Left atrial reservoir strain may be a load independent index of diastolic dysfunction in liver cirrhosis patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction. Specifically, diastolic dysfunction has been correlated with the prognosis in liver cirrhotis patients independently of the disease severity. Left atrial reservoir strain (LASr) is a novel index which is inversely correlated with left ventricular end-diastolic pressure, but has not been adequately studied in cirrhotic patients.

Purpose

To investigate the correlations between LASr and diastolic function or disease severity in cirrhotic patients.

Methods

  Echocardiographic analysis of 51 consecutive cirrhotic patients was performed and images were analyzed off-line. LASr was calculated semi-automatically using dedicated software and was feasible in 49 patients.  Clinical and biochemical examination was used to assess severity of liver disease by calculating MELD-Na score.

Results

Mean age was 58.0± 8.6 years, 37 (75.5%) were males, mean MELD-Na score was 15.6 ±7.5 and mean LASr was 39.7 ±12.5. LASr correlated with age (r=-0.415, p = 0.003), LAVI (r=-0.329, p = 0.022), e’ (r = 0.476, p = 0.001), E/e (r=-0.401, p = 0.004) and GLS (r=-0.388, p = 0.006), but not with ejection fraction, stroke volume or MELD-Na score.  MELD-Na score correlated with ejection fraction (r = 0.316, p = 0.029), stroke volume (r = 0.549, p < 0.001), left atrial volume index (r = 0.575, p < 0.001), GLS (r = 0.521, p < 0.001), right atrial end systolic area (r = 0.368, p = 0.011) and right ventricular diameter (r = 0.541, p < 0.001) reflecting high cardiac output state in patients with advanced cirrhosis. LASr was significantly lower in patients with E/e’ >14 (22.5 ± 13.6) when compared to patients with E/e’ 8-14 (37.3± 10.6, p = 0.039) and E/e’<8 (44.7± 12.0, p = 0.003). The two latter groups also differed significantly (p = 0.034). LASr correlation with E/e’ was the only statistically significant correlation in a multiple regression model including left ventricular end diastolic volume, ejection fraction and left atrial volume (B=-1.371, P = 0.023). Correlation of LASr with MELD-Na score remained non-significant.

Conclusion

LASr correlates inversely with E/e’ ratio in liver cirrhotic patients, but does not correlate with load dependent echocardiographic parameters and disease severity. Hence in this special population, LASr may be an earlier and more specific index of diastolic dysfunction than traditional echocardiographic indices. Further studies are needed to examine the prognostic significance of LASr in cirrhotic patients.

Correlation of global longitudinal strain with disease severity in liver cirrhosis

Funding Acknowledgements

Type of funding sources: None.

Introduction/purpose

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction and has been correlated with cirrhosis severity and prognosis. Global longitudinal strain (GLS) is a sensitive marker of cardiac dysfunction which is considered relatively independent of preload and afterload conditions and thus may be of high diagnostic significance in this special population. We sought to investigate alterations of GLS relating to disease severity in cirrhotic patients.

Methods

Echocardiographic analysis of 51 consecutive cirrhotic patients was performed. Images were acquired and analyzed off-line. GLS was calculated with a semi-automatic way using dedicated software.  Clinical and biochemical examination were used to assess severity of liver disease by calculating Child-Pugh class (class C patients have more severe disease than class B and A patients) and MELD-Na score (increased score as the disease progresses).

Results

Mean age was 58.4 ± 8.7 years, 38 (74.5%) were males. Among patients, 22 (43.1%) were Child-Pugh class A, 17 (33.3%) Child-Pugh B and 12 (23.5%) Child-Pugh C and mean MELD-Na score was 15.3 ± 7.5. Mean left ventricular end-systolic volume (LVEDV) was 117 ± 29ml, mean stroke volume (SV) 72.5 ± 19.9ml , mean left ventricular ejection fraction (LVEF) 61.0 ± 5.0%, mean systolic blood pressure (SBP) 128 ± 13mmHg, mean ratio of peak transmitral to peak annular (septal) velocity during early diastole (E/e’ ratio) 10.4 ± 4.5, mean left atrial volume index (LAVI) 37.4 ± 11.8 ml/cm2  and mean GLS -21.6 ± 2.6%. GLS of Child-Pugh class A patients (-20.3 ± 2.4) was higher (less negative) than GLS of Child-Pugh class B (-22.2 ± 2.2) and class C (-23.0 ± 2.8) patients. Difference between groups B and C was non-significant (figure). Severity of cirrhosis as determined by higher MELD-Na score correlated with LAVI (r = 0.592, p < 0.001), SV (r = 0.554, p < 0.001), GLS (r=-0.441, p = 0.001) and LVEDV (r = 0.428, p = 0.002). GLS correlated with SV (r=-0.369, p = 0.008) but not with preload (LVEDV), or afterload (SBP). In a linear regression model, GLS was independently associated with Meld-Na score when adjusting for age, SBP, LVEDV and NASH etiology [B=-0.139 (-0.252; -0.025), p = 0.018].

Conclusions

GLS is lower (more negative) in patients with liver cirrhosis as disease progresses a relation not affected by preload and afterload conditions. Further research works are required to explain the underlying pathophysiology and to assess prognostic significance of reduced GLS values in patients with advanced cirrhosis.

Abstract Figure. GLS stratified by Child-Pugh score

P4983Safety of dobutamine stress contrast echocardiography; a single-center experience of 15 years

Introduction

Dobutamine stress contrast echo (DSCE) is an accurate method for the diagnosis of coronary artery disease (CAD). Scarcity of serious adverse events has led to its establishment as a popular method for the diagnosis of CAD and to its increased use beyond CAD. However, data regarding the safety of single-line dobutamine and contrast infusion are limited. The aim of our study was to assess the safety of a DSCE protocol using a single line of intravenous access.

Methods

Over a 15-year period (2004–2018), 34,675 patients underwent DSCE in our department, which was performed using 10–20–30–40–50 μg/kg/h of dobutamine with dosage increase every three minutes, while atropine up to 1mg could also be administered. Two commercially available contrast agents were used at rest and at peak in all patients and a single intravenous line was used for infusion of dobutamine, atropine and contrast agents. Demographic data, risk factors and information concerning the most common cardiovascular or allergic adverse events were available for all patients. Finally, the adverse events of DSCE were compared with respective events reported by relevant studies in order to determine the safety of our method.

Results

Mean age of patient population was 63.9 (SD: 11.4 years), while 67.9% of patients (n=23,544) were males. There were 22,731 hypertensive patients (65.6%), 9,256 diabetics (26.7%), 21,683 patients (62.5%) had dyslipidemia, 11,760 (33.9%) were smokers and 10,437 (30.1%) had a positive family history of CAD. Adverse events were reported in 876 patients (2.5%). Allergic reaction was reported in 69 patients (0.2%). We recorded 643 patients (1.85%) with non-sustained VT or frequent premature ventricular ectopic beats and 154 patients (0.44%) with AF or SVT episodes leading to protocol termination. In 24 patients (0.07%) with sustained VT, antiarrhythmic drugs were given intravascularly, while in 10 patients (0.03%) with VT or VF, resuscitation was needed. No death was reported. Frequency of life threatening adverse events reported by relevant studies did not differ significantly when compared to the present results.

Conclusion

DSCE protocols involving single line infusion of dobutamine, atropine and ultrasound enhancing agents are safe, since adverse event rates are low and do not differ significantly to rates reported for unenhanced DSE by other relevant studies. Implementation of such protocols in clinical practice may increase patient comfort and cost-effectiveness and should therefore be encouraged.

P1503Decrement of vortex formation time during dobutamine stress echo

Background

Vortex Formation Time (VFT) is a novel index of systolic and diastolic function which may be also affected by left ventricular geometry, but has never been evaluated during dobutamine stress echocardiography (DSE) protocols. We sought to investigate the changes in VFT during DSE protocol.

Methods

DSE was performed in 50 consecutive patients. Patients with poor acoustic window, atrial fibrillation, cardiac valve disease or pacemaker were excluded. Apical four and apical two chamber views were acquired and the following parameters were calculated off- line without knowledge of DSE result both at rest and at peak: left ventricular end-diastolic and end-systolic volume, stroke volume, ejection fraction, stroke work, e and a wave peak velocity and VTI, TDI-derived mitral annular early diastolic velocity at the lateral wall and mitral valve diameter. VFT calculated according to the following equation: VFT = [4 *(1 − β) * α3 * EF]/π, where α = (LVEDV/α3)(1/3) and is affected by ventricular geometry and β = VTIa-wave/(VTIe wave + VTIa-wave) reflecting the atrial filling fraction.

Results

Median age of the study population was 61 [53–72], 38 men (76%) and 13 (26%) had an old myocardial infarction. Fifteen patients (30%) were positive for myocardial ischemia during DSE. At rest, median LVEDV was 121.5ml (101.8–148.0), median EF (%): 59.9 [54.4–64.1], median atrial filling fraction: 0.43 [0.40–0.48], median mitral valve diameter (cm): 2.8 [2.6–3.0] and median VFT: 2.44 [1.74–3.10]. At peak, median LVEDV was 102.0ml [86.4–122.3] median EF (%) 65.7 [58.8–69.8], median atrial filling fraction: 0.67 [0.59–0.73], median mitral valve diameter (cm): 2.7 [2.5–2.9] and median VFT: 1.45 [1.05–1.88]. VFT decreased in the whole population (Wilcoxon rank test, p<0.001) (figure 1A) and when patients were stratified according to test result. Median VFT decrease was significantly higher in patients with a positive DSE (50%) than in patients with negative DSE (39%) (Mann- Whitney U test, p=0.048) (figure 1B).

Figure 1

Conclusion

The VFT decreased significantly during DSE and most prominently in patients with ischemic response. This may indicate the deterioration of left ventricular diastolic or systolic function as well as change in left ventricular geometry during DSE protocol.