Microvascular dysfunction is associated with impaired myocardial work in obstructive and nonobstructive hypertrophic cardiomyopathy: a multimodality approach

Introduction

Myocardial work is a dynamic non-invasive method for assessing myocardial deformation. Microvascular dysfunction is a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between impaired myocardial work, evaluated by echocardiography, and left ventricular (LV) ischemia, detected by cardiac magnetic resonance (CMR).

Methods

Prospective assessment of HCM patients' (P) myocardial strain parameters with 2D speckle-tracking echocardiography. All P underwent CMR protocol (1.5-T) for the analysis of stress perfusion and late gadolinium enhancement (LGE). Perfusion defects were quantified as burden of ischemia (% of LV mass). Results were stratified according to obstructive (oHCM) and nonobstructive (nHCM) HCM as well as according to the presence of significant replacement fibrosis (LGE of ≥15% or <15% of LV mass). Multivariate regression analyses were used to explore the relation between myocardial work and the burden of ischemia.

Results

75 P with HCM (63% male, age 55±15 years), 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH and 28% exhibiting LV outflow tract obstruction (mean maximal LVOT gradient of 89±60 mmHg). Perfusion defects were found in 68 P (90.7%), with a mean of 22.5±16.9% of LV mass and 29 P (38.7%) had LGE ≥15% of LV mass.

A lower global work index (GWI) significantly correlated with higher burden of myocardial perfusion defects (r=−0.520, β-estimate −0.019, 95% CI −0.028 to −0.010, p<0.001). Likewise, impaired values of global work efficiency (GWE) were linked to higher percentage of hypoperfusion (r=−0.477, β-estimate −0.713, 95% CI −1.250 to −0.176, p<0.001). Moreover, impaired global constructive work (GCW) (r=−0.519, β-estimate −0.021, 95% CI −0.030 to −0.013, p<0.001) and a higher global wasted work (GWW) (r=0.280, p=0.017) were associated with a higher burden of perfusion defects (Figure 1).

GWI showed a higher correlation with perfusion defects in oHCM P (r=−0.518, p=0.019) vs. nHCM P (r=−0.492, p<0.001), and the same was also found with GWE (oHCM: r=−0.591, p=0.006 vs. nHCM: r=−0.317, p=0.022) (Figure 2A). Furthermore, GCW showed a slightly higher correlation with hypoperfusion in oHCM P (r=−0.564, p=0.010) vs. nHCM P (r=−0.520, p<0.001). There was no significant difference between oHCM and nHCM P regarding GWW.

In P with LGE ≥15%, GWI showed a better correlation with perfusion defects (r=−0.489, p=0.007) vs. P with LGE of <15% (r=−0.369, p=0.007). Moreover, GCW showed a higher correlation with hypoperfusion in P with LGE ≥15% (r=−0.455, p=0.013) comparing with P with LGE <15% LV mass (r=−0.359, p=0.019) (Figure 2B). No difference was found regarding GWE and GWW according to LGE burden.

Conclusion

In our cohort of P with HCM, impaired GWI, GWE and GCW and a higher GWW were significantly correlated with the presence of myocardial ischemia in CMR. This correlation was greater in P with oHCM and in P with LGE of ≥15% of LV mass.

Funding Acknowledgement

Type of funding sources: None.

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA.

Methods

In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2).

Conclusions

The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations.

Funding Acknowledgement

Type of funding sources: None.

Permanent pacemaker implantation after Alcoholic Septal Ablation: long-term outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete heart block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term pacemaker dependency in patients with PPM after ASA and to assess the long-term impact of PPM in these patients.

Methods

In a tertiary center, patients who underwent ASA were retrospectively analyzed. Patients with previous PPM or implantable cardio-defibrillator were excluded. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and outcomes. In the group who implanted PPM, the long-term pacing rates were evaluated.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding co-morbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). In the PPM group, the mean pacing rates at 1 month, 1 year and 2 years were 66.6±38.0, 50.4±44.1 and 50.8±42.5, respectively, with 2 patients (12.5%) having 1-5% pacing and none having pacing <1% at 2 years. In the group without PPM, 5 patients (6.2%) required posteriorly PPM implantation during the follow-up. There were no statistically significant differences in the two groups regarding in-hospital mortality, 1 year mortality or 1 year re-hospitalization. Despite a lower mean follow-up period in the PPM group (2.3±1.5 years versus 3.5±2.2 years, p0.05), there were no differences in the groups regarding all-cause mortality, cardiac cause mortality and cardiac cause re-hospitalization, with a statistical tendency to a lower all cause re-hospitalization in the PPM group (19% versus 43%, p0.07).

Conclusions

The registered pacing rates shows that all devices were adequately implanted. The long-term impact analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to reduce all cause re-hospitalizations.

Ecocardiographic comprehensive evaluation of OHCM patients treated with percutaneous ASA

Funding Acknowledgements

Type of funding sources: None.

Introduction

Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment.

The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure.

Methods and results

Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a > 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU).

110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively.

Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve.

During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. 

Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). 

During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). 

Conclusion

ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.

Three dimensional myocardial deformation parameters are associated with functional capacity in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P).

Methods

This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing.

Results

83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p < 0.001), global radial 3D strain (r = 0.336, p = 0.003) and global circumferential 3D strain (r=-0.353, p = 0.002) (Figure 1).

Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012).

Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p < 0.001), circulatory power (r=-0.272, p = 0.032) and (VE/VCO2 slope)/peak VO2 ratio (r = 0.391, p = 0.002). LV twist (r=-0.135, p = 0.284), torsion (r=-0.120, p = 0.341) and global area strain (r = 0.152, p = 0.235) impairment did not correlate with VE/VCO2 slope. Exercise capacity was not associated with LV mass index (r = 0.209, p = 0.095), LV end-diastolic volume (r = 0.058, p = 0.639), maximum wall thickness (r = 0.041, p = 0.744), LVEF (r=-0.092, p = 0.458), 2D global longitudinal strain (r=-0.024, p = 0.848) or peak LVOT gradient (r=-0.006, p = 0.964). In a subanalysis examining only the nonobstructive (nHCM) P, we found that peak VO2 had a superior correlation with global longitudinal 3D strain (r=-0.420, p = 0.004), global radial 3D strain (r = 0.356, p = 0.016) and global circumferential 3D strain (r=-0.357, p = 0.016) as well as LV twist (r = 0.300, p = 0.046) and torsion (r = 0.336, p = 0.024).

Conclusion

Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters  Abstract Figure. LV twist, torsion and global area strain

Microvascular dysfunction and myocardial fibrosis impact on left ventricular myocardial deformation in hypertrophic cardiomyopathy: per segment analysis by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular hypertrophy (LVH) and microvascular dysfunction are hallmarks of hypertrophic cardiomyopathy (HCM). We hypothesized that microvascular dysfunction contributes to LV myocardial deformation impairment.

Methods

Prospective evaluation of adult patients with HCM (patients with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume, late gadolinium enhancement (LGE) and stress perfusion. Three-dimensional strain analysis was obtained by using feature-tracking from cine images. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for longitudinal, circumferential and radial strain were performed.

Results

A total of 1200 myocardial segments were analysed (Table 1) (75 patients, 63% male, age 54.6 ± 14.7 years) including 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH, 28% exhibiting LV outflow tract obstruction. The mean MLVWT was 20 ± 4.5mm.

Higher values of longitudinal strain (lower deformation) were found in segments with MLVWT ≥15mm (β-estimate: 2.31, 95% CI 0.91-3.70, p < 0.001) and in patients with obstructive HCM (β-estimate: 2.44, 95% CI 1.15-3.72, p < 0.001]) (Table 2). No association was found between perfusion defects, LGE and longitudinal strain.

Higher values of circumferential strain (lower deformation) were found in segments with MLVWT 12-14mm (β-estimate: 2.31, 95% CI 1.36-3.25, p < 0.001), MLVWT ≥15mm (β-estimate: 5.29, 95% CI 4.47-6.12, p < 0.001), with perfusion defects (β-estimate: 2.75, 95% CI 2.0-3.5, p < 0.001), with LGE (β-estimate: 2.49, 95% CI 1.77-3.22, p < 0.001) and in patients with obstructive HCM (β-estimate: 1.25, 95% CI 0.44-2.06, p = 0.003).

Lower radial strain values were found in segments with MLVWT 12-14mm (β-estimate: -10.64, 95% CI -13.95 to -7.33, p < 0.001), with MLVWT ≥15mm (β-estimate: -20.67, 95% CI -23.36 to -17.97, p < 0.001), with perfusion defects (β-estimate: -10.60, 95% CI -13.08 to -8.13, p < 0.001), and with LGE (β-estimate: -10.49, 95% CI  -12.86 to -8.11) (table 2).

Diabetes, hypertension and BMI > 25 kg/m2 were also associated with impaired myocardial deformation. Male gender correlated with worse radial and circumferential strain values.

No association was found between parametric mapping values and LV myocardial deformation.

Conclusion

In patients with HCM, three-dimensional speckle tracking parameters for LV systolic function were particularly impaired in segments with LVH, microvascular dysfunction or fibrosis. LVH was associated with abnormal longitudinal, circumferential and radial strain while perfusion defects and LGE correlated with impaired circumferential strain and radial strain. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariate analysis

Assessment of myocardial work: a promising tool in obstructive and nonobstructive hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial work is a novel dynamic non-invasive method for assessing myocardial deformation providing incremental information to left ventricular ejection fraction (LVEF) and strain imaging. The aim of this study was to assess left ventricular myocardial work in hypertrophic cardiomyopathy (HCM) and compare patients with obstructive HCM (oHCM) and nonobstructive HCM (nHCM).

Methods

Prospective assessment of HCM patients’ myocardial strain parameters with 2D speckle-tracking echocardiography, stratified according to LV segments (basal, midcavity and apical regions). Results were compared between oHCM and nHCM patients.

Results

83 patients with HCM, 60% male, 33% oHCM (with a LVOT gradient of 89 ± 60 mmHg). There was no significant difference between groups in mean age (56 ± 13 years vs. 55 ± 15 years, p = 0.719), LV mass index (186 ± 75 g/m2 vs. 158 ± 65 g/m2, p = 0.103), maximum wall thickness (21 ± 4 mm vs. 19 ± 5 mm, p = 0.425) or left ventricular ejection fraction (LVEF) (68 ± 8% vs. 67 ± 11%, p = 0.584).

Regarding global work index (GWI) there was no significant difference between oHCM and nHCM (1206 ± 431 mmHg% vs. 1384 ± 437 mmHg%, p = 0.090), although oHCM patients had a significantly inferior GWI in the basal (921 ± 383 mmHg% vs. 1364 ± 419 mmHg%, p < 0.001) and midcavity (1049 ± 456 mmHg% vs. 1288 ± 492 mmHg%, p = 0.038) segments (Figure 1). No significant difference was noted in the apical segments (1680 ± 653 mmHg% vs. 1519 ± 770 mmHg%, p = 0.335). Myocardial work index in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.242, p = 0.032) and maximum provoked LVOT gradient (r=-0.291, p = 0.010). Furthermore, patients with septal hypertrophy pattern showed significantly impaired basal myocardial work index compared with apical hypertrophy patients (1090 ± 428 mmHg% vs 1537 ± 389 mmHg%, p < 0.001).

Global constructive work (GCW) (1443 ± 449 mmHg% vs. 1604 ± 426 mmHg%, p = 0.123) and global wasted work (GWW) (197 ± 140 mmHg% vs. 154 ± 107 mmHg%, p = 0.137) were not significantly different between groups.

Global work efficiency (GWE) was significantly reduced in oHCM patients vs. nHCM (84.1 ± 7% vs. 88.3 ± 7.3%, p = 0.017), particularly in the basal (80.2 ± 11.2% vs. 88.3±.7.2%, p = 0.033) and midcavity segments (85.4 ± 9.2% vs. 90.0 ± 8.5%, p = 0.044) (Figure 2). No significant difference was noted in the apical segments (88.2 ± 9.9% vs. 87.0 ± 12%, p = 0.679). Myocardial work efficiency in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.389, p = 0.002) and maximum provoked LVOT gradient (r=-0.446, p < 0.001). Moreover, patients with septal hypertrophy pattern showed significantly reduced basal myocardial work efficiency versus apical hypertrophy patients (83 ± 9% vs 92 ± 3%, p < 0.001).

Conclusion

Myocardial work is a promising tool to evaluate myocardial function in patients with oHCM and nHCM. oHCM patients had a significantly inferior GWI and GWE particularly in the basal and midcavity segments versus nHCM patients. Abstract Figure 1: Myocardial Work Index  Abstract Figure 2: Myocardial Work Efficiency

Three-dimensional myocardial deformation parameters are associated with functional capacity assessed by cardiopulmonary exercise testing in patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial deformation parameters, derived from three-dimensional (3D) speckle-tracking echocardiography (3DSTE) are useful tools to determine left ventricular (LV) systolic function, and are often abnormal before a decline in ejection fraction (EF).

Aims

To study the correlation between systolic function evaluated by myocardial deformation parameters obtained by 3DSTE and functional capacity in patients with HCM.

Methods

HCM patients seen prospectively at outpatient cardiomyopathy clinic at a tertiary centre were included. Systolic function was assessed by strain measures – global longitudinal, circumferential and radial strain - obtain by 3DSTE, LVEF by 2D and 3D echocardiography were also assessed.  Functional capacity was evaluated by CPET.

Results

Of 67 P with HCM (mean age 57 ± 14 years, 41 males), 38 P (56.7%) were in New York Heart Association (NYHA) functional class I, 24 (35.8%) in class II and 5 (7.5%) in class III. 46P (68.7%) had obstructive (HCM), with a maximum LV wall thickness (MWT) of 20 (7) mm. 3DSTE and CPET parameters are reported in Table 1.

Absolute values of 3D global radial strain showed correlation with pVO2 (r=-0.336, p = 0.006), as well as longitudinal strain (r=-0.280, p= 0.024). No association was found between LVEF and pVO2. MWT did not correlate with 3DSTE strain measures.

Conclusion

Impaired myocardial deformation was associated with worse functional capacity assessed by peak oxygen consumption.

Segmental analysis of microvascular dysfunction and tissue characterization in hypertrophic cardiomyopathy by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

While left ventricular hypertrophy (LVH) and myocardial fibrosis are frequently evaluated in hypertrophic cardiomyopathy (HCM), microvascular dysfunction is often overlooked. The aim of this study was to assess the association between wall thickness, microvascular dysfunction and tissue characteristics in HCM patients (P), comparing individual myocardial segments.

Methods

Prospective evaluation of adult P with HCM (P with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume (ECV), late gadolinium enhancement (LGE) and stress perfusion. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for perfusion defects and tissue characteristics were performed.

Results

75 P (total of 1200 myocardial segments analysed), 63% male, mean age 55 ± 15 years, MLVWT of 20 ± 4.5mm (61% asymmetric septal LVH, 29% apical LVH and 8% concentric LVH). 28% presented LV outflow tract obstruction.

MLVWT was greater in the basal and mid septum (table 1). Among the 424 segments (35.3%) with a perfusion defect, 286 (23.8%) had a defect only in the endocardial layer and 138 (11.5%) in both endocardial and epicardial layers with defects more often detected in hypertrophied segments. This association was verified in segments with MLVWT 12-14mm and MLVWT ≥15mm (OR 7.83, 95% CI 5.75-10.67, p < 0.001) (table 2). Among the 660 segments with normal MLVWT (≤11mm), 123 (19%) presented perfusion defects. A perfusion defect was more frequent in segments of obstructive HCM P (OR 1.48, 95% CI 1.13-1.92, p = 0.004).

Microvascular dysfunction was associated with changes in tissue characteristics. For the same thickness, segments with perfusion defects had a higher T1 mapping (β-estimate 20.91, 95% CI 16.87-24.96, p < 0.001) and T2 mapping mean values than those without. Furthermore, regardless of MLVWT, segments with perfusion defects had LGE more often (OR 4.16, 95% CI 3.19-5.41, p < 0.001) and a higher ECV. On the other hand, among the 424 segments with a perfusion defect, 115 (27%) did not present LGE.

MLVWT was associated with tissue characteristics. Comparing to non-hypertrophied segments, T1 mapping mean value was higher in segments with MLVWT 12-14mm and with ≥15mm (β-estimate 37.71, 95% CI 31.2-44.21, p < 0.001). Segments with MLVWT ≥15mm showed a significantly superior ECV mean value comparing to non-hypertrophied segments. LGE was more frequent in the more hypertrophied segments: MLVWT 12-14mm and ≥15mm (OR 9.02, 95% CI 6.42-12.67, p < 0.001) (Table 2).

Conclusion

Microvascular dysfunction is more prevalent in obstructive HCM, particularly in the more hypertrophied segments. The presence of microvascular dysfunction is associated with diffuse tissue abnormalities and replacement fibrosis. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariable analyses

Cardiac magnetic resonance in the assessment of pericardial abnormalities: a case series

Background

Cardiac magnetic resonance (CMR) has a unique role in evaluating pericardial disease, permitting non-invasive tissue analysis, and haemodynamic assessment.

Case summary

In Case 1 of recurrent pericarditis, CMR confirmed reactivation of inflammation with late gadolinium enhancement and native T1/T2 mapping techniques, prompting therapeutic changes. In constrictive pericarditis, CMR is the only modality capable of differentiating a subacute potentially reversible form (Case 2), from a chronic, burnt out irreversible phase characterized by constrictive physiology (Case 3).

Discussion

Cardiac magnetic resonance is an effective tool to tailor individual therapy, particularly in cases of recurrent and constrictive pericarditis. Late gadolinium enhancement provides diagnostic and prognostic information, and multiparametric mapping has emerged as a promising tool with incremental diagnostic value.

What are the predictors of heart failure in patients admitted with acute coronary syndrome? Data from a large national registry

Background

Heart failure (HF) is a serious and frequent complication of acute myocardial infarction with important impact in outcome. Early treatment according to contemporaneous guidelines is essential to avoid that complication. Previous ischemic heart disease and HF are important predictors. Our objective is to identify additional predictors of HF in patients admitted with acute coronary syndrome (ACS).

Methods

Analysis of all consecutive patients prospectively included in a large national registry of ACS. Patients with a previous history of ACS, myocardial revascularization or heart failure were excluded from the analysis. The group that developed HF was compared with the group without HF and multivariate logistic regression analysis was performed to identify independent predictors of HF during hospitalization (Killip class >1).

Results

A total of 19,248 patients were included, and 17.3% developed HF during hospitalization. Patients with HF were older, less often males and smokers, and more often with hypertension and diabetes, as well as other comorbidities (p<0.001). ST elevation myocardial infarction (STEMI), atrial fibrillation, mechanical and electrical complications are also more frequent. Patients that developed HF have higher in-hospital mortality (0.9% vs. 12.1%). Independent predictors of HF are female gender (OR 1.64, 95% CI 1.15–2.33), age (1.42, 1.25–1.62, per 10-year increase) diabetes (1.97, 1.44–2.69), atrial fibrillation (2.65,1.66–4.23), STEMI (2.30, 1.70–3.10), multivessel disease (1.52, 1.13–2.05) and initial admission in a hospital without catheterization laboratory as a protective factor (0.71, 0.52–0.96). In STEMI patients, anterior location is also an independent predictor.

Conclusions

In patients admitted with a first ACS and without previous ischemic heart disease or heart failure, female gender, increasing age, diabetes, atrial fibrillation, STEMI and multivessel disease are the main predictors of worst outcome and these patients should be treated more aggressively to avoid HF development.

Funding Acknowledgement

Type of funding sources: None.

A 3D-TTE left atrial function study in cardio-oncology patients

Introduction

Transthoracic Doppler echocardiography (TTE) remains the standard imaging method to evaluate cancer therapeutics-related cardiac dysfunction (CTRCD). 3D-TTE with strain analysis is a novel technique, proved useful for earlier detection of left ventricular (LV) function impairment. However, diastolic and left atrial (LA) function impact is less studied.

Purpose

To assess LA volumetric and LA strain (LAS) features by 3D-TTE in cardio-oncology patients.

Methods

A prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D and 3D-TTE. Standard 2D, 3D-TTE and LAS parameters were evaluated, including longitudinal (LALS) and circumferential strain (LACS) during conduit (cd), contraction (ct) and reservoir (r) phases. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). CTRCD was defined as an absolute decrease in 2D LVEF >10% to a value <54% or a relative decrease in 2D GLS >15%, according to literature. P with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded.

Results

98 P (mean age 54.6±12.0 years-old), mostly treated with anthracyclines (78.6%, cumulative dose 268.2±77.6mg/m2), anti-HER (70.4%) and radiotherapy (80.6%) were included. 2D LV and LA volumes had a significantly raise from baseline to T1 (2D LVEDV 82.2±18.8 vs 91.9±18.8 mL, p=0.019 and LA 43.3±12.9 vs 49.8±13.3 mL, p=0.005). 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality. 2D GLS was also impaired at T1 (−19.9±2.6% vs −18.6±3.1%, p=0.009). During a mean follow-up of 14.1±8.1months, 31 P (31.6%) developed CTRCD. 3D LV and LA volumes also globally increased at T1 comparing to baseline with partially recovery at T2. Maximum LA volume was significantly higher at T1 (39.1±9.3 vs 43.6±10.6 ml, p=0.024). 3D LA ejection fraction (T0 53.7±9.7%, T1 53.4±8.6%, T2 49.9±8.6%, pT0-T2=0.039) and LAS values tended to progressively worse during TH. LA dilation (vol>34ml/m2) at baseline was correlated to dysfunction in contraction phase at T1 (LACSct −19.6±8.6 vs −17.3±4.6%, p=0.024). LACSr has substantially decreased from baseline to T2 (31.4±11.6 vs 27.0±10.4%, p=0.05). In univariate analysis, delta LALSr (T1-T0) was a predictor of CTRCD (mean −5.2% vs 1.9%, p=0.05).

Conclusion

CTRCD was frequent during the earlier phase of breast cancer treatment. LA function was also affected, mirroring LV volumetric and functional changes. Diastolic dysfunction, assessed through LA reservoir strain, was impaired in association with CTRCD. 3D-TTE usefulness in the surveillance and monitoring of CTRCD goes beyond systolic LV function assessment, allowing a detailed LA function analysis.

Funding Acknowledgement

Type of funding sources: None.

Coronary microvascular dysfunction in hypertrophic cardiomyopathy – impact from tissue characteristics to clinical manifestations

Background

Coronary microvascular dysfunction (CMD) is an important pathophysiological feature in hypertrophic cardiomyopathy (HCM).

Purpose

This study investigated the role of CMD in tissue characteristics, left ventricular (LV) systolic performance and clinical manifestations in HCM.

Methods

This prospective study enrolled patients with HCM without obstructive epicardial coronary artery disease. Each patient underwent cardiovascular magnetic resonance (CMR) including parametric mapping, perfusion imaging during regadenoson-induced hyperemia, late gadolinium enhancement (LGE) and three-dimensional longitudinal, circumferential and radial strains analysis. Electrocardiogram and 24 hours Holter recording were performed to assess arrhythmias.

Results

75P were enrolled, 47 (63%) males, mean age 54.6 (14.8) years; 51 patients (68%) had non obstructive HCM, mean maximum wall thickness (MWT) was 20.2 (4.6)mm, LV ejection fraction 71.6 (8.3)%, ischemic burden 22.5 (16.9)% of LV.

Greater MWT was associated the severity of ischemia (β-estimate: 1.809, 95% CI: 1.073; 2.545; p<0.001).

Ischemic burden was strongly associated with higher values of native T1 (β-estimate: 9.018, 95% CI: 4.721, 13.315; p<0.001).

An association between ischemia and the extent of LGE was found (β-estimate: 2.02, 95% CI: 0.93, 3.10; p<0.001). Ischemia in ≥21% of LV was associated with LGE >15% (AUC 0.766, sensitivity 0.724, specificity 0.659).

In multivariable analysis, in the overall population, MWT and LGE were independently associated with ischemia, however the evidence of association between ischemia and extent of LGE became weaker (β-estimate: 1.070, 95% CI: −0.106; 2.245; p=0.074).

In subgroup analysis, the association between ischemia and LGE remained significant in individuals with MWT 15–20mm, non-obstructive HCM, female and age <40 years.

The severity of ischemia was not associated with markers of LV systolic function, namely LVEF, longitudinal, radial and circumferential strain

A strong evidence of association was found between ischemia and atrial fibrillation/flutter (AF/AFL) (OR: 1.481, 95% CI: 1.020,2.152; p=0.039), but no association was verified with non-sustained ventricular tachycardia.

Conclusion

In HCM, CMD is related to the severity of LV hypertrophy. Ischemia secondary to CMD promotes fibrosis and is associated with an increase in the odds of AF/ALF.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular noncompaction: the importance of identifying high-risk patients within the scope of left ventricular hypertrabeculation

Introduction

Prominent left ventricular (LV) trabeculation is frequently encountered, however LV noncompaction (LVNC) criteria are not always fulfilled. The clinical and prognostic significance of these findings remains unclear.

Objectives

To characterize the patients (P) with echocardiographic suspicion of LVNC and to assess clinical outcomes.

Methods

Retrospective single-centre study that included all echocardiograms between January 2018 and June 2020 perceiving LV hypertrabeculation. The cohort underwent diagnostic assessment for LVNC by Chin and Jenni criteria. Baseline characteristics were evaluated. Composite endpoint of cardiovascular death, heart failure (HF) hospitalization, ventricular arrythmias (VA) and nonfatal stroke was considered.

Results

51P, 75% male, mean age 50±18 years. 35P (69%) had associated heart conditions, of which 57% had other known cardiomyopathy (mainly dilated cardiomyopathy), 14% congenital, 26% ischemic and 3% valvular heart disease. 2P were in postpartum period and 1P was an athlete. Family history of cardiomyopathy was present in 8P (16%). 12P underwent genetic testing, with TTN and MYH7 mutations being the most frequently detected. Prior clinical HF was reported in 53%, previous stroke in 14%, and non-sustained and sustained VA in 24% and 4%, respectively. Mean NYHA classification was 1.8±0.7, with 31% being asymptomatic.

The prevalence of LVNC by Chin criteria was 31% and by Jenni criteria was 55%. 32P (63%) met at least one LVNC criteria. This group was younger (45±18 vs 59±15, p=0.004), had higher NT-proBNP levels (3644±2819 vs 389±640, p=0.048) and QRS fragmentation (59% vs 21%, p=0.027). Significantly higher LV end-diastolic volume (84 (41) vs 64 (28)ml/m2, p=0.008) and end-systolic volume (51 (37) vs 35 (20)ml/m2, p=0.004), along with lower LV ejection fraction (39±12 vs 49±13%, p=0.009) and global longitudinal strain (−11±5 vs −17±4%, p=0.003) were noticed. P who met LVNC criteria also had higher number of affected LV segments (6.4±1.8 vs 4.2±1.6, p<0.001).

Over a mean follow-up of 18±9 months, the incidence of composite endpoint was 35%. Univariate Cox analysis showed a significant association between the presence of LVNC criteria and adverse outcomes (HR: 5.108, 95% CI: 1.682–11.236, p=0.030) (Fig. 1).

Conclusion

LV hypertrabeculation can be encountered in a variety of clinical scenarios and often overlaps with other heart diseases. P satisfying criteria for LVNC had more impairment in LV performance and worse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Myocardial work brings a new insight into left ventricule remodelling in cardiooncology patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Serial echocardiographic assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) is the gold standard screening method for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages, as it incorporates measurements of myocardial deformation and LV pressure.

Purpose

To evaluate the impact of cardiotoxic treatments in MW indices.

Methods

Prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D, 3D transthoracic echocardiography (TTE) and concomitant blood pressure assessment. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). PSL analysis allowed the calculation of the following indices: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE). CTRCD was defined as an absolute decrease in 2D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%, according to literature. 

Results

122 patients (mean age 54.7 ± 12.0 years), mostly treated with anthracyclines (77.0%, cumulative dose 268.6 ± 71.8mg/m2), anti-HER (75.4%) and radiotherapy (77.0%) were included. 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality (2D LVEF T0-T1 64.2 ±7.6 vs 61.1 ± 8.2%, p = 0.006 and 3D LVEF T0-T1 60.2 ± 6.7 vs 56.9 ±6.3%, p = 0.022). 2D GLS was also more impaired at T1 (-19.8 ± 2.7% vs -18.5 ± 3.0%, p = 0.003).

All MW indices were significantly reduced at T1 compared to baseline (GWI 1756.9 ± 319.2 vs 1614.3 ± 338.5mmHg%, p = 0.005; GCW 2105.6 ± 352.0 vs 1970.5 ± 376.2 mmHg%, p = 0.015; GWW 121.1 ± 66.6 vs 161.1 ± 84.1 mmHg%, p = 0.001; GWE 93.5 ± 3.1 vs 91.1 ± 4.5%, p = 0.001). Between T1 and T2 no statistical difference was found but a partial recovery of parameters was observed when comparing T2 to T0 (GWI (T2) 1650.6 ± 357.5 mmHg%, p = 0.035; GCW (T2) 2013.3 ± 379.3 mmHg%, p = 0.086; GWW (T2) 148.0 ± 85.0 mmHg%, p = 0.02 and GWE (T2) 92.0 ± 4.7%, p = 0.012). 

During a mean follow-up of 14.9 ± 9.3 months, 36 patients (29.5%) developed CTRCD.  P presenting CTRCD revealed a significant decrease in GWI and GWE at T1 comparing with women without CTRCD (GWI 1.8 ± 21.6 vs -14.2 ± 18.5%, p = 0.004 and GWE -1.0 ±3.0 vs -3.6 ±3.9%, p = 0.005). GWW had a substantially increase at T1 in P with cardiotoxicity (27.6 ± 76.3% vs 64.1 ± 68.0%, p = 0.051).

Conclusion

Left ventricular systolic function study with MW showed a reduction in cardiac performance with a peak at 6 months from the start of chemotherapy and partial recovery after term. Assessment of myocardial deformation parameters, namely MW, proved to be a useful tool for a better characterisation of cardiac remodelling, and could enhance patient selection for cardioprotective therapeutics.

Abstract Figure. TTE parameters

Association between microvascular dysfunction and impaired myocardial deformation in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Objective

To analyze the relationship between coronary microvascular dysfunction (MCD) and left ventricular (LV) myocardial deformation in hypertrophic cardiomyopathy (HCM). 

Methods

Prospectively inclusion of HCM patients (P). MCD was assessed by CMR, during regadenoson-induced hyperemia. For perfusion assessment, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer). Ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Epicardial coronary artery disease was excluded by computed tomography or invasive coronary angiography.

LV myocardial deformation was evaluated by 2D and 3D speckle-tracking echocardiography (STE), including global longitudinal strain (GLS), peak systolic dispersion (PDS), global circumferential strain (GCS), global radial strain (GRS), area strain, twist and torsion.

Results

31 P enrolled (51%male,age57.8 ± 15.5years). Asymmetric septal hypertrophy was seen in 55%, apical in 29%, concentric in 16%,maximal wall thickness (MWT) of 20.5 ± 4.9mm; 26% with LVOT obstruction; LV ejection fraction 67.9 ± 7.9%.

In 2DSTE analysis, P with more ischemia (>20%of LV) presented more severe impaired GLS and greater PDS, comparing with patients with ≤20% of ischemia.

Similarly, 3DSTE imaging showed worse LV performance in P with greater ischemic burden, expressed by significant difference in GLS, GRS and area strain. GCS also trended to be worse in the presence of >20% of ischemia.

The stronger correlation was found between 2D GLS and ischemic burden (Pearson correlation factor 0.545; p = 0.002).

Conclusion

In HCM, the severity of ischemia secondary to MCD was associated with impairment in LV myocardial deformation evaluated by 2D and 3D STE.

Table 1. Echocardiography Ischemic burden (% of LV) 2D parameters ≤ 20% (n = 15) > 20% (n = 16) p-value GLS (%) -15.6 ± 2.7 -12.1 ± 4.7 0.016 PSD (ms) 73.2 ± 25.6 102.1 ± 57.6 0.150 3D parameters GLS (%) -10.3 ± 4.5 -7.3 ± 3.0 0.010 GCS (%) -12.6 ± 3.0 -10.1 ± 4.5 0.079 GRS (%) 30.8 ± 8.5 22.8 ± 11.4 0.035 Area strain(%) -20.8 ± 4.9 -15.8 ± 6.3 0.020 Twist (deg) 6.0 ± 4.8 4.1 ± 4.0 0.175 Torsion (deg/cm) 1.2 ± 0.9 0.8 ± 0.7 0.232

Haemorrhagic risk of oncology patients with myocardial infarction

 

The approach of acute coronary syndrome (ACS) in oncology patients (pts) is challenging due to higher haemorrhagic risk.

Objectives and methods

Retrospective analysis of pts included in an ACS registry between October 2010 and September 2019 with cancer (active or diagnosed in <5 years). Aim: evaluate safety and efficacy of single vs dual antiplatelet therapy (DAPT), anticoagulation and revascularization strategy. Primary safety endpoint: major haemorrhagic events (MHE). Secondary efficacy endpoints: ischemic events, intra-hospital (IH) mortality; combined efficacy endpoint of IH mortality, reinfarction and ischemic stroke.

Results

934 pts (5%) of a total of 18845 pts with ACS had diagnosis of cancer. Compare to pts without malignancy, oncology pts were older, had more atrial fibrillation (AF), lower left ventricle ejection fraction (LVEF), underwent invasive coronary angiography (ICA) and angioplasty less often. Oncology pts had more events: MHE (2.9% vs 1.5%, p<0.001), mortality (5.8% vs 3.4%, p<0.001) and combined endpoint (7.4% vs 4.9%, p<0.001). Oncology population: pts with MHE (N=27) had more previous haemorrhagic events, AF, higher creatinine level, ST-Elevation Myocardial Infarction (STEMI), more use of anticoagulation, less use of DAPT or acetylsalicylic acid (ASA) and higher IHmortality. In multivariate analysis, previous haemorrhagic events, AF, STEMI and no ASA were independent predictors of MHE. Pts who reached combined endpoint (N=69) were older, had more renal impairment, thrombocytopenia, STEMI, Killip class > I, lower LVEF, less prescribe with antiplatelet therapy and neurohormonal therapy, less submitted to ICA and a trend to less angioplasty. In multivariate analysis, STEMI, Killip >I, creatinine >2mg/dL, thrombocytopenia, LVEF<40%, no ACEi therapy and no ICA were independent predictors of the combined endpoint (Table 1).

Conclusion

Oncology pts had worse prognosis than general population with ACS. MHE were mainly related to previous haemorrhagic event and AF, associated with anticoagulation strategy. On the other hand, IH mortality, reinfarction and ischaemic stroke were associated with lower use of antiplatelet and neurohormonal therapy and ICA.

Funding Acknowledgement

Type of funding source: None

Myocardial work: a new way to predict fibrosis in patients with hypertrophic cardiomyopathy

Aims

Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) adds prognostic information in patients with hypertrophic cardiomyopathy (HCM). Whether Myocardial work (MW), a new parameter on transthoracic echocardiographic (TTE), can predict significant fibrosis in HCM patients is unknown.

Methods

Single-centre evaluation of consecutively recruited HCM patients in which TTE and CMR were performed. MW and related indices were calculated from global longitudinal strain (GLS) and from estimated left ventricular pressure curves. The extent of LGE was quantitatively assessed. LGE ≥15% was chosen to define significant fibrosis.

Logistic regression analysis was used to find the variables associated with LGE ≥15% and cut-off values were determined.

Results

Among the thirty-two patients analysed mean age was 57±16 years, 18 (56%) were male patients and the mean left ventricular ejection fraction by TTE was 67±8%.

Global constructive work (GCW), global work index and GLS were significant predictors of LGE ≥15%. A cut-off ≤1550 mmHg% of GCW was able to predict significant fibrosis with a sensitivity of 92% and a specificity of 79%, while the best cut-off for GLS (>−15%) had a sensitivity of 86% and a specificity of 72%.

Conclusion

GCW was the best parameter to predict significant left ventricular myocardial fibrosis in CMR, suggesting its utility in patients who may not be able to have a CMR study.

Myocardial Work and LGE in CMR in HCM

Funding Acknowledgement

Type of funding source: None

Optimizing diagnosis of obstructive coronary artery disease by CT angiography: RCT's final results and 12-months follow-up

Aim

In patients (pts) with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve pt selection for invasive coronary angiography (ICA) as alternative to functional testing. However. the role of CTA in symptomatic pts after abnormal functional test (FT) is incompletely defined.

Methods and results

This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic pts with mild to moderately abnormal FT referred to ICA to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Pts with high risk features on FT, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR<60ml/min/1.73m2) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic (DY) and revascularization (RY) yields of ICA in either group were also assessed. Pts were followed up for at least 1 year for the primary safety endpoint of all cause death/ nonfatal myocardial infarction/ stroke. Unplanned revascularization

(UP) and symptomatic status (SS) were also evaluated. Pts averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, non-obstructive

CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (p<0.001 Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, p=0.152). Both DY (84.4% vs 41.7, p<0.001) and RY (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard FT-guided ICA. The rate of the primary safety endpoint was similar between both groups (1.9% vs 0%, p=0.244), as well as the rates of UP (0.9% vs 0.9%, p=1.000) and SS (persistent angina: 29.6% vs 24.8%, p=0.425).

Conclusions

In pts with suspected CAD and mild to moderately abnormal ischemia test, a diagnostic strategy including CTA as gatekeeper is safe, effective and significantly improves diagnostic and revascularization yields of ICA.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF<50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS >1 was identified in 22 P (23.4%). An EF/GLS ratio >4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS>1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS>−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding source: None

1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF < 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS > 1 was identified in 22 P (23.4%). An EF/GLS ratio > 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS>-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Abstract 1226 Figure. Kaplan–Meier curves and ASPB

P747 Echocardiographic evaluation of haemoglobinopathies patients and their correlation with haematologic determinants

Background

Although heart disease in haemoglobinopathy have dramatically reduced with modern therapy, cardiac complications are still a leading cause of morbimortality. It became essential to detect cardiac complications in early stages in order to provide specific therapy and to improve prognosis. Transthoracic echocardiography (TTE) has a paramount role in this field.

Purpose

To evaluate cardiac function in haemoglobinopathy patients and to correlate echocardiographic parameters with haematological determinants.

Methods

Retrospective analysis of haemoglobinopathy patients (pts) referred to a tertiary centre for cardiac evaluation and transthoracic echocardiography. Epidemiological, clinical, laboratory and echocardiographic data were analysed. Comparations between echocardiographic data and haemoglobin and serum ferritin levels were performed (independent T test). P value <0.05 was considered statistically significant.

Results

55 pts were included: 58% female, mean age 37.9 ± 10.9 years, 85% with sickle cell disease, 13% (N = 7) with previous thromboembolic event and 20% (N = 11) with documented hemosiderosis. 36% (N = 20) were symptomatic (9 pts with palpitations, 6 pts with thoracic pain and 5 pts with exertion dyspnea – New York Heart Association class II). The mean haemoglobin level was 8.96 ± 1.91 g/dL and serum ferritin 1335.5 ± 2452 ng/mL. All patients had preserved left and right ventricular systolic function (TAPSE 27.1 ± 4.9mm) The mean left ventricular (LV) end-diastolic diameter indexed to body surface area (female 32.2 ± 4.7mm/m2; male: 31.2 ± 4.0mm/m2) and LV mass index (female 105.6 ± 31.4g/m2; male: 134.7 ± 97.3g/m2) were increased in both genders, although interventricular septum thickness was in the superior normal range (mean 9.3 ± 1.6mm). Left atrium enlargement was also present (29.9 ± 8.4mm/m2). The mean global ratio between early mitral inflow velocity and mean (septal and lateral) mitral annular early diastolic velocity (E/e") was 7.5 ±2.3, and 12 pts (21.8%) had impairment of LV diastolic function. Global longitudinal strain (GLS) was assessed in 35 pts, with a mean value of 19.6 ± 2.9%. 40% (14 pts) had GLS > -18%, being the septal wall the most frequently affected. Pulmonary hypertension was rare (3 pts), with mean arterial pulmonary pressure of 27.7 ± 7.0mmHg. An agreement was found between serum ferritin levels and GLS impairment defined as GLS > -18% (2649ng/ml vs 549ng/ml, p = 0.04). Pts with diastolic dysfunction had a trend to higher serum ferritin levels (2753ng/ml vs 1001ng/ml, p = 0.06). The haemoglobin levels did not correlate with echocardiographic parameters.

Conclusion

In the study population of haemoglobinopathy pts, mainly constituted by cardiac asymptomatic individuals, LV diastolic dysfunction and LV global longitudinal strain were impaired in 22% and 40%, respectively. These echocardiographic parameters revealed to be related to serum ferritin levels.

P229 Primary cardiac angiosarcoma of the right atrium: a rare entity presenting with an atrial arrhythmia

Introduction

Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor.

We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia.

Clinical case

A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain.

Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute.

Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L).

A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia.

The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed:

- Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus).

- Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava.

Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression.

Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped.

The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization.

During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism.

After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month.

Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor.

Abstract P229 Figure. Echocardiogram: right atrium mass

P1594 Relationship between left ventricular morphology and systolic performance and coronary microcirculatory dysfunction in hypertrophic cardiomyopathy

Background

Myocardial ischemia constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy (HCM). Chronic and recurrent myocardial ischemia leads to fibrosis, which may culminate in myocardial dysfunction.

Objective

To analyse the relationship between left ventricular (LV) morphology and systolic performance and coronary microcirculatory dysfunction in HCM.

Methods

The present study prospectively included HCM patients (P) who underwent transthoracic echocardiography. Left ventricular (LV) function was evaluated by ejection fraction (LVEF), global longitudinal strain (GLS) and tissue Doppler septal and lateral s’. The evaluation of coronary flow velocity reserve (CFVR) was performed in apical three chambers view for the left anterior descending (LAD) artery and in an apical three chambers view for the posterior descending (PD) artery. Diastolic coronary flow velocity was measured in basal conditions and in hyperemia, induced by adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). Absolute CFVR was calculated as the ratio of hyperemic to basal peak diastolic flow velocities; relative CFVR was calculated as the ratio between CFVR LAD and CFVR PD.

Results

23 P were enrolled (57% male, mean age 57.9 ± 13.7 years). Asymmetric septal hypertrophy was verified in 70% of P, with maximal wall thickness of 21.6 ± 4.3mm. Obstructive HCM was documented in 35% of patients.

CFV was successfully measured in the LAD in all patients, but only in 70% of patients in the PD due to technical issues related to poor acoustic window and anatomical constraints. 78% of P (n = 18) presented CFVR <2, denoting microcirculatory dysfunction. Relative CFVR (LAD CFVR/ PD CFVR) was ≥1 in 43% of P.

P with maximal wall thickness (MWT)>20mm presented higher CFV PD at baseline (46.5 ± 17.4 vs 32.5 ± 12.6 cm/s; p = 0.072), lower CFVR PD (1.3 ± 0.3 vs 2.5 ± 0.8; p = 0.003) and greater regional difference of microcirculation (relative CFVR 1.4 ± 0.6 vs 0.8 ± 0.3; p = 0.048).

At baseline conditions, CFV LAD was higher in obstructive HCM (44.0 ± 4.8 vs 35.3 ± 10.6 cm/s; p = 0.040).

P with impairment in global longitudinal strain (GLS>-18%) had higher basal CFV LAD (40.1 ± 8.6 vs 30.0 ± 12.2 cm/s; p = 0.059) and PD (44.5 ± 15.2 vs 20.0 ± 5.0 cm/s; p = 0.015) but lower CFVR PD (1.5 ± 0.5 vs 2.8 ± 1.1; p = 0.039). The reduction in CFVR PD was also noted in P with time to peak longitudinal strain dispersion >90mseg (CFVR PD 1.2 ± 0.2vs1.9 ± 0.9;p = 0.012).

Conclusion

Higher CFV at baseline was noted in P with greater MWT, obstructive HCM and worse GLS. Coronary microcirculatory dysfunction was associated with the degree of LV hypertrophy and impairment in LV systolic performance.

P1373 Cardiac source of embolism diagnosed by transeophageal echocardiography - what to expect in nowadays clinical practice

Background

Transeophageal echocardiography (TEE) is an essential tool to diagnose cardiac source of embolism (CSE) and to define treatment approach. Purpose: To review the identified CSE in 25 years experience in TEE at a tertiary centre. Methods: Retrospective study of consecutive patients (pts) who underwent TEE to search for CSE, from 1994 to 2019. Results: 2936 pts (55% males, mean age 53 ± 13 years). Ischemic cerebral event (96%) was the main location of embolism. TEE identified potential CSE in 41.5% and 7% had more than one diagnostic. The most frequent CSE were patnt foramen ovale (PFO) (16.3%) and atrial septal aneurysm (ASA), among these 65% had concomitant PFO or atrial septal defect (ASD) (14.1%). Aortic plaques ≥ 4mm were noted in 9.6%, followed by valve disease or prosthesis (5.4%), intracavitary thrombi (3.9%), vegetations (1.6%), ASD (1.5%), dilated cardiomyopathy (1.4%) and tumors (0.7%). In the last 15 years, the diagnostic effectiveness increased (35.6% vs 45.95%) and there was a shift in etiologies with an increased in the diagnose of PFO/ASD (26.8% vs 38.5%) and valve disease or prosthesis became less frequent (29.9% vs 3.7%). Overall, in elderly pts there was a preponderance of atherosclerotic plaques in the aorta, contrasting with younger pts who presented a predominance of PFO (Table1). The prevalence of spontaneous echo contrast increased with age. Pts with ischemic cerebral event were younger, mostly male and PFO was the main source of embolism (17%), while in pts with peripheral embolism the most frequent etiologies were intracavitary trombi (16%) and aortic plaques ≥ 4mm (14%). Conclusion: The main cause to perform a TEE to search for CSE was cerebral embolism, with a diagnostic effectiveness overall of 41.5%, that increased in the last 15years.

Table 1 Characteristics <50 years (n = 1191) 50-75 years (n = 1569) ≥75 years (n = 171) Male (%) 601 (50%) 931 (59%) 80 (47%) Atrial septal defect (%) 23 (2%) 20 (1%) 0 Patent foramen ovale (%) 239 (20%) 226 (14%) 12 (7%) Atrial septal aneurysm (%) 70 (6%) 130 (8%) 13 (8%) Vegetations (%) 8 (0.7%) 29 (2%) 9 (5%) Tumors (%) 10 (0.8%) 8 (0.5%) 4 (2%) Intracavitary trombi (%) 28 (2%) 74 (5%) 14 (8%) Aortic plaque ≥4mm (%) 31 (3%) 203 (13%) 48 (28%) Valve disease or prothesis (%) 54 (4.5%) 109 (6%) 11 (6%) Spontaneous echo contrast (%) 36 (3%) 155 (10%) 32 (19%) Distribution of cardiac source embolism by age

P1787 Pharmacologic stress test: still an important prognostic factor? a follow-up study

Introduction

Dobutamine stress echocardiography (DSE) is an established exam for evaluation of extent and severity of coronary artery disease.

Purpose

To analyse the results and complications of DSE and identify prognostic predictors in patients (P) who underwent DSE for myocardial ischemia detection.

Methods

220P who underwent consecutive DSE from 2013 to 2017. P with significant valvular disease were excluded. Clinical data, echocardiographic parameters and data from follow up (FU) regarding all-cause mortality and MACEs were analysed. Mean age 64.8 ± 12.0 years(Y), 143 men (65%).

Results

88P (40%) had positive, 102 had negative and 30 had inconclusive DSE; complications rate of 15%. Prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, prior MI, percutaneous coronary interventionc (PCI), coronary arterial bypass graft (CABG) and HF was 82.7%, 42.3%, 67.7%, 35.9%, 31.8%, 10.9% and 9.5%, respectively. Mean left ventricular endsystolic (LVSD) and enddiastolic dimensions were 33.7 ± 8.9 and 52.8 ± 7.1 mm. Mean resting wall motion score index (rWMSI) and peak (pWMSI) were 1.16 ± 0.28 and 1.24 ± 0.34. Mean resting GLS (rGLS) and peak GLS (pGLS) were -16.3 ± 4.3 and -16.6 ± 4.3. Mean no. of ischemic segments was 1.7 ± 2.4 and 16.8% had ischemia >3 segments. There was ischemia in left anterior descending (LAD) coronary in 53P and in circumflex and right coronary territories in 18 and 68P. 22.6% had more than one ischemic territory. 43P (49.4%) underwent intervention, 38 with PCI and 5 with CABG. During a mean FU of 38.8 ± 16.8 months, 47 MACEs were observed, including 32 deaths (14.5%). Positive DSE (p = 0.012), no. of ischemic segments (p = 0.019), ischemia in the LAD (p = 0.003), rGLS (p = 0.038) and pGLS (p = 0.038) were related to the occurrence of MACEs. In Cox regression analysis, age (p = 0.005), DM (p = 0.005), HF (p = 0.006), prior CABG (p = 0.015), LVSD (p = 0.026), rWMSI (p = 0.029), pWMSI (p = 0.013) and pGLS (p = 0.038) were associated with increased all-cause mortality. Kaplan–Meier survival analysis showed that survival was significantly worse for ischemia > 3 segments (log rank 0.005), ischemia of more than one territory (log rank 0.025) and pWMSI >1.5 (log rank < 0.0005). With multivariate Cox regression analysis, age >65Y (HR 4.22, p = 0.004), DM (HR 2.49,p = 0.038) and pWMSI > 1.5 (HR 9.73,p = 0.007) were independently associated with all-cause mortality.

Conclusion

In patients who underwent DSE there were some baseline and DSE-related independent predictors of long-term prognosis: age, DM and peak WMSI.

Abstract P1787 Figure. Kaplan–Meier curves

The accuracy of PiCCO® in measuring cardiac output in patients under therapeutic hypothermia: Comparison with transthoracic echocardiography

BACKGROUND

Invasive cardiac monitoring using thermodilution methods such as PiCCO® is widely used in critically ill patients and provides a wide range of hemodynamic variables, including cardiac output (CO). However, in post-cardiac arrest patients subjected to therapeutic hypothermia, the low body temperature possibly could interfere with the technique. Transthoracic Doppler echocardiography (ECHO) has long proved its accuracy in estimating CO, and is not influenced by temperature changes.

OBJECTIVE

To assess the accuracy of PiCCO® in measuring CO in patients under therapeutic hypothermia, compared with ECHO.

DESIGN AND PATIENTS

Thirty paired COECHO/COPiCCO measurements were analyzed in 15 patients subjected to hypothermia after cardiac arrest. Eighteen paired measurements were obtained at under 36°C and 12 at ≥36°C. A value of 0.5l/min was considered the maximum accepted difference between the COECHO and COPiCCO values.

RESULTS

Under conditions of normothermia (≥36°C), the mean difference between COECHO and COPiCCO was 0.030 l/min, with limits of agreement (-0.22, 0.28) - all of the measurements differing by less than 0.5 l/min. In situations of hypothermia (<36°C), the mean difference in CO measurements was -0.426 l/min, with limits of agreement (-1.60, 0.75), and only 44% (8/18) of the paired measurements fell within the interval (-0.5, 0.5). The calculated temperature cut-off point maximizing specificity was 35.95°C: above this temperature, specificity was 100%, with a false-positive rate of 0%.

CONCLUSIONS

The results clearly show clinically relevant discordance between COECHO and COPiCCO at temperatures of <36°C, demonstrating the inaccuracy of PiCCO® for cardiac output measurements in hypothermic patients.

Occupational therapy intervention for cancer patients with metastatic disease

Very little information is available on the role of occupational therapy in the care of cancer patients who are being actively treated for metastatic disease. To gain information on occupational therapy assessment and treatment procedures, we reviewed the records of 54 adult inpatients who received occupational therapy services during a hospital admission. We found that assessment focused on independent living skills, sensorimotor components, and therapeutic adaptations. Treatment also focused on these areas but placed heavy emphasis on physical daily living skills, range of motion, assistive/adaptive equipment, and energy conservation. These findings indicate that occupational therapy has a unique role in the physical care of cancer patients with metastatic disease.