P129 IMPACT OF THE ATHEROSCLEROTIC PABULUM ON IN–HOSPITAL MORTALI–TY FOR SARS–COV–2 INFECTION. IS CALCIUM SCORE ABLE TO IDENTIFY AT RISK PATIENTS?

Background

Although the primary cause of death in COVID–19 infection is respiratory failure, there are evidences that cardiac manifestations may contribute to overall mortality and can even be the primary cause of death. More importantly, it is recognised that COVID–19 is associated with a high incidence of thrombotic complications.

Aim of the Study

evaluate if CAC score was useful to predict in–hospital mortality and complications in patients with COVID infection

Methods

Two–hundred–eighty–four patients with proven SARS–CoV2 infection who had a non–contrast Chest CT at our facility were retrospective analysed for coronary artery calcium (CAC) score. Primary endpoint was in–h mortality. Secondary end–points were need for mechanical ventilation and Intensive Care Unit admission. Clinical and radiological data were retrieved.

Results

Patients with coronary calcium had higher inflammatory burden at admission (D–dimer, CRP, Procalcitonin) and higher high–sensitive Troponin I (HScTnI) at admission and at peak. While there was no association with presence of consolidation and ground glass opacities, patients with coronary calcium had higher incidence of bilateral infiltration and higher in–hospital mortality. The main finding of our research is that CAC alone does not completely identify all the population at risk of events in the setting of COVID 19 patients. Peak HScTnI was associated with higher mortality, intensive care unit admission and mechanical ventilation in both univariable at multivariable analysis.

Conclusions

Together with the presence of higher inflammation burden CAC may be a useful marker in identifying patients at risk of cardiovascular complications and in hospital mortality.

Feasibility and role of echocontrast evaluation of patients with LVAD

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with Advanced heart failure (AHF) long-term support with durable mechanical circulatory support (MCS) devices such as left ventricular assist device (LVAD) brings survival benefits and improvement in quality of life, compared with conventional medical treatments. Development of RVF in patients with LVAD has a direct effect on mortality and is associated with prolonged length of stay in intensive care unit and in-hospital stay and with poor quality of life. Purpose: the evaluation of clinical safety and feasibility of  echocontrast (EC) in patients implanted with 3 different types of LVAD (HeartWAre HVAD, Jarvik 2000, HeartMate 3); the assessment of the improvement in the visualization of heart structures; the intra and inter-operator agreement of RV measurements (FAC, TAPSE, sPAP, TR,  regional wall motion abnormalities) with and without contrast. Methods: Between 2014 and 2019, 43 patients were implanted with LVAD, in particular 7 (16%) patients were implanted with Jarvik 2000, 31 (72%) with HeartMAte 3, 5 (12%) pts with HeartWAre HVAD. Nine patients (21%) either had contraindication or refused contrast injection. In 3 (7%) patients, it was technically challenging to obtain apical images at all levels. Two (5%) patients lost their follow-up. Our final population was of 29 (67%) patients. We also assessed the reproducibility of these measurements between two different expert operators (blind analysis). Results:  We observed no allergic reaction to EC. Total 329 (64%) of 516 RV wall segments were available for qualitative analysis without contrast vs 451 (87%) with contrast (p < 0.001) with a significant improvement of the evaluability of regional contractility and FAC  (41% vs 90%, p < 0.001). Evaluation of TAPSE, TR and sPAP was similar with and without contrast (p = NS) All the RV parameters showed little inter-operator variability when measured with contrast. TAPSE, FAC, and RWMA showed an excellent reproducibility (ICC >0.86) while it was good for 2D-baseline derived parameters (ICC = 0.74) showing improvement of inter operator reproducibility in the evaluation of regional contractility in the contrast echocardiography modality. Conclusion: EC is safe with all the types of LVAD we examined. Accurate and reproducible visualization of RV is imperative for reliability of information, a routine use of EC could play a pivotal role in interpreting RV features.  EC improves RV morphologic and functional judgment; allowing greater accuracy and precision in the assessment of both global and regional RV functions. This finding may have important clinical improvement, especially in the future for analysis focused in RV prognostic role in LVAD patients

Feasibility and reproducibility of right ventricle stress echocardiography and its capability to assess the right ventricle contractile reserve of patient with at least trivial tricuspid regurgitation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND. Stress echocardiography (SE) is widely used for the assessment of left ventricular (LV) function, diagnostic and prognostic stratification of patients with coronary artery disease and for assessment of mitral and aortic valve disease. However, the assessment of the right ventricle (RV) in general, and in particular in regard to the contractile reserve of the RV in patients with tricuspid valve (TV) disease is an area that has not been previously explored in adult patients. The physiology and function of the RV is different than that of the LV and the use of SE provides the possibility to test both systolic and diastolic function of the RV in response to increased loading conditions. This can potentially be used to assess the RV function prior to surgery  and to predict which subset of patients may benefit from intervention on the TV before the RV displays signs of failure

PURPOSE. We therefore propose a study to investigate the potential use of SE for the assessment of RV function in adult patients. The aim is to evaluate the feasibility of RV SE in any patients with more than trivial tricuspid regurgitation (TR) and to assess the presence and degree of RV contractile reserve.

METHODS. We enrolled 81 patients undergoing a phisical or dobutamine SE for CV risk stratification or chest pain. Inclusion criteria were age≥ 18 years, normal baseline RV function (FAC> 35%, TAPSE> 16 mm). Exclusion criteria were presence of RV dysfunction, pulmonary stress hypertension, positive stress test for left myocardial ischemia, presence of moderate or severe valvular disease, grade III or higher diastolic dysfunction at baseline, severe respiratory, renal or hepatic dysfunction. We evaluated the average values of TAPSE, fractional area change (FAC), S wave, sPAP (pulmonary systolic blood pressure), RV strain during baseline and at the peak of the effort. We also assessed the reproducibility of these measurement between two different expert operators (blind analysis).

RESULTS. We were able to measure the RV parameters both during baseline and at the peak of the effort in all patients, demonstrating an excellent feasibility. Differences in parameters collected at baseline and at peak were assessed using paired Wilcoxon signed rank test. All variables showed a statistical significant increase (p < 0.001) at peak compared to the baseline. Average percentage increases at peak were 31.1% for TAPSE, 24,8% for FAC, 50,6% for S wave, 55,2% for PAPS and 39.8 % for RV strain. Bland-Altman method was used to evaluate the agreement between measurements collected by two separate operators and it showed  good Intraclass Correlation Coefficients  (Figure).

CONCLUSIONS. RV SE proved to be feasible and showed little inter-operator variability  in patients with at least trivial TR. It provided valuable informations about RV contractile  reserve that may help stratifying the risk of RV failure in patients undergoing TV surgery.

Abstract Figure

Added value of left atrial expansion index for non-invasive estimation of pulmonary capillary wedge pressure

Introduction

Right heart catheterization (RHC) is the reference technique for pulmonary capillary wedge pressure (PCWP) measurement but remains invasive. Transthoracic echocardiography (TTE) diastolic parameters (DPs) are used as non-invasive surrogates but have suboptimal accuracy. Left atrial expansion index (LAEI), describing LA reservoir function, could be used for indirectly estimate PCWP.

Purpose

To evaluate the correlation between LAEI and PCWP and to compare LAEI accuracy against DPs in estimating PCWP.

Methods

We retrospectively included the patients admitted to our department from 05/2015 to 02/2018 who underwent both a clinically indicated RHC and TTE within 24 hours. PCWP was obtained during RHC. DPs were measured offline and LAEI was calculated from LA maximum volume (MaxVol) and LA minimum volume (MinVol) as LAEI = [(LAMaxVol − LAMinVol) / LAMinVol)] × 100.

Results

We enrolled 405 patients (left ventricular ejection fraction (LVEF)<50% n=172; PCWP>12mmHg n=209). LAEI showed a logarithmic correlation with PCWP. The log-transformed LAEI (lnLAEI) had an excellent linear correlation (r=−0.82; p<0.001) with PCWP, higher than DPs (LAMaxVoli: r=0.42; E/A: r=0.57; E/e': r=0.51; TRMaxVel r=0.17; all p<0.001). lnLAEI had the highest accuracy in identifying PCWP>12 mmHg (lnLAEI AUC 0.921, p<0.001) when compared to DPs and their association (Figure). lnLAEI showed an independent and added predictive value in estimating PCWP in a model including atrial fibrillation (Afib), heart rate (HR), LVEF, mitral regurgitation (MR), LAMaxVoli, E/A, E/e' and TRMaxVel (Table).

Conclusions

LAEI is a simple parameter strongly associated with PCWP which might be used for PCWP estimation.

Funding Acknowledgement

Type of funding source: None

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.

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.

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%.

P1257 Additional value of echocardiography in critical patient: a quick and effective tool to improve diagnosis and treatment

Learning point

in challenging cases with unclear diagnosis of septic versus cardiogenic shock, both TTE and TOE play a pivotal role showing a series of findings that can help clarifying the diagnosis and guide patient treatment in emergency settings.

Abstract P1257 Figure

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.