogenic mechanisms that were studied as potential biomarkers and can be easily incorporated into clinical practice. Some accumulation biomarkers seem to be useful to detect non-classic forms of the disease and could even improve diagnosis of female patients. The combination of such biomarkers with some response biomarkers, may be useful for early detection of organ injury. The incorporation of some biomarkers into clinical practice may increase the capacity of detection compared to that currently obtained with the established diagnostic markers and provide more information on the progression and prognosis of the disease.

Long term outcomes in left ventricular noncompaction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular noncompaction (LVNC) is a heterogeneous entity with a wide phenotypic expression. Risk factors have not been well established and prognostic stratification remains challenging.

Objectives

Describe long term outcomes of LVNC patients and determine predictors of cardiovascular events. 

Methods

 

Prospective multicentric study of consecutive patients fulfilling imaging diangostic criteria for LVNC (Jenni echo criteria and Petersen CMR criteria). Demographic, ECG, imaging and genetic variables were collected. End points were heart failure (HF), ventricular arrhythmias (VA), systemic embolisms (SE) and all-cause death. Major adverse cardiovascular events (MACE) was the combination of the four previous end points.

Results

585 patients from 12 referral centres were included from 2000 to 2018. Age at diagnosis was 45 ± 20 years, 334 (57%) were male, baseline LVEF was 48 ± 17% and 18% presented late gadolinium enhancement (LGE). During a median follow-up of 5.1 years (IQR 2.3-8.1), 110 (19%) patients presented HF, 87 (15%) VA, 18 (3%) SE and 34 (6%) died. MACE occurred in 223 (38%) patients.

LVEF was independently associated with HF, VA, SE and MACE: HR were 1.08, 1.02, 1.04 and 1.02 respectively (all p &lt; 0.05). LGE was more frequent in patients with reduced LVEF (39 Vs 53%, p &lt; 0.001) and was associated with higher HF and VA risk in patients with LVEF &gt; 35% (HR 2.69 and 2.48 respectively, p &lt; 0.05) (Figure 1). Patients with a normal ECG, LVEF≥50%, no LGE and no family aggregation presented no MACE (0%) at long term follow-up.

Among patients who underwent genetic testing (354, 61%), TTN variants and complex genotype (more than one variant) presented lower LVEF and higher HF risk. ACTC1 variants were associated with VA.

Conclusions

LVNC carries a high long term risk of heart faliure and ventricular arrhythmias. LVEF is the most important predictor and myocardial fibrosis is associated with increased risk in patients without severe systolic dysfunction. Genotype is a modifier of outcomes. These factors might be used to risk stratify LVNC patients.

Abstract Figure. Kaplan Meier survival curves

Leaflets fusion length in bicuspid aortic valve is related to ascending and aortic root dilation and ascending aorta wall shear stress

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities, Instituto de Salud Carlos III

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect, consisting in the fusion of two aortic valve leaflets. Altered flow patterns have been related to aortic wall degeneration in BAV patients and may be responsible for the high prevalence of aortic disease in these patients. A number of studies on excised BAV or using advanced imaging modalities reported a wide variability of fusion extent between leaflet, but no previous study assessed whether leaflet fusion length may be used to stratify BAV patients.

Purpose

We aimed to test whether leaflet fusion extent can be quantified by cardiac magnetic resonance imaging (CMR) and whether it is related to aortic dilation and flow abnormalities in non-dysfunctional BAV.

Methods

One hundred and twenty BAV adults with no previous aortic or aortic valve surgery or significant valvular disease were consecutively enrolled. Patients with two sinuses of Valsalva (true BAV) or fusion of the left and non-coronary cusps, both being rare forms of BAV, were excluded. Twenty-eight healthy volunteers were also included for comparison. A 4D flow CMR sequence was acquired and circumferential wall shear stress and pulse wave velocity were assessed in the ascending aorta. A stack of double-oblique cine images of the aortic valve were used to quantify the length of the fusion between leaflets.

Results

The length of the fusion between leaflets was effectively measured in 112/120 patients (93%). Reproducibility was good (ICC = 0.826). Fusion length varied greatly (range 2.3 – 15.4 mm, 7.8 ± 3.2 mm, tertiles cut-off points were 6 and 9.3 mm). After correction for age, BSA, stroke volume and BAV fusion morphotype, fusion length was independently associated with diameter at the sinus of Valsalva (p = 0.002). Moreover, once corrected for age, stroke volume and ascending aorta pulse wave velocity, fusion length was positively related to ascending aorta diameter (p = 0.028). The comparison of maps of circumferential peak-systolic WSS in healthy volunteers (left) and BAV patients pertaining to the three leaflet fusion length tertiles is shown in Figure 1. Circumferential WSS progressively increase with larger fusion length. This trend was statistically significant (p &lt; 0.05) in the right and outer regions of the proximal and mid ascending aorta.

Conclusions

Bicuspid aortic leaflet fusion length varies considerably and it is independently associated with ascending aorta and aortic root dilation, possibly through flow alterations.

Abstract Figure 1

Semi-automatic quantification of aortic root progressive dilation by automatic co-registration of computed tomography angiograms: a preliminary comparison with manual assessment in Marfan patients

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Spanish Ministry of Science, Innovation and Universities Instituto de Salud Carlos III

Background. Dilation of the aortic root is a key feature of Marfan syndrome and it is related to the occurrence of aortic events and death. On top of maximum diameter, rapid annual growth rate is suggested by guidelines for indication of aortic root replacement. Current gold-standard for aortic root diameter assessment is manual quantification on multiplanar reformatted 3D computed tomography (CT) or magnetic resonance angiogram. However, inter- and intra-observer reproducibility are limited and different measurement methods, i.e. cusp-to-cusp and cusp-to-commissure, may be used in different clinical centres, leading to difficulties in the clinical assessment of progressive dilation.

Purpose. We aimed to test whether aortic root growth rate during follow-up can be reliably quantified by semi-automatic co-registration of two CT angiograms.

Methods. Seven Marfan syndrome patients, free from previous aortic surgery, with a total of 11 pairs of CT were identified. Manual assessment of six aortic root diameters (right-non coronary -RN- , right-left -RL- and left-non coronary -LN- cusp-to-cusp and R, L and N cusp-to-commissure) was obtained from all CTs by an experienced researcher blind to semi-automatic results. The thoracic aorta and the outflow tract were semi-automatically segmented in the baseline CT and commissure and cusps were manually located. A 10 mm-thick region of interest containing the aortic wall was automatically generated from segmentation boundary. Co-registration was obtained with three, fully-automatic steps. Firstly, baseline and follow-up CT scans were aligned by means of a rigid registration. Then, scans were co-registered with multi-resolution affine followed by b-spline non-rigid registrations based on mutual information metric. The transformation pertaining to the location of baseline commissure and cusps points was used to locate the same points in the follow-up scan (Fig. 1 top).

Results. Follow-up duration was 35 ± 22 (range 12-70.3) months. Automatic quantification of diameter growth during the follow-up was obtained in 62 out of 66 (94%) diameter comparisons. High Pearson correlation coefficients (R) and ICC were found between manual and semi-automatic assessment of growth rate, both for cusp-to-cusp and cusp-to-commissure diameters: R = 0.727 and ICC = 0.678 for RN; R = 0.822 and ICC = 0.602 for RL; R = 0.648 and ICC = 0.668 for LN; R = 0.726 and ICC = 0.711 for R; R = 0.911 and ICC = 0.895 for L and R = 0.553 and ICC = 0.482 for N. Scatter and Bland-Altman plots for all growth rates (Fig. 1) confirmed very good correlation (R = 0.810) but a slight tendency (R=-0.270) for underestimation at high growth rate.  No correlation was found between follow-up duration and difference between techniques (R = 0.06).

Conclusions. Semi-automatic quantification of aortic root growth rate by co-registration of pairs of CT angiograms is feasible for follow-up as short as one year. Larger studies are needed to confirm these preliminary data.

Abstract Figure. CT measurements. Automatic vs manual.

Heart Disease in Eosinophilic Granulomatosis with Polyangiitis (EGPA) Patients: a screening approach proposal

OBJECTIVE

To define the pattern of cardiac involvement in eosinophilic granulomatosis and polyangiitis (EGPA) and propose an algorithm for heart disease screening.

METHODS

Retrospective study of EGPA patients attending a specialized vasculitis clinic (1989-2016). Clinical characteristics and cardiovascular evaluation (CE) results (serum troponin, ECG, echocardiography and cardiac magnetic resonance) were collected and compared according to symptoms and inflammatory cardiac disease (ICD).

RESULTS

131 EGPA patients were included, of whom 96 (73%) had undergone CE. The median age was 50 [IQR 38-58] years and 36% showed ANCA+. Asthma preceded diagnosis by a median of 97 [36-240] months. Among the 96 patients who underwent CE, 43% were symptomatic, being dyspnea (47%) and chest pain (29%) the predominant symptoms. In asymptomatic patients, CE reported abnormalities in 45% of cases with a subsequent earlier diagnosis (4 vs 11 months). Overall, 27 patients had EGPA-related ICD (rICD) that was already present at diagnosis in 20 cases, preceded it in 2 cases and developed later in 5. EGPA-rICD patients were younger (46 vs 50 years; p= 0.04), had more frequently abnormal ECG (30.8% vs 2.1%; p< 0.001), negative ANCA (85% vs 69%; NS), higher BVAS score (3 vs 1; p= 0.005), higher eosinophil count (5.60 vs 1.60x109/l; p= 0.029) and higher C reactive protein (52 vs 15 mg/l; p= 0.017). Overall, 11% of cases with EGPA-rICD were asymptomatic.

CONCLUSION

In our study, 45% of asymptomatic patients had an abnormal baseline cardiac evaluation, which allowed an earlier diagnosis of cardiac disease. We recommend prompt cardiac screening in all EGPA patients, instead of a symptoms-guided algorithm.

Clinical Phenotypes and Prognosis of Dilated Cardiomyopathy Caused by Truncating Variants in the TTN Gene

BACKGROUND

Truncating variants in the TTN gene (TTNtv) are the commonest cause of heritable dilated cardiomyopathy. This study aimed to study the phenotypes and outcomes of TTNtv carriers.

METHODS

Five hundred thirty-seven individuals (61% men; 317 probands) with TTNtv were recruited in 14 centers (372 [69%] with baseline left ventricular systolic dysfunction [LVSD]). Baseline and longitudinal clinical data were obtained. The primary end point was a composite of malignant ventricular arrhythmia and end-stage heart failure. The secondary end point was left ventricular reverse remodeling (left ventricular ejection fraction increase by ≥10% or normalization to ≥50%).

RESULTS

Median follow-up was 49 (18-105) months. Men developed LVSD more frequently and earlier than women (45±14 versus 49±16 years, respectively; P=0.04). By final evaluation, 31%, 45%, and 56% had atrial fibrillation, frequent ventricular ectopy, and nonsustained ventricular tachycardia, respectively. Seventy-six (14.2%) individuals reached the primary end point (52 [68%] end-stage heart failure events, 24 [32%] malignant ventricular arrhythmia events). Malignant ventricular arrhythmia end points most commonly occurred in patients with severe LVSD. Male sex (hazard ratio, 1.89 [95% CI, 1.04-3.44]; P=0.04) and left ventricular ejection fraction (per 10% decrement from left ventricular ejection fraction, 50%; hazard ratio, 1.63 [95% CI, 1.30-2.04]; P<0.001) were independent predictors of the primary end point. Two hundred seven of 300 (69%) patients with LVSD had evidence of left ventricular reverse remodeling. In a subgroup of 29 of 74 (39%) patients with initial left ventricular reverse remodeling, there was a subsequent left ventricular ejection fraction decrement. TTNtv location was not associated with statistically significant differences in baseline clinical characteristics, left ventricular reverse remodeling, or outcomes on multivariable analysis (P=0.07).

CONCLUSIONS

TTNtv is characterized by frequent arrhythmia, but malignant ventricular arrhythmias are most commonly associated with severe LVSD. Male sex and LVSD are independent predictors of outcomes. Mutation location does not impact clinical phenotype or outcomes.

EuroCMR 2019 highlights

Cardiovascular magnetic resonance (CMR) has become one of the main imaging techniques for the diagnosis and prognostic stratification of the different cardiovascular diseases. Proof of this is the growing interest in training in this imaging technique which was evident in the past EuroCMR 2019 where 1379 specialists (26.5% more than in the previous edition) met in Lido (Venice) to discuss the latest scientific advances in the CMR field. In this review, we will discuss the most recent research presented during this congress that aroused maximum interest.

P1441 Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

BACKGROUND

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

PURPOSE

To evaluate the rate of SE in LVNC and describe risk factors.

METHODS

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

RESULTS

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9-7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% Vs 24%, p = 0.31) and atrial fibrillation (35% Vs 19%, p = 0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p = 0.04). A LA diameter &gt; 45 mm had an independent 3 fold increased risk of SE (OR 3.04, p = 0.02) (Image 1).

CONCLUSIONS

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

Table 1 Systemic embolisms (n = 23) No systemic embolisms (n = 491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR) - yr 60 (48-76) 48 (30-64) 0.02 Median follow up (IQR) - yr 5.9 (3.1-7.8) 4.2 (1.8-7.1) 0.18 OAC, n (%) 19 (83) 118 (24) 0.01 LVEF (SD) - % 37 (15) 48 (17) 0.01 LVEDD (SD) - mm 58 (11) 54 (10) 0.04 LA diameter (SD) - mm 46 (9) 39 (9) 0.01 Characteristics of patients with and without systemic embolisms

Abstract P1441 Figure. Image 1

P372 Aortic stiffness in Loeys-Dietz syndrome: a comparison with Marfan syndrome patients and healthy volunteers

Funding Acknowledgements

ISCIII PI14/0106 and PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

Genetic syndromic aortic diseases are rare, with Marfan syndrome (MFS) being the most common. However, less is known of Loeys-Dietz syndrome (LDS) which has much lower prevalence and presumed worse prognosis. Increased aortic stiffness in MFS has been previously described but no studies have evaluated aortic biomechanics in LDS. Pulse wave velocity (PWV) is the gold standard measure for arterial stiffness and can be quantified by 4D flow MRI. We aim to evaluate regional aortic PWV by 4D flow MRI in LDS compared to MFS and healthy volunteers.

METHODS

Sixteen LDS patients with a pathogenic mutation, 76 MFS and 49 healthy volunteers were prospectively and consecutively included. No patient had previous aortic dissection or surgery. All underwent a 4D flow MRI study in a 1.5 T clinical scanner. Ascending (AAo) and descending (DAo) aorta PWV were computed using wavelet analysis of the systolic upslope for transit time calculation (Figure). Statistical comparison was made with non-parametric analysis to account for the non-normality of data and multivariate analysis was evaluated separately for AAo and DAo PWV.

RESULTS

Ascending and descending aortic PWV revealed stiffer aortas in LDS patients than in healthy volunteers, even after adjustment for diameter of sinus of Valsalva (SoV) and sex. Conversely, no differences in aortic stiffness were found between LDS and MFS patients (Table).

CONCLUSIONS

Abnormally high regional aortic stiffness was observed in LDS patients when compared with controls. The severity of increased regional aortic stiffness was found similar to the one affecting MFS patients.

Table Controls (N = 49) LDS (N = 16) MFS (N = 76) LDS vs. HV LDS vs. MFN Parameter Unadjusted p-value Adjusted p-value Unadjusted p-value Adjusted p-value Age [years] 39 ± 12 39 ± 16 36 ± 12 0.903 0.599 Men 32 (65%) 6 (37%) 34 (45%) 0.079 0.782 Weight [kg] 72 ± 11 69 ± 13 74 ± 16 0.288 0.194 Height [cm] 172 ± 8 172 ±12 181 ± 11 0.834 0.008 Systolic BP [mmHg] 126 ± 18 125 ± 14 127 ± 17 0.957 0.523 Diastolic BP [mmHg] 70 ± 11 77 ± 6 75 ± 12 0.011 0.318 SoV diameter [mm] 30.6 ± 3.9 35.4 ± 4.6 38.1 ± 5.9 0.001 0.060 AAo diameter [mm] 27.7 ± 3.8 29,0 ± 5.0 29.7 ± 5.4 0.458 0.579 DAo diameter [mm] 20.0 ± 2.0 21.3 ± 3.6 22.9 ± 3.8 0.546 0.124 AAo PWV [m/s] 5.2 ± 1.9 7.6 ± 2.4 7.3 ± 2.8 0.001 0.050* 0.534 NS DAo PWV [m/s] 7.1 ± 2.2 9.4 ± 2.6 10.7 ± 4.6 0.003 0.025** 0.493 NS

Abstract P372 Figure

P1600 Aortic dilatation in patients with chronic descending aorta dissection is related to maximum false-lumen systolic flow deceleration rate as evaluated by 4D-flow MRI

Background

Due to improved surgical strategies a growing number of patients survive acute aortic dissection. Patent false lumen (FL) is common in chronic dissection and it has been associated with poor prognosis, which is mainly driven by FL expansion. Several variables indirectly related to flow characteristics have been associated with progressive aortic dilation. We aimed to evaluate whether the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4D-flow MR, is related to FL dilation in chronic type B aortic dissection.

Methods

Twenty-nine patients with a patent FL after aortic dissection and a prior follow-up of at least 3 years underwent contrast-enhanced 4D-flow MR. Marfan patients were excluded. Time-resolved FL flow acceleration was calculated in a 5 cm-long volume of the descending aorta around the level of the pulmonary bifurcation. MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was measured as the difference between final and initial maximum FL diameters obtained by angio-CT divided by follow-up duration. Population was divided into tertiles based on GR.

Results

Demographic and clinical variables were similar among GR tertiles (Table). MSDR was lower in patients with a GR &lt;1mm/year (group 1) compared to both the other two patient groups (p = 0.009 and 0.003 for groups 2 and 3, respectively) (Figure 1c). MSDR showed a marked positive linear correlation with GR (R = 0.481, p = 0.008) (Figure 1b).

Conclusions

The MSDR in the FL of chronic type B aortic dissection is linearly related to FL growth rate and discriminated between tertiles of aortic dilation. Prospective longitudinal studies are need to unveil possible prognostic value of this parameter.

Table Group 1 (n = 9) Group 2 (n = 10) Group 3 (n = 10) p-value Age (years) 63.44 ±13.54 62.50 ± 13.60 64.56 ± 6.67 0.902 BSA (m2) 2.00 ± 0.18 1.77 ± 0.20 1.94 ± 0.12 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atheroclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial Diameter (mm) 45.00 ± 7.69 36.00 ± 4.20 37.00 ± 6.48 0.078 Final Diameter (mm) 49.50 ± 6.74 44.86 ± 5.70 59.25 ± 9.84 0.049 Follow-up (year) 11.83 ± 8.79 7.82 ± 3.34 8.08 ± 4.05 0.921 GR (mm/year) 0.27 ± 0.29 1.18 ± 0.26 2.64 ± 0.97 &lt;0.001 MSDR (cm/s3) 1212.18 ± 467.61 2410.54 ± 1034.30 2558.16 ± 1098.06 0.005

Abstract P1600 Figure 1

P1442 Outcomes of patients with left ventricular noncompaction and preserved ejection fraction

CONCLUSIONS

Patients with LVNC and pEF have an overall excellent prognosis, which is markedly better than those with rEF. However, there is progressive decrease in LVEF, associated with heart failure, and moderate risk of life threatening arrhythmias. Therefore, periodic follow-up should be promoted.

Table 1 LVNC pEF (n = 239) LVNC rEF (n = 252) p Men, n (%) 131 (55) 146 (58) 0.65 Median age at diagnosis (IQR) - yr 38 (23-54) 58 (42-72) 0.01 Median follow up (IQR) - yr 4.9 (2.1-7.3) 3.9 (1.4-7.9) 0.04 QRS (SD) - ms 93 (18) 117 (32) 0.01 LGE, n (%) 18 (9) 52 (30) 0.01

Abstract P1442 Figure. Image 1

P1601 Relationship between aortic distensibility and aortic regurgitation assessed by CMR in bicuspid valve patients

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

The severity of aortic regurgitation can be evaluated with cardiac magnetic resonance (CMR) through calculation of regurgitant fraction (RF) in phase contrast sequences acquired at the aortic root (as close as possible to the aortic valve). However, the impact of aortic distensibility in this evaluation remains unkown.

PURPOSE

The aim of the study was to evaluate the relation between aortic distensibility and RF valve in bicuspid aortic valve patients.

METHODS

We enrolled bicuspid aortic valve patients without significant aortic stenosis (maximum velocity &lt;2.5 m/s) and connective tissue disease. All patients underwent a CMR study with phase contrast sequences for evaluation of regurgitant fraction at the level of the aortic valve. Aortic regurgitation was considered as mild, moderate or severe depending on RF value (mild &lt;15%; moderate 15-30%; severe &gt;30%). Furthermore we used cine-sequences of aortic root, ascending and proximal descending aorta to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

RESULTS

A total of 98 bicuspid aortic valve patients were included (30% female, 49.7 ± 14.5 years). 75 (76,5%) AR was mild, 17 (17,4%) moderate and 6 (6,1%) severe. RF valvewas significantly correlated with aortic root diameter (r= 0.430 y p &lt; 0.001 )and aortic distensibility at the level of the ascending (r = 0.273 p =0.016) and descending aorta (r = 0.502 and p&lt; 0.001). Aortic distensibility was positively correlated with RFvalve even after adjustment for aortic diameter ( p = 0.002 and p &lt;0.001 respectively) . (Table) (IMG)

CONCLUSIONS

In our study, aortic regurgitation in bicuspid valve patients, evaluated by CMR using RF valve, is related to aortic distensibility. Thus, aortic distensibility should be included in the evaluation of aortic regurgitation by CMR as additional parameter. However, longitudinal studies are needed to evaluate the impact of including aortic distensibility in the evaluation of AR severity by CMR.

AR SEVERITY MILD MODERATE SEVERE Descending aorta distensibility(mean ± std. deviation) 2693,68 ± 997,5 3285,8 ±1952,7 5042,99 ±2873,44 Correlation between AR severity (by RFvalve) and descending aorta distensibility

Abstract P1601 Figure.

P4131Abnormal flow pattern in the main pulmonary artery of Marfan patients is related to local dilation

Introduction

Marfan syndrome (MFS) is a hereditary connective tissue disorder caused by mutation in the FBN1 gene. Main pulmonary artery (MPA) dilation is very prevalent in MFS patients. Indeed, the old Ghent nosology considered main pulmonary artery (MPA) dilation as diagnostic criterion of MFS patients. Although clinical complications related to pulmonary dilation in MFS are rare, this may potentially lead to MPA dissection or be a marker of vascular disease in MFS. Studies regarding potential causes of MPA dilation in MFS patients are very scarce.

Purpose

Through 4D flow CMR, we aimed to assess whether flow abnormalities exist in the MPA of MFS patients and their relation to local diameter.

Methods

Fifty-five consecutive Marfan syndrome adults (MFS) and 22 healthy volunteers (HV) were prospectively enrolled. All subjects underwent non-contrast-enhanced 4D flow-MRI, obtaining 4D flow field and a 3D angiography. The MPA was segmented from the 3D angiography, and the segmentation was used to mask 4D velocity data. Four, equidistant analysis planes were placed in the MPA between the pulmonary valve and the pulmonary artery bifurcation. Common descriptors of large arteries hemodynamics were computed at each plane: maximum velocity, systolic flow reversal ratio (a descriptor of the amount of systolic backward flow) and circumferentially-averaged axial and circumferential wall shear stress (WSS). Pulmonary artery diameters were measured on axial images. MPA dilation was defined as a diameter larger than 27 mm in women and 29 mm in men. Systolic (SBP) and diastolic (DBP) systemic blood pressure were measured at the brachial artery with a calibrated cuff immediately after the scan.

Results

Compared with HV, MFS patients presented similar age, BSA, SBP and maximum blood velocity, but had larger MPA diameter (27.8 vs 25.1 mm, p<0.001) and higher DBP (75.5 vs 66.8 mmHg, p=0.003). According to the used threshold, 45% (27) of MFS patients had MPA dilation. Compared with HV, Marfan patients presented an increased systolic flow reversal ratio in the proximal part of the MPA (Figure 1). In MFS patients axial WSS was reduced in central sections of the MPA, while the circumferential component was not difference with respect to HV. All these flow abnormalities were also present in the subset of 28 MFS patients without pulmonary artery dilation. In multivariable analysis, MPA diameter was independently related to age (B=0.056; p=0.032), sex (B=−2.3; p=0.02) and axial (B=6.4; p=0.039) and circumferential (B=33.9; p<0.001) WSS.

Figure 1

Conclusions

Dilation of the main pulmonary artery is prevalent in Marfan syndrome patients. Abnormal increase in systolic vortexes and reduction in axial WSS were present in dilated and non-dilated MPA in MFS patients. Axial and circumferential WSS were independently related to MPA diameter. The eventual predictive role of abnormal pulmonary flow pattern in pulmonary artery dilation in MFS patients remain to be established

Acknowledgement/Funding

Instituto de Salud Carlos III (PI14/0106), La Maratό de TV3 (20151330), CIBERCV and FP7/People (267128)

P1827Maximum systolic flow deceleration rate in the false lumen by 4D-flow MRI is associated with aortic dilatation in patients with chronic descending aorta dissection

Introduction

Patent false lumen (FL) in aortic dissection has been associated with poor prognosis mainly due to aortic expansion. Although morphologic variables have been related to aortic dilatation as expression of high pressure in the FL, they do not reflect flow characteristics. We propose the maximum systolic flow deceleration rate (MSDR) in the FL, quantified by 4Dflow, assuming that flow should be strongly decelerated during systole under high pressure.

Methods

Twenty-nine patients with a patent FL after aortic dissection (no Marfan syndrome) and with a follow-up of at least 3 years underwent a contrast-enhanced 4D-flow MR. FL acceleration was calculated during the cardiac cycle in a sub-volume of the descending aorta (5 cm around the level of the pulmonary bifurcation). MSDR was determined as the maximum minus the minimum acceleration in systole over the corresponding time interval (Figure 1a). Aortic growth rate (GR) was defined as the difference between final and initial aortic diameters obtained by angio-CT over the period of follow-up. Population was divided into tertiles based on GR.

Results

Demographic, clinical variables or basal aortic diameter did not show differences among GR groups (Table 1). MSDR was statistically different in patients with a GR <1mm/year (group 1) compared to fast-dilating patients (groups 2, 3) (Figure 1c). MSDR showed a positive linear correlation with GR resulting in a Pearson's correlation of 0.481 (p=0.008) (Figure 1b).

Table 1. Demographic and other variables Tertile 1 Tertile 2 Tertile 3 p-value Age (year) 63.4 (±13.5) 62.5 (±13.6) 64.6 (±6.7) 0.902 BSA (m2) 2.0 (±0.2) 1.8 (±0.2) 1.9 (±0.1) 0.213 Men 6 (86%) 4 (57%) 4 (100%) 0.210 Hypertension 4 (66%) 5 (71%) 4 (100%) 0.438 Atherosclerosis 1 (17%) 1 (14%) 0 (0%) 0.699 Initial diameter 45.0 (±7.69) 36.0 (±4.2) 37.0 (±6.5) 0.078 Final diameter 49.5 (±6.74) 44.9 (±5.7) 59.2 (±9.8) 0.049* Follow-up (year) 11.8 (±8.79) 7.9 (±3.3) 8.1 (±4.0) 0.921 Aortic GR (mm/year) 0.3 (±0.3) 1.2 (±0.3) 2.6 (±1.0) 0.001* MSDR (cm/s3) 1212 (±468) 2411 (±1034) 2558 (±1098) 0.005* Values are mean (±SD) or n (%).

Conclusion

MSDR of flow in the FL derived from 4D-flow RM is related to GR of dissected descending aorta. It is useful to discriminate mild vs. significant aorta enlargement and identify patients who may benefit from earlier therapy.

P1821Proximal aorta longitudinal but not circumferential strain predicts aortic events and aortic root dilation rate in marfan syndrome patients

Background

The most common cardiovascular complications in Marfan syndrome (MFS) are aortic root dilation and type A aortic dissections. Elective aortic root surgery is indicated when maximum aortic diameter is larger than a defined threshold or in the case of fast-progressing dilation. However, maximum aortic diameter is limited for the prediction of aortic events. Indeed, a large international registry of acute aortic syndromes reported that as much as 40% of aortic dissections happen with maximum aortic diameter lower than 50 mm. Consequently, there is a need for new, non-invasive biomarkers to improve the prediction of aortic complications.

Purpose

The aim of the present study was to assess if proximal aorta circumferential and longitudinal strain and ascending aorta distensibility were associated with progressive aortic dilation and incidence of aortic events in Marfan syndrome patients.

Methods

Eighty seven Marfan syndrome patients free from previous cardiac/aortic surgery or dissection, were prospectively included in a multicenter follow-up. Patients were diagnosed by original Ghent criteria. Proximal aorta longitudinal and circumferential strain and distensibility were computed from baseline cine CMR images by means of feature-tracking. The predictive capacity of each stiffness biomarkers was separately tested with multivariable linear regression analysis (aortic growth) and with Cox logistic regression analysis (aortic events), both corrected for clinical and demographic variables, including baseline maximum aortic diameter.

Results

During a follow-up of 81.6±17 months, mean diameter growth-rate was 0.65±0.67 mm/year and z-score growth rate was 0.07±0.13 / year. Elective aortic root replacement was performed in 11 patients while two patients presented type A aortic dissection.Baseline proximal aorta longitudinal strain was independently related to diameter growth-rate (p=0.001), z-score growth-rate (p=0.018) and aortic events (p=0.018). Conversely, neither circumferential strain nor distensibility were independent predictors of diameter growth-rate (p=0.385 and p=0.381, respectively), z-score growth-rate (p=0.515 and p=0.484, respectively) and aortic events (p=0.064 and p=0.205, respectively).

Conclusions

Proximal aorta longitudinal strain predicts aortic root dilation and major aortic events in Marfan syndrome patients beyond aortic root diameter and clinical and demographic characteristics.

Acknowledgement/Funding

ISCIII PI14/0106, La Maratό de TV3 (20151330) and CIBERCV. Guala A. FP7/People n° 267128

P1475Risk stratification after STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Introduction

Cardiac magnetic resonance (CMR) has emerged as the most potent non-invasive imaging technique for risk stratification after ST-segment elevation myocardial infarction (STEMI) but an indiscriminate use in all patients is unfeasible. Echocardiography (Echo) has been universally used for prognostication in this scenario. We hypothesized that left ventricular ejection fraction (LVEF) by Echo can represent the gatekeeper for selecting those patients who benefit most from CMR for prognostic purposes.

Methods

Data were obtained from a large prospective registry of reperfused STEMI patients (n=516) in whom Echo (2D and Doppler variables) and CMR (cine images, microvascular obstruction and infarct size) were simultaneously recorded at pre-discharge (7±2 days). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (whichever occurred first). Patients were categorized in reduced LVEF (r-LVEF, <40%), mid-range LVEF (mr-LVEF, 40–49%) and preserved LVEF (p-LVEF, ≥50%). Hierarchical multivariate Cox regression analyses including first clinical+Echo variables and then CMR variables where carried out. C-statistics, “net reclassification” (NRI) and “integrated discrimination” (IDI) indexes were obtained.

Results

During a mean and median follow-up of 4 years, 86 first MACE (17%) were registered (39 deaths and 47 re-admissions for acute heart failure). In the whole study group (n=516), the independent predictors of MACE were time to revascularization (min), GRACE score, CMR-LVEF (%) and CMR-microvascular obstruction (% of LV mass); C-statistic 0.82 (p<0.001). The MACE rate in patients with r-LVEF, mr-LVEF and p-LVEF was 47%, 23% and 11% by Echo-LVEF and 45%, 17% and 8% by CMR-LVEF. LVEF was lower by CMR than by Echo (51±13 vs. 54±10, p<0.001) and r-LVEF was more frequently detected by CMR (n=94, 18%) than by Echo (n=48, 9%), p<0.001. CMR significantly improved clinical+Echo stratification in those 112 patients (22%) with mr-Echo-LVEF (C-statistitics 0.74 vs 0.82; NRI and IDI: p<0.05) but it did not in those 355 patients (69%) with p-Echo-LVEF (C-statistitics 0.75 vs 0.76; NRI and IDI: non-significant) and in those 49 patients (9%) with r-Echo-LVEF (C-statistitics 0.77 vs 0.77; NRI and IDI: non-significant).

Figure 1. Risk stratification after STEMI

Conclusions

Applied in an individualized manner, Echo-LVEF appears as a useful gatekeeper for a selective use of CMR soon after STEMI for prognostic purposes. The event rate is high in patients with reduced Echo-LVEF and low in those with preserved Echo-LVEF; CMR does not seem to significantly improve risk stratification in these scenarios. Nevertheless, the occurrence of mid-range Echo-LVEF permits discriminating the specific subset of STEMI patients (less than a quarter) who really benefit from pre-discharge CMR in terms of risk assessment.

Acknowledgement/Funding

Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).

P5555Predictors of systemic embolisms in a large cohort of left ventricular noncompaction patients

Background

Left ventricular noncompaction (LVNC) is associated with an increased risk of systemic embolisms (SE). However, incidence and risk factors are not well established.

Purpose

To evaluate the rate of SE in LVNC and describe risk factors.

Methods

LNVC patients were included in a multicentric registry. Those with SE were considered for the analysis.

Results

514 patients with LVNC from 10 Spanish centres were recruited from 2000 to 2018. During a median follow-up of 4.2 years (IQR 1.9–7.1), 23 patients (4.5%) had a SE. Patients with SE (Table 1) were older at diagnosis, with no differences in gender and had similar cardiovascular risk factors. They were more frequently under oral anticoagulation (OAC). Besides, they had a more reduced LVEF, and more dilated LV and left atrium (LA). Late gadolinium enhancement (LGE) was more frequent, altogether suggesting a more severe phenotype.

Patients with SE had non-significantly higher rates of hospitalization for heart failure (33% vs 24%, p=0.31) and atrial fibrillation (35% vs 19%, p=0.10). In multivariate analysis, only LA diameter was an independent predictor of SE (OR 1.04, p=0.04). A LA diameter>45 mm had an independent 3 fold increased risk of SE (OR 3.04, p=0.02) (Image 1).

Table 1 Systemic embolisms (n=23) No systemic embolisms (n=491) p Men, n (%) 15 (65) 289 (56) 0.52 Median age at diagnosis (IQR), yr 60 (48–76) 48 (30–64) 0.02 Median follow up (IQR), yr 5.9 (3.1–7.8) 4.2 (1.8–7.1) 0.18 Hypertension, % 8 (33) 118 (24) 0.31 Diabetes mellitus, % 3 (14) 39 (8) 0.41 OAC, % 19 (83) 118 (24) 0.01 LVEF (SD), % 37 (15) 48 (17) 0.01 LVEDD (SD), mm 58 (11) 54 (10) 0.04 LVESD (SD), mm 45 (13) 38 (11) 0.01 LA diameter (SD), mm 46 (9) 39 (9) 0.01 LVEDV CMR (SD), mL 193 (75) 163 (70) 0.12 LVESV CMR (SD), mL 121 (64) 85 (64) 0.04 LGE, % 9 (40) 88 (18) 0.04

Conclusions

LVNC carries a moderate mid-term risk of SE, which appears to be irrespective of atrial fibrillation and associated with age, LV dilatation and systolic dysfunction and mainly LA dilatation. This subgroup of patients should be considered for oral anticoagulation in primary prevention.

477Partial fusion of two aortic valve leaflets is related to alterations in ascending aorta flow: 4D flow CMR study

Introduction

Bicuspid aortic valve (BAV) is the most common congenital valve defect. It consists in the fusion of two aortic valve leaflets, and it is associated with a high prevalence of proximal aorta dilation. Dilation is highly prevalent (around 30%) in BAV patient relatives with a tricuspid valve (TAV) identified by echocardiography. However, the presence of partial aortic valve leaflet fusion (also called mini-raphe or forme fruste BAV, see figure 1A) is easily missed by echocardiography. A recent study reported that 44% of patients from a small cohort of BAV patient relatives with aortic dilation followed by CT showed mini-raphe.

Purpose

We aimed to use 4D flow CMR to assess if the presence of mini-raphe is associated with aortic flow alterations, which may be concurs in the etiology of aortic dilation in BAV patient relatives.

Methods

Twenty BAV patients first-degree relatives with partial fusion (<50%) of aortic valve leaflets and proximal aorta dilation were identified by CT or cine CMR and prospectively included. One-hundred twenty-five BAV and 95 patients with TAV from our prospective dataset of 4D flow CMR were included for comparison. Propensity score matching was used throughout the study to correct the comparisons between mini-raphe and BAV and mini-raphe and TAV patients for differences in age, maximum aortic diameter, sex, height, weight, proximal aortic pulse wave velocity and, only for BAV, fusion pattern. The hemodynamic parameters previously related to aortic dilation were computed. They were jet angle, normalized flow displacement and systolic flow reversal ratio (SFRR, identifying through-plane vortexes) were computed and compared in the ascending aorta and in the aortic arch.

Results

The presence of mini-raphe was statistically-significantly associated with increase in jet angle (Figure 1B), flow displacement (Figure 1C) and vortexes (Figure 1D) in most of the ascending aorta and aortic arch when mini-raphe patients were compared with TAV patients. The severity of flow asymmetry found in mini-raphe patients was lower than the one characteristic of BAV patients, but vortexes were even higher in a small region at the distal ascending aorta.

Figure 1

Conclusion

Partial fusion of the aortic valve leaflets is related to increase in proximal aorta flow eccentricity and vorticity. These flow abnormalities are not as marked as those associated with BAV. Data regarding prevalence of mini-raphe as evaluated with CT or cine CMR are needed, especially in familiar of BAV patients.

Acknowledgement/Funding

European FP7/People 267128; Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1 and Instituto de Salud Carlos III PI14/0106

P5596Something is moving in acute aortic syndrome management and mortality. Results of Spanish registry of acute aortic syndrome (RESA-III)

Background

The impact of recent advances on the management of acute aortic syndrome (AAS) is usually reported by centres with great experience in aortic diseases. Current data on the management of this specific disease in Spain remains unknown.

Purpose

The Spanish Registry of Acute Aortic Syndrome (RESA-III) was established to assess current results in the management of AAS in a large cohort of hospitals from the same geographical area.

Methods

All patients admitted for AAS to 29 Spanish tertiary hospitals were enroled over 18 months (2017/2018).

Results

574 patients, (68% men; mean age 64±14y; range 18–99) were prospectively and consecutively included. Aortic dissection was the underlying disease in 474 (82.6%) (375 type A, 99 type B), aortic haematoma in 76 (13.2%) (43 type A and 33 type B) and penetrating ulcer in 24 (4.2%) (7 type A and 17 type B). From the subgroup of type A AAS (74% n=425), 81% underwent surgical treatment and medical management was chosen in the remaining 19%. 78 patients did not undergo surgery principally because of severe comorbidities (n=34) or advanced age (n=24), patient refusal (n=7), or presence of an intramural haematoma (n=2). Regarding the cohort of patients with type B AAS (26% n=149), 52% were managed only medically, 37% with endovascular treatment, and 11% underwent open surgery. Endovascular treatment was indicated owing to recurrent pain (n=19), progressive vessel dilation (n=9), dissection expansion (n=5), peripheral (n=5) or visceral ischaemia (n=4), high blood pressure (n=18), peripheral bleeding (n=17) or haemodynamical instability (n=8).

Overall type A mortality during hospitalisation was 36.4%; 26.4% in surgically treated and 79.4% in medically-treated patients (p=0.001). In type B AAS, overall mortality was 19.1%; 21.9% in the treated medically subgroup, 43.8% in those treated with open surgery and 7.8% in the endovascular treatment cohort (p=0.004).

Conclusion

Despite significant advances in acute aortic syndrome diagnosis and management, in-hospital mortality remains high. In type A AAS, medical management rate was too high (19%); however, in type B AAS, endovascular treatment yielded excellent results with less mortality than medical management (7.8% vs 19.1%, respectively). Our data support the need for continued improvement in the management of acute aortic syndrome.

4936Cardiac magnetic resonance strain analysis predicts functional recovery following acute ST-segment elevation myocardial infarction

Background

Late gadolinium enhancement (LGE) is the clinical reference standard for estimation of infarct extension and prediction of functional recovery following reperfused acute ST-segment elevation myocardial infarction (STEMI). Nevertheless, myocardial edema, microvascular obstruction and intramyocardial hemorrhage as well as the timing of image acquisition after contrast administration may influence the extent of LGE and underestimate the potential for recovery. Dobutamine stress testing has been recommended to more accurately predict functional recovery when infarct transmurality is between 25 to 75%. We hypothesized that cardiac magnetic resonance (CMR) tissue tracking strain analysis may provide additional value to LGE for the prediction of functional recovery.

Methods

In 370 patients with STEMI who underwent successful primary percutaneous revascularization and were studied with CMR within 3–5 days of the event, peak systolic longitudinal (LS), circumferential (CS) and radial (RS) strain were analyzed with routine SSFP images of 3 long-axis and a stack of short-axis slices (Tissue Tracking, CVI42®, Figure panel A and B). Inversion-recovery echogradient sequences were analyzed 20 minutes after contrast administration for LGE transmurality (Panel C). All per-segment analysis was performed according to the AHA 16-segment model. CMR was repeated at 6 months and functional recovery was defined as persistent normokinesia or improvement of wall motion score from baseline to 6-month CMR.

Results

At baseline CMR, of a total of 5920 segments 70.4% were normokinetic, 7.2% were hypokinetic, 21.9% were akinetic and 0.6% were dyskinetic. All strain parameters decreased significantly with worsening wall motion. At follow-up, 81.5% of the segments showed functional recovery. All strain parameters were significantly associated with functional recovery (p<0.001) and showed higher predictive value for improvement of wall motion than LGE transmurality (ROC AUC 0.713 LS, 0.710 CS, 0.683 RS and 0.660 LGE). For basal CMR dysfunctional segments, a CS <−10.7% showed the highest accuracy (66%) to predict wall motion improvement, with 58% sensitivity, 76% specificity, 75% positive predictive value (PPV) and 59% negative predictive value (NPV). These results were comparable to LGE transmurality <50% (65% accuracy, 59% sensitivity, 73% specificity, 74% positive predictive value and 58% negative predictive value). Nevertheless, adding CS analysis to a 50% LGE transmurality cutoff was the best combination for prediction of functional recovery and increased the overall accuracy to 70%, with 76% sensitivity, 64% specificity, 65% PPV and 75% NPV.

CS analysis in an inferior STEMI

Conclusions

Acute CMR tissue tracking strain analysis complements LGE assessment for prediction of functional recovery following an STEMI. The combination of LGE infarct transmurality under 50% and a CS strain higher than −10.7% showed the highest accuracy for prediction of recovery of function.

P3373Predictors of dilatation of ascending aorta in patients with bicuspid aortic valve, a longitudinal multicenter study

Introduction

The bicuspid aortic valve (BAV) is frequently associated to dilation of the ascending aorta. Some cross-sectional studies have related the aortic dilation with morphotype and valvular dysfunction. The aim of this longitudinal multicenter study was to analyze the progression of the aortic dilation and to identify its predictors.

Methods

We included 459 patients (mean age 52±17; 325 men 70.8%) with BAV, without aortic coarctation. The BAV morphotype, significant valvular dysfunction and dilation of the aortic root and ascending aorta were established by echocardiography. The patients were followed annually, with an average of 7.5±3.2 years.

Results

77% of the patients had BAV with a fusion between left and right cusps, 21% between right and non coronary cusps and 2% between left and non coronary cusps, with a raphe in 77% of these patients. Risk factors included: 35% hypertension, 20% smoking, 5% diabetes and 18% dyslipidemia. The baseline study showed a maximum root diameter of 36±6.2 mm and ascending aorta of 39±8.1 mm. In 7% the aortic root was>45 mm, while in 32% the ascending aorta>45 mm. There was no valvular dysfunction in 17% of patients, while the 8% had significant aortic stenosis and 35% significant aortic regurgitation. The annual growth of the aortic root was 0.33±0.2 mm and for the ascending aorta was 0.38±0.3 mm. At the end of follow-up, 16% of the patients had a root>45 mm and 41% an ascending aorta>45 mm. The annual progression of aortic diameters was not related to valvular morphotype, valvular dysfunction or cardiovascular risk factors. The univariate analysis showed a significant relationship between the annual growth of the aortic root and arterial hypertension (p=0.028) and the annual growth of the ascending aorta with the male sex (p=0.019), smoking (p=0.046) and significant (moderate or severe) aortic stenosis (p=0.013). Diabetes mellitus and the presence of raphe were found to be slightly protective (p=0.049 and p=0.031, respectively). In the multivariate analysis, only the male sex and significant aortic stenosis were independent predictors of dilation of the ascending aorta.

Conclusions

In patients with bicuspid aortic valve, the progression of the dilation of the aortic root is related to hypertension and the growth of the ascending aorta with the male sex and the presence of significant aortic stenosis. Both bicuspid valve morphotype, basal aortic diameter or age were not related to the progression of aortic dilation.

P6397Ejection fraction by cardiac magnetic resonance 6 months after STEMI: impact on risk stratification in chronic phase

Background

Left ventricular ejection fraction (LVEF) has traditionally been used as the cornerstone for risk stratification after STEMI and it can be accurately quantified by cine cardiovascular magnetic resonance (CMR). In recent years, the additional prognostic value of contrast CMR-derived infarct size (IS) and microvascular obstruction (MVO) soon after infarction has been demonstrated. The usefulness of CMR-derived LVEF in chronic phase for risk stratification late after STEMI is unclear.

Purpose

We hypothesized that 6-month CMR-derived LVEF can contribute in the prediction of clinical events late after STEMI beyond pre-discharge LVEF, IS and MVO.

Methods

Data were obtained from a prospective registry of reperfused STEMI patients (n=456) who were stable 6 months after infarction and in whom 1-week and 6-month CMR-derived LVEF, IS and MVO were sequentially quantified. Major adverse cardiac events (MACE) were defined as a combined clinical end-point that included death or re-admission for acute decompensated heart failure (r-ADHF), whichever occurred first, occurring after the 6-month CMR.

Results

During a mean and median follow-up of 6 years, 56 late MACE (12%, 32 deaths and 24 r-ADHF) were registered. From 1-week to 6-month, CMR parameters exhibited significant dynamic changes (p<0.001): LVEF improved (52±12 vs. 56±13%), IS decreased (21±14 vs. 18±12% of LV mass) and MVO vanished (2±4 vs. 0±1% of LV mass). At 6-month CMR, 60 patients (13%) displayed reduced LVEF (<40%), 69 (15%) mid-range LVEF (40–50%) and 327 (72%) preserved LVEF (≥50%). Late MACE rates were 28% in patients with reduced LVEF, 14% in those with mid-range LVEF and 9% in those with preserved LVEF at 6-month CMR (p<0.001 for the trend). After adjustment for baseline characteristics and for 1-week and 6-month CMR parameters, more preserved LVEF at 6 months independently associated with a lower risk of MACE late after STEMI (hazard ratio 0.96 [0.94–0.98] per 1% increase).

Conclusions

Dramatic dynamic changes occur in CMR parameters within the first months after STEMI. Reassessment of CMR-derived LVEF in chronic phase in those patients who remain stable provides relevant prognostic information for long-term risk stratification.

Acknowledgement/Funding

Funded by “Instituto de Salud Carlos III”/FEDER (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and Generalitat Valenciana (GV/2018/116).

Prognostic Value of Initial Left Ventricular Remodeling in Patients With Reperfused STEMI

OBJECTIVES

This study sought to establish the best definition of left ventricular adverse remodeling (LVAR) to predict outcomes and determine whether its assessment adds prognostic information to that obtained by early cardiac magnetic resonance (CMR).

BACKGROUND

LVAR, usually defined as an increase in left ventricular end-diastolic volume (LVEDV) is the main cause of heart failure after an ST-segment elevated myocardial infarction; however, the role of assessment of LVAR in predicting cardiovascular events remains controversial.

METHODS

Patients with ST-segment elevated myocardial infarction who received percutaneous coronary intervention within 6 h of symptom onset were included (n = 498). CMR was performed during hospitalization (6.2 ± 2.6 days) and after 6 months (6.1 ± 1.8 months). The optimal threshold values of the LVEDV increase and the LV ejection fraction decrease associated with the primary endpoint were ascertained. Primary outcome was a composite of cardiovascular mortality, hospitalization for heart failure, or ventricular arrhythmia.

RESULTS

The study was completed by 374 patients. Forty-nine patients presented the primary endpoint during follow-up (72.9 ± 42.8 months). Values that maximized the ability to identify patients with and without outcomes were a relative rise in LVEDV of 15% (hazard ratio [HR]: 2.1; p = 0.007) and a relative fall in LV ejection fraction of 3% (HR: 2.5; p = 0.001). However, the predictive model (using C-statistic analysis) failed to demonstrate that direct observation of LVAR at 6 months adds information to data from early CMR in predicting outcomes (C-statistic: 0.723 vs. 0.795).

CONCLUSIONS

The definition of LVAR that best predicts adverse cardiovascular events should consider both the increase in LVEDV and the reduction in LV ejection fraction. However, assessment of LVAR does not improve information provided by the early CMR.