Is pulmonary artery wedge pressure a reliable surrogate of left ventricular end-diastolic pressure during exercise for diagnosing HFpEF in patients with unexplained dyspnea?

Background

Left ventricular end-diastolic pressure (LVEDP) is the gold-standard for the assessment of LV filling pressure. For practical reasons, pulmonary artery wedge pressure (PAWP) is used as a surrogate for LVEDP. However, the interposition of the left atrium (LA) may account discrepancies between LVEDP and PAWP. The imprecision of both end-diastolic (or mid-A) and mean PAWP estimates for LVEDP has been widely described for cardiac catheterization at rest. PAWP measurement during exercise has been advocated to discriminate heart failure with preserved ejection fraction (HFpEF) from non-cardiac dyspnea, with an end-expiratory pathologic threshold ≥25 mmHg. However, a formal comparison of PAWP (either mid-A or mean PAWP) vs LVEDP during exercise has never been performed.

Aim

To compare LVEDP and PAWP during exercise.

Methods

We retrospectively analyzed consecutive patients with unexplained dyspnea and a normal LV ejection fraction, who had a clinical indication of right and left heart catheterization at rest and during exercise to assess unexplained dyspnea. Patients with mitral regurgitation ≥ moderate were excluded. Hemodynamic measurements were always taken at end-expiration.

Results

Forty-six consecutive patients were included in the analysis (80% with a peak mean PAWP ≥25 mmHg). We found a good correlation between both mid-A and mean PAWP on one side, and LVEDP on the other side (R2>0.55). At peak exercise, mid-A PAWP had no bias as compared with LVEDP, while mean PAWP slightly overestimated LVEDP by 1–2 mmHg. However, confidence intervals were quite large (Figure 1), suggesting imprecision of PAWP estimates for LVEDP in the individual patient. A disagreement between mean PAWP and LVEDP, using a threshold of ≥25 mmHg for both variables at peak exercise, was found in 11% of patients. In 4% of them, mean PAWP was ≥25 but LVEDP <25 mmHg, due to the appearance of tall V waves in the PAWP position (LA stiffness), increasing PAWP above LVEDP. In the remaining 7%, LVEDP was ≥25 but PAWP <25 mmHg. The latter patients, in whom HFpEF would have not been diagnosed based on peak PAWP alone, showed a PAWP increase during exercise relative to cardiac output changes (PAWP/CO slope) >2 mmHg/L/min, as an alternative parameter suggesting HFpEF.

Conclusions

In patients with unexplained exertional breathlessness, both mid-A and mean PAWP showed good correlation with LVEDP during exercise with minimal average bias, but their ability to estimate LVEDP was burdened by a relevant imprecision. Therefore, when in these patients peak PAWP is <25 mmHg, its assessment might need to be complemented by additional measurements (including LVEDP or PAWP/CO slope) to maximize the diagnostic power of exercise cardiac catheterization in identifying HFpEF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Cardiac magnetic resonance feature-tracking analysis of left atrial volumes and function in standard vs left-atrial focused images

Background

Left atrial (LA) volume and function have shown prognostic value in several cardiac conditions. Routine cardiac magnetic resonance (CMR) evaluation of the LA is obtained from standard 2- and 4-chamber long-axis cine images focused on the left ventricle. Previous echocardiographic data showed that LA-focused apical views provide a more accurate estimation of LA maximum volume, as compared to standard apical images. CMR LA-focused imaging could improve the accuracy of LA morpho-functional analysis. CMR feature-tracking (CMR-FT) analysis is emerging as a feasible semi-automatic tool for the evaluation of LA volumes and function.

Purpose

To investigate the potential of LA-focused CMR cine images using LA CMR-FT analysis.

Methods

100 consecutive patients clinically referred to CMR were included in this prospective, observational, multicenter study. LA volumes (LAVmax, LAVmin), emptying fraction (EF), atrial strain reservoir (ɛs), conduit (ɛe), booster (ɛa) and strain rate reservoir (SRɛs) were calculated by CMR-FT analysis on both standard and LA-focused 2- and 4-chamber long-axis cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method (RefMeth) for LA volumes and EF.

Results

In comparison to the RefMeth, the standard acquisitions underestimated LA volumes (LAVmax: bias = −8ml, LOA = +20, −35ml; LAVmin: bias = −6 ml, LOA = +15, −27ml) and slightly overestimated EF (bias = +3%, LOA = +17, −11%). Conversely, LA-focused images provided a more accurate estimation (LAV max bias = −1ml, LOA = +11, −9ml; LAV min bias = −2ml, LOA = +12, −7ml) and EF (bias = −2%, LOA = +9, −12%). All three LA strain (εs: bias 7%, LOA = 25, −11%; εe: bias 4%, LOA = 15, −8%; εa: bias 3%, LOA = 14, −8%) and SRεs (bias 0.2 s–1, LOA = 1.13, −0.7 s–1) were significantly higher in standard vs LA-focused images (all p<0.001).

Conclusions

Assessment of LA volumes using CMR-FT applied to dedicated LA-focused long-axis cine images is more accurate than the use of standard acquisitions. LA strain and SRɛs obtained from LA-focused images are significantly lower than those obtained from standard LA acquisitions, possibly due to the inclusion in LA-focused images of LA posterior wall, where pulmonary veins convey and atrial deformation is blunted.

Funding Acknowledgement

Type of funding sources: None.

Right heart adaptation during exercise in pulmonary arterial hypertension and in pulmonary hypertension due to heart failure with preserved ejection fraction

Background

Right heart failure (RHF) represents the final step of distinct diseases, such as pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF). RHF may be defined by the inability of the heart to maintain a normal cardiac output (CO) or to do so at the expense of high right atrial pressure (RAP), at rest or during exercise.

However, exercise hemodynamic features suggestive of RHF, as well as their determinants, have still not been defined.

Aim

We sought to i. define the limits of normal of RAP increase during exercise; ii. describe the behavior of RAP during exercise in PAH and in PH-HFpEF, and its relation to right heart afterload and preload.

Methods

We retrospectively analyzed data from consecutive patients referred for suspicion of PH, who underwent both a resting and exercise right heart catheterization at two centers with identical methodology. We included patients with PH-HFpEF or PAH. Right heart adaptation to exercise was described either using absolute or CO-normalized RAP increase during exercise (RAP/CO slope), this latter representing the inverse of the Frank-Starling reserve. A control cohort of subjects with normal hemodynamics at rest and during exercise served to define abnormal increase in RAP, i.e. values of RAP and RAP/CO slope > mean ± 2 standard deviation of controls.

Estimated stressed blood volume (eSBV), as a measure of effective preload, was computed using a commercially-available software.

Results

80 patients were included in the analysis, of which 29 were PH-HFpEF, 30 PAH and 21 controls.

HFpEF patients were older than PAH patients and with a higher burden of cardiovascular comorbidities (p<0.05). Sex representation, BMI, and NTproBNP values were similar in the two groups.

Mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and total vascular resistance (TPR) were higher in PAH than in PH-HFpEF both at rest and during exercise (p<0.01), in spite of similar CO (Table 1). At rest, eSBV did not differ between HFpEF and PAH, but it was higher in HFpEF at peak exercise.

On average, PH-HFpEF had higher resting and peak RAP than PAH, as well as higher RAP/CO slope (Figure 1).

The upper limit of normal of exercise RAP and of RAP/CO slope, as determined in control subject, was 12 mmHg and 1.55 mmHg/L/min. A higher rate of HFpEF patients, compared with PAH, had a RAP/CO slope and a peak RAP above normal limits (78% and 91% of PH-HFpEF vs 47% and 44% of PAH, respectively, p<0.001).

RAP/CO slope in the whole cohort was associated with eSBV but not with right ventricular afterload measures (PAP, TPR, PVR).

Conclusions

PH-HFpEF display more frequently a steeper increase of RAP during exercise than PAH patients in spite of similar CO, suggesting a more exhausted Frank-Starling reserve. The steep RAP increase during exercise seems to reflect a dysfunctional preload rather than an afterload-mismatch.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease

Background

Pulmonary hypertension (PH) is associated with a poor prognosis in patients with left heart disease (LHD). Several hemodynamic variables have been shown to predict outcome, including pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and the diastolic pressure gradient (DPG). We sought to provide an updated analysis on the association of these variables with prognosis in PH-LHD.

Methods

We performed a systematic literature review including studies reporting association measurements between DPG and/or PVR and/or PAC and death in PH-LHD patients. These hemodynamic variables were extracted to estimate the pooled hazard ratio (HR) of adverse outcome for each one, and cumulative meta-analysis was performed to investigate temporal trends in the effects reported in the literature as well as the impact of sample size.

Results

17 articles were identified, including 9716 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, we found that PVR (HR, 1.09; 95% CI: 1.06–1.12), DPG (HR, 1.02; 95% CI: 1.01–1.02) and PAC (HR, 0.73; 95% CI: 0.76–0.81) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG (Figure 1). Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD (either heart failure with preserved or reduced left ventricular ejection fraction, or valvular heart disease). Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018 (Figure 2).

Conclusions

Despite the heterogeneity of PH-LHD group and the intrinsic limitations of each variable, PVR, DPG, and PAC have an established prognostic value in PH-LHD. The strongest correlation with PVR and PAC supports their use in defining disease severity and identifying a subgroup of patients at higher risk of adverse outcome. We believe that these results are consistent through the years and unlikely to change with the addition of further studies.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Prognostic power of a new index of right ventricle-pulmonary artery coupling based on right ventricular volumes in patients with secondary tricuspid regurgitation

Background

Although echocardiographic surrogates of right ventricular -arterial coupling (RVAC) have been reported to be associated with outcome in patients with moderate or severe secondary tricuspid regurgitation (STR), pulmonary artery systolic pressure (SPAP) is difficult to be estimated using echocardiography in patients with severe STR.

Purpose

Accordingly, we evaluated the predictive power of indexes of RVAC obtained using RV volumes measured using three-dimensional echocardiography (3DE).

Methods

We prospectively enrolled 180 patients with moderate or severe STR and complete two-dimensional, Doppler and 3DE data. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome.

Results

After a median follow up of 24 months (IQR: 2–48), 72 patients (40%) reached the primary endpoint. Most of the echocardiographic parameters of RV function were associated with outcomes. Among the different parameters of RVAC, the receiver operating curve (ROC) analysis selected the ratio between (RV stroke volume [SV]-RegVol)/ RV End-systolic volume (ESV) (i.e. the RV forward SV/ESV) as the best predictor of the combined endpoint (AUC 0.80 [IC 95% 0.73–087]), with a threshold value of 0.49.

Event-free survival of patients with RV forward SV/ESV higher and lower 0.49 has been performed (Figure 1).

Multivariable Cox proportional hazards models were constructed (Figure 2). Adding sequentially the 3D-RVEF, TAPSE/SPAP and the forward RV SV/RV ESV on top of a basal model made of TR severity, New York Heart Association (NYHA) functional class and tricuspid anulus plane systolic excursion (TAPSE), the χ2 of the model increased from 40 to 43 (p=0.13) by adding 3D RVEF, from 43 to 46 (p=0.04) by adding TAPSE/SPAP, and from 46 to 51 (p=0.02) by adding RV forward SV/ESV. Severe TR (HR 3.53 [CI 95%: 1.84–6.78], p<0.001) and RV forward SV/ESV <0.49 (HR 2.45 [CI 95% 1.16–5.18], p=0.02) were the only parameters independently associated with outcome.

Conclusions

The RV forward SV/ESV is an index of RVAC obtained by 3DE which is independent from SPAP and it is strongly associated with the occurrence of death or heart failure hospitalization in patients with STR.

Funding Acknowledgement

Type of funding sources: None.

A meta-analysis of exercise hemodynamics in heart failure with preserved ejection fraction: the relevance of PAWP/CO slope

Background

Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current hemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise hemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects.

Methods

We performed a systematic literature review following the PRISMA statement until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all hemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP / cardiac output (CO) slope during exercise was extrapolated.

Results

Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, HfpEF cohorts showed a summary estimate of PAWP at peak which was twice as high as compared with control cohorts (30; 95% CI: 29–31 mmHg and 16; 95% CI: 15–17 mmHg, respectively), as well as of delta PAWP (15; 95% CI: 14–16 mmHg and 7; 95% CI: 6–8 mmHg, respectively), and of right atrial pressure (18; 95% CI: 16–19 mmHg and 8; 95% CI: 8–9 mmHg, respectively). These differences persisted after adjustment for age, sex, body mass index, body position. Additionally, summary estimates of PAWP at peak performed during supine exercise was slightly higher than that obtained in upright position only for HFpEF cohorts (supine position: 31; 95% CI: 30–32 mmHg vs upright position; 26; 95% CI: 25–27 mmHg, respectively, p-value<0.01). However, peak PAWP values were highly heterogeneous among the cohorts (I2=93%), with a relative overlap with controls (Figure 1). HFpEF had a significantly larger impairment in the hemodynamic response to exercise, witnessed by a steeper summary PAWP/CO slope than controls (3.75; 95% CI: 3.20–4.28 mmHg/L/min and 0.95; 95% CI: 0.30–1.59 mmHg/L/min, p-value <0.0001), even after adjustment for covariates (p=0.007) (Figure 2). Finally, summary estimates of PAWP/CO slope were higher in HFpEF cohorts performing exercise in the supine position compared with those in upright position (p<0.0001 and p=0.0002 at non-adjusted and adjusted analysis, respectively), but not in control cohorts (p=0.135 and p=0.966 at non-adjusted and adjusted analysis, respectively).

Conclusions

Despite methodological heterogeneity across centers, the hemodynamic profile of HFpEF patients is consistent across studies and characterized by a higher left and right filling pressure at rest compared with controls, enhanced by physical exercise. A PAWP/CO slope cut-off >2 mmHg/L/min seems to retain validity also for studies conducted in the supine position, potentially overcoming the need of different supine and upright PAWP cut-offs.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship.

Routine use of automated strain analysis and 3D echocardiography provides a more comprehensive assessment of cardiac chambers than conventional 2D echocardiography and is time-saving

Funding Acknowledgements

Type of funding sources: None.

Background. In most laboratories three-dimensional echocardiography (3DE) and longitudinal strain (Lstrain) analysis are not part of the routine studies. Although these modalities have been shown to provide additional clinical information and prognostic value compared to conventional two-dimensional echocardiography (2DE), their acquisition and analysis are perceived as being time-consuming.  Recently, new automated tools have been developed to perform accurate, fast and reproducible analyses of heart chambers’ geometry and function. However, their cost-effectiveness when compared to conventional 2DE remains to be demonstrated.

Aim. We designed a prospective, multicenter, observational study aimed to compare the time required for the acquisition and analysis of conventional transthoracic 2DE vs advanced echocardiography (AEcho, i.e. 3DE+ Lstrain) for the assessment of cardiac chambers and myocardial mechanics.

Methods. According to current guidelines, 196 consecutive patients referred for clinically indicated echocardiography underwent complete 2DE and Doppler echocardiography. In addition, 3DE datasets of the left atrium (LA), left and right ventricle (LV, RV) were acquired using automated 3DE software package (Heart Model). Acquisition time for both 2DE and 3DE images were recorded. Conventional 2DE analyses of LA (biplane volume), LV (biplane volumes and mass) and RV (both linear dimensions, areas, and longitudinal function) were performed following current guidelines, and the time required for acquisition and analysis was recorded. The time spent for AEcho analysis (both 3DE volumetric analysis and Lstrain of LA, LV and RV) was also recorded.

Results. Feasibility of AEcho was 86% (169 patients). The additional time for 3D dataset acquisition over conventional 2DE was 38 ± 0.16 sec. Quantitative analysis of the cardiac chambers by 2DE required an average of 5.55 ± 1.51 min vs 4.25 ± 1.23 min using AEcho (p < 0.001). Total time for both 3D dataset acquisition and AEcho assessment was 5.03 ± 1.28 min vs 5.55 ± 1.51 min of 2DE analysis alone (p < 0.001). Globally, AEcho provided a more comprehensive assessment of heart chambers than 2DE (Table). Moreover, the time spent for 3DE dataset acquisition and AEcho analysis on top of standard 2DE acquisition was significantly shorter compared to the 2DE acquisition and analysis (18:50 ± 4.23 vs 19:42 ± 4.24 min, p < 0.001) (Table).

Conclusions. Our data showed that the use of new AEcho automated tools are highly feasible resulting in significant time-savings compared to standard 2DE evaluation, while providing significant additional information. Abstract Table

Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Funding Acknowledgements

Type of funding sources: None.

Background

Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, assessment of TR severity is pivotal. Calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are still the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations.

Purpose: The aims of our study were

(1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC.

Methods

Forty-one patients with functional TR (73.5 ± 11.8 years,51% men,36% sinus rhythm,17% severe), underwent 2D  and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RVSV) – left ventricular forward SV (LVSV), where RVSV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI)  (Fig. 1). TR RVol by PISA was calculated as EROA x VTITR. Uncorrected EROA was calculated using the formula: 6.28 r2 xVa/ PeakVTR (r - PISA radius, Va, aliasing velocity, PeakVTR – TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 x Va (α/180)/ PeakV TR (PISAac), where α was measured using a protractor generated by dedicated software.

Results

Application of AC to PISA method resulted in larger EROA and RVol (0.34± 0.38 cm2 vs 0.24± 0.24cm2 and, 25.2± 19.3 mL vs 18.6 ± 13.1mL, respectively). The percentage change in EROAac was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias -3.95mL, LOA ± 6.41 mL,  r= .987; p< .001) than the conventional PISA without AC (bias -10.5 mL, LOA ± 15 mL, r= .975). Angle correction resulted in a change of TR severity in 32% of cases (Fig. 2) and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs 52%, 22/41 without AC).

Conclusions

Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to 1/3 of patients with functional TR. Abstract Figure. Representation of study method  Abstract Figure. Reclassification of TR severity

Automated left atrial volume measurement by two-dimensional speckle-tracking echocardiography: feasibility, accuracy and reproducibility

Funding Acknowledgements

Type of funding sources: None.

Introduction - A by-product of left atrial (LA) strain analysis is the automated measurement of LA maximal volume (LAVmax), which may decrease the time of echocardiography reporting, and increase the reproducibility of the LAVmax measurement. However, the automated measurement of LAVmax by two-dimensional speckle-tracking analysis (2DSTE) has never been validated.

Purpose – Accordingly, we sought to: i. assess the feasibility of automated LAVmax measurement by 2DSTE; ii.  compare the automated LAVmax by 2DSTE with conventional two-dimensional (2DE) biplane and three-dimensional echocardiography (3DE) measurements; and iii. evaluate the accuracy and reproducibility of the three echocardiography techniques.

Methods – LAVmax (34­-197 mL) were prospectively obtained from 198/210 (feasibility 94%) consecutive patients with various cardiac diseases (median age 67 years, 126 men) by 2DSTE, 2DE and 3DE.

Results – 2DE and 2DSTE measurements resulted in similar LAVmax values (bias = 1.5 mL, limits of agreement, LOA ± 7.5 mL), and slightly underestimated 3DE LAVmax (biases=-5 mL, LOA ± 17 mL, and -6 mL, LOA ± 16 mL, respectively). LAVmax by 2DSTE and 2DE were strongly correlated to those obtained by cardiac magnetic resonance (CMR) (r=.946, and r=.935, respectively; p<.001). However, LAVmax obtained by 2DSTE (bias=-9.5 mL, LOA ± 16 mL), and 2DE (bias=-8 mL, LOA ± 17 mL) were significantly smaller than those measured by CMR. Conversely, 3DE LAVmax were similar to CMR (bias=-2 ml, LOA ± 10 mL). Excellent intra- and inter-observer intraclass correlation coefficients were found for 3DE (0.995 and 0.995), 2DE (0.990 and 0.988), and 2DSTE (0.990 and 0.989).

Conclusion – Automated LAVmax measurement by 2DSTE is highly feasible, highly reproducible, and provided similar values to conventional 2DE calculations in consecutive patients with a wide range of LAVmax. Abstract Figure. Echocardiography and CMR correlations  Abstract Figure. Echocardiography techniques correlations

Prognostic value of different echocardiographic indices reflecting right ventriculo-arterial coupling in a large cohort of patients with various cardiac diseases

Funding Acknowledgements

Type of funding sources: None.

Introduction – Non-invasive parameters used to assess right ventricular (RV) function, i.e. tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (FAC), RV ejection fraction (RVEF), and RV free-wall longitudinal strain (RVFWLS) have shown their prognostic implications. However, since they are extremely load dependent, they do not provide an accurate representation of the RV intrinsic performance. On the other end, invasive indices of RV-arterial coupling (RVAC) derived from pressure-volume loops are not routinely performed, rising the urgency for more feasible, and reliable non-invasive estimates of RVAC.

Purpose – To: i. evaluate the prognostic value of echocardiography-derived RVAC surrogates: RVEF/systolic pulmonary artery pressure (sPAP), RVFWLS/sPAP, TAPSE/sPAP, FAC/sPAP, and RV stroke volume/end-systolic volume (SV/ESV), ii. identify the cut-off values associated to all-cause mortality; and iii. compare their prognostic value with that of classical parameters of RV function.

Methods – We prospectively enrolled 366 patients with various cardiac diseases, undergoing clinically-indicated comprehensive two- and three-dimensional echocardiography.

Results – During a mean follow-up of 7.6 ± 1 years, 80 (21.9%) patients died. At univariable Cox regression, most of the echocardiographic parameters were related to all-cause mortality. The echocardiographic parameters with significance at univariable analysis (p < 0.01) were included in a multivariable regression model. Left ventricular ejection fraction (LVEF), RVEF, TAPSE, RVEF/sPAP and RVFWLS/sPAP remained independently associated to all-cause mortality (p < 0.05 for all). Subsequently, they were tested in receiving operator characteristics (ROC) curves. At ROC analysis, RVEF/sPAP (area under the curve, AUC = 0.807, p < 0.001) and RVFWLS/sPAP (AUC = 0.743, p < 0.001) showed the greatest predictive value (p < 0.001 between them). However, all RV parameters significantly improved their prognostic values after indexing for sPAP (p < 0.01 for all). The best cut-offs to predict the outcome were 1.5 for RVEF/sPAP (specificity 71%, sensitivity 83%) and 0.67 for RVFWLS/sPAP (specificity 72%, sensitivity 68%). At Kaplan-Meier analysis, patients with reduced RVAC (less than the predefined cut-offs) had significantly lower probability of survival (p < 0.001 for all).

Conclusion – RVAC surrogates provide incremental prognostic value compared to standard RV functional measurements. RVEF/sPAP, with a cut-off value of 1.5, was the best parameter for risk stratification, and was independently related to all-cause mortality. Abstract Figure. Prognostic value of RVAC surrogates  Abstract Figure. Kaplan-Meier curves survival probability

Right heart chambers geometry and function in patients with the atrial and the ventricular phenotypes of functional tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

Introduction — Atrial functional tricuspid regurgitation (A-FTR) is a recently defined phenotype of FTR associated with persistent/permanent atrial fibrillation. Differently from the classical ventricular form of FTR (V-FTR), patients with A-FTR might present with severely dilated right atrium (RA) and tricuspid annulus (TA), and with preserved right ventricular (RV) size and systolic function. However, the geometry and function of the RV, RA and TA in patients with A-FTR and V-FTR remain to be systematically evaluated.

Purpose — Accordingly, we sought to: i. study the geometry and function of the RV, RA and TA in A-FTR by two- and three-dimensional transthoracic echocardiography; and ii. compare them with those found in V-FTR.

Methods — We prospectively analysed 113 (44 men, age 68 ± 18 years) FTR patients (A-FTR = 55 and V-FTR = 58) that were compared to two groups of age- and sex-matched controls to develop the respective Z-scores.

Results — The severity of FTR, and the degree of TA dilation were similar in A-FTR and V-FTR patients. The Z-scores of RV size were significantly larger, and those of RV function were significantly lower in V-FTR than in A-FTR (p < 0.001 for all). The RA was significantly enlarged in both A-FTR and V-FTR compared to controls (p < 0.001, Z-scores > 2), with similar RA maximal volumes (RAVmax) between A-FTR and V-FTR (p = 0.2). Whereas, the RA minimal volumes (RAVmin) were significantly larger in A-FTR than in V-FTR (p = 0.001).

Conclusion — Despite similar degrees of FTR, RAVmax and TA size, A-FTR patients show larger RAVmin than V-FTR patients. Conversely, V-FTR patients show dilated, more elliptic and dysfunctional RV than A-FTR patients. Abstract Figure. A-FTR versus V-FTR  Abstract Figure. Remodelling patterns in A-FTR and V-FTR

Dark blood ischemic LGE segmentation using a deep learning approach

Funding Acknowledgements

Type of funding sources: None.

Introduction

The extent of ischemic scar detected by Cardiac Magnetic Resonance (CMR) with late gadolinium enhancement (LGE) is linked with long-term prognosis, but scar quantification is time-consuming. Deep Learning (DL) approaches appear promising in CMR segmentation.  Purpose: To train and apply a deep learning approach to dark blood (DB) CMR-LGE for ischemic scar segmentation, comparing results to 4-Standard Deviation (4-SD) semi-automated method. Methods: We trained and validated a dual neural network infrastructure on a dataset of DB-LGE short-axis stacks, acquired at 1.5T from 33 patients with ischemic scar. The DL architectures were an evolution of the U-Net Convolutional Neural Network (CNN), using data augmentation to increase generalization. The CNNs worked together to identify and segment 1) the myocardium and 2) areas of LGE. The first CNN simultaneously cropped the region of interest (RoI) according to the bounding box of the heart and calculated the area of myocardium. The cropped RoI was then processed by the second CNN, which identified the overall LGE area. The extent of scar was calculated as the ratio of the two areas. For comparison, endo- and epi-cardial borders were manually contoured and scars segmented by a 4-SD technique with a validated software. Results: The two U-Net networks were implemented with two free and open-source software library for machine learning. We performed 5-fold cross-validation over a dataset of 108 and 385 labelled CMR images of the myocardium and scar, respectively. We obtained high performance (> ∼0.85) as measured by the Intersection over Union metric (IoU) on the training sets, in the case of scar segmentation. With regards to heart recognition, the performance was lower (> ∼0.7), although improved (∼ 0.75) by detecting the cardiac area instead of heart boundaries. On the validation set, performances oscillated between 0.8 and 0.85 for scar tissue recognition, and dropped to ∼0.7 for myocardium segmentation. We believe that underrepresented samples and noise might be affecting the overall performances, so that additional data might be beneficial. Figure1: examples of heart segmentation (upper left panel: training; upper right panel: validation) and of scar segmentation (lower left panel: training; lower right panel: validation). Conclusion: Our CNNs show promising results in automatically segmenting LV and quantify ischemic scars on DB-LGE-CMR images. The performances of our method can further improve by expanding the data set used for the training. If implemented in a clinical routine, this process can speed up the CMR analysis process and aid in the clinical decision-making. Abstract Figure.

Prognostic value of right ventricular mechanical pattern assessed with 3D echocardiography in patients with left-sided heart disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the New National Excellence Programme (ÚNKP-19-3-I) of the Ministry for Innovation and Technology in Hungary, and the Artificial Intelligence Research Field Excellence Programme of the National Research, Development and Innovation Office of the Ministry of Innovation and Technology in Hungary.

Background

Right ventricular (RV) ejection fraction (EF) has established prognostic significance, which is independent of left ventricular (LV) EF in various cardiac diseases. However, RV EF is a cumulative result of the complex interplay between distinct mechanical components (i.e., shortening along the longitudinal, radial, and anteroposterior directions), and the prognostic value of RV motion decomposition remains to be quantified.

Objective

Our aim was to explore whether the assessment of longitudinal, radial, and anteroposterior motion components of the RV with 3D transthoracic echocardiography offers prognostic value in patients with left-sided heart disease.

Methods

Two hundred and ninety-two consecutive patients (age 59 ± 17 years, 70% male) with left-sided heart disease underwent standard clinical investigations and 3D echocardiographic examination. They were followed-up for 6.7 ± 2.2 years, and cardiac death served as the primary endpoint. LV and RV volumes and ejection fractions were quantified by the offline analysis of 3D datasets. The ReVISION method was applied to the 3D models of the RV to decompose the motion along the three orthogonal axes and to calculate longitudinal, radial, and anteroposterior EF (LEF, REF, AEF, respectively). Conventional parameters of RV systolic function (tricuspid annular plane systolic excursion [TAPSE], fractional area change [FAC]) were also assessed.

Results

Cardiac death occurred in 60 (21%) patients. Patients who died had lower LV EF (39 ± 16 vs. 52 ± 12%, p < 0.001), RV EF (40 ± 11 vs. 48 ± 8%, p < 0.001), and each mechanical component showed significantly lower values compared to patients alive (LEF: 13 ± 6 vs. 19 ± 6%; REF: 22 ± 7 vs. 25 ± 7%; AEF: 14 ± 6 vs. 18 ± 5%, all p < 0.001). LEF was decreased to a greater degree compared to RV EF (relative %: -30 vs. -18). In univariate Cox regression models, RV EF (Hazard Ratio [HR]: 0.928, 95% Confidence Interval [CI] 0.909 – 0.948, p < 0.001), LEF (0.855 [0.816 – 0.896], p < 0.001), REF (0.932 [0.898 – 0.967], p < 0.001), AEF (0.879 [0.841 – 0.919], p < 0.001), TAPSE (0.881 [0.841-0.923], p < 0.001), and FAC (0.955 [0.933-0.977], p < 0.001) were all found to be significant predictors of cardiac death. From all parameters that were predictive, the optimal combination of variables was identified with an automated stepwise selection algorithm. The final multivariate model included serum creatinine (1.015 [1.010 – 1.020], p < 0.001), haemoglobin concentration (0.965 [0.948 – 0.982], p < 0.001), LV EF (0.977 [0.955 – 0.999], p < 0.05), and LEF (0.899 [0.843 – 0.959], p < 0.01) as independent predictors of cardiac death. Notably, the algorithm rather selected LEF and not RV EF.

Conclusions

3D echocardiography-derived measurements of RV systolic function are able to predict outcomes in patients with left-sided heart disease independently of LV function. The separate quantification of RV mechanical components can hold additional prognostic value compared to conventional echocardiographic parameters.

Vendor-independent software shows limited variability in speckle tracking strain measurements on images of different vendors

Funding Acknowledgements

Type of funding sources: None.

Background

Vendors use proprietary speckle tracking software algorithms for echocardiographic strain measurements, which results in high inter-vendor variability. Little is known about potential advantages or disadvantages of using vendor-independent software in clinical practice.

Purpose

We therefore investigated the reproducibility, accuracy, and ability to identify scar of strain measurements on images from different vendors by using a vendor-independent software.

Methods

A vendor-independent software (TomTec Image Arena) was used to analyze datasets of 63 patients which were obtained on four ultrasound machines from different vendors (GE, Philips, Siemens, Toshiba). We measured the tracking feasibility, inter-vendor bias, the relative and absolute test-re-test variability of strain measurements and their ability to detect scar. Cardiac magnetic resonance delayed enhancement images were used as the reference standard of scar definition.

Results

Tracking feasibility differed depending on the image source (p < 0.05). Variability of global longitudinal strain (GLS) (Figure 1A) was similar (ANOVA p = 0.124) among the images of different vendors whereas variability of segmental longitudinal strain (SLS) (Figure 1B) showed modest difference (ANOVA- peak systolic strain (PS); p = 0.077, end-systolic strain (ES); p = 0.171, post-systolic strain (PSS); p = 0.020). Relative test-re-test variability of GLS showed no differences (ANOVA p = 0.360). Absolute test-re-test errors of SLS measurements showed modest differences among images of different vendors (ANOVA- PS; p = 0.018, ES; p = 0.001, PSS; p = 0.090). No relevant difference in scar detection capability was observed (Figure 1C).

Conclusions

Vendor independent software leads to low bias among strain measurements on images from different vendors. Likewise, measurement variability and the ability to identify scar becomes similar. Our findings suggest that a vendor independent speckle tracking software could help to overcome inter-vendor bias. To which extend such measurements would be more accurate compared to vendor specific software remains to be determined.

Abstract Figure 1

Functional adaptation of the right ventricle to different degrees of the left ventricular systolic dysfunction in patients with left-sided heart disease: a three-dimensional echocardiography study

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular (RV) systolic dysfunction in patients with left-sided heart disease is known adverse factor. However, the RV adaptation at the different degrees of left ventricular (LV) dysfunction remains to be clarified.

Purpose

 to assess the change in RV contraction pattern in relation to LV ejection fraction (EF) in patients with left-sided heart disease.

Methods. LV and RV volumes and EF were measured by 3D-echocardiography in 295 patients with left-sided heart disease (59 ± 17years, 69% male). The 3D meshmodel of the RV was postprocessed by the ReVISION software and its contraction pattern was decomposed along the longitudinal, radial and anteroposterior directions (Fig. A) providing longitudinal, radial and anteroposterior EF (LEF, REF, AEF). Relative contribution of each component to the RV systolic function was measured as the ratio between LEF, REF and AEF and global RVEF (LEFi, REFi, AEFi).

Results. Patients with LV systolic dysfunction also had reduced RVEF. Relative contribution of the longitudinal and anteroposterior components decreased, while radial component increased in patients with reduced LVEF (Table).

RV LEF and AEF significantly correlated with the LVEF (Rho 0.50 and 0.51, p < 0.0001), while the correlation between REF and LVEF was weak (Rho 0.22, p = 0.0002).

There was a significant drop in LEF and AEF (Fig. B) and their relative contribution to the total RVEF (Fig. C) starting from the earlier stages of LV dysfunction. However, it was effectively compensated by significant increase in the radial RV component resulting in preservation of total RVEF in those with normal, mildly and moderately reduced LVEF (50 [46;54] vs 47 [44;52] vs 46 [42;49]%), whereas total RVEF dropped significantly only in severe LV dysfunction (30 [25;39]%; p < 0.0001) (Fig. D).

Conclusions. The longitudinal and anteroposterior RV contraction was related to the LVEF and decreased from early stages of the LV systolic dysfunction. Increase in the radial component compensated for the loss of longitudinal and anteroposterior RV components in mild and moderate LV dysfunction to maintain total RVEF. Drop in all three components resulted in significant reduction of total RVEF in severe LV dysfunction.

Characteristics of study population Overall (N = 295) LVEF≥50% (N = 166) LVEF < 50% (N = 129) LV EF, % 49.6 ± 14.3 59.9 ± 5.6 36.4 ± 10.9* RV EF, % 46.5 ± 9.2 49.8 ± 6.9 42.3 ± 10.0* RV LEFi 0.42 ± 0.09 0.45 ± 0.09 0.38 ± 0.09* RV REFi 0.47 ± 0.1 0.45 ± 0.1 0.50 ± 0.09* RV AEFi 0.39 ± 0.08 0.41 ± 0.08 0.37 ± 0.07* *p < 0.0001 Abstract Figure.

P167 The burden of post-actinic heart disease: a case of severe valvular and coronary artery disease in a cancer survivor

Background

A 47-year old female complaining of exertional dyspnoea (NYHA class III) was admitted at our Cardiology department. She had a history of nodular sclerosis Hodgkin lymphoma (HL), treated with chemo- and radiotherapy, and complicated by post-actinic pneumopathy and cardiopathy. At the age of 39, she had undergone coronary artery bypass grafting with left internal mammal artery (LIMA) to left anterior descendent artery and saphenous vein to obtuse marginal branch, and aortic valve replacement with a mechanical prosthesis due to severe aortic stenosis. Some years later, she had undergone percutaneous stenting of the left main (LM) due to occlusion of the LIMA bypass graft.

At admission, the patient was hemodynamically stable, with signs of right-sided congestive heart failure. Both 2D and 3D transthoracic echocardiogram (TTE) showed preserved biventricular function, normal function of the aortic prosthesis, and diffuse calcification of the whole mitral valve apparatus, involving the leaflets, the annulus, the tendinous chords and the anterolateral papillary muscle (Figure Panels A-B), causing severe mitral stenosis (mean gradient 10 mmHg, 3D planimetric area 0.9 cm2, Wilkins score 12) and moderate organic insufficiency (Panel C). The tricuspid valve was also affected, with thickened, hypomobile leaflets, causing mild stenosis (mean gradient 4 mmHg, 3D planimetric area 3.8 cm2) and severe insufficiency (Panel D). Transesophageal echocardiogram (TOE) couldn"t be performed because of actinic oesophagitis. Percutaneous valvuloplasty was contraindicated due to moderate mitral insufficiency, high Wilkins score and a huge amount of calcium affecting the whole valve apparatus but sparing the commissures.

The patient was scheduled to PCI on the LM due to intrastent restenosis, but died during the procedure as a consequence of an intrastent massive thrombosis leading to cardiac arrest.

Learning points

Hodgkin lymphoma survivors are at increased cardiovascular and intraoperative risk. Old radiotherapy protocols for HL may cause severe post-actinic valvular and coronary disease. Post-actinic valvular heart disease often affects aortic and mitral valve more than a decade after irradiation, and may manifest as stenosis, insufficiency or both. Organic regurgitation and stenosis of tricuspid valve are uncommon, but may also occur and lead to worse patient outcome. Despite TOE may bring additional valuable informations in challenging cases, the coexistence of oesophageal sequelae from post-actinic oesophagitis may limit its applicability. TTE is the first line and often the only diagnostic tool available for identifying the characteristic valvular lesions in cancer survivors exposed to radiotherapy. 3D TTE may be particularly useful to identify subtle signs of primary involvement of tricuspid apparatus and quantify the anatomical area of a stenotic tricuspid valve, when severe regurgitation coexists and transvalvular gradients may be unreliable.

Abstract P167 Figure

P181 An uncommon mechanism of severe mitral regurgitation due to infective endocarditis mimicking acute myocardial infarction

Learning points

coronary artery embolization and papillary muscle abscess are very rare and often fatal consequences of infective endocarditis (IE). High (otherwise unexplained) fever and signs of embolism are minor Duke modified criteria for IE that should lead the physician to look for major criteria, such as positive blood cultures or echocardiography suggestive for IE. Emboli seen in the very distal part of the coronary arteries might have caused the ALPM abscess.

Abstract P181 Figure

102 Different mechanics of septal and lateral walls and their effects on left ventricular ejection fraction in patients with left bundle-branch block

Funding Acknowledgements

Karolina Kupczynska was supported by research grant awarded by the Club 30 of the Polish Cardiac Society

Background

Left bundle branch block (LBBB) impairs left ventricular (LV) mechanics and can lead to systolic dysfunction. However, LV mechanical changes that differentiate LBBB patients with preserved and reduced LV ejection fraction (LVEF) remain to be clarified.

Purpose

To measure myocardial work (MWI) and myocardial work efficiency (MWE) of the septal and LV lateral wall in patients with LBBB and various degrees of LV dysfunction using non-invasive strain-derived method.

Methods

Fifty-eight LBBB patients without coronary artery disease (mean age 65 ± 13 years, 60% male) were divided into 4 groups based on their LVEF according to current recommendations for cardiac chamber quantification (figure A): normal (n= 25), mildly (n= 16), moderately (n= 11), and severely (n= 6) reduced LVEF. Septal and lateral wall MWI and MWE were estimated by LV pressure-strain loop obtained by echocardiography.

Results

Both MWI (787 mmHg%, 95% CI 651-924 vs 1956 mmHg%, 95% CI 1758-2154; p < 0.0001) and MWE (71%, 95% CI 66-76 vs 85%, 95% CI 82-87; p = 0.0001) were lower in the septum than in the lateral wall. There was a progressive decrease in septal MWI and MWE with the worsening of LVEF (figure B). Conversely, MWI and MWE of the lateral wall were preserved in patients with normal, mildly and moderately reduced LVEF groups. A significant reduction of MWI and MWE in the lateral wall was detected only in patients with severely reduced LVEF (figure C).

Conclusion

In patients with LBBB, impairment in septal myocardial work escalates according to LVEF loss. Septal dysfunction was compensated by the effective myocardial work of the lateral wall in patients with normal, mildly and moderately reduced LVEF. Mechanical dysfunction of the lateral wall was associated with severe reduction of LVEF.

Abstract 102 Figure.

P798 Right atrial phasic function and correlation with right ventricular function in patients with reduced left ventricular ejection fraction and no pulmonary hypertension:insights from 3D echocardiography

Background

The right atrium (RA) is a highly dynamic chamber with 3 mechanical functions (reservoir, conduit, booster pump) and prognostic implications in heart failure (HF) and pulmonary hypertension (PH). However, RA function and its interplay with the right ventricular (RV) performance in patients (pts) with reduced left ventricular ejection fraction (LVEF) and without PH remain to be clarified.

Methods

We used three-dimensional echocardiography to study 55 pts (61 ± 14 years, 43 men) with LVEF < 40% no more than mild tricuspid regurgitation (TR), and maximum velocity of the TR jet < 3 m/s. We measured the three-dimensional RA total, passive, active ejection volumes (EV) and the respective emptying fractions (EF). In addition, we compared RV volumes and ejection fraction (RVEF) between patients with normal and abnormal RA function.

Results

Mean LVEF was 30 ± 7%. Mean echo-derived pulmonary vascular resistance was 1.64 ± 0.54 Wood units. 28 pts (51%) had reduced RA reservoir function (total EF = 34 ± 9%), 34 pts (62%) had reduced RA conduit function (passive EF = 15 ± 4%), and 10 pts (18%) had reduced RA pump function (active EF = 11 ± 3%). Pts with reduced RA reservoir function showed larger RV end-systolic volume (RVESV 124 ± 48ml vs. 90 ± 32ml; p = 0.004) and lower RVEF (38 ± 8% vs. 46 ± 6%; p < 0.001) than pts with normal RA function. Pts with reduced RA conduit function showed smaller RV stroke volume (RVSV 65 ± 19 ml vs. 80 ± 22ml; p = 0.009). Pts with impaired RA pump function showed larger RVESV (142 ± 45ml vs. 99 ± 41ml; p = 0.02) and lower RVEF (36 ± 6% vs. 43 ± 8%; p = 0.006).

RVESV was positively correlated with total (r2 = 0.47, p < 0.001), passive (r2 = 0.29, p = 0.03) and active (r2 = 0.39, p = 0.003) RAEV, while it was negatively correlated with total (r2=-0.41, p = 0.002), passive (r2=-0.34, p = 0.01) and active (r2=-0.31, p = 0.02) RAEF. RVSV showed a positive correlation with both total (r2 = 0.4, p = 0.002) and passive (r2 = 0.41, p = 0.002) RAEV. Finally, RVEF was positively correlated with total (r2 = 0.51, p < 0.001), passive (r2 = 0.47, p < 0.001), and active (r2 = 0.36, p = 0.007) RAEF.

Conclusions

RA dysfunction is not uncommon in pts with reduced LVEF, even in the absence of PH. In these pts, RA function is associated with significant changes in RV function. The RA acts as a dynamic modulator of RV pump function by redistributing RV filling and ejection force among reservoir, conduit and pump functions in the setting of altered hemodynamics. The clinical and prognostic significance of RA function in pts with reduced LVEF warrant further studies.

47 Identification of threshold values to define right chamber enlargement consistent with severe tricuspid regurgitation

Background

Right ventricle (RV), tricuspid anulus (TA) and right atrium (RA) dilatation, are listed among the supportive signs to grade severe tricuspid regurgitation (TR) according to current EACVI and ESC guidelines. However, at present, there is no cut-off value to define RV, RA and TA dilatation associated to severe TR.

Purpose

Accordingly, we sought to identify the threshold values of RV, RA and TA size associated to severe TR.

Methods

302 patients (59 ± 13 years, 54 % women) with functional TR underwent three- (3D) and two-dimensional (2D) echocardiography to obtain: 3D RV end diastolic volume (RVEDVi) indexed for body surface area (BSA), 3D RV end systolic volume indexed for BSA (RVESVi), 3D RA max volume indexed for BSA (3DRAi), 2D RA systolic volume indexed for BSA (3DRAi), 2D RV basal diameter (2DRVd), 2D RV basal diameter indexed for BSA (2DRVdi), 2D TA measured in the apical 4-chamber view and 2D TA measured in the apical 4-chamber view indexed for BSA. To identify the threshold values of the parameters that discriminate patients with right chamber enlargement associated to severe TR, we selected the probability which returns the best sum of sensitivity and specificity on the ROC curve of the model.

Results

According to EACVI multiparametric approach, 50/302 pts (17%) were found to have severe TR. As shown in Figure, 3DRAi > 45 ml/m2 and 2DRAi > 45 ml/m2 identified patients with RA enlargement associated to severe TR. RVEDVi and RVESVi did not show any predictive value for severe TR. Conversely, 2DRVd > 52 mm (or >30 mm/m2) was associated to severe TR. 2DTA > 42 mm ( or >24 mm/m2) was the selected threshold value for TA dilatation.

Conclusions

Our study provided the threshold values to define the right chamber and TA dilatation associated to severe TR. Implementation of those values in current guidelines can help clinicians to improve their accuracy to identify patients with severe TR.

Abstract 47 Figure.

P190 Chest pain and syncope in Turner"s syndrome: going beyond the obvious to not miss the critical diagnosis. Role of multimodality imaging approach

Learning points

Chest pain and syncope are challenging symptoms in pts presenting in ED. AV pathology and aortic dissection should be always suspected and ruled out. TS is associated with multiple congenital cardiovascular abnormalities and is the most common established cause of aortic dissection in young women. 30% of Turner’s pts have congenitally AV abnormalities, and dilation of the ascending aorta is frequently associated. However, unicuspid AV is a very rare anomaly, usually stenotic at birth and requiring replacement. The presence of pericardial effusion in a pt with chest pain and syncope should raise the suspicion of aortic dissection, even if those symptoms usually accompany severe aortic stenosis. Even if CT is the gold standard imaging technique to rule out aortic dissection, the accuracy of a test is critically related to the image quality. When the suspicion of dissection is high and the reliability of the reference test is low, it’s reasonable to perform a different test to rule out the pathology. Aortography and TOE were pivotal to identify the limited dissection of the ascending aorta.

Abstract P190 Figure.

P173 When the heart doesn"t want to grow up

Background

Blood cysts of heart valves are uncommon and, usually, incidental findings in pediatric population. Rarely seen in adults, blood cysts are normally asymptomatic, even though several cases of embolization, valvular disfunction and left ventricle outflow tract (LVOT) obstruction have been described. Clinical Presentation. We report the case of a 23 year-old woman, with history of a small nodular mass of the mitral valve, found on a previous cardiac magnetic resonance (CMR) at the age of thirteen, who was admitted to our emergency department complaining atypical chest pain. She denied shortness of breath, syncope, tachycardia and fever. She was hemodynamically stable and a fast regression of symptoms was observed. The physical examination was unremarkable. Both the electrocardiogram (ECG) and blood tests were normal. A chest radiography showed normal heart size, without other abnormalities. After having ruled out an acute coronary syndrome, the patient was discharged with the indication to undergo further cardiological assessments. Diagnostic techniques and their most important findings. Therefore, a trans-thoracic echocardiogram was performed revealing normal biventricular function, no aortic root dilation, no pericardial effusion, no valvular regurgitation or stenosis. A round (7x11 mm) mass with hyperechogenic borders and hypoechogenic content was detected on the ventricular side of the anterior mitral valve leaflet consistent with a valvular blood cyst (figure 1: a,b,c). Only trivial mitral valve regurgitation without LVOT obstruction was present. The 3D echo reconstruction allowed to confirm the suspicion of blood cyst and detect a cleft of the posterior mitral valve leaflet, located in the P2 scallop (figure 1: d,e). A repeated CMR showed no contrast enhancement of the mass. Due to the clinical stability and the absence of complications, the patient was suggested to continue an echocardiographic follow-up. Discussion. Cardiac blood cysts are a rare condition with uncertain origin, usually found in infants in the first six months of life. A natural regression after that age has been described, making this condition very unusual in adults. Despite its benign features, when persistent beyond the childhood, the blood cyst can grow and reach even huge dimensions, potentially impairing the valvular function and/or causing LVOT obstruction. Another potential complication of blood cysts may be the arterial embolization. In all these situations surgical resection must be considered. In our patient, the contribution of trans-thoracic echocardiogram and in particular the 3D reconstruction, were pivotal to address the correct diagnosis.

Abstract P173 Figure 1

P275 Feasibility and accuracy of the automated quantification of two- and three-dimensional left ventricular ejection fraction and its role in the arrhythmic risk stratification of organic heart disease

BACKGROUND

New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified.

PURPOSE

We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients.

METHODS

We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF < 50%, no previous MAE or coronary artery revascularization < 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve.

RESULTS

During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE <39% (p = 0.006) and 3DE <37% (p = 0.005). The model including the 2DE FA LVEF showed an area under the curve (AUC) larger than the one including conventional 2DE LVEF (0.83 vs 0.80). Conversely, the AUC obtained with FA 3DE LVEF model was slightly lower than the one obtained using SA 3DE LVEF model (0.80 vs 0.84).

CONCLUSIONS

Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

P764 Right ventricular basal diameter, but not volume, can predict severe tricuspid regurgitation

Background

According to current EACVI guidelines, right ventricle (RV), tricuspid anulus (TA) and right atrium (RA) dilatation are supportive signs to identify severe functional tricuspid regurgitation (TR) by echocardiography. However, the ranking by which those parameters should be considered to identify severe TR remains to be clarified.

Purpose

Accordingly, the aim of this study is to compare RV, RA and TA association with severe TR and to rank them in order of importance to predict severe TR.

Methods

302 patients (59 ± 13 years, 54 % women) with functional TR underwent two- and three-dimensional echocardiography. Using the nonparameteric Variable Importance (VIMP) software package, we assessed the relative importance of 6 differerent parameters (indexed by body surface area) to identify severe TR: 3D RV end diastolic volume (RVEDVi), 3D RV end systolic volume (RVESVi), 3D RA max volume (3DRAi), 2D RA systolic volume (3DRAi), 2D RV basal diameter (2DRVdi) and 2D TAi measured in the apical 4-chamber view.

Results

According to EACVI multiparametric approach, 50/302 pts (17%) were found to have severe TR. 3DRAi (VIMP = 0.075) was the most important predictor of severe TR. 2DRVdi (VIMP= 0.005) was the second most important parameter and was the only parameter of RV dilation (RVEDVi= -0.0011 and RVESVi= -0.0012) associated to severe TR. Also, 2DRAi (VIMP= 0.023), and 2D TAi (VIMP= 0.004) showed good predictive ability.

Conclusions

Among the various right heart structures undergoing remodeling in patients with functional TR, RA dilation was the most important predictor of severe TR. Also the RV basal diameter, but not the volumes, was a predictor of severe TR. This underlines the importance of the shape, more than the volume of the RV as a predictor of severe TR.

P1581 The global myocardial work index is a powerful predictor of major arrhythmic events in patients with organic heart disease and reduced left ventricular ejection fraction

Background

Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection.

Purpose

We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF.

Material and Methods

we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF <50%, in whom we re-measured LVEF using 3DE, and obtained MD and GWI using 2DE speckle tracking. Major arrhythmic events were defined as sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation and appropriate ICD shocks. We assessed the predictive power of 4 different parameters: 2DE LVEF< 35%; 3DE LVEF< 35%; MD > 80 ms; and GWI< 672 mmHg% to identify patients at risk of major arrhythmic events.

Results

During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF< 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF< 35%, and 0.77 (95%CI 0.68-0.86) for GWI < 672 mm Hg%. Whereas, MD > 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)).

Conclusions

GWI< 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF < 50%.

P669 Functional remodeling of the left atrium after first acute ST-elevation myocardial infarction: a 3D echocardiography study

Background

Left atrium (LA) is a dynamic structure which is functionally coupled with the left ventricle and modulates its function in many cardiac conditions. The geometric and functional remodeling of the LA occurring early after myocardial infarction are poorly understood.

Purpose

We sought to evaluate the early changes in LA geometry and function occurring in survivors of a first acute ST-elevation myocardial infarction (STEMI), using three-dimensional echocardiography (3DE).

Methods

LA phasic volumes and strain (both longitudinal and circumferential) were measured using a dedicated automated software package in 54 patients at pre-discharge after STEMI, and in 54 age- and sex-matched healthy volunteers (controls), (figure 1).

Results

In STEMI patients, both maximal (LAV max) and minimal (LAV min) LA volumes were significantly larger than in controls 63 ± 15 vs. 53 ±11 ml; p = 0,002 and 38 ± 15 ml vs. 25 ± 6; p <0.0001 (respectively). Moreover, when compared to controls (Table 1). Both longitudinal (LASr) and circumferential strain reservoirs showed a significant negative correlation with peak cardiac troponin I values (r=-0.344; p = 0.007 and r=-0.357; p = 0.005, respectively) as an estimate of the extent of myocardial damage.

Conclusion

STEMI was associated to significant geometrical and functional remodeling of the LA which was correlated with the extent of myocardial damage.

Table 1 Controls STEMI patients P-value Longitudinal% LASr 21.8 ± 8.4 13.72 ± 8.27 <0.0001 LAScd -12.8 ± 8.48 -6.43 ± 4.74 <0.0001 LASct -9.73 ± 6.04 -7.26 ± 5.87 0.05 Circumferential % LASr-c 27.31 ± 8.07 18.92 ± 9.16 <0.0001 LAScd-c -11.2 ± 5.93 -6.46 ± 5.68 0.0002 LASct-c -16.22 ± 6.33 -12.41 ± 5.94 0.004 LASr longitudinal strain reservoir, LAScd: longitudinal strain conduit, LAScd: longitudinal strain contraction, LASr-c: circumferential strain reservoir, LAScd-c: circumferential strain conduit , LASct-c:circumferential strain contraction

Abstract P669 Figure 1

38 Prognostic validation of partition values obtained with conventional two-dimensional and doppler echocardiography to grade tricuspid regurgitation severity

Background

Morbidity and mortality associated with severe tricuspid regurgitation (TR) have prompted interest in new corrective transcatheter procedures. However, to properly select patients for interventional procedures, and to assess their effectiveness, a reliable and reproducible grading system of TR severity is mandatory. However, the cut-off values used by current guidelines to differentiate among mild, moderate and severe TR lack clinical validation.

Purpose

We aimed to obtain the threshold values of the currently recommended quantitative echocardiographic parameters used to grade TR severity using pts’ outcome as a reference.

Methods

296 pts, with at least mild TR and complete 2D, 3D and Doppler echocardiographic study, were enrolled and assessed for potential confounders: age, NYHA class, left ventricular ejection fraction, coexistent valvular heart disease and right ventricular (RV) systolic pressure. Average diameter of the vena contracta (VCavg), effective regurgitant orifice area (EROA), regurgitant volume (RVol) and regurgitant fraction (RF) were obtained to grade TR severity. Median follow-up was 47 (17-80) months. The primary composite endpoint was the occurrence of death of any cause or hospitalization for right heart failure (RHF). Survival curves for the composite endpoint were divided in quartiles at median follow-up. Cut-off values for the echo parameters were derived to grade mild (below the 1st quartile), moderate (between 1st and 3rd quartiles), and severe (above the 3r quartile) TR.

Results

33 deaths and 72 hospitalizations for RHF occurred. Event-free rate from death or RHF at the end of follow-up was 14%, 46% and 93% in pts with severe, moderate, and mild TR, respectively. Differences reached statistical significance early (at 1 month), and lasted during the whole follow-up period (Figure). The new threshold values for mild, moderate and severe TR are summarized in Table.

Conclusions

Partition values of quantitative echo-Doppler parameters used to grade mild, moderate and severe TR according to pts’ clinical outcome are significantly lower than those currently reported in guidelines. Further studies are needed to test if these new threshold values for severe TR will translate in earlier referral of pts to valve repair and improved prognosis.

Mild Moderate Severe VCavg <3 mm 3-6 mm >6 mm EROA <0.15 cm² 0.15-0.30 cm² >0.30 cm² R Vol <15 ml 15-30 ml >30 ml RF <25% 25-45% >45%

Abstract 38 Figure.

6067Right ventricular global longitudinal strain predicts cardiovascular mortality and heart failure hospitalization in patients with functional tricuspid regurgitation

Background

Functional tricuspid regurgitation (FTR) and its increasing severity are well-known factors associated with increased morbidity and mortality in patients with pulmonary artery hypertension or left heart diseases.

Purpose

To assess the main clinical and echocardiographic determinants of outcome in patients with various causes of FTR.

Methods

A total of 140 patients (pts) (72±14 years, 40% men) with FTR of diverse etiologies underwent complete 2D and additional 3D echocardiography acquisitions and were followed for a median of 5.2 years (interquartile range 2.1 - 6.7 years). Severe FTR was defined by ≥2 parameters: (1) coaptation defect; (2) vena contract ≥7; (3) PISA radius >9 mm; (4) hepatic vein systolic flow reversal. The primary composite outcome was defined as death from cardiovascular causes and hospitalization due to right-sided heart failure (HF).

Results

74 pts (53%) developed the primary composite outcome. Death occurred in 31 pts (22%), while hospitalization due to right-sided HF occurred in 66 pts (47%). At baseline, patients who developed the primary composite outcome, compared to those who did not, had more symptoms, more severe FTR, higher pulmonary systolic pressure (60±27 vs 43±16 mmHg), larger right atrium (69±34 vs 51±22 mL/mm2), right ventricular (RV) basal diameter (29±6 vs 24±4 mm/m2), larger RV end-diastolic (102±45 vs 76±25 mL/m2) and end-systolic (62±37 vs 43±17 mL/m2) volumes, larger tricuspid annulus area (7.7±1.8 vs 6.8±1.8 cm2/m2), lower RV systolic function (RVEF [42±11 vs 46±8%], TAPSE [18±4 vs 21±4], S' [11±3 vs 12±2], RV global longitudinal strain (RVGLS) [16±5 vs 19±4], RV free wall longitudinal strain [19±7 vs 23.5]); all p-values <0.03. There were no significant differences in age, body size or comorbidities. After multivariable Cox regression analysis, FTR grade severity (hazard ratio [HR]=2.95, 95% confidence interval [CI] 2.14–4.06, p<0.001) and RVGLS (HR= 0.91, 95% CI 0.86–0.95) were the only independent predictors of mortality. A cutoff of −17.5 for RVGLS had 57% sensitivity, 73% specificity and a HR of 2.34 (95% CI of 1.42–3.88, p-value=0.001). The Kaplan Meier survival curve showed that patients with an RVGLS ≥ −17.5 had a higher probability of developing the primary composite outcome, especially at an earlier phase of the follow up when compared to those with higher LS (log rank test chi-square = 13.0, p<0.001) (Figure). At the end of follow up, 60% of patients with a RVGLS ≥-17.5 did not developed the primary composite outcome vs 29% in the group with a LS lower than −17.5.

Kaplan-Meier curve of outcome by RVGLS

Conclusions

In patients with FTR, a decreased RVGLS, with a cutoff of −17.5, proved to be an independent prognostic factor for the development of HF hospitalizations and death from cardiovascular causes.

An atypical case of pulmonary embolism from a jugular vein

Neck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

Evaluation of right ventricular function performed by 3d-echocardiography in scleroderma patients

The impairment of the right ventricle (RV) in systemic sclerosis (SSc) is usually related to pulmonary arterial hypertension (PAH). New echocardiographic techniques, such as 3-dimensional echocardiography (3DE) and 2-dimensional speckle tracking (2DSTE), allow an accurate evaluation of the RV function. The aim of this study was to evaluate the RV function using 3DE and 2DSTE in SSc patients with no history of heart disease and no PAH. Forty-five SSc patients, 42 females and 3 males, 28 with limited cutaneous SSc (lcSSc) and 17 with diffuse cutaneous SSc (dcSSc), were studied. Forty-three age- and gender-matched healthy subjects were enrolled as controls. All of them underwent a 3DE and 2DSTE ecocardiographic evaluation of the RV function. Systolic pulmonary arterial pressure (sPAP) and total pulmonary vascular resistance (tPVR) were also estimated by power doppler. RV echocardiographic parameters were compared in the different subsets of SSc patients. A statistical analysis was performed by t-test, ANOVA and multiple logistic regression. RV areas in 2DSTE and volumes in 3DE were higher and RV function parameters were reduced in SSc patients compared with controls. Also sPAP and tVPR were higher, but they did not reach pathological values. Echocardiographic alterations were more pronounced in patients with lcSSc. 3DE and 2DSTE echocardiography allowed us to detect morphological and functional alterations of the RV in a group of SSc patients with no clinical signs of heart disease and no PAH. These patients had significantly higher sPAP and tPVR than healthy controls without reporting values compatible with PAH. These data suggest that RV alterations are related to a pressure overload rather than to an intrinsic myocardial involvement in SSc.