Aortopathy and aortic valve surgery in patients with bicuspid aortic valve with and without raphe

AIM

To evaluate the association between raphe in bicuspid aortic valve (BAV) patients and valve dysfunction, aortopathy and aortic valve surgery in the REBECCA registry [REgistro della valvola aortica Bicuspide della Società Italiana di ECocardiografia e CArdiovascular Imaging (SIECVI)].

METHODS

Prevalence of aortic valve dysfunction and aortopathy was investigated in BAV patients with and without raphe. Aortic valve dysfunction (regurgitation or stenosis) was categorized as mild, moderate and severe. Aortopathy was defined as annulus ≥14 mm/m2; root ≥20 mm/m2; sinotubular junction ≥16 mm/m2; ascending aorta ≥17 mm/m2, and classified in Type A, isolated ascending aorta dilatation; Type B, aortic root and ascending aorta dilatation; and Type C, isolated aortic root dilatation.

RESULTS

Overall, 695 patients with BAV were enrolled; 520 (74.8%) with raphe and 175 (25.2%) without raphe. BAV patients with raphe presented more frequently with moderate or severe aortic stenosis than BAV patients without raphe (183 [35.2%] vs 34 [19.4%], p < 0.001). A higher prevalence of aortopathy, particularly Type B, was observed in patients with vs without raphe. At multivariable analysis, raphe was a predictor of aortic valve surgery at three-year follow-up (odds ratio 2.19, 95% confidence interval 1.08-4.44, p < 0.001).

CONCLUSIONS

Patients with BAV and raphe have a higher prevalence of significant aortic stenosis, aortopathy, especially Type B, and a higher risk of undergoing aortic valve surgery at three-year follow-up.

Pericardial agenesis: a case report of a rare congenital heart disease

Background

Pericardial agenesis is a rare congenital heart disease characterized by a variable clinical presentation.

Case summary

A 32-year-old man was sent by an occupational health physician to our health care centre because of pathological electrocardiogram (ECG). On transthoracic echocardiogram, we had some difficulty to obtain a good quality of four-chamber apical view that was shifted upper and laterally towards the left anterior axillary line. Nonetheless, an abnormal diastolic expansion of the apex of the left ventricle (LV) that had an otherwise normal systolic function was detected. A chest X-ray confirmed the leftward shift of the heart, with the elongation of the left border of cardiac silhouette and cardiac MRI, finally revealed the absence of left-sided pericardium associated with a leftward dislocation of the heart and a dysmorphism of the LV apex that appeared rounded and curved. The non-invasive work-up was completed with 48 h long Holter ECG that was unremarkable. The exercise test was also negative for both inducible myocardial ischaemia and arrhythmias. Patient was scheduled for loop-recorder implantation, and a 6-month clinical follow-up was advised.

Discussion

Pericardial agenesis is a rare congenital heart disease associated with an increased risk of cardiac arrhythmias and type A aortic dissection, however its clinical course could be also completely unremarkable. The diagnosis is challenging, and cardiac MRI remains the gold standard imaging modality. In complete left-sided and asymptomatic forms, no treatment is needed. Prognosis is not well established due to both the rarity of disease and extreme variability of clinical presentation.

Management of cancer patients at high and very-high risk of cardiotoxicity: Main questions and answers

In recent years, important advances have been made in the field of Cardio-Oncology. The 2022 ESC Guidelines on Cardio-Oncology proposed a baseline cardiovascular risk stratification for cancer patients and preventive strategies in patients at high and very-high risk of cardiotoxicity. Cardiovascular toxic effects of anti-cancer drugs are being extensively studied; surveillance programs have been proposed, based on the baseline cardiovascular risk. On the other hand, there is little data on Cardio-Oncological management of patients at high and very-high cardiovascular risk with previous cardiovascular diseases. For example, little is known about management of cancer patients with heart failure with reduced ejection fraction (HFrEF), patients with a recent myocardial infarction or other cardiovascular diseases; when to resume anti-cancer drugs after a cardiovascular toxic event. Collaboration between Cardiologists and Oncologists and multidisciplinary team evaluations are certainly essential to decide the best therapeutic strategy for cancer patients, to treat cancer while saving the heart. Therefore, in the present review, we attempt to provide a useful guide to clinicians in treating patients with high and very-high risk of cardiotoxicity by enucleating main questions and answering them based on the evidence available as well as expert opinion and our clinical experience.

Arterial hypertension in patients with takotsubo syndrome: prevalence, long-term outcome, and secondary preventive strategies: a report from the Takotsubo Italian Network register

AIMS

The aim of this study was to investigate the long-term outcome of takotsubo syndrome (TTS) patients with and without hypertension (HT) and to evaluate the effectiveness of treatment with beta-blockers (BBs) and/or renin-angiotensin-aldosterone system inhibitors (RAASi).

METHODS AND RESULTS

The study population includes a register-based, multicentre cohort of consecutive patients with TTS, divided into two groups according to the history of HT. Further stratification was performed for BB/RAASi prescription at discharge. The primary outcome was the composite of all-cause death and TTS recurrence at the longest available follow-up. The propensity score weighting technique was used to account for potential confounding. In the overall population (903 patients, mean age 70 ± 11 years), HT was reported in 66% of cases. At a median 2-year follow-up, there was no difference in the risk of the primary composite outcome between patients with and without HT. The adjusted Cox regression analysis showed a significantly lower risk for the primary outcome [adjusted hazard ratio (aHR): 0.69; 95% confidence interval (CI): 0.49-0.99] in patients who received BB vs. those who did not. Renin-angiotensin-aldosterone system inhibitors treatment was not associated with the primary study outcome. The lower risk for the primary outcome with BB treatment was confirmed in patients with HT (aHR: 0.37; 95% CI: 0.24-0.56) but not in patients without (aHR: 1.83; 95% CI: 0.92-3.64; Pinteraction < 0.001).

CONCLUSION

In this TTS study, HT did not affect the long-term risk of adverse events but increased the probability of benefit from BB treatment after discharge. Owing to the favourable outcome impact of BB prescription in TTS patients with HT, a tailored pharmacological therapy should be considered in this cohort.

Myocardial Work Appraisal in Transthyretin Cardiac Amyloidosis and Nonobstructive Hypertrophic Cardiomyopathy

Global left ventricular (LV) myocardial work (MW) indexes can be recognized at ultrasound imaging from the LV pressure/global longitudinal strain (GLS) loop analysis. A total of 4 indexes, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), have been demonstrated to overcome the methodological limitations of GLS and provide useful information on myocardial dysfunction in some clinical settings. Although impaired MW indexes have been demonstrated in patients with transthyretin cardiac amyloidosis (ATTR) or with nonobstructive hypertrophic cardiomyopathy (HCM), there are no comparative studies at present. This study aimed to describe the characteristics of MW in both these clinical settings compared with patients with well-controlled hypertension (HTN). A total of 83 patients, 32 with ATTR (aged 70 ± 11 years, 32% mutated, 68% wild-type, 72% men), 29 with HCM (aged 57 ± 17 years), and 22 HTN controls (aged 56 ± 5.6 years, 59% men) were prospectively enrolled at 2 clinical centers. All participants had New York Heart Association class I or II. Overall, the LV mass index was greater in both study groups than in HTN, whereas the LV ejection fraction (EF) was significantly lower in ATTR compared with other groups. Based on this finding, patients with ATTR were further divided into 2 subgroups: ATTR1 (LVEF ≤0.50), n = 14 (44%) and ATTR2 (LVEF >0.50), n = 18 (56%). Overall, the GWI and GCW were lower in all ATTR patients (mostly in ATTR1) than in the other groups (p <0.001), whereas only small differences in GWE and none in GWW were found among the groups. Of interest, the pairwise comparison and receiver operating characteristic analysis in preserved LVEF patients showed that GWI was a better discriminator of ATTR2 from HCM patients than GLS, with the cut-off value ≤1,419 mm Hg% (89% sensitivity; 55% specificity; p = 0.013). In conclusion, MW analysis was confirmed to be a modern way to investigate myocardial function in patients with hypertrophic phenocopies. GWI and GCW were more impaired in patients with ATTR compared with HCM and HTN controls. Furthermore, this study likely revealed an additional discriminative value of GWI over GLS alone in preserved LVEF settings.

Atrial Strain Assessment for the Early Detection of Cancer Therapy-Related Cardiac Dysfunction in Breast Cancer Women (The STRANO STUDY: Atrial Strain in Cardio-Oncology)

Left ventricular global longitudinal strain (GLS) has an important role in the diagnosis of cancer therapy-related cardiac dysfunction (CTRCD). Little is known about the role of atrial function in diagnosing CTRCD. The aim of our study was to assess the impact of anti-cancer drugs on atrial function measured by speckle-tracking echocardiography in breast cancer women. A prospective multicenter study was conducted enrolling 169 breast cancer women treated with anthracyclines. A cardiological evaluation including an electrocardiogram and echocardiogram with an analysis of GLS, left atrial (LA) strain, and LA stiffness (LASi) was performed at baseline (T0), 3 (T1), and 6 months (T2) after starting chemotherapy. The patients were divided into two groups: patients with asymptomatic mild cardiotoxicity at T1 (with a relative reduction in GLS > 15%; Group 1) and those without (Group 2). We did not find a significant change in left ventricular ejection fraction (LVEF) at T1 and T2; we found a significant change in GLS (p-value < 0.0001) in the peak atrial longitudinal strain (PALS) and in LASi (p-value < 0.0001). Impairment of atrial function was greater in Group 1 compared to Group 2. A PALS variation > 20.8% identified patients who were most likely to develop asymptomatic mild cardiotoxicity [AUC 0.62; CI (0.51-0.73) p = 0.06, sensitivity 45%, specificity 69.5%]. Conclusions: PALS and LASi significantly change during chemotherapy in association with GLS. Atrial strain is an additional parameter that could be measured together with GLS to detect cardiotoxicity early.

Echocardiographic Patterns of Abnormal Septal Motion: Beyond Myocardial Ischemia

Abnormal septal motion (ASM), which often is associated with myocardial ischemia, is also observed in other diseases. Owing to the position of the interventricular septum (IVS) in the heart, its movement not only relies on contractile properties but is also affected by the pressure gradient between the 2 ventricles and by the mode of electrical activation. Echocardiography allows the operator to focus on the motion of the IVS, analyzing its characteristics and thereby gaining information about the possible underlying pathophysiological mechanism. In this review, we focused on the main echocardiographic patterns of ASM that are not related to a failure of contractile properties of the septum (i.e., acute coronary syndrome and cardiomyopathies), showing their pathophysiological mechanisms and underlining their diagnostic usefulness in clinical practice.

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

A Very Late Atrial Septal Erosion After an Ostium Secundum Percutaneous Closure

Complications after device closure of ostium secundum defects are rare but possible. We present a very late erosion of the interatrial septum after a percutaneous closure of an ostium secundum defect. Identification of early clinical and imaging clues associated with this condition is fundamental for a timely diagnosis and treatment. (Level of Difficulty: Intermediate.).

Stress Echocardiography in Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging

Background

The Italian Society of Echography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand the volumes of activity, modalities and stressors used during stress echocardiography (SE) in Italy.

Methods

We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved through an electronic survey based on a structured questionnaire, uploaded on the SIECVI website.

Results

Data were obtained from 228 echocardiographic laboratories, and SE examinations were performed in 179 centers (80.6%): 87 centers (47.5%) were in the northern regions of Italy, 33 centers (18.4%) were in the central regions, and 61 (34.1%) in the southern regions. We annotated a total of 4057 SE. We divided the SE centers into three groups, according to the numbers of SE performed: <10 SE (low-volume activity, 40 centers), between 10 and 39 SE (moderate volume activity, 102 centers) and ≥40 SE (high volume activity, 37 centers). Dipyridamole was used in 139 centers (77.6%); exercise in 120 centers (67.0%); dobutamine in 153 centers (85.4%); pacing in 37 centers (21.1%); and adenosine in 7 centers (4.0%). We found a significant difference between the stressors used and volume of activity of the centers, with a progressive increase in the prevalence of number of stressors from low to high volume activity (P = 0.033). The traditional evaluation of regional wall motion of the left ventricle was performed in all centers, with combined assessment of coronary flow velocity reserve (CFVR) in 90 centers (50.3%): there was a significant difference in the centers with different volume of SE activity: the incidence of analysis of CFVR was significantly higher in high volume centers compared to low - moderate - volume (32.5%, 41.0% and 73.0%, respectively, P < 0.001). The lung ultrasound (LUS) was assessed in 67 centers (37.4%). Furthermore for LUS, we found a significant difference in the centers with different volume of SE activity: significantly higher in high volume centers compared to low - moderate - volume (25.0%, 35.3% and 56.8%, respectively, P < 0.001).

Conclusions

This nationwide survey demonstrated that SE was significantly widespread and practiced throughout Italy. In addition to the traditional indication to coronary artery disease based on regional wall motion analysis, other indications are emerging with an increase in the use of LUS and CFVR, especially in high-volume centers.

Hybrid Palliation for Hypoplastic Left Heart Syndrome: Role of Echocardiography

Hypoplastic left heart syndrome is a spectrum of complex congenital cardiac defects. Although in borderline cases, biventricular repair is a viable option, in the majority of cases, univentricular palliation is the treatment of choice. Hybrid palliation can be a valid alternative to classic Norwood operation in the neonatal period, especially in selected cases such as high-risk patients or borderline left ventricles. Echocardiography is the main diagnostic modality in this pediatric population, from the fetal diagnosis to the subsequent surgical steps of palliative treatment. Hybrid palliation is performed after birth and is characterized by surgical banding of the pulmonary arteries along with transcatheter stenting of the ductus arteriosus. There are some peculiar aspects of cardiac imaging that characterize this type of palliation, and that should be considered in the different phases before and after the procedure. We aimed to review the current literature about the role of echocardiography in the management of patients with hypoplastic left heart undergoing hybrid palliation.

Hybrid Palliation for Hypoplastic Borderline Left Ventricle: One More Chance to Biventricular Repair

Treatment options for hypoplastic borderline left ventricle (LV) are critically dependent on the development of the LV itself and include different types of univentricular palliation or biventricular repair performed at birth. Since hybrid palliation allows deferring major surgery to 4-6 months, in borderline cases, the decision can be postponed until the LV has expressed its growth potential. We aimed to evaluate anatomic modifications of borderline LV after hybrid palliation. We retrospectively reviewed data from 45 consecutive patients with hypoplastic LV who underwent hybrid palliation at birth between 2011 and 2015. Sixteen patients (mean weight 3.15 Kg) exhibited borderline LV and were considered for potential LV growth. After 5 months, five patients underwent univentricular palliation (Group 1), eight biventricular repairs (Group 2) and three died before surgery. Echocardiograms of Groups 1 and 2 were reviewed, comparing LV structures at birth and after 5 months. Although, at birth, all LV measurements were far below the normal limits, after 5 months, LV mass in Group 2 was almost normal, while in Group 1, no growth was evident. However, aortic root diameter and long axis ratio were significantly higher in Group 2 already at birth. Hybrid palliation can be positively considered as a "bridge-to-decision" for borderline LV. Echocardiography plays a key role in monitoring the growth of borderline LV.

Which is the best Myocardial Work index for the prediction of coronary artery disease? A data meta-analysis

BACKGROUND

Early diagnosis of Coronary Artery Disease (CAD) plays a key role to prevent adverse cardiac events such as myocardial infarction and Left Ventricular (LV) dysfunction. Myocardial Work (MW) indices derived from echocardiographic speckle tracking data in combination with non-invasive blood pressure recordings seems promising to predict CAD even in the absence of impairments of standard echocardiographic parameters. Our aim was to compare the diagnostic accuracy of MW indices to predict CAD and to assess intra- and inter-observer variability of MW through a meta-analysis.

METHODS

Electronic databases were searched for observational studies evaluating the MW indices diagnostic accuracy for predicting CAD and intra- and inter-observer variability of MW indices. Pooled sensitivity, specificity, and Summary Receiver Operating Characteristic (SROC) curves were assessed.

RESULTS

Five studies enrolling 501 patients met inclusion criteria. Global Constructive Work (GCW) had the best pooled sensitivity (89%) followed by GLS (84%), Global Work Index (GWI) (82%), Global Work Efficiency (GWE) (80%), and Global Wasted Work (GWW) (75%). GWE had the best pooled specificity (78%) followed by GWI (75%), GCW (70%), GLS (68%), and GWW (61%). GCW had the best accuracy according to SROC curves, with an area under the curve of 0.86 compared to 0.84 for GWI, 0.83 for GWE, 0.79 for GLS, and 0.74 for GWW. All MW indices had an excellent intra- and inter-observer variability.

CONCLUSIONS

GCW is the best MW index proving best diagnostic accuracy in the prediction of CAD with an excellent reproducibility.

Organization and Activity of Italian Echocardiographic Laboratories: A Survey of the Italian Society of Echocardiography and Cardiovascular Imaging

Background

The Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI) conducted a national survey to understand better how different echocardiographic modalities are used and accessed in Italy.

Methods

We analyzed echocardiography laboratory activities over a month (November 2022). Data were retrieved via an electronic survey based on a structured questionnaire, uploaded on the SIECVI website.

Results

Data were obtained from 228 echocardiographic laboratories: 112 centers (49%) in the northern, 43 centers (19%) in the central, and 73 (32%) in the southern regions. During the month of observation, we collected 101,050 transthoracic echocardiography (TTE) examinations performed in all centers. As concern other modalities there were performed 5497 transesophageal echocardiography (TEE) examinations in 161/228 centers (71%); 4057 stress echocardiography (SE) examinations in 179/228 centers (79%); and examinations with ultrasound contrast agents (UCAs) in 151/228 centers (66%). We did not find significant regional variations between the different modalities. The usage of picture archiving and communication system (PACS) was significantly higher in the northern (84%) versus central (49%) and southern (45%) centers (P < 0.001). Lung ultrasound (LUS) was performed in 154 centers (66%), without difference between cardiology and noncardiology centers. The evaluation of left ventricular (LV) ejection fraction was evaluated mainly using the qualitative method in 223 centers (94%), occasionally with the Simpson method in 193 centers (85%), and with selective use of the three-dimensional (3D) method in only 23 centers (10%). 3D TTE was present in 137 centers (70%), and 3D TEE in all centers where TEE was done (71%). The assessment of LV diastolic function was done routinely in 80% of the centers. Right ventricular function was evaluated using tricuspid annular plane systolic excursion in all centers, using tricuspid valve annular systolic velocity by tissue Doppler imaging in 53% of the centers, and using fractional area change in 33% of the centers. When we divided into cardiology (179, 78%) and noncardiology (49, 22%) centers, we found significant differences in the SE (93% vs. 26%, P < 0.001), TEE (85% vs. 18%), UCA (67% vs. 43%, P < 0001), and STE (87% vs. 20%, P < 0.001). The incidence of LUS evaluation was similar between the cardiology and noncardiology centers (69% vs. 61%, P = NS).

Conclusions

This nationwide survey demonstrated that digital infrastructures and advanced echocardiography modalities, such as 3D and STE, are widely available in Italy with a notable diffuse uptake of LUS in the core TTE examination, a suboptimal diffusion of PACS recording, and conservative use of UCA, 3D, and strain. There are significant differences between northern and central-southern regions and echocardiographic laboratories that pertain to the cardiac unit. This inhomogeneous distribution of technology represents one of the main issues that must be solved to standardize the practice of echocardiography.

Rapid Onset Idiopathic Pulmonary Hypertension: A Case Report with a Review of Echocardiographic Parameters

Pulmonary hypertension (PHT) is an emerging issue. The prognosis in PHT is usually poor, independently from the etiology, with progressive right ventricle failure. Despite right Heart Catheterism is the gold standard for diagnosis of PHT, echocardiography provides important information about prognosis and is helpful in both follow-up and first evaluation of PHT patients, showing a good correlation with invasively measured parameters by right heart catheterization. However, it is important to understand the limits of this method, particularly in some settings, where transthoracic echocardiography has shown a lack of accuracy. In this case report we documented a case of rapid onset (3 months) idiopathic PHT and we provided a critical analysis of echocardiographic role in PHT.

61 LEFT ATRIAL RESERVOIR AND STIFFNESS IN PATIENTS WITH WILD-TYPE TRANSTHYRETIN AMYLOID VS HYPERTROPHIC CARDIOMYOPATHY

Objectives

Left atrial (LA) function can be investigated by advanced ultrasound speckle tracking modality, much better than in the past. Modern ultrasound technology allows attaining myocardial deformation profiles from both ventricular and atrial chambers. Each of the 3 components of LA function [reservoir, also known as peak longitudinal strain (PALS); conduit and pump] can be impaired in various chronic diseases. We previously demonstrated that PALS (reservoir) and pump function weaken in patients with cardiac transthyretin amyloidosis (ATTR) and hypertrophic cardiomyopathy (HCM). In the present study we sought to recognize LA stiffness (LAst), a relatively novel marker of atrial dysfunction, in the same clinical settings.

Methods

17 patients, 9 with ATTR wild-type (wt) and 8 with non-obstructive HCM, mean aged 67±12 years, were investigated by using transthoracic color-Doppler and strain ultrasound equipment. LV mass index (LVMI), LA area index (LAAI), LV ejection fraction (LVEF), E/E’ ratio, LV global longitudinal strain (GLS), PALS and LAst were assessed in both groups. LAst was calculated by PALS/E/E’ ratio, as suggested by studies.

Results

LVMI and LAAI were similar in the 2 groups: 171±40 vs 161±51 g/m2.7 and 14±3 vs 16±4 cm/m2.7 in ATTRwt vs HCM, respectively (p=NS). However, patients in the former group showed poorer LV diastolic and systolic function (LVEF was 47±9 vs 58±5%, respectively, p&lt;0.01), as well as GLS (9.5±2.2 vs 12.6±2.8, respectively, p=0.02). PALS and LAst were more impaired in ATTRwt compared to HCM patients (Figure), despite similar LA chamber size. Considering that LAst value &gt;0.65 has been reported as a predictor of adverse LA morphofunctional remodeling, both groups were considered at risk for atrial dysfunction, but mainly the former one.

Conclusions

Although present findings were achieved by a small patient population, LA reservoir and stiffness were impaired in patients with ATTRwt more than in those with HCM. Left atrial dysfunction may not be strictly related with LVMI or LA size, but with LV-GLS, confirming an atrio-ventricular functional interplay in cardiac amyloidosis. Further larger study is needed to corroborate present results.

945 TRANSIENT LEFT VENTRICULAR THROMBOSIS TAKOTSUBO-RELATED

Background

Takotsubo syndrome (TTS) is an increasingly widespread syndrome characterized by an acute and usually transient left ventricular (LV) dysfunction. Despite its transient nature, the acute phase can be characterized by serious complications such as LV thrombosis, as occurred in this case.

Case description

A 93-year-old woman was admitted to our emergency department due to a recent and self-limiting episode of acute chest pain. The ECG showed ST-elevation in leads V2, V3 and V4 (Fig.1), with cardiac biomarkers elevation. Transthoracic echocardiography (TTE) revealed apical akinesia and hypokinesia of the other LV segments with a severely reduced ejection fraction (EF 35%). Emergency coronary angiography showed normal epicardial coronary vessels. So, Takotsubo cardiomyopathy was hypothesized as diagnosis. A mass suspect for a thrombus was detected into the apex on day 3, despite a mild improvement of the other segments contraction (EF 40%), and clearly confirmed with the contrast echocardiography on day 5 (Fig.2). Unexpectedly, any LV thrombus was identified with cardiac MRI study performed on day 7 (Fig.3). Meanwhile, the patient never showed neurological disorders or other signs of thromboembolic complications. Echocardiography performed on day 11, before discharge, showed a great improvement of regional wall motion with residual LV apical hypokinesia (EF 55%) and no apical masses.

Discussion

This case emphasizes the need of frequent echocardiographic follow up in stress-induced cardiomyopathy, not only during the akinetic phase but also during the period of wall motion recovery, in order to diagnose and treat as soon as possible a LV apical thrombosis avoiding thromboembolic complications. We hypothesized that the early anticoagulation therapy combined with the initial improvement in LV wall motion facilitated the process of thrombosis resolution. Cardiac MRI played a relevant role in the comprehensive assessment of the functional and structural LV changes; the absence of late gadolinium enhancement (LGE) can be considered as a positive prognostic factor, indicating a complete resolution without residual fibrosis.

Conclusion

A multimodality imaging approach, based on a frequent echocardiographic follow up combined with cardiac MRI, is fundamental for an early diagnosis and a rapid treatment of LV thrombosis Takotsubo-related.

1083 RISK STRATIFICATION AND PREDICTORS OF OUTCOME IN ASYMPTOMATIC AORTIC STENOSIS: THE ROLE OF MULTIMODALITY IMAGING

Background

Management of asymptomatic severe aortic stenosis is controversial and the decision to intervene requires careful assessment of the benefits and risks in an individual patient. Multimodality imaging approach is becoming an important tool to evaluate the severity and outcome of aortic stenosis (AS).

Aim

To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low-flow, low-gradients (LFLG) severe AS.

Methods

70 (81.4±8.4yrs) prospective asymptomatic patients with AS were followed for 2.77±2.01yrs with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1.

Results

Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31 ±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13(18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p&lt;0.001), pulse pressure (p=0.005) and dilated ascending aorta (p&lt;0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA =1cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p&lt;0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55AU/m2) and true severe in 12 (3388±1188 AU;1858 ±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations.

Conclusions

Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function.

631 THE IMPACT OF BMI ON MYOCARDIAL WORK AND LEFT ATRIAL STRAIN IN YOUNG OVERWEIGHT PATIENTS WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION

Introduction

Overweight and obesity are a health problem of growing significance all over the world with increasing prevalence in both developed and developing countries. Numerous studies have demonstrated a relationship between obesity and cardiovascular diseases, underscoring the need to early treat this pathological condition. Overweight and obesity cause structural and functional changes on left ventricular (LV) and left atrial (LA) performance, which lead to heart failure. In this context we aimed to evaluate the impact of BMI on myocardial work parameters and left atrial strain to early detect LV and LA performance changes in overweight patients.

Methods

80 young individuals were prospectively enrolled, distinguishing between overweight patients with BMI greater than or equal to 25 to 29.9 kg/m^2 (n= 36; 45±11 years) and normal weight patients with BMI greater than or equal to 18.5 to 24.9 kg/m^2 (n=44; 43±9 years). All patients underwent transthoracic echocardiogram to calculate global longitudinal strain (GLS), global work index (GWI), global work efficiency (GWE), global wasted work (GWW), global constructive work (GCW) and left atrial strain.

Results

Overweight patients have higher BSA (1,9±0,16 vs 1,6±0,17 mq; p&lt;0,0001), Diastolic Blood pressure (81±12 vs 74±10 mmHg; p= 0,01) mean arterial pressure (98±15 vs 91±11 mmHg; p = 0,01), Heart Rate (71±13 vs 70±12 bpm; p= 0,02) and Global Longitudinal Strain (-19,3% ±1,7 vs -20,3% ±1,8; p = 0,02). With respect to myocardial work parameters, in overweight patients GWE (93% vs 95%; p=0,01) is significantly reduced, whereas GWW (132 vs 102 mmHg%; p=0,03) is significantly increased. Left atrial reservoir (LAres) (36% vs 40%; p=0,04) and conduit (-19% vs -24%; p=0,005) function are significantly reduced in overweight patients. BMI inversely correlates with GWE (r=-0,36; p=0,005) and LAres (r=-0,33; p=0,007), whereas it directly correlates with GWW (r=0,31; p = 0,006).

Conclusions

Overweight induces early LV and LA performance changes that can be precociously detected by myocardial work and left atrial strain, in order to better characterize individual cardiovascular risk profile.

1095 WHICH IS THE BEST MYOCARDIAL WORK INDEX FOR THE PREDICTION OF CORONARY ARTERY DISEASE? A DATA METANALYSIS

Background

Early diagnosis of Coronary Artery Disease (CAD) plays a key role to prevent adverse cardiac events such as myocardial infarction and Left Ventricular (LV) dysfunction. Myocardial Work (MW) indices derived from echocardiographic speckle tracking data in combination with non-invasive blood pressure recordings are able to predict CAD even in the absence of impairments of standard echocardiographic parameters. Our aim was to compare the diagnostic accuracy of MW indices to predict CAD and to assess intra-observer and inter-observer variability of MW through a metanalysis.

Methods

Electronic databases were searched for observational studies evaluating the MW indices diagnostic accuracy for predicting CAD and intra-observer and inter-observer variability of MW indices. Pooled sensitivity, specificity, and Summary Receiver Operating Characteristic (SROC) curves were assessed.

Results

5 studies enrolling 501 patients met inclusion criteria. Global Constructive Work (GCW) had the best pooled sensitivity (89%) followed by GLS (84%), Global Work Index (GWI) (82%), Global Work Efficiency (GWE) (80%) and Global Wasted Work (GWW) (75%). GWE had the best pooled specificity (78%) followed by GWI (75%), GCW (70%), GLS (68%) and GWW (61%). GCW had the best accuracy according to SROC curves, with an Area Under The Curve of 0.86 compared to 0.84 for GWI, 0.83 for GWE, 0.79 for GLS and 0.74 for GWW (Figure 1). All MW indices had an excellent intra-observer and inter-observer variability.

Conclusions

GCW is the best MW index proving best diagnostic accuracy in the prediction of CAD with an excellent reproducibility.

Figure 1: Pooled sensitivity, pooled specificity, SROC curves and AUC of Myocardial Work indices and GLS

783 RELATIONSHIP BETWEEN PULSE WAVE VELOCITY AND MYOCARDIAL WORK IN UNTREATED HYPERTENSIVE PATIENTS WITH PRESERVED LVEF

Introduction

Hemodynamic interaction between left ventricular (LV) and arterial system is a key determinant of cardiovascular performance. The non-invasive carotid-femoral Pulse Wave Velocity (PWV), obtained with applanation tonometry, is considered the most precise way of estimating arterial stiffness. The LV myocardial work (MW), based on non-invasive LV pressure-strain loop (PSL), is a new promising tool to assess LV function.

Aims

The aim of the study was to evaluate the correlation between PWV and MW parameters in a population of non-hypertensive and newly diagnosed untreated hypertensive people.

Materials and methods

80 people (M=48), divided in hypertensive (group 1 n=40, 45±10 years) and non-hypertensive (group 2 n=40, 40±12 years), were prospectively enrolled. All underwent conventional transthoracic echocardiogram and at the same day carotid femoral PWV was calculated with applanation tonometry (SphygmoCor® XCEL). MW parameters were obtained using 2D Speckle-tracking technique.

Results

Comparing the two groups, PWV and Global Work Wasted (GWW) were significantly higher in the hypertensives group (9,73±2,4 vs 7,79±1,1; p=0,001 and 146±50 vs 85±27, p=0,001), as shown in Figure 1, whereas Global Work Efficiency (GWE) and Global Work Constructive (GWC) were significantly lower (93,6±2,5 vs 95,6±1,2, p=0,001 and 2410±122 vs 2167±65, p=0,002). We found a linear and positive correlation of PWV with GWW (r=0,271, p=0,016), as seen in Figure 2, and a linear and negative correlation of PWV with GWE (r=-0,282, p=0,012).

Conclusion

This study highlights the role of PWV and MW evaluation in hypertensives. Higher PWV and GWW could be considered as red flags of myocardial damage suggesting the need of an early appropriate antihypertensive therapy.

409 PROGNOSTIC VALUE OF TENTING AREA ASSESSED BY CMR IN PATIENTS WITH ISCHEMIC MITRAL REGURGITATION

Objectives

Mitral regurgitation (MR) due to complications of coronary artery disease is defined as ischemic mitral regurgitation (IMR) and, in the chronic phase after myocardial infarction (MI), it has a negative prognostic value, independently of baseline patient characteristics and degree of left ventricular (LV) dysfunction. In this context, we aimed to determine the additive prognostic role of morphological parameters, assessed by cardiac magnetic resonance (CMR), in patients with ischemic mitral regurgitation (IMR).

Methods

250 patients were recruited with diagnosis of IMR, and they were divided into two groups: those with cardiac death (or appropriate ICD shocks) event at 10 years follow-up (35 patients) and those without cardiac death event (215 patients). All patients underwent CMR imaging for the assessment of left ventricular (LV) ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), tenting area, tenting height, interpapillary muscles displacement and late gadolinium enhancement (LGE). Echocardiography was performed to assess MR.

Results

The average age of the entire sample is 64±10 years, with no significant differences between the two groups (63.2 ±10 vs 68 ±9). For what regards the echocardiographic parameters, there are no statistically significant differences in LVEDV, LVESV, SIV and PP; whereas telesystolic diameter (52 ±7 vs 42 ±9; p &lt; 0,0001), telediastolic diameter (61 ±4 vs 56 ±7; p = 0,003), the EROA (0.3 ±0.09 vs 0.25 ±0.6; p &lt; 0,0001) and left atrial volume (46±19 ml/m2 vs 38.7±11ml/m2 p= 0,0001) are greater in the event group. According to MRI data, patients in the event group, have significantly higher values of LVEDV (155 ±38 ml/m2 vs 111.09 ±38 ml/m2; p&lt;0,001), LVESV (114.04 ±36.8 ml/m2 vs 70 ± 38; p&lt;0,001), sphericity index (0.53 ±0.2 vs 0.44 ±0.1; p&lt;0,001), WMSI (2 ±0.3 vs 1.75 ±0.61, p=0,02), interpapillary distance (20 ±4 vs 18.4 ±6; p&lt;0,001) and posteromedial papillary muscle LGE (33% vs 16%; 0,03). Also, LVEF (28.2 ±9.03% vs 40.42 ±14.9%; p&lt;0,001) is more impaired in the cardiac death event group. There is statistically significant difference between the two groups for what concerns the tenting area (3.7 ±1.4 cm2 vs 2.6 ±0.8cm2; p&lt;0,001) and the tenting height (13 ±2.3 vs 10.5 ±2.6; p&lt;0,001) which are higher in patients with cardiac death event. In the univariate analysis, parameters that were significantly associated with a worst prognosis are: the severe extent of mitral regurgitation (HR 4,886; 95% CI 2,198-10,861), the tenting area (HR 1,009; 95% CI 1,006-1,013), the tenting height (HR 1,295; 95% CI 1,131-1,482; p&lt;0.05), the PISA radius (HR 1,329; 95% CI 1,083-1,631; p&lt;0.05) the EROA (HR 511,636; 95% CI 6,932-37763,8; p&lt;0.05), LGE PAP PM (HR 2,169; 95% CI 1,025-4,589; p&lt;0.05) and VTDi (HR 1,012; 95% CI 1,005-1,018; p&lt;0.05). In the multivariate analysis it appears that tenting area is an independent predictor (HR 1.009 IC (1.00–1.016) p&lt;0.05) of negative prognosis.

Conclusions

Increased tenting area, assessed by CMR, has independent negative prognostic value in patients with ischemic mitral regurgitation. This finding suggests that local remodeling, which occurs in ischemic cardiomyopathy, influences the severity and the prognosis of IMR, underscoring that anatomical compromission has a preeminent role in influencing outcomes in these patients, better than functional parameters.

221 NONBACTERIAL THROMBOTIC ENDOCARDITIS WITH ATYPICAL PRESENTATION AS OVERT CONGESTIVE HEART FAILURE

Introduction

Non-Bacterial Thrombotic Endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or, rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography.

Case presentation

An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep vein thrombosis. On physical examination, he was apyretic, mildly hypotensive and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed “thrombotic” thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed in the diagnostic workup and prescribed palliative care.

Discussion

Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo-density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about treatment of NBTE and the only role of anticoagulation to prevent systemic embolism.

Conclusions

We report a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging played a crucial role for the final diagnosis.

444 PULSE WAVE VELOCITY TO GLOBAL WORK EFFICIENCY RATIO IN HYPERTENSION: A NEW WAY TO EXPLORE VENTRICULAR-ARTERIAL COUPLING

Introduction

Ventricular–arterial coupling (VAC) is considered as the cornerstone of the functional interaction between ventricles and the arterial system. VAC is commonly assessed as arterial elastance (Ea) to ventricular end-systolic elastance (Ees) ratio and it has independent prognostic value in hypertension, so it may be used to refine risk stratification and monitor therapeutic interventions in hypertensive patients. Therefore, VAC may be better characterized by the measurement of each component of this ratio through novel and more sensitive markers of myocardial function (e.g. global longitudinal strain and myocardial work parameters) and arterial function (e.g. pulse wave velocity). In this context, we aim to investigate whether new coupling indices may be able to identify left ventricular (LV) performance changes induced by blood pressure (BP) overload earlier than conventional ones.

Methods

50 young individuals were prospectively enrolled, distinguishing between newly diagnosed untreated hypertensives (n= 25; 40±8 years) and controls (n=25; 39±9 years), matched for age and gender. All patients underwent at the same time carotid-femoral pulse wave velocity (PWV) measurement through an applanation tonometer (SphygmoCor® XCEL) and a transthoracic echocardiogram to calculate Ea/Ees ratio, assessed as end-systolic volume to stroke volume ratio (ESV/SV), global longitudinal strain (GLS) and myocardial work efficiency (GWE). Two new indices of VAC were derived: PWV/GLS, previously validated and PWV/GWE, still unknown.

Results

Ea/Ees ratio was lower in hypertensives (0,48±0,17) than in controls (0,57±0,14) but without any significant difference (p=0.18), whereas PWV/GLS was significantly higher in hypertensives than in controls (0,45±0,19 vs 0,35 ± 0,09 m/sec%; p= 0,02). PWV/GLS ratio correlated to Ea/Ees (r= 0,52; p &lt; 0,01), diastolic dysfunction degree (r=-0,59; p&lt;0,001), age (r=-0,64; p&lt;0,001), systolic BP (r=-0,41; p=0,002), diastolic BP (r=-0,39; p=0,005) and mean arterial pressure (MAP) (r=-0,40; p=0,004). PWV/GWE was higher in hypertensives than in controls (0,10± 0,02 vs 0,08±0,01 m/sec%; p=0,001) and it was associated with Ea/Ees (r=- 0,55; p = 0,006), age (r= 0,59; p&lt;0,001), diastolic dysfunction degree (r=0,55;p&lt; 0,001), systolic BP (r=0,8; p&lt; 0,001), diastolic BP (r=0,5;p&lt; 0,001) and MAP (r=0,52; p&lt;0,001).

Conclusions

Innovative indices of ventricular-arterial coupling could be more sensitive to investigate the impact of hypertension on LV performance.

Cardiotoxicity Induced by Immune Checkpoint Inhibitors: What a Cardio-Oncology Team Should Know and Do

Immune checkpoint inhibitors (ICIs) have revolutionized the therapeutic scenario for several malignancies. However, they can be responsible for immune-related adverse events (irAEs), involving several organs, with a pooled incidence ranging between 54% and 76%. The frequency of cardiovascular system involvement is <1%. Among the cardiovascular irAEs, myocarditis is the most common and the most dangerous but other, less common manifestations of ICI-related cardiotoxicity include pericardial disease, arrhythmias, Takotsubo-like syndrome, and acute myocardial infarction, all of which remain poorly explored. Both oncologists and cardiologists, as well as the patients, should be aware of the possible occurrence of one or more of these complications, which in some cases are fatal, in order to implement effective strategies of cardiac surveillance. In this review, we summarize the latest studies and recommendations on the pathogenesis, clinical manifestation, diagnosis, and management of ICI-related cardiotoxicity in order to realize a complete and updated overview on the main aspects of ICI-related cardiotoxicity, from surveillance to diagnosis to management, useful for both oncologists and cardiologists in their clinical practice. In particular, in the first part of the review, we realize a description of the pathogenetic mechanisms and risk factors of the main cardiovascular irAEs. Then, we focus on the management of ICI-related cardiotoxicity by analyzing five main points: (1) identifying and evaluating the type and severity of the cardiotoxicity; (2) deciding whether to withhold ICI therapy; (3) initiating steroid and immunosuppressive therapy; (4) starting conventional cardiac treatment; and (5) restarting ICI therapy. Finally, we discuss the existing evidence on surveillance for ICI-related cardiotoxicity and propose a surveillance strategy for both short- and long-term cardiotoxicity, according to the most recent guidelines.

A new way to explore ventricular-arterial coupling in young patients with untreated hypertension

Introduction

Commonly assessed as arterial elastance (Ea) to ventricular end-systolic elastance (Ees) ratio, ventricular-arterial coupling (VAC) has independent prognostic value in hypertension.

Aim

To investigate whether new coupling indices may be able to identify left ventricular (LV) performance changes induced by blood pressure (BP) overload earlier than conventional ones.

Materials and methods

50 young individuals were prospectively enrolled: 25 (40±8 years) newly diagnosed untreated hypertensives and 25 controls (38±9 yrs). All underwent at the same time carotid-femoral pulse wave velocity (PWV) measurement through a tonometer and an echocardiogram to calculate global longitudinal strain (GLS) and myocardial work efficiency (GWE). Two new indices of VAC were derived: PWV/GLS, previously validated and PWV/GWE, still unknown.

Results

ESV/SV ratio was lower in hypertensive (0.48±0.17) than in controls (0.57±0.14) but without any significant difference (p=0.18), whereas PWV/GLS was significantly lower in hypertensives than in controls (−0.45±0.19 vs −0.35±0.09 m/sec%; p=0.02). PWV/GLS ratio correlated with Ea/Ees (r=0.52; p&lt;0.01), diastolic dysfunction degree (r=−0.59; p&lt;0.001), age (r=−0.64; p&lt;0.001), systolic BP (r=−0.41; p=0.002), diastolic BP (r=−0.39; p=0.005) and mean arterial pressure (MAP) (r=−0.40; p=0.004). PWV/GWE was higher in hypertensives than in controls (0.10±0.02 vs 0.08±0.01 m/sec%; p=0.001) and it was associated with Ea/Ees (r=−0.55; p=0.006), age (r=0.59; p&lt;0.001), diastolic dysfunction degree (r=0.55; p&lt;0.001), systolic BP (r=0.8; p&lt;0.001), diastolic BP (r=0.5; p&lt;0.001) and MAP (r=0.52; p&lt;0.001).

Conclusions

Innovative indices of ventricular-arterial coupling could be more sensitive for investigating the impact of hypertension on LV performance.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): G. Martino University Hospital, Department of Clinical and Experimental Medicine - Cardiology Unit, University of Messina, Messina, Italy

Multimodality imaging to assess severity and outcome in asymptomatic patients with aortic stenosis: a medium-long term follow-up study

Background

Multimodality imaging approach is becoming more and more common in evaluating the severity and outcome of aortic stenosis (AS).

Aim

To assess the outcome of asymptomatic AS and the usefulness of aortic calcium score (CS) by computed tomography (CT) for solving the dilemma of low flow, low gradients (LFLG) severe AS.

Methods

70 (81.4±8.4 years) prospective asymptomatic patients with AS were followed for 2.77±2.01 years with a trans-thoracic echo (TTE) every 6 months. End-points were all cause mortality, aortic valve replacement (AVR or TAVR), aortic velocity and gradients progression and symptoms occurrence. Prevalence of LFLG-AS was investigated and these patients underwent CT for CS calculation at the end of follow-up (FU), Figure 1.

Results

Baseline TTE results from the 70 pts were: peak velocity 3.1±0.8m/sec; peak gradient 44±21mmHg; mean gradient 26±14 mmHg; AVA 1±0.3 cm2; DVI 0.31±0.1; Svi 33.8±18 ml/m2; EF: 55±9% with an AS being mild in 32.9%, moderate in 28.4%, severe in 27.1%; 36.8% of severe AS were LFLG. During FU, 23 (32.8%) pts died (5.7% LFLG) and 13 (18.5%) underwent AVR/TAVR. Predictors of mortality were aortic gradients (p=0.03), AVA (p=0.008), DVI (p&lt;0.001), pulse pressure (p=0.005) and dilated ascending aorta (p&lt;0001). Predictors of AVR/TAVR were: gradients (p=0.003), peak aortic velocity (p=0.02) and dilated ascendent aorta (p=0.01). The best cut-off to predict survival was AVA = 1 cm2 (100% sensitivity and 80% specificity). In 34 pts ending FU we found an overall progression of AS severity (peak velocity 3.6±0.9m/sec; peak gradient 50±24 mmHg; mean gradient 33±15 mmHg; AVA 0.7±0.3 cm2; DVI 0.25±0.08; Svi 36±10 ml/m2; EF 54±10%; p&lt;0.05 for all vs baseline) with 24 (70.5%) pts with severe AS and 10 (29.5%) with not severe AS. 18 (75%) of progressive severe AS were LFLG, 12 asymptomatic and 6 symptomatic and all underwent CS revealing that AS was not severe in 6 (1233±1123 AU; 622±55 AU/m2) and true severe in 12 (3388±1188 AU; 1858±795 AU/m2; p=0.005 and p=0.002, respectively). Symptomatic severe LFLG AS were all true severe according to CS (Figure 1). Table 1 shows the main CS correlations.

Conclusions

Asymptomatic AS in elderly people is associated with high mortality risk and rapid progression. AVA remains the best predictor of outcome. In severe LFLG AS, calcium score correlates with symptoms occurrence, progression of valve disease, LV hypertrophy and function and also with RV function.

Funding Acknowledgement

Type of funding sources: None.

Relationship between Pulse Wave Velocity and Myocardial Work in untreated hypertensive patients with preserved LVEF

Introduction

Hemodynamic interaction between left ventricular (LV) and arterial system is a key determinant of cardiovascular performance. The non-invasive carotid-femoral Pulse Wave Velocity (PWV), obtained with applanation tonometry, is considered the most precise way of estimating arterial stiffness. The LV myocardial work (MW), based on non-invasive LV pressure-strain loop (PSL), is a new promising tool to assess LV function.

Purpose

The aim of the study was to evaluate the correlation between PWV and MW parameters in a population of non-hypertensive and newly diagnosed untreated hypertensive people.

Material and methods

50 people (M=30), divided in hypertensive (group 1: n=25, 40±8 years) and non-hypertensive (group 2: n=25, 38±9 years), were prospectively enrolled. All underwent conventional transthoracic echocardiography and at the same day carotid femoral PWV was calculated with applanation tonometry (SphygmoCor® XCEL). MW parameters were obtained using 2D Speckle-tracking technique.

Results

Comparing the two groups, PWV and Global Work Wasted (GWW) were significantly higher in the hypertensives group (9.44±2.4 vs 7.56±1.1; p=0.001 and 130±2.5 vs 80.60±1.5, p=0.002), as shown in Figure 1, whereas Global Work Efficiency (GWE) and Global Work Constructive (GWC) were significantly lower (94±2.5 vs 95.8±1.2, p=0.003 and 2393±20 vs 2166±18, p=0.02). We found a linear and positive correlation of PWV with GWW (r=0.315, p=0.026), as seen in Figure 2, and a linear and negative correlation of PWV with GWE (r=−0.315, p=0.026).

Conclusion

This study highlights the role of PWV and MW evaluation in hypertensives. Higher PWV and GWW could be considered as red flags of myocardial damage suggesting the need of an early appropriate antihypertensive therapy.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Ospital G. Martino - Messina

Nonbacterial Thrombotic Endocarditis with Atypical Presentation as Overt Congestive Heart Failure

Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography. An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep-vein thrombosis. On physical examination, he was apyretic, mildly hypotensive, and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed "thrombotic" thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed with the diagnostic workup and prescribed palliative care. Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about the treatment of NBTE and the only role of anticoagulation to prevent systemic embolism. We have reported a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging has played a crucial role in the final diagnosis.

Beta-blockers are associated with better long-term survival in patients with Takotsubo syndrome

OBJECTIVE

The advantage of beta-blockers has been postulated in patients with Takotsubo syndrome (TTS) given the pathophysiological role of catecholamines. We hypothesised that beta-blocker treatment after discharge may improve the long-term clinical outcome in this patient population.

METHODS

This was an observational, multicentre study including consecutive patients with TTS diagnosis prospectively enrolled in the Takotsubo Italian Network (TIN) register from January 2007 to December 2018. TTS was diagnosed according to the TIN, Heart Failure Association and InterTAK Diagnostic Criteria. The primary study outcome was the occurrence of all-cause death at the longest available follow-up; secondary outcomes were TTS recurrence, cardiac and non-cardiac death.

RESULTS

The study population included 825 patients (median age: 72.0 (63.0-78.0) years; 91.9 % female): 488 (59.2%) were discharged on beta-blockers and 337 (40.8%) without beta-blockers. The median follow-up was 24.0 months. The adjusted Cox regression analysis showed a significantly lower risk for all-cause death (adjusted HR: 0.563; 95% CI: 0.356 to 0.889) and non-cardiac death (adjusted HR: 0.525; 95% CI: 0.309 to 0.893) in patients receiving versus those not receiving beta-blockers, but no significant differences in terms of TTS recurrence (adjusted HR: 0.607; 95% CI: 0.311 to 1.187) and cardiac death (adjusted HR: 0.699; 95% CI: 0.284 to 1.722). The positive survival effect of beta-blockers was higher in patients with hypertension than in those without (pinteraction=0.014), and in patients who developed cardiogenic shock during the acute phase than in those who did not (pinteraction=0.047).

CONCLUSIONS

In this real-world register population, beta-blockers were associated with a significantly higher long-term survival, particularly in patients with hypertension and in those who developed cardiogenic shock during the acute phase.

P118 THE ROLE OF PULMONARY ACT IN THE PATIENT WITH SARS–COV–2 INFECTION

Already from the first data in China it emerged that patients with cardiovascular comorbidities had an increased risk of contracting SARS–CoV–2 infection and a more unfavourable clinical course. From March to May 2020, 85 patients affected by COVID–19 were enrolled, hospitalized at the Hospital of Reggio Calabria. All patients underwent anamnesis, clinical evaluation, chest CT, ECG and measurement of markers of cardiovascular damage (Troponin I, CK–MB, LDH, D–dimer, BNP) and of inflammation (PCR, IL–6, and PCT). Thirty–one patients underwent echocardiography. In particular, we evaluated parietal dimensions and thicknesses, biventricular function and transvalvular tricuspid and pulmonary flows and correlated the data obtained with ECG, radiological, clinical, and biohumoral parameters. The aim of our study was to evaluate the prognostic impact of cardiovascular involvement in COVID– 19, investigating the effect of cardiovascular risk factors, levels of cardiovascular damage markers and newly emerging ECG and echocardiographic changes on a composite primary endpoint, consisting of the combination of death and the need for intensive care (ICU). The enrolled patients were divided into two subpopulations: those with better prognosis and those with poorer prognosis (ICU/exitus). We analysed the reciprocal correlation of each of the parameters and searched for the presence of echocardiographic signs of repercussion on the right sections of the pulmonary pathology. All markers of cardiovascular damage had significantly higher values in the most critically ill patients and similar behaviour had indices of inflammation. Patients with poorer prognosis had significantly lower lung AcT values, which correlated with higher D–dimer levels and more complicated hospital stays. There were no statistically significant differences between PAPs, right ventricular size, TAPSE and pulmonary trunk diameter in the two subpopulations. Larger right ventricular diameters were associated with more dilated lung trunks and higher IL–6 levels. The most interesting data of our study is the behaviour of pulmonary AcT: lower values of AcT were associated with higher levels of D–dimer, expression of a greater pulmonary microthrombotic burden, and a poorer prognosis, in the presence of PAPs normal. The dynamic analysis of this parameter, which is easy to calculate in the patient’s bed, can play a crucial role in the instrumental follow–up of patients hospitalized for SARS–CoV–2 infection.

Wasted myocardial work may affect left ventricular remodelling occurrence after primary percutaneous coronary revascularization

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular function recovery (LV-REC) or left ventricular adverse remodelling (LV-REM) after acute myocardial infarction (AMI) play an important role for identifying patients at risk of heart failure.

Purpose

In this study we aim to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV-REC or LV-REM after AMI.

Methods

Fifty patients with AMI (mean age, 63,8 ±13,4 years), treated by primary percutaneous coronary intervention (PCI), were prospectively enrolled.  They underwent a baseline transthoracic Doppler echocardiography (TTE) within 48 hours after PCI and a second TTE after a median of 31 days during the follow-up. MW was derived from the strain-pressure loops, integrating in its calculation the non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. LV-REC was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥ 5% from LVEF at baseline, whereas LV-REM was defined as an increase of ≥ 20% of the LV end diastolic volume (LVEDV) at 1 month follow up.

Results

We overall found a significant improvement from baseline to one-month follow-up for values of LVEF (49,8 ± 9,5 % vs 52,8 ± 9,3 %, p = 0.001), Global Longitudinal Strain (GLS) (-13,4 ± 3,9 % vs -18,7 ± 5,4 %, p = 0.016), Global Work Index (GWI) (1368,6 ±435,2 vs 1788 ±493 mmHg/%, p = 0.0001), Global Work Efficiency (GWE) (89,96 ± 9,3 % vs 91,3 ± 6,4 %,  p = 0.001), Global Constructive Work (GCW) (1619,16 ± 497,9 mmHg/% vs 2008,6 ± 535,3 mmHg/%, p = 0.0001), Global Wasted Work (GWW) (188,8 ± 19,8 mmHg/% vs 149,2 ± 16,5 mmHg/%). However, LV-REC at 1 month of follow-up was observed only in 36 % of the population enrolled, whereas LV-REM was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 202 mmHg/% for baseline GWW (Sensitivity 75%, Specificity 62%, AUC 0.6667, CI 95%: 0,51618 - 0,81715, p =0.0001) to identify patients with LV-REM at 1 month. With regards to conventional echo parameters, patients with LV-REC showed lower baseline Wall Motion Score Index (WMSI) than those without LV-REC (1,73 vs 1,38, p = 0.007).

Conclusions

Among standard and advanced TTE parameters, only baseline GWW is able to predict early LV-REM at 1 month after primary PCI. Therefore, it could be used during baseline evaluation of AMI patients for a more accurate stratification of those at higher risk of heart failure. However, further larger scale studies are needed to validate these findings. Abstract table 1  Abstract table 2

Impairment of LA strain and LV myocardial work in Ph+ Chronic myeloid leukaemia patients treated with TKis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Worsening of cardiac function with increased arrhythmic risk is common in cancer patients undergoing chemotherapy. Impaired LV Global Longitudinal Strain (GLS) in these patients despite preserved ejection fraction is a common issue. Recently, myocardial work by speckle-tracking echocardiography has been used to overcome GLS limitations in various conditions, but little is known about its usefulness in the detection of cardiac toxicity. Moreover, left atrial (LA) toxicity may occur early in the course of cancer therapy. The main aim of the study was to assess the cardiotoxic effects of tyrosine kinase inhibitors (TKIs) on patients with Philadelphia chromosome-positive chronic myeloid leukaemia (Ph+ CML) by using novel echocardiographic tools as myocardial work and atrial strain analysis.

Methods

We retrospectively enrolled Ph+ CML patients treated with TKIs followed at the cardio-oncology outpatient clinic of our hospital from December 2018 to March 2019 who underwent clinical evaluation with ECG and echocardiogram (TTE) before and after one year of treatment with TKIs. Healthy subjects were enrolled in the control group matched for gender, age and cardiovascular risk factors. Myocardial work was derived from the strain-pressure relation, integrating in its calculation the non-invasive arterial pressure. LA longitudinal strain (reservoir, conduit and booster) was obtained from an optimized apical 4-chamber view of the LA.

Results

The study recruited 32 patients in Ph+ CML group and 32 healthy controls. 39% of patients were treated with Imatinib, 29.3% with Nilotinib, 4.9% with Dasatinib and 4.9% with Ponatinib. Main results are detailed in the Table 1. At one-year follow-up there was a significant reduction compared to baseline in Global Constructive Work (2555.22 ± 564.33 vs 2119.31 ± 700.19; p = 0.0001), Global Work Efficiency (96.13 ± 1.90 vs 94.00 ± 2.96; p = 0.002) and Global Work Index (2340.75 ± 579.57 vs 1938.46 ± 680.23; p = 0.001), and a non-significant reduction in Global Wasted Work (p = 0.393). Regarding left atrial strain analysis at the one-year follow-up there was a statistically significant reduction in LA contractile strain (booster= 14.63 ± 1.408 vs 12.38 ± 1.581; p= 0.018). LA contractile strain reduction was also observed in the comparison with controls (12.38 ± 2.99 vs 14.91 ± 3.09; p = 0.009). Any other significant difference was detected between baseline and FU TTE data in the Ph+ CML group.

Conclusions

New imaging methods for the study of cardiotoxicity provide an additional tool for early prediction of potential adverse effects of antineoplastic drugs. TKIs therapy leads to an impairment of atrial contractility, which can be detected by atrial strain e myocardial work analysis. Abstract table 1  Abstract figure 1

Lipomatous hypertrophy of the interatrial septum: A case report and insights from the literature

Lipomatous hypertrophy of the interatrial septum (LHIS) is a histologically benign cardiac lesion that is defined by excessive fat accumulation in the area of the interatrial septum (IAS) that does not include the fossa ovalis. Another unusual illness is lipomatosis, which is defined as a broad overgrowth of mature adipose tissue that involves a large portion of an extremity or trunk. We describe a rare case with significant LHIS accompanied by subcutaneous lipomatosis. Echocardiography revealed a mass in the right atrium in this patient. Magnetic resonance imaging revealed that this mass was composed of the adipose tissue and was an extension of a huge thickened IAS. Furthermore, this significant hypertrophy of the IAS was in direct continuation with the excessive mediastinal and epicardial fat.

Incremental value of left atrial function analysis in the assessment of left ventricular filling pressures in patients with ST-elevation myocardial infarction

Background:

Left atrial (LA) reservoir strain provides interesting information about left ventricular (LV) filling pressure. However, the advantages of atrial reservoir strain in comparison with conventional parameters in patients with myocardial infarction are not clear yet.

Methods:

Fifty patients with ST-elevation myocardial infarction (STEMI) prospectively underwent echocardiographic assessment of LV systolic and diastolic function by conventional parameters and two-dimensional speckle tracking longitudinal strain of left atrium. LV filling pressure was estimated by brain natriuretic peptide (BNP) levels.

Results:

Systolic and conventional diastolic parameters did not show significant differences between patients with increased and normal BNP values, whereas LA reservoir strain was reduced (33.1 ± 8% vs. 46.5 ± 9.8%; P = 0.001) in patients with higher BNP levels. LA reservoir strain had higher area under curve value (0.880) than the other parameters in identifying patients with elevated BNP and a cut-off value of 40.5% reached sensitivity and specificity values of 93% and 86% and positive and negative predictive values of 92% and 85%. LA reservoir strain reclassified 23 patients with increased BNP values, which were previously estimated to have normal (16 patients) and undeterminable LA pressure (seven patients) by using the recommended algorithm for diastolic function.

Conclusions:

LA reservoir strain is a useful tool for the evaluation of diastolic function and seems to be more sensitive than conventional parameters in the detection of subtle increase of LV filling pressure in patients with STEMI. It allows physicians to reclassify patients with undeterminable diastolic function according to conventional algorithm.

754 Non-conducted premature atrial complexes: a new predictor for atrial fibrillation in cryptogenic stroke patients

Aims

Atrial fibrillation (AF) is the main cardiac cause of stroke, but it frequently remains undetected. In these patient monitoring for AF is recommended using a Holter electrocardiogram (ECG). The aim of the present study is to study non-conducted atrial complexes (ncPAC) recorded on Holter ECG as a new predictor of AF.

Methods and results

Patients admitted to the Stroke Unit of our hospital for cryptogenic stroke from December 2018 to January 2020 who underwent 24-h electrocardiographic monitoring were prospectively enrolled in the study and were subsequently submitted to 3-month and 6-month follow-up to investigate the occurrence of AF. The study recruited 112 patients. At follow-up visit, AF was diagnosed in 21.4% of the population. The only statistically significant difference between the group with and without a AF diagnosis was the presence of ncPAC (83.3% vs. 16.7%; P &lt; 0.0001). ROC analysis was performed and showed that ncPAC had the best diagnostic accuracy in the AF diagnosis [AUC: 0.798; confidence interval (CI): 0.675–0.921]. The AUC of ncPAC was significantly better than the AUC of premature atrial complexes (PACs) (P &lt; 0.05), CHA2DS2-VASc, HATCH, HAVOC, and C2HEST scores (P &lt; 0.01). Kaplan–Meier curve survival estimate for AF onset by the presence of ncPAC revealed that there was a significant difference in the AF onset between patients with ncPAC and those without (P &lt; 0.0001) and multivariate Cox-proportional hazard analysis revealed that ncPAC presence was an independent predictors of AF onset [hazards ratio (HR): 9.28; CI 95%: 2,66–32,40; P = 0.0001].

Conclusions

The presence of ncPAC represents a new predictor of AF that could further guide the investigation of AF in patients with cryptogenic stroke.

636 Global cardiovascular assessment in patients with PH+ chronic myeloid leukaemia treated with TKI: long-term follow-up

Aims

Patients affected by Philadelphia chromosome+ chronic myeloid leukaemia (Ph+CML) undergoing to therapy with tyrosine kinase inhibitors (TKIs) are prone to develop cardiovascular complications, which have relevant prognostic implications. Speckle-tracking echocardiography, allowing strain and myocardial work analyses, can be useful in the early detection of cardiac toxicity. Aim of our study was to assess the cardiotoxic effects of TKIs.

Methods

We evaluated, at baseline and during FU, 20 patients affected by Ph+ CML (59.7 ± 12.2 years, 13 males), treated Imatinib (52.6%), Nilotinib (36.8%), Ponatinib (5.3%), Dasatinib (5.3%). We measured systolic and diastolic blood pressure (SBP-DBP) and calculated corrected QT interval (QTc). In addition, we analysed echocardiographic parameters including left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE), and peak left atrial longitudinal strain (PALS). Cardiovascular (CV) events that we considered were symptomatic or asymptomatic LV dysfunction, acute coronary syndrome (ACS), peripheral artery disease (PAD), and arrhythmias.

Results

Follow-up (FU) time was 3.4 ± 1 years. Most of patients (63.2%) had cardiovascular risk factors, including arterial hypertension (50%), type2 diabetes mellitus (15%), dyslipidaemia (40%) and cigarette smoking (15%). At the end of FU, SBP was unchanged (128.9 ± 19.6 mmHg vs. 129.1 ± 9.8 mmHg; P=NS) whereas DBP increased (69.4 ± 8.5 mmHg vs. 75 ± 7.7 mmHg; P = 0.004); moreover QTc was longer than baseline (404.4 ± 20.1 ms vs. 424.3 ± 29.8 ms; P &lt; 0.001) and LVEF showed a significant decrease (62.2 ± 3.9% at baseline vs. 59.3 ± 4.8% at FU; P = 0.003); similarly, GCW (2444.1 ± 540mmHg% vs. 2234.7 ± 179.4 mmHg%; P = 0.034), GWI (2158.1 ± 589.6 mmHg% vs. 1923.1 ± 174.5 mmHg%; P = 0.022) and PALS (36.3 ± 17.1% vs. 32.8 ± 9.7%; P = 0.002) decreased during cancer therapy. On the other hand, GLS (−18.6 ± 3.1% vs. −19.4 ± 1.1%; P=NS), GWE (94.3 ± 4.1% vs. 93.6 ± 3.6%; P=NS) and GWW (120.6 ± 94.3 mmHg% vs. 106.3 ± 68.9 mmHg%; P=NS) did not change significantly. CV events were observed in 66.7% of the study population. These were mostly represented by ACS, atrial arrhythmias and symptomatic LV dysfunction (30.7% for each) and, to a lesser extent, PAD (7.6%). By comparing patients with events (group A) with those without events (group B) we found that differently from group B, group A showed during FU a significant increase of DBP (from 66 ± 5.2 mmHg to 71.2 ± 6.1 mmHg, P = 0.010; vs. group B= from 76 ± 12.mmHg to 78 ± 4.1 mmHg, P=NS) and a significant QTc prolongation (from 415.7 ± 16.1 ms to 441 ± 29.8 ms, P &lt; 0.001; vs. group B= from 390.4 ± 19.3 ms to 405.6 ± 23.3 ms, P=NS); as to echocardiographic parameters, we found, in patients with CV events, a significant decrease of: LVEF (from 62.7 ± 4.7% to 58.8 ± 4.3%, P = 0.004; vs. group B from 61.4 ± 2.8% to 60 ± 1.7%, P=NS), GCW (from 2566.2 ± 669.6 mmHg% to 2230.1 ± 199.4 mmHg%, P = 0.021, vs. group B 2194 ± 167.5 mmHg% to 2212.6 ± 160mmHg%, P=NS) and PALS (from 36.1 ± 17% to 29.6 ± 6.6%, P = 0.022 vs. group B from 32.7 ± 8% to 35 ± 8.5%, P = 0.003). Of these parameters, only PALS was significant independent predictor of CV events on logistic regression analysis (OR 0.82 CI 95 0.69–0.98, P = 0.034).

Conclusions

Advanced echocardiographic parameters, including myocardial work and left atrial strain analysis, are particularly valuable in the early detection of TKI-induced cardiac toxicity. PALS could be an useful tool to predict outcome in these patients.

691 Distribution of wall motion abnormalities in young patients presenting with acute coronary syndrome

Aims

Distribution of wall motion abnormalities (WMA) in young patients presenting with acute coronary syndrome (ACS) is not well described.

Methods and results

We included 91 consecutive young patients (≤45 years at presentation) with ACS with obstructive or without obstructive coronary artery disease referred from October 2013 until March 2021 to our clinic. Wall motion abnormalities, wall motion score index (WMSI) and left ventricle ejection fraction (LVEF) were evaluated. A wall motion abnormality in at least one segment was present in 78.7% of patients. Mean LVEF was 50.9 ± 8.8% and mean WMSI was 1.38 ± 0.37%. Akinesia of at least one segment was present in 49.4%, dyskinesia and aneurysm were rare (1.1%, respectively). Ventricular thrombus was observed in 4.7%. Distribution of wall motion abnormalities is presented in Figure A. Most frequently WMA affected the apex and the basal inferior wall. The severity of WMA for each segment is presented in Figure B. The mean highest severity of WMA affected the apex, and the inferior and infero-septal wall. In the subgroup of patients presenting without obstructive coronary artery disease, WMA were less prevalent (37.5%), LVEF was higher (57.1% vs. 50.4% P = 0.032), and WMSI was lower (1.16% vs. 1.40% P = 0.07), but similarly affected with higher frequency the apex area.

Conclusions

In conclusion, WMA are frequent in young patients presenting with ACS, mostly affecting the apex. More severe abnormalities of wall kinesis affect the apex and the inferior and infero-septal wall.

704 Stress echocardiography: myocardial work ‘works’

Stress echocardiography is a widely employed diagnostic technique relying on subjective assessment of left ventricular wall motion and particular expertise. We report a case of a male patient with chronic coronary syndrome, who underwent dipyridamole echocardiography before planned non cardiac surgery. Despite the absence of symptoms and relevant electrocardiographic and wall motion changes, only 2D strain and, especially, Myocardial Work analysis was able to detect abnormalities suggestive of myocardial ischaemia. Thus, coronary angiography was performed, showing critical stenosis of the proximal Circumflex artery, that was treated with angioplasty and drug-eluting stent implantation. Interestingly, the location of strain and myocardial work abnormalities was consistent with the culprit vessel territory. This case highlights the particular usefulness of advanced echocardiographic techniques, especially for the detection of one-vessel coronary artery disease, during stress echocardiography.

747 Long-term effects of pharmacological treatment in patients with takotsubo syndrome with or without hypertension: a report from the takotsubo Italian network

Aims

Hypertension (HT) is one of the most frequent comorbidities reported in patients with Takotsubo syndrome (TTS). However, the clinical outcome as well as the effect of pharmacological treatment on long-term follow-up have never been investigated in this cohort. To investigate the impact of the pharmacological treatment with beta-blocker (BB) and/or renin–angiotensin–aldosterone system inhibitor (RAASi) on long-term outcome of TTS patients with and without HT.

Methods and results

This study included TTS patients prospectively included in the Takotsubo Italian Network register from January 2007 to December 2018. The study population was divided in two groups according to the presence or not of HT. The effect of BB and RAASi at discharge was evaluated in these groups. The primary outcome was the composite of all-cause death and TTS recurrence; secondary outcomes were the single components of the primary outcome. The propensity score weighting technique was employed to account for potential selection bias in treatment assignment at discharge. The study population included 825 patients [median age 72 (63–78) years; 8.1% were males]; 525 (63.6%) patients had history of HT and 300 (36.4%) patients did not. At median follow-up of 24.0 months (11.0–38.0), the primary outcome occurred in 102 patients (12.4%); all-cause death and TTS recurrence were reported in 76 (9.2%) and 33 (4.0%), respectively. There were no differences in terms of the primary outcome (adjusted HR: 1.082; 95% CI: 0.689–1.700; P = 0.733), all-cause death (adjusted HR: 1.214; 95% CI: 0.706–2.089; P = 0.483) and TTS recurrence (adjusted HR: 0.795; 95% CI: 0.373–1.694; P = 0.552) between patients with vs. without HT. Among patients with HT, those receiving BB at discharge showed a significantly lower risk of the primary outcome (adjusted HR: 0.375; 95% CI: 0.228–0.617; P &lt; 0.001) compared with patients not receiving BB. There was also a significantly lower risk of all-cause death (adjusted HR: 0.381; 95% CI: 0.217–0.666; P &lt; 0.001) and TTS recurrence (adjusted HR: 0.393; 95% CI: 0.155–0.998; P = 0.049) in patients treated with BB. Among patients without HT, there was no significant association of BB treatment with any of the study outcomes. RAASi treatment showed no significant effect on the primary and secondary outcomes. These results were consistent between patients with and without HT.

Conclusions

TTS patients with HT patients experienced a survival benefit from BB treatment in terms of both all-cause death and TTS recurrence; this effect was not confirmed in patients without HT. Conversely, RAASi did not affect long-term outcome, independently from the coexistence of HT. Albeit hypothesis-generating, a such evidence supports a tailored pharmacological therapy after discharge in TTS patients taking into account the coexistence of HT.

767 Correlations between myocardial work parameters and pulse wave velocity

Aims

The myocardial work (MW) is a new echocardiographic method, based on the pressure–strain loop, which allows to quantify the cardiac performance. On the other hand, the pulse wave velocity (PWV) evaluates arterial stiffness, knowing that as the stiffness of an artery increases, the transmission velocity of the anterograde and the retrograde sphygmic wave increase. The aim of the study is to evaluate the correlation between MW and PWV parameters.

Methods and results

We enrolled 32 healthy patients (mean age: 39 ± 17 years), who underwent transthoracic Doppler echocardiography (TTE). The MW parameters was derived from the strain–pressure loop, including in its calculation the measurement non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. The PWV measurement was obtained by tonometry at the level of the common carotid artery and the common femoral artery. None of the parameters measured was pathological according to the normality studies considered. It was found a linear correlation between PWV and global wasted work (GWW) (linear R2: 0.603; P = 0.001) and an inverse linear correlation between PWC and global work efficiency (GWE) (linear R2: −0.307; P = 0.032).

Conclusions

The study highlights the possibility of PWV to predict pre-clinical myocardial changes, given the correlation with GWW and the linear inverse correlation with GWE.

466 The role of pulmonary act in the patient with SARS-CoV-2 infection

Already from the first data in China in early 2020 it emerged that patients with cardiovascular comorbidities had an increased risk of contracting SARS-CoV-2 infection and a more unfavourable clinical course. From March to May 2020, 85 patients affected by COVID-19 were enrolled, hospitalized at the Great Metropolitan Hospital of Reggio Calabria. The mean age was 63.6 ± 16.5 years. All patients underwent anamnesis, clinical evaluation, chest CT, ECG and measurement of markers of cardiovascular damage (Troponin I, CK-MB, LDH, D-dimer, BNP) and of inflammation (PCR, IL-6, and PCT). Thirty-one patients underwent echocardiography to look for signs of left ventricular dysfunction and/or repercussions of lung disease on the right sections. In particular, we evaluated parietal dimensions and thicknesses, biventricular function and transvalvular tricuspid and pulmonary flows and correlated the data obtained with ECG, radiological, clinical, and biohumoral parameters. The aim of our study was to evaluate the prognostic impact of cardiovascular involvement in COVID-19, investigating the effect of cardiovascular risk factors, levels of cardiovascular damage markers and newly emerging ECG and echocardiographic changes on a composite primary endpoint, consisting of the combination of exitus and the need for intensive care (ICU). For this purpose, the enrolled patients were divided into two subpopulations: those with better prognosis and those with poorer prognosis (ICU/exitus). We then analysed the reciprocal correlation of each of the investigated parameters and searched for the presence of echocardiographic signs of repercussion on the right sections of the pulmonary pathology. Among the patients with the poorest prognosis, 81.2% were hypertensive, 12.5% diabetic, 25% dyslipidaemic. Comparing the two subpopulations analysed, it emerged that patients with the worst prognosis were known hypertensive (P 0.02). Longer QTc intervals were associated with higher levels of CRP (P < 0.0001) and PCT (P 0.005). All markers of cardiovascular damage had significantly higher values in the most critically ill patients (P 0.001 for d-dimer, P < 0.001 for baseline and peak Troponin, P 0.001 for CK-MB, P 0.007 for BNP) and similar behaviour had indices of inflammation (P < 0.001 for PCR and IL-6). Patients with poorer prognosis had significantly lower lung AcT values ( P 0.002), which correlated with higher d-dimer levels (P 0.01) and more complicated hospital stays (P 0.02). There were no statistically significant differences between PAPs, right ventricular size, TAPSE, and pulmonary trunk diameter in the two subpopulations. Larger right ventricular diameters were associated with more dilated lung trunks (P 0.009) and higher IL-6 levels (P 0.004). The most interesting data of our study is the behaviour of pulmonary AcT: lower values of AcT were associated with higher levels of d-dimer, as an expression of a greater pulmonary microthrombotic burden, and a poorer prognosis, in the presence of PAPs basically normal. The dynamic analysis of this parameter, which is easy to calculate in the patient's bed, can play a crucial role in the instrumental follow-up of patients hospitalized for SARS-CoV-2 infection.

709 Non-invasive assessment of myocardial work: an useful tool for predicting LV remodelling after myocardial infarction?

Aims

Left ventricular function recovery (LV-REC) or left ventricular adverse remodelling (LV-REM) after acute myocardial infarction (AMI) play an important role for identifying patients at risk of heart failure. In this study we aim to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LV-REC or LV-REM after AMI.

Methods and results

Fifty patients with AMI (mean age, 63.8 ± 13.4 years), treated by primary percutaneous coronary intervention (PCI), were prospectively enrolled. They underwent a baseline transthoracic Doppler echocardiography (TTE) within 48 h after PCI and a second TTE after a median of 31 days during the follow-up. MW was derived from the strain-pressure loops, integrating in its calculation the non-invasive arterial pressure, according to standard speckle tracking echocardiography recommendations. LV-REC was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥ 5% from LVEF at baseline, whereas LV-REM was defined as an increase of ≥ 20% of the LV end diastolic volume (LVEDV) at 1 month follow-up. We overall found a significant improvement from baseline to one-month follow-up for values of LVEF (49.8 ± 9.5% vs. 52.8 ± 9.3%, P = 0.001), global longitudinal strain (GLS) (−13.4 ± 3.9% vs. −18.7 ± 5.4%, P = 0.016), global work index (GWI) (1368.6 ± 435.2 vs. 1788 ± 493 mmHg/%, P = 0.0001), global work efficiency (GWE) (89.96 ± 9.3% vs. 91.3 ± 6.4%, P = 0.001), global constructive work (GCW) (1619.16 ± 497.9 mmHg/% vs. 2008.6 ± 535.3 mmHg/%, P = 0.0001), global wasted work (GWW) (188.8 ± 19.8 mmHg/% vs. 149.2 ± 16.5 mmHg/%). However, LV-REC at 1 month of follow-up was observed only in 36% of the population enrolled, whereas LV-REM was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 202 mmHg/% for baseline GWW (sensitivity 75%, specificity 62%, AUC 0.6667, CI 95%: 0.51618–0.81715, P = 0.0001) to identify patients with LV-REM at 1 month. With regards to conventional echo parameters, patients with LV-REC showed lower baseline wall motion score index (WMSI) than those without LV-REC (1.73 vs. 1.38, P = 0.007).

Conclusions

Among standard and advanced TTE parameters, only baseline GWW is able to predict early LV-REM at 1 month after primary PCI. Therefore, it could be used during baseline evaluation of AMI patients for a more accurate stratification of those at higher risk of heart failure. However, further larger scale studies are needed to validate these findings.

Prediction of early left ventricular recovery and adverse remodelling in patients with acute myocardial infarction: the role of non-invasive myocardial work evaluation

Background

Left ventricular recovery (LVR) and adverse left ventricular remodelling (aLVR) after acute myocardial infarction (AMI) play an important prognostic role.

Purpose

Our aim was to evaluate the usefulness of non-invasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and aLVR.

Methods

Fifty patients with AMI (mean age, 63,8±13,4 years), treated by percutaneous coronary intervention (PCI), were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 48 hours after PCI and a median of 31 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the non-invasive arterial pressure. Segmental LVR was defined as an absolute improvement of left ventricular ejection fraction (LVEF) ≥5% from LVEF at the baseline. The aLVR was defined as an increase of ≥20% of the LV end diastolic volume (LVEDV) at 1 month follow up.

Results

We found significant differences between the baseline and the follow-up value of LVEF (49,28 vs 52,80 p=0.001), Global Longitudinal Strain (GLS) (−13,41 vs −18,72, p=0.016), Global Work Index (GWI) (1368,68 vs 1788,08, p&lt;0.0001), Global Work Efficiency (GWE) (86,96 vs 91,36, p=0.001), and Global Constructive Work (GCW) (1619,16 vs 2008,68, p&lt;0.0001). The LVR at 1 month of follow-up was observed in 36% of the population enrolled, whereas aLVR was described in 18% of cases. Using ROC curve analysis, we identified a cut off value of 137 mmHg/% for baseline Global Wasted Work (Sensitivity 100%, Specificity 57,14%, AUC 0.6667, CI 95%: 0,51618- 0,81715, p&lt;0.0001) to identify patients with aLVR at 1 month. With regards to conventional echo parameters, patients with LVR showed lower baseline Wall Motion Score Index (WMSI) than those with LVR (1,73 vs 1,38, p=0.007).

Conclusions

Baseline global wasted work can predict early adverse left ventricular remodelling at 1 months after AMI. These parameters could be used at baseline in order to predict worse outcome in AMI patients. Further larger scale studies are needed to validate these findings.

Funding Acknowledgement

Type of funding sources: None.

Left atrial strain and left atrial stiffness for early detection of cardiotoxicity in cancer patients

Background

Anti-cancer drugs can cause cardiovascular complications. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are usually used to identify clinical and subclinical cardiotoxicity.

Purpose

The aim of our study was to assess the addictional role of left atrial reservoir strain (LAS-S) and left atrial stiffness (LASI – the ratio of E/e' to LAS-S) in identifying patients at higher risk of cardiotoxicity.

Methods

102 breast cancer patients (median age 53±9.5 years), without cardiovascular diseases, were enrolled before starting chemotherapy. Electrocardiogram and transthoracic echocardiogram (conventional measurements based on EACVI recommendations; GLS, LAS-S and LASI measurement) were performed in all patients before starting chemotherapy (T0) and 3 (T1) and 6 months (T2) after chemotherapy.

Results

No patient developed clinical cardiotoxicity. Moreover we did not find at all times a significant reduction in LVEF compared to baseline.

At T1 and T2, we found a significant reduction in GLS (−21.1% IQR −21.9, −20.2% at T0 vs −18.8% IQR −9.5, −18.1% at T1 vs −18.0% IQR −19.8, −17.8% at T2; p value &lt;0.01) and LAS-S (34.4% IQR 31.4–37.4% at T0 vs 28.5% IQR 26.2–30.8% at T1 vs 30.8% IQR 27.6–34% at T2; p&lt;0.001), a significant increase of LASI (0.21%-1 IQR 0.10–0.20%-1 at T0 vs 0.28%-1 IQR 0.20–0.31%-1 at T1 vs 0.35%-1 IQR 0.23–0.41%-1 at T2, p&lt;0.001).

In addiction patients were divided into 2 groups based on the presence at T2 and not at T1 (A group) or absence (B group) of a subclinical cardiac dysfunction (identified by a reduction in GLS ≥15% compared to baseline).

In A group (47% of population) LASI increased significantly already at T1 and remained significantly increased at T2 (0.21±0.07 at T0 vs 0.3±0.12 at T1, p value &lt;0.0001; 0.33±0.16 at T2, p value &lt;0.0001); LAS-S was significantly reduced at T1 and T2 (35±5 at T0 vs 30±8 at T1, p value 0.0005; 29±9 at T2, p value 0.0001).

In patients without subclinical cardiac dysfunction during follow-up (B group, 53% of population), a significant reduction in LAS-S was already evident at T1 and not only at T2 (p value &lt;0.0001 at T1-T2); we found a significant increase in LASI at T1 and T2 (p value &lt;0.0001).

Conclusion

LAS-S and LASI are able to identify subclinical cardiac dysfunction during chemotherapy, they appear to be even more precious markers of cardio-toxicity than GLS. Further study are needed to verify the prognostic implications of atrial strain impairment during chemotherapeutic treatment.

Funding Acknowledgement

Type of funding sources: None.

CMR predictors of secondary moderate to severe mitral regurgitation and its additive prognostic role in previous myocardial infarction

BACKGROUND

We aimed to determine predictors and the additive prognostic role of moderate to severe (MS) ischemic mitral regurgitation (MR) in myocardial infarction (MI).

METHODS

Four hundred twenty-two patients with previous MI underwent cardiac magnetic resonance (CMR) imaging for the assessment of left ventricular (LV) ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV), sphericity index, wall motion score index (WMSI), and late gadolinium enhancement (LGE). Echocardiography was performed to assess MR.

RESULTS

Thirty-eight had from moderate to severe MR (MS-MR group) and 384 did not (No MS-MR group). The S-MR group had higher LV volumes, sphericity index, WMSI, and LGE extent, and lower LVEF. At univariate logistic regression analysis, dilated volumes, SI >0.43, dyskinesia of inferolateral wall, papillary muscle (PM)-LGE, and LGE extent >16% were associated with MS-MR. At multivariate analysis, only SI (OR=5.7) and PM-LGE (OR=3) were independently associated with MS-MR. Considering only patients without LV dilatation, only dyskinesia in the inferolateral wall was a predictor of MS-MR (OR 34.8). Thirty cardiac events (cardiac death, appropriate implantable cardioverter-defibrillator firing, and resuscitated cardiac arrest) occurred during a median follow-up of 1,276 days. After adjusting the prognostic variables at univariate analysis by age (>65 years) and selecting those that were significant (EDV > 95 ml/m², ESV >53 ml/m², EF <30%, WMSI >1.65, LGE >12%, S-MR), only WMSI >1.65 and MS-MR remained an independent predictor of cardiac events.

CONCLUSIONS

Increased WMSI and PM-LGE in the overall population and inferolateral dyskinesia in patients without ESV dilatation are predictors of MS-MR; MS-MR and elevated WMSI have independent negative prognostic value.

Anthracyclines and regional myocardial damage in breast cancer patients. A multicentre study from the Working Group on Drug Cardiotoxicity and Cardioprotection, Italian Society of Cardiology (SIC)

AIMS

In breast cancer (BC) patients treated with anthracyclines-based therapies, we aim at assessing whether adjuvant drugs impact cardiac function differently and whether their cardiotoxicity has a regional pattern.

METHODS AND RESULTS

In a multicentre study, 146 BC patients (56 ± 11 years) were prospectively enrolled and divided into three groups according to the received treatments: AC/EC-Group (doxorubicin or epirubicin + cyclophosphamide), AC/EC/Tax-Group (AC/EC + taxanes), FEC/Tax-Group (fluorouracil + EC + taxanes). Fifty-six patients of the total cohort also received trastuzumab. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were calculated before starting chemotherapy (T0), at 3 months (T3), at 6 (T6), and 12 months (T12). A ≥10% drop of EF, while remaining within the normal range, was reached at T6 in 25.3% of patients from the whole cohort with an early decrease only in FEC/Tax-Group (P = 0.04). A ≥15% GLS reduction was observed in many more (61.6%) patients. GLS decreased early both in the whole population (P < 0.001) and in the subgroups. The FEC-Tax Group showed the worst GLS at T6. Trastuzumab further worsened GLS at T12 (P = 0.031). A significant reduction of GLS was observed in all LV segments and was more relevant in the anterior septum and apex.

CONCLUSIONS

The decrease of GLS is more precocious and pronounced in BC patients who received FEC + taxanes. Cardiac function further worsens after 6 months of adjuvant trastuzumab. All LV segments are damaged, with the anterior septum and the apex showing the greatest impairments.

Bicuspid aortic valve and aortopathy: novel prognostic predictors for the identification of high-risk patients

AIMS

Bicuspid aortic valve (BAV) may be complicated by aortic aneurysms and dissection. This study aimed to evaluate the prognostic efficacy of markers from cardiac imaging, as well as genetic and new biomarkers, to early predict aortic complications.

METHODS AND RESULTS

We re-evaluated after a mean time of 48 ± 11 months 47 BAV patients who had undergone previous echocardiography for evaluation of aortic stiffness and 2D aortic longitudinal strain (LS) (by speckle-tracking analysis), and who had given a blood sample for the assessment of a single-nucleotide polymorphism of elastin gene (ELN rs2 071307) and quantification of elastin soluble fragments (ESF). Surgical treatment of aortic aneurysm/dissection was the primary endpoint, and an aortic dimension increase (of one or more aortic segments) ≥1 mm/year was the secondary endpoint. Nine patients underwent surgical treatment of ascending aorta (AA) aneurysms. Out of the 38 patients who did not need surgical intervention, 16 showed an increase of aortic root and/or AA dimension ≥1 mm/year. At multivariate Cox regression analysis, an impaired AA LS was an independent predictor of aortic surgery [P = 0.04; hazard ratio (HR) 0.961; 95% confidence interval (CI) 0.924-0.984] and aortic dilatation (P = 0.007; HR 0.960; 95% CI 0.932-0.989). An increased quantity of ESF was correlated (P = 0.015) with the primary endpoint at univariate Cox regression analysis but it did not keep statistical significance at multivariate analysis.

CONCLUSION

In BAV patients, impairment of elastic properties of the AA, as assessed by 2D LS, is an effective predictor of aortic complications.

Correlation between non-invasive myocardial work indices and main parameters of systolic and diastolic function: results from the EACVI NORRE study

AIMS

The present study sought to evaluate the correlation between indices of non-invasive myocardial work (MW) and left ventricle (LV) size, traditional and advanced parameters of LV systolic and diastolic function by 2D echocardiography (2DE).

METHODS AND RESULTS

A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from LV pressure-strain loops using custom software. Peak LV pressure was estimated non-invasively from brachial artery cuff pressure. LV size, parameters of systolic and diastolic function and ventricular-arterial coupling were measured by echocardiography. As advanced indices of myocardial performance, global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained. On multivariable analysis, GWI was significantly correlated with GLS (standardized beta-coefficient = -0.23, P < 0.001), ejection fraction (EF) (standardized beta-coefficient = 0.15, P = 0.02), systolic blood pressure (SBP) (standardized beta-coefficient = 0.56, P < 0.001) and GRS (standardized beta-coefficient = 0.19, P = 0.004), while GCW was correlated with GLS (standardized beta-coefficient = -0.55, P < 0.001), SBP (standardized beta-coefficient = 0.71, P < 0.001), GRS (standardized beta-coefficient = 0.11, P = 0.02), and GCS (standardized beta-coefficient = -0.10, P = 0.01). GWE was directly correlated with EF and inversely correlated with Tei index (standardized beta-coefficient = 0.18, P = 0.009 and standardized beta-coefficient = -0.20, P = 0.004, respectively), the opposite occurred for GWW (standardized beta-coefficient =--0.14, P = 0.03 and standardized beta-coefficient = 0.17, P = 0.01, respectively).

CONCLUSION

The non-invasive MW indices show a good correlation with traditional 2DE parameters of myocardial systolic function and myocardial strain.