A 64k pixel CMOS-DEPFET module for the soft X-rays DSSC imager operating at MHz-frame rates

The 64k pixel DEPFET module is the key sensitive component of the DEPFET Sensor with Signal Compression (DSSC), a large area 2D hybrid detector for capturing and measuring soft X-rays at the European XFEL. The final 1-megapixel camera has to detect photons with energies between [Formula: see text] and [Formula: see text], and must provide a peak frame rate of [Formula: see text] to cope with the unique bunch structure of the European XFEL. This work summarizes the functionalities and properties of the first modules assembled with full-format CMOS-DEPFET arrays, featuring [Formula: see text] hexagonally-shaped pixels with a side length of 136 μm. The pixel sensors utilize the DEPFET technology to realize an extremely low input capacitance for excellent energy resolution and, at the same time, an intrinsic capability of signal compression without any gain switching. Each pixel of the readout ASIC includes a DEPFET-bias current cancellation circuitry, a trapezoidal-shaping filter, a 9-bit ADC and a 800-word long digital memory. The trimming, calibration and final characterization were performed in a laboratory test-bench at DESY. All detector features are assessed at [Formula: see text]. An outstanding equivalent noise charge of [Formula: see text]e-rms is achieved at 1.1-MHz frame rate and gain of 26.8 Analog-to-Digital Unit per keV ([Formula: see text]). At [Formula: see text] and [Formula: see text], a noise of [Formula: see text] e-rms and a dynamic range of [Formula: see text] are obtained. The highest dynamic range of [Formula: see text] is reached at [Formula: see text] and [Formula: see text]. These values can fulfill the specification of the DSSC project.

Bioimpedance Spectroscopy Reveals Important Association of Fluid Status and T1 -Mapping by Cardiovascular Magnetic Resonance

BACKGROUND

Extracellular matrix expansion is a key pathophysiologic feature in heart failure and can be quantified noninvasively by cardiac magnetic resonance T₁ -mapping. Free water within the interstitial space of the myocardium, however, may also alter T₁ -mapping results.

PURPOSE

To investigate the association between systemic fluid status and T₁ -mapping by cardiac magnetic resonance.

STUDY TYPE

Prospective, observational single-center study.

POPULATION

Two-hundred eighty-five consecutive patients (44.4% female, 70.0 ± 14.9 years old) scheduled for cardiac MR due to various cardiac diseases.

SEQUENCE AND FIELD STRENGTH

1.5-T scanner (Avanto Fit, Siemens Healthineers, Erlangen, Germany). For T₁ -mapping, electrocardiographically triggered modified-Look-Locker inversion (MOLLI) recovery sequence using a 5(3)3 prototype on a short-axis mid-cavity slice and with a four-chamber view was performed.

ASSESSMENTS

MR parameters including native myocardial T₁ -times using MOLLI and extracellular volume (MR-ECV) were assessed, and additionally, we performed bioimpedance analysis (BIA). Furthermore, demographic data and comorbidities were assessed.

STATISTICS

Wilcoxon's rank-sum test, chi-square tests, and for correlation analysis, Pearson's correlation coefficients were used. Regression analyses were performed to investigate the association between patients' fluid status and T₁ -mapping results. A P-value <0.05 was considered statistically significant.

RESULTS

The mixed cohort presented with a mean overhydration (OH) of +0.2 ± 2.4 liters, as determined by BIA. By MR, native T₁ -times were 1038 ± 51 msec and MR-ECV was 31 ± 9%. In the multivariable regression analysis, only OH was significantly associated with MR-ECV (adj. beta: 0.711; 95% CI: 0.28 to 1.14) along with male sex (adj. beta: 2.529; 95% CI: 0.51 to 4.55). In linear as well as multivariable analysis, only OH was significantly associated with native T₁ times (adj. beta: 3.750; 95% CI: 1.27 to 6.23).

CONCLUSION

T₁ -times and MR-ECV were significantly associated with the degree of OH on BIA measurement. These effects were independent from age, sex, body mass index, and hematocrit. Patients' volume status may thus be an important factor when T₁ -time and MR-ECV values are interpreted.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 3.

Transcatheter Versus Surgical Valve Repair in Patients with Severe Mitral Regurgitation

Background. Transcatheter edge-to-edge mitral valve repair (TMVR) is increasingly performed. However, its efficacy in comparison with surgical MV treatment (SMV) is unknown. Methods. Consecutive patients with severe mitral regurgitation (MR) undergoing TMVR (68% functional, 32% degenerative) or SMV (9% functional, 91% degenerative) were enrolled. To account for differences in baseline characteristics, propensity score matching was performed, including age, EuroSCORE-II, left ventricular ejection fraction, and NT-proBNP. A composite of heart failure (HF) hospitalization/death served as primary endpoint. Kaplan-Meier curves and Cox-regression analyses were used to investigate associations between baseline, imaging, and procedural parameters and outcome. Results. Between July 2017 and April 2020, 245 patients were enrolled, of whom 102 patients could be adequately matched (73 y/o, 61% females, EuroSCORE-II: 5.7%, p > 0.05 for all). Despite matching, TMVR patients had more co-morbidities at baseline (higher rates of prior myocardial infarction, coronary revascularization, pacemakers/defibrillators, and diabetes mellitus, p < 0.009 for all). Patients were followed for 28.3 ± 27.2 months, during which 27 events (17 deaths, 10 HF hospitalizations) occurred. Postprocedural MR reduction (MR grade <2: TMVR vs. SMV: 88% vs. 94%, p = 0.487) and freedom from HF hospitalization/death (log-rank: p = 0.811) were similar at 2 years. On multivariable Cox analysis, EuroSCORE-II (adj.HR 1.07 [95%CI: 1.00–1.13], p = 0.027) and residual MR (adj.HR 1.85 [95%CI: 1.17–2.92], p = 0.009) remained significantly associated with outcome. Conclusions. In this propensity-matched, all-comers cohort, two-year outcomes after TMVR versus SMV were similar. Given the reported favorable long-term durability of TMVR, the interventional approach emerges as a valuable alternative for a substantial number of patients with functional and degenerative MR.

Prognostic impact of left atrial function in heart failure with preserved ejection fraction in sinus rhythm vs. persistent atrial fibrillation

Aims

We sought to determine the prognostic impact of left atrial (LA) size and function in patients with heart failure with preserved ejection fraction (HFpEF) in sinus rhythm (SR) vs. atrial fibrillation (AF).

Methods and results

We enrolled consecutive HFpEF patients and assessed indexed LA volumes and emptying fractions (LA‐EF) on cardiac magnetic resonance imaging. In addition, all patients underwent right and left heart catheterization, 6 min walk test, and N‐terminal prohormone of brain natriuretic peptide evaluation. We prospectively followed patients and used Cox regression models to determine the association of LA size and function with a composite endpoint of heart failure hospitalization and cardiovascular death. A total of 188 patients (71% female patients, 70 ± 8 years old) were included of whom 92 (49%) were in persistent AF. Sixty‐five patients reached the combined endpoint during a follow‐up of 31 (9–57) months. Multivariate Cox regression adjusted for established risk factors revealed that LA‐EF was significantly associated with outcome in patients in SR [adjusted hazard ratio 2.14; 95% confidence interval (1.32–3.47) per 1‐SD decline, P = 0.002]. In persistent AF, no LA imaging parameter was related to outcome. By receiver operating characteristic and restricted cubic spline analyses, we identified an LA‐EF ≥ 40% as best indicator for favourable outcomes in patients with HFpEF and SR. Persistent AF carried a similar risk for adverse outcome compared with impaired LA‐EF (<40%) in SR (log‐rank, P = 0.340).

Conclusions

In HFpEF patients in SR, impaired LA‐EF is independently associated with worse cardiovascular outcome, which is similar to persistent AF. In persistent AF, LA parameters lose their prognostic ability.

Identification of Subclinical Microvascular Biomarkers in Coronary Heart Disease in Retinal Imaging

Purpose

Cardiovascular disease and foremost coronary heart disease (CHD) are the worldwide leading causes of death. The aim of this study was to use non-invasive, multimodel retinal imaging to define microvascular features in patients with and without coronary angiography (CA)-confirmed CHD.

Methods

In this prospective, cross-sectional pilot study we included adult patients who presented to a tertiary referral center for elective CA due to suspected CHD. All patients underwent widefield fundus photography for retinopathy grading. Optical coherence tomography angiography was used to measure vessel density (VD) of the individual capillary plexuses in 6 × 6-mm macular volume scans. Adaptive optics imaging was performed to assess the first-order arteriolar lumen diameter (LD), total diameter (TD), wall-to-lumen ratio (WLR), and wall cross-section area, as well as to qualitatively describe vessel morphology.

Results

Of the included 45 patients (13 females; 65 ± 10 years old), 27 were confirmed with CHD in elective CA. The most prevalent retinal vascular pathologies were arteriovenous nickings, focal arterial narrowings, and microaneurysms. VD in the superficial capillary plexus, deep capillary plexus, and choriocapillaris was lower in CHD patients, although the odds ratios were not significantly different from 1 (P = 0.06–0.92). Median arterial LD, TD, and WLR values were 98.3 µm (interquartile range [IQR] = 13.0), 122.9 µm (IQR = 17.6), and 0.26 µm (IQR = 0.07), respectively, with a trend toward a higher WLR in CHD patients.

Conclusions

In a cardiovascular risk population, high-resolution quantitative and qualitative microvascular phenotyping in the retina may provide valuable subclinical indicators for coronary artery impairment, although larger clinical trials are needed.

Translational Relevance

Subclinical retinal microvascular changes may serve as non-invasive, cost-effective biomarkers for risk stratification of patients with CHD.

Endurance Training Improves Oxygen Uptake and Endurance Capacity in Patients With Moderate to Severe Valvular Disease

Aim: Peak oxygen uptake (peakVO₂) is one of the strongest predictors of survival in patients with valvular heart disease. The purpose of this study was to determine whether endurance training improves peakVO₂ and endurance capacity in patients with moderate-severe aortic and mitral valve disease.

Methods: 30 patients with moderate-severe valvular heart disease were randomly assigned to 12 weeks of endurance training (TG) (n = 16) or standard care (SC) (n = 14). PeakVO₂ and maximum working capacity (Watt_max) were assessed by cardiopulmonary exercise testing, as well as submaximal endurance test at 80% of peakVO₂ at baseline and after 12 weeks.

Results: There was a significant improvement in peakVO₂ from 27.2 ± 5.9 ml/kg to 30.4 ± 6.3 ml/kg (P < 0.001) in TG compared to the SC (peakVO₂ from 24.6 ± 4.4 to 24.7 ± 3.8) and in the Watt_max from 151.8 ± 41.0 Watt to 171.2 ± 49.7 Watt in the TG compared to the SC (152.9 ± 35.6 Watt to 149.2 ± 28.4 Watt). The endurance capacity increased significantly from 17.0 ± 9.4 min to 32.8 ± 16.8 min (p = 0.003) in the TG compared to the SC (11.7 ± 6.2 min to 11.2 ± 7.6 min). The heart rate during the endurance test decreased in the TG from 154 ± 14 b/min to 142 ± 20 b/min for the same workload. No changes could be seen in the SC.

Conclusion: Endurance training in patients with moderate to severe valvular heart disease increased significantly the peakVO₂ as well as the endurance capacity.

Right ventricular function and outcome in patients undergoing transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.

Objectives. To compare RV function parameters on echocardiography and CMR for prognostication in TAVI patients.

Methods. Consecutive patients scheduled for TAVI underwent echocardiography and CMR.  RV fractional area change (FAC), TAPSE, RV free-lateral-wall tissue Doppler (S’) and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with 1) NT-proBNP levels, 2) prolonged in-hospital stay (&gt;14 days), and 3) a composite of heart failure hospitalization and death.

Results. 204 patients (80.9 ± 6.6y/o; 51% female; EuroSCORE-II: 6.5 ± 5.5%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay (adj. OR 1.98 [95%CI: 1.15-3.41], p = 0.013 and 2.29 [95%CI: 1.43-3.67], p = 0.001, respectively). A total of 56 events occurred during follow-up (mean 13.7 ± 9.5months). After adjustment for the EuroSCORE-II and NT-proBNP levels, only RVEF was significantly associated with the composite endpoint (adj. HR 1.69 [95%CI: 1.24-2.30], p &lt; 0.001, Figure 1).

Conclusions. RVD as defined by echocardiography is associated with an advanced disease state, but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVI patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

Abstract Figure 1. Outcome analysis

Right ventricular function and outcome in patients undergoing transcatheter aortic valve replacement

AIMS

Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.

METHODS AND RESULTS

Consecutive patients scheduled for TAVR underwent echocardiography and CMR. RV fractional area change (FAC), tricuspid annular plane systolic excursion, RV free-lateral-wall tissue Doppler (S'), and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with (i) N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels, (ii) prolonged in-hospital stay (>14 days), and (iii) a composite of heart failure hospitalization and death. Two hundred and four patients (80.9 ± 6.6 y/o; 51% female; EuroSCORE-II: 6.3 ± 5.1%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay [adjusted odds ratio 1.86, 95% confidence interval (CI) 1.07-3.21; P = 0.027 and 2.29, 95% CI 1.43-3.67; P = 0.001, respectively]. A total of 56 events occurred during follow-up (mean 13.7 ± 9.5 months). After adjustment for the EuroSCORE-II, only RVEF was significantly associated with the composite endpoint (adjusted hazard ratio 1.70, 95% CI 1.32-2.20; P < 0.001).

CONCLUSION

RVD as defined by echocardiography is associated with an advanced disease state but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVR patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

Diagnosis and treatment of cardiac amyloidosis: an interdisciplinary consensus statement

The prevalence and significance of cardiac amyloidosis have been considerably underestimated in the past; however, the number of patients diagnosed with cardiac amyloidosis has increased significantly recently due to growing awareness of the disease, improved diagnostic capabilities and demographic trends. Specific therapies that improve patient prognosis have become available for certain types of cardiac amyloidosis. Thus, the earliest possible referral of patients with suspicion of cardiac amyloidosis to an experienced center is crucial to ensure rapid diagnosis, early initiation of treatment, and structured patient care. This requires intensive collaboration across several disciplines, and between resident physicians and specialized centers. The aim of this consensus statement is to provide guidance for the rapid and efficient diagnosis and treatment of light-chain amyloidosis and transthyretin amyloidosis, which are the most common forms of cardiac amyloidosis.

Right ventricular rather than left ventricular systolic dysfunction predicts outcome in patients undergoing transcatheter aortic valve implantation: insights from cardiac magnetic resonance imaging

Background

Right ventricular (RV) function is strongly associated with outcome in heart failure. Whether it also adds important prognostic information in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown.

Methods

We consecutively enrolled patients with severe aortic stenosis (AS) scheduled for TAVI and preprocedural cardiac magnetic resonance (CMR) imaging. Kaplan-Meier estimates and multivariate Cox regression analyses were used to identify factors associated with outcome. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

423 consecutive patients (80.7±7.3 years; 48% female) were prospectively included, 201 (48%) underwent CMR imaging. 55 (27%) patients presented with RV systolic dysfunction (RVSD) defined by RV ejection fraction (RVEF) &lt;45%. RVSD was associated with male sex (69 vs. 40%; p&lt;0.001), New York Heart Association (NYHA) functional status (NYHA ≥ III: 89 vs. 57%; p&lt;0.001), NT-proBNP serum levels (9365 vs. 2715 pg/mL; p&lt;0.001), and history of atrial fibrillation (AF: 51 vs. 30%; p=0.005). On CMR, RVSD was associated with left ventricular (LV) volumes (end-diastolic: 187 vs. 137 mL, end-systolic: 119 vs. 53 mL; p&lt;0.001) and EF (39 vs. 64%; p&lt;0.001).

A total of 51 events (37 deaths, 14 hospitalizations for heart failure) occurred during follow-up (9.8±9 months). While LVSD (LVEF &lt;50%) was not significantly associated with outcome (HR 0.83, 95% CI: 0.33 – 2.11; p=0.694), RVSD showed a strong and independent association with event-free survival by multivariate Cox regression analysis (HR 2.47, 95% CI: 1.07–5.73; p=0.035), which was adjusted for all relevant CMR parameters (LV volumes and EF), cardiovascular risk factors (sex, NYHA, AF, diabetes mellitus type II, use of diuretics), and routine biomarkers (NT-proBNP, creatinine).

Conclusions

RVSD rather than LVSD, as determined on CMR, is an important predictor of outcome in patients undergoing TAVI. RV function might thus add useful prognostic information on top of established risk factors.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Cardiac remodeling in ambitious endurance-trained amateur athletes older than 50 years

Background

Data on cardiac remodeling in athletes are conflicting and rarely available in veteran athletes.

Purpose

Therefore, in this study we aimed to define echocardiographic features of healthy endurance athletes older than 50 years.

Methods

We included probands aged &gt;50 years, who have performed endurance sports at 70% of their maximum heart rate for at least 1 hour 3 times per week over the previous 5 years.

Results

Between November 2018 and May 2019, 69 probands were recruited. Median age was 57 years (IQR 52–64) and 26% were female. Groups were formed according to the median training time of 6 hours per week: (A) 45 probands with ≥6 hours (IQR 6–10) and (B) 24 probands with &lt;6 hours (IQR 3.5–5). Age, sex and body mass index were similar. Group A demonstrated slightly smaller right atrial and left atrial (LA) diameters when compared to probands in B (53mm (IQR 49–55) vs. 53mm (IQR 51–58), p=0.045, and 52mm (IQR 49–55) vs. 53mm (IQR 52–58), p=0.039, respectively) and showed preserved diastolic function (p=0.026) with lower E/E' ratio (7 (IQR 6–9) vs. 9 (IQR 7–10), p=0.039). Interventricular septal thickness and relative wall thickness ratio were similar.

Global right and left ventricular (LV) strain were similar, but LA reservoir strain was higher in group A than in B (27% (IQR 22–34) vs. 20% (IQR 15–29), p=0.016).

Conclusion

Endurance training in healthy athletes older than 50 years does not result in relevant chamber dilatation or LV hypertrophy and a weekly training duration of ≥6 hours seems beneficial to preserve diastolic function associated with an increased LA reservoir function.

Funding Acknowledgement

Type of funding source: None

Impact of treatment strategies on long-term outcome of CTO patients

BACKGROUND

The percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remains debated. Therefore the aim of this large-scale observational multi-center registry was to compare the long-term outcome of CTO patients undergoing different therapeutic approaches comparing successful CTO revascularization either by PCI or coronary artery bypass graft (CABG), failed CTO-PCI and optimal medical therapy (OMT) alone.

METHODS AND RESULTS

A total of 6630 CTO patients were enrolled from two high-volume centers to compare different treatment strategies. All procedures were performed by high-volume CTO operators in tertiary university hospital. Successful CTO-PCI was performed in 3906 patients, failed CTO-PCI in 1479 patients, 412 patients underwent CABG surgery and 833 patients were treated with OMT. During the 5-year follow-up period, 1019 (15%) patients died. Kaplan-Meier analysis unveiled a significantly improved long-term outcome for CTO patients undergoing revascularization either by PCI or by CABG compared to patients with failed CTO-PCI or OMT alone (log-rank P < 0.001). In the multivariate Cox-regression analysis successful CTO-PCI was associated with significantly improved long-term outcome compared to patients under OMT (adj. HR 0.39, 95%CI 0.33-0.45, P < 0.001) or CABG (adj. HR 0.68, 95%CI 0.53-0.86, P = 0.002) independent of clinical confounders encompassing age, BMI, diabetes, kidney function and left ventricular function.

CONCLUSIONS

This study showed an improved long-term outcome for CTO revascularization compared to optimal medical therapy, independent from revascularization mode, with the highest survival rate in patients undergoing successful CTO-PCI.

Feature Tracking of Global Longitudinal Strain by Using Cardiovascular MRI Improves Risk Stratification in Heart Failure with Preserved Ejection Fraction

Background In heart failure with preserved ejection fraction (HFpEF), echocardiographic studies suggest that global longitudinal strain (GLS) has an impact on survival. Feature-tracking cardiovascular MRI also allows for strain analysis; however, to the knowledge of the authors, little is known about its prognostic value and whether it reflects severity of diffuse fibrosis, as assessed by cardiovascular MRI T1 mapping. Purpose To investigate the association between myocardial strain at cardiovascular MRI with extracellular volume by T1 mapping and outcome in participants with HFpEF. Materials and Methods In this secondary analysis of a prospective study (NCT03405987), consecutive participants with HFpEF underwent cardiovascular MRI between July 2012 and March 2018, including T1 mapping and three-dimensional strain analysis. Extracellular volume and strain results were assessed to determine if there was a correlation between these two factors. Cox regression was performed to determine the prognostic relevance of MRI-derived myocardial strain for a combined end point (events) of heart failure hospitalizations and cardiovascular death. Results In total, 206 consecutive participants with HFpEF (mean age, 71 years ± 8 [standard deviation]; 69% women) were included. Median myocardial global longitudinal strain (GLS) at MRI was -8.5% and showed low correlation with extracellular volume (r = 0.28; P = .003). A total of 109 events (53%) were recorded during a follow-up of 38 months ± 29. Participants with a GLS above the median had higher event rates (log-rank test, P < .001). By multivariable Cox regression analysis, GLS remained independently associated with outcome (hazard ratio, 1.06 per 1% strain increase; 95% confidence interval: 1.01, 1.11; P = .03) when corrected for risk factors including age, diabetes, renal function, N-terminal pro-b-type natriuretic peptide serum concentration, and right ventricular size and function. Conclusion In participants with heart failure with preserved ejection fraction, global longitudinal strain at cardiovascular MRI was correlated with extracellular volume by T1 mapping and was associated with cardiovascular events. © RSNA, 2020 Online supplemental material is available for this article.

Light-chain and transthyretin cardiac amyloidosis in severe aortic stenosis: prevalence, screening possibilities, and outcome

Aims

Concomitant cardiac amyloidosis (CA) in severe aortic stenosis (AS) is difficult to recognize, since both conditions are associated with concentric left ventricular thickening. We aimed to assess type, frequency, screening parameters, and prognostic implications of CA in AS.

Methods and results

A total of 191 consecutive AS patients (81.2 ± 7.4 years; 50.3% female) scheduled for transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Overall, 81.7% underwent complete assessment including echocardiography with strain analysis, electrocardiography (ECG), cardiac magnetic resonance imaging (CMR), ^99mTc‐DPD scintigraphy, serum and urine free light chain measurement, and myocardial biopsy in immunoglobulin light chain (AL)‐CA. Voltage/mass ratio (VMR; Sokolow–Lyon index on ECG/left ventricular mass index) and stroke volume index (SVi) were tested as screening parameters. Receiver operating characteristic curve, binary logistic regression, and Kaplan–Meier curve analyses were performed. CA was found in 8.4% of patients (n = 16); 15 had transthyretin (TTR)‐CA and one AL‐CA. While global longitudinal strain by echo did not reliably differentiate AS from CA‐AS [area under the curve (AUC) 0.643], VMR as well as SVi showed good discriminative power (AUC 0.770 and 0.773, respectively), which was comparable to extracellular volume by CMR (AUC 0.756). Also, VMR and SVi were independently associated with CA by multivariate logistic regression analysis (P = 0.016 and P = 0.027, respectively). CA did not significantly affect survival 15.3 ± 7.9 months after TAVR (P = 0.972).

Conclusion

Both TTR‐ and AL‐CA can accompany severe AS. Parameters solely based on ECG and echocardiography allow for the identification of the majority of CA‐AS. In the present cohort, CA did not significantly worsen prognosis 15.3 months after TAVR.

Persistent atrial fibrillation in heart failure with preserved ejection fraction: Prognostic relevance and association with clinical, imaging and invasive haemodynamic parameters

BACKGROUND

Atrial fibrillation (AF) is a frequent finding in HFpEF. However, its association with invasive haemodynamics, imaging parameters and outcome in HFpEF is not well established. Furthermore, the relevance of AF subtype with regard to outcome is unclear. This study sought to investigate the prognostic impact of paroxysmal and persistent AF in a well-defined heart failure with preserved ejection fraction (HFpEF) population.

MATERIALS AND METHODS

Between 2010 and 2016, 254 HFpEF patients were prospectively enrolled. All patients underwent echocardiography as well as left and right heart catheterization. Patients without contraindications underwent CMR including T1 mapping. Follow-up and outcome data were collected. Patients with significant coronary artery disease were excluded.

RESULTS

A total of 153 patients (60%) suffered from AF, 119 (47%) had persistent and 34 (13%) had paroxysmal AF. By multiple logistic regression analysis, persistent AF was independently associated with NT-proBNP (P = .003), NYHA functional class (P = .040), left and right atrial size (P = .022 and <.001, respectively), cardiac output (P = .002) and COPD (P = .034). After a median follow-up of 23 months (interquartile range 5-48), 92 patients (36%) reached the primary end point defined as hospitalization for heart failure or cardiovascular death. By multivariate Cox regression analysis, only persistent AF (P = .005) and six-minute walk distance (P = .011) were independently associated with the primary end point.

CONCLUSIONS

Sixty percent of our HFpEF patients suffered from AF. Persistent but not paroxysmal AF was strongly associated with event-free survival and was independently related to NYHA functional class, serum NT-proBNP, atrial size, cardiac ouput and presence of COPD.

P896Effects of tafamidis in patients with transthyretin amyloid cardiomyopathy

Background

Transthyretin amyloid cardiomyopathy (ATTR-CA) is caused by deposition of amyloid fibrils in the myocardium. The deposition occurs when transthyretin (TTR) becomes unstable and misfolds. Tafamidis is a kinetic stabilizer of TTR that prevents tetramer dissociation and amyloidogenesis by TTR.

Methods

Eighteen patients with diagnosis of ATTR-CA (hATTR or wtATTR) from our national amyloidosis registry were treated with 20 mg of tafamidis for a period of six months. In our explorative analysis we aimed to evaluate the effects of tafamdis by changes from baseline of the serum NT-proBNP concentration, 6-minute walking distance, as well as cardiac structure and function.

Results

The exploratory analysis showed a decrease in serum NT-proBNP concentration in tafamidis treated patients, compared to increase in untreated patients (median difference, −481.0 pg/mL). Tafamidis improved the walking distance during the 6-minute walk test at month six, compared to baseline (mean, 31.25 m). Echocardiographic findings revealed an improvement of the global longitudinal strain (mean, 0.77%), a decrease in left atrial size (mean, −1.65 mm) and a decrease in left ventricular size (mean, −4.13 mm) in tafamidis treated patients compared to untreated patients. Due to insufficient power the results did not differ significantly between tafamidis treated patients and untreated patients.

Change from baseline Tafamidis No treatment Treatment Difference p-value Cardiac Biomarkers n=18 n=15   NT-proBNP, ng/L Baseline, median 2740.0 2835.0 CFB to 6 months, median −207.0 274.0 −481.0 0.329 Functional Status n=8 n=7   6MWT, m Baseline, mean 441.00 420.50 CFB to 6 months, mean 31.25 −16.50 +47.75 0.373 Echocardiogram n=17 n=15   LA, mm Baseline, mean 63.41 61.33 CFB to 6 months, mean −1.65 0.60 −2.25   LV, mm Baseline, mean 44.13 41.80 CFB to 6 months, mean −4.13 0.33 −4.46 0.075   LV wall thickness, mm Baseline, mean 22.06 18.47 CFB to 6 months, mean 0.68 −0.60 +1.28 0.055   Longitudinal strain, % Baseline, mean −10.66 −12.42 CFB to 6 months, mean 0.77 −1.03 +1.80 0.652 MRI n=7 n=6   ECV, % Baseline, mean 52.26 44.22 CFB to 6 months, mean 0.81 3.70 − 2.89 0.493   LV mass, g Baseline, mean 187.71 170.33 CFB to 6 months, mean 24.29 19,67 +4.62 0.612

Conclusion

Treatment with tafamidis for a period of six months in patients with ATTR-CA leads to positive effects on NT-proBNP level, 6-minute walking distance, as well as cardiac structure and function compared to untreated patients.

P2727Hemodynamic profiles in patients with cardiac amyloidosis

Background

Intracardiac filling and pulmonary arterial pressures play a central role in various heart failure entities, as they are strong predictors of outcome. However, their role in patients with cardiac amyloidosis (CA) is less clear.

Purpose

We aimed to characterize hemodynamic profiles of CA patients and assess their association with outcomes.

Methods

The present study was conducted within a prospective, national CA registry.

Patients underwent invasive hemodynamic, clinical, laboratory, and echocardiography assessment, as well cardiac magnetic resonance imaging with T1-mapping. The main outcome measure was a combined endpoint consisting of hospitalization for heart failure or cardiovascular death.

Results

Between March 2012 and October 2018, 63 consecutively recruited CA patients underwent invasive hemodynamic profiling. Of those, 36 had cardiac transthyretin amyloidosis (ATTR) and 25 cardiac light-chain amyloidosis (AL). In two patients amyloid subtyping was not possible.

Median age of the study population was 74.0 years and the majority were male (61.9%). Almost half of the patients were in New York Heart Association (NYHA) class ≥III (47.6%) and showed elevated N-terminal prohormone of brain natriuretic peptides (NT-proBNP) with a median of 3222 pg/mL. In comparison to AL, cardiac TTR patients were older (75.0 years versus 69.0 years, p=0.004), more often male (80.6% versus 40.0%, p=0.001), less symptomatic (NYHA class ≥III: 38.9% versus 64.0%, p=0.021), and had lower NT-proBNP values (2324pg/mL versus 5151pg/mL, p=0.004).

Hemodynamic profiling revealed significantly increased intracardiac as well as pulmonary arterial pressures (PAP). On an average, pulmonary artery wedge pressure was 20.0mmHg [interquartile range (IQR): 17.0–25.0], mean PAP (mPAP) was 30.0mmHg (IQR: 25.0–37.0), and mean right atrial pressure (mRAP) was 11.0mmHg (IQR: 7.0–16.0). No differences between ATTR and AL patients could be detected (p=0.148, p=0.398, p=0.620). During a median follow-up of 63.0 weeks, 28 study participants (44.4%) reached the combined endpoint. Moreover, cardiac AL patients had significantly more events as their ATTR counterparts (72.0% versus 27.8%, p=0.001). In cardiac ATTR patients, mPAP was significantly associated with outcome [hazard ratio (HR): 1.083, p=0.034, Figure 1A], which was not the case in the AL group (HR: 1.024, p=0.186, Figure 1B). Cardiac output and pulmonary vascular resistance were not associated with outcome. Neither in the ATTR (p=0.144; p=0.063) nor in AL cohort (p=0.420; p=0.115).

Figure 1

Conclusion

Despite differences in the severity of symptoms between cardiac AL and cardiac ATTR patients, no differences with regards to hemodynamic profiles could be detected.

Furthermore, intracardiac filling and pulmonary arterial pressures seem to be of greater clinical importance in cardiac ATTR as compared to cardiac AL, as these parameters were associated with outcome in the first, but not the latter group.

P895Apical sparing in patients without cardiac amyloidosis

Background

Apical sparing describes a reduced longitudinal strain in the basal segments and preserved or supranormal longitudinal strain in the apical segments of the left ventricular (LV) myocardium. This pattern has been described as a typical finding in patients with cardiac amyloidosis (CA) and restrictive cardiomyopathy. However, apical sparing is not a quantitative parameter and is fairly subjective to the echocardiographer's judgement. It is not known, if a certain degree of apical sparing is also present in patients with only mild LV hypertrophy and diastolic dysfunction such as it is present in heart failure with preserved ejection fraction (HFpEF).

Methods

Patients with cardiac transthyretin and light chain amyloidosis and patients with HFpEF were included in a clinical registry at our outpatient clinic. CA was diagnosed according to current guidelines. All patients underwent a comprehensive transthoracic echocardiography (TTE) exam at the time of study inclusion. The TTE protocol included standard and speckle-tracking imaging to assess the presence of apical sparing as well as the basal to apical strain gradient. Patients with known coronary artery disease were excluded.

Results

In total 115 patients were included in this study. Of these, 87 (75.7%) were diagnosed with CA and 28 (24.3%) with HFpEF. Not surprisingly, apical sparing was found in a majority (86.2%) of patients with CA, however mild forms of this phenomenon were also present in 67.9% of patients with HFpEF (p=0.029, Figure 1). Median basal longitudinal strain was significantly more impaired in patients with CA (p<0.001) but there was no difference between longitudinal strain in the apical segments when comparing CA to HFpEF (p=0.443). This resulted in a higher median apical to basal strain gradient in patients with CA (2.3 (IQR 1.7–3.83) versus 1.13 (IQR 1.5–1.8), p<0.001).

Figure 1

Conclusion

Mild forms of apical sparing can be found in patients without CA. Gradual reduction in strain from base to apex could be an unspecific pathophysiologic mechanism which is remarkably pronounced in patients with CA.

P5261Feature tracking by CMR: left ventricular dysfunction predicts outcome in heart failure with preserved ejection fraction

Objectives

To investigate the association between global longitudinal strain (GLS) using feature tracking (FT) cardiovascular magnetic resonance imaging (CMR) and prognosis in patients with heart failure and preserved ejection fraction (HFpEF).

Background

Echocardiography-based studies have demonstrated that in HFpEF left ventricular (LV) strain analyses can detect impaired systolic function despite preserved ejection fraction and might also predict outcome. CMR also allows strain analysis using FT and is furthermore the gold standard for assessment of ventricular volumes and ejection fractions. In addition, T1-mapping allows non-invasive tissue characterization. However, the prognostic relevance of FT-CMR is unknown. In addition right ventricular (RV) FT-CMR is poorly investigated.

Methods

Consecutive patients with confirmed diagnosis of HFpEF underwent CMR on a 1.5T scanner. We used dedicated software (cvi42, Circle Cardiovascular Imaging Inc.) for global longitudinal left ventricular strain (LV-GLS) in a 3D and global longitudinal RV strain (RV-GLS) in a 2D model using feature tracking (FT). In addition, we performed uni- and multivariable Cox regression using a combined endpoint of heart failure hospitalizations, and cardiovascular death to determine the prognostic relevance of FT-CMR.

Results

We included a total of 131 HFpEF patients (70.4±8.6 years old, 70.2% female). Median LV-GLS by FT-CMR was −8% [IQR: −10% to 5%] and median RV-GLS was −11.9% [IQR: −16.57% to −12.23%]. LV and RV GLS values were significantly correlated with LV and RV ejection fractions (r=−0.463, p<0.001 for LV, and r=−0.306, p=0.001 and RV, respectively). 77 (58.8%) events were recorded during a follow-up of 42.0±31.4 months. Patients with an LV-GLS worse than the median (−8%) showed a significantly reduced event-free survival rate (log-rank, p=0.009).In a multivariable Cox-regression model correcting for the strongest clinical variables, including age (HR 1.018 [0.985–1.052], p=0.290), GFR (HR 0.987 [0.975–1.000], p=0.055), diabetes (HR 1.696 [1.028–2.799], p=0.039), and 6-min-walking distance (HR 0.997 [0.995–0.999)], p=0.014), LV-GLS remained significantly associated with outcome (HR 1.093 [1.039–1.150], p=0.001) while RV-GLS had no effect on outcome (p>0.05).

Conclusions

In patients with HFpEF, LV-GLS but not RV-GLS by FT-CMR is significantly associated with cardiovascular events.

P2726Extremely boosted prediction of cardiac amyloidosis by routine laboratory paramaters

Background/Introduction

Cardiac amyloidosis (CA) is a rare and complex condition with poor prognosis. Novel therapies have been shown to improve outcome, however, most of the affected individuals remain undiagnosed, mainly due to a lack in awareness among clinicians. One approach to overcome this issue is to use automated diagnostic algorithms that act based on routinely available laboratory results.

Purpose

We tested the performance of flexible machine learning and traditional statistical prediction models for non-invasive CA diagnosis based on routinely collected laboratory parameters. Since laboratory routines vary between hospitals or other health care providers, special attention has been taken to adaptive and dynamic parameter selection, and to dealing with the frequent occurrence of missing values.

Methods

Our cohort consisted of 376 clinically accepted patients with various types of heart failure. Of these, 69 were diagnosed with CA via endomyocardial biopsy (positives), and 307 had unrelated cardiac disorders (negatives). A total of 63 routine laboratory parameters were collected from these patients, with a high incidence of missing values (on average 60% of patients for each parameter). We tested the performance of two prediction models: logistic regression, and extreme gradient boosting with regression trees. To deal with missing values we adopted two strategies: a) finding an optimal overlap of parameters and deleting all patients with missing values (reduction of parameters and samples), and b) retaining all features and imputing missing values with parameter-wise means. To fairly assess the performance of prediction models we employed a 10-fold cross validation (stratified to preserve sample class ratio). Finally, area under curve for receiver-operator characteristic (ROC AUC) was used as our final performance measure.

Results

A complex machine learning model based on forests of regression trees proved to be the most performant (ROC AUC 0.94±4%) and robust to missing values. The best regression model was obtained with the 25 most frequent variables and patient deletion in case of missing values (ROC AUC 0.82±0.8%). While progressive inclusion of predictor variables worsened the performance of the logistic regression, it increased that of the machine learning approach.

Conclusions

Extreme gradient boosting of regression trees by routine laboratory parameters achieved staggering accuracy results for the automated diagnosis of CA. Our data suggest that implementations of such algorithms as independent interpreters of routine laboratory results may help to establish or suggest the diagnosis of CA in patients with heart failure symptoms, even in the absence of specialized experts.

P5258Native T1 time of right ventricular insertion points by CMR: relation with invasive hemodynamics and outcome in HFPEF

Background

Increased afterload to the right ventricle (RV) has been shown to induce myocardial fibrosis at the RV insertion points (RVIPs). Such changes can be discrete but potentially detected by cardiac magnetic resonance (CMR) T1-mapping. Whether RVIP fibrosis is associated with prognosis in heart failure with preserved ejection fraction (HFpEF) is unknown.

Methods

We prospectively investigated 167 consecutive HFpEF patients, a population frequently suffering from postcapillary pulmonary hypertension (PH), who underwent CMR including T1-mapping. 92,8% also underwent right heart catheterization for hemodynamic assessment. Kaplan–Meier analysis, cox regression analysis and Spearman's rank order correlation were applied as statistical methods. The parameter with the strongest discriminative power of each group (clinical, hemodynamic and CMR) by receiver operating curve analysis was selected to the enter the multivariate cox model.

Results

Native T1 times were 995±73 ms at the anterior and 1040±90 ms at the inferior RVIP. By Spearman's rank order testing, RVIP T1 times were significantly correlated with pulmonary artery pressure (mean PAP, r=0.313 and 0.311 for anterior and inferior RVIP, respectively), pulmonary artery wedge pressure (r=0.301 and 0.251) and right atrial pressure (r=0.245 and 0.185; p for all<0.05). During a mean follow-up of 43.2±22.6 months, 30 (18.0%) subjects died. By multivariable Cox regression, NTproBNP (Hazard ratio [HR] 2.105, 95% confidence interval [CI] 1.332–3.328; p=0.001), systolic PAP (HR 1.618, 95% CI 1.175–2.230; p=0.003), and native T1 time of the anterior RVIP (HR 1.659, 95% CI 1.125–2.445; p=0.011) were significantly associated with outcome. Also, by Kaplan-Meier analysis, T1 time at the anterior RVIP had a significant effect on survival (log-rank, p=0.002).

Kaplan Meier Curve

Conclusions

Interstitial expansion of the anterior RVIP as detected by CMR T1-mapping reflects hemodynamic alterations, and is independently related with prognosis in HFpEF.

131Left atrial phasic function in heart failure with preserved ejection fraction: cardiac magnetic resonance myocardial feature tracking, invasive hemodynamics and outcome

Background

Global left atrial (LA) size and function have been shown to be associated with adverse events in heart failure with preserved ejection fraction (HFpEF). The machanism of coupling from left heart failure to pulmonary circulation is still controversially discussed.

Purpose

To study the prognostic most relevant determinant of LA size and function and its backward and forward interplay.

Methods

188 HFpEF patients were prospectively enrolled and underwent baseline clinical assessment, cardiac magnetic resonance imaging (CMR) and invasive hemodynamic assessment. Coronary artery disease was ruled out by coronary angiography. 92 patients were in atrial fibrillation (AF), 96 in sinus rhythm. LA size and function were assessed by CMR including LA strain imaging by myocardial feature tracking (Figure 1A & B).

Results

Patients in AF had more pronounced dilatation of all phasic LA volumes and reduction of all phasic LA functions when compared to sinus rhythm (each p<0.001 respectively).

After 31 (9–57) months 66 patients reached the combined endpoint defined as combination from hospitalization due to heart failure and cardiovascular death. In AF no atrial functional or volume parameter was correlated to outcome. In contrast in sinus rhythm several phasic LA volume and functional parameters were associated with outcome. After multivariate cox regression analysis only reduced total LA ejection fraction and conduit strain rate were still predictive for worse outcome (p=0.031 and <0.001 respectively). After adjustment for known risk factors in HFpEF like age, six minute walking distance (6MWD), systolic pulmonary artery pressure (sPAP) and right ventricular ejection fraction as derived by CMR only impaired LA conduit strain rate remained predicitve for cardiovascular events (p=0.001). In contrast to LA booster pump function LA conduit function parameters were significantly correlated to reduced 6MWD (Figure 1C) and coupled backwards to pulmonary vasculature via correlation to sPAP and pulmonary vascular resistance (PVR) but without coupling to CMR derived elevated LV extracellular volume and left ventricular end diastolic pressure.

Conclusion

Total LA ejection fraction plays a key role in the prognosis of HFpEF. This effect seems to be mainly related to its LA conduit function but not to LA booster pump function. LA conduit function correlates to impaired 6MWD, sPAP and PVR.

P4128The right heart in patients undergoing transcatheter aortic valve replacement: insights from cardiac magnetic resonance imaging

Background

Cardiac magnetic resonance (CMR) provides the gold standard for the assessment of ventricular volumes and mass. However, data on right ventricular systolic dysfunction (RVSD) and its prognostic significance on outcome in patients undergoing transcatheter aortic valve replacement (TAVR) are lacking.

Methods

We consecutively enrolled patients with severe aortic stenosis scheduled for TAVR who underwent preprocedural CMR. Kaplan-Meier estimates and multivariate Cox-regression analysis were used to identify factors associated with outcome, including RVSD. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

145 consecutive patients (80.5±7.6 years; 51.7% female) were prospectively included, 25 (17.2%) of which had RVSD defined as RV ejection fraction (RVEF) <40%. RVSD was significantly associated with male sex, atrial fibrillation, reduced left ventricular (LV) EF (<50%) and RV endsystolic volume on CMR (all p<0.05). Serum NT-proBNP (14065±12042 vs. 3203±4615 ng/ml; p<0.001) and creatinine levels (1.59±0.96 vs. 1.29±1.03 mg/dl; p=0.201) were elevated in patients with RVSD. A total of 27 events occurred during follow-up (29±13 weeks). While LVSD was not significantly associated with outcome (p=0.654), RVSD showed a strong and independent association with event-free survival in the multivariate Cox-regression analysis [hazard ratio 3.836 (95% confidence interval 1.670–8.810); p=0.002], which included all relevant CMR parameters, cardiovascular risk factors and routine biomarkers.

Conclusions

RVSD rather than LVSD, as determined by CMR, is an important predictor of outcome in patients undergoing TAVR. RV function might thus add useful prognostic information on top of established risk factors.

Native T1 time of right ventricular insertion points by cardiac magnetic resonance: relation with invasive haemodynamics and outcome in heart failure with preserved ejection fraction

Aims

Increased afterload to the right ventricle (RV) has been shown to induce myocardial fibrosis at the RV insertion points (RVIPs). Such changes can be discrete but potentially detected by cardiac magnetic resonance (CMR) T1-mapping. Whether RVIP fibrosis is associated with prognosis in heart failure with preserved ejection fraction (HFpEF) is unknown.

Methods and results

We prospectively investigated 167 consecutive HFpEF patients, a population frequently suffering from post-capillary pulmonary hypertension, who underwent CMR including T1-mapping. About 92.8% also underwent right heart catheterization for haemodynamic assessment.

Native T1 times were 995 ± 73 ms at the anterior and 1040 ± 90 ms at the inferior RVIP. By Spearman’s rank order testing, RVIP T1 times were significantly correlated with pulmonary artery pressure (mean PAP, r = 0.313 and 0.311 for anterior and inferior RVIP), pulmonary artery wedge pressure (r = 0.301 and 0.251) and right atrial pressure (r = 0.245 and 0.185; P for all &lt;0.05). During a mean follow-up of 43.2 ± 22.6 months, 30 (18.0%) subjects died. By multivariable Cox regression, NTproBNP [Hazard ratio (HR) 2.105, 95% confidence interval (CI) 1.332–3.328; P = 0.001], systolic PAP (HR 1.618, 95% CI 1.175–2.230; P = 0.003), and native T1 time of the anterior RVIP (HR 1.659, 95% CI 1.125–2.445; P = 0.011) were significantly associated with outcome. Also, by Kaplan–Meier analysis, T1 times at the anterior RVIPs had a significant effect on survival (log-rank, P = 0.002).

Conclusion

Interstitial expansion of the anterior RVIP as detected by CMR T1-mapping reflects haemodynamic alterations, and is independently related with prognosis in HFpEF.

Plasma renin levels are associated with cardiac function in primary adrenal insufficiency

BACKGROUND

Despite adequate glucocorticoid (GC) and mineralocorticoid (MC) replacement therapy, primary adrenal insufficiency (AI) is associated with an increased mortality, mainly due to cardiovascular disease. The role of MC replacement is not known. Therefore, we assessed whether renin concentrations during routine GC and MC substitution therapy are associated with heart function and morphology.

METHODS

Thirty two patients with primary AI were included in a cross-sectional case-control study. In total, 17 patients and 34 healthy controls (age: 48 ± 12 vs. 46 ± 18 years; BMI: 23 ± 3 vs. 24 ± 3 kg/m2) underwent magnetic resonance spectroscopy and imaging measurements to assess cardiac function, morphology, ectopic lipids, and visceral/subcutaneous fat mass. Patients were divided according to their actual plasma renin concentration at the study visit (Actual-Reninlow vs. Actual-Reninhigh) and their median plasma renin concentration of previous visits (Median-Reninlow vs. Median-Reninhigh).

RESULTS

Ejection fraction was higher (67 ± 5 vs. 55 ± 3%; p = 0.001) and left ventricular mass was lower (60 ± 9 vs. 73 ± 10 g/m2; p = 0.025) in Actual-Reninhigh. Median-Reninhigh was associated with lower cardiac mass (64 ± 9 vs. 76 ± 11 g/m2; p = 0.029). Blood pressure, glucose, and lipid metabolism, as well as ectopic lipid content, pericardial fat mass, and visceral/subcutaneous fat were not different between the groups. Compared with controls, ejection fraction was significantly lower in patients with AI (56 ± 4 vs. 63 ± 8%; p = 0.019). No differences were found in patients with ≤20 mg compared with >20 mg of hydrocortisone per day.

CONCLUSIONS

Higher renin concentrations are associated with more favorable cardiac function and morphology in patients with primary AI.

Angs (Angiotensins) of the Alternative Renin-Angiotensin System Predict Outcome in Patients With Heart Failure and Preserved Ejection Fraction

The renin-angiotensin system plays an important role in the development and progression of heart failure (HF). In addition to the classical renin-angiotensin pathway, an alternative pathway produces Angs (angiotensins), which counteract the negative effects of Ang II. We hypothesized that Ang profiling could provide insights into the pathogenesis and prognosis of HF with preserved ejection fraction. We aimed to investigate the effects of Angs on outcome in HF with preserved ejection fraction. Consecutive patients were included into a prospective single-center registry. Clinical, laboratory, and imaging parameters were assessed and serum samples were taken at baseline and measured by mass spectroscopy. Serum equilibrium levels were analyzed in regard to the combined clinical end point of cardiovascular death or HF hospitalization. In total, 155 patients were included during a median follow-up time of 22.5 (interquartile range, 4.0-61.0) months, 52 individuals (34%) reached the combined end point. We identified higher levels of Ang 1-7 and Ang 1-5 as predictors for poor outcome. After adjusting for potential confounding factors, Ang 1-5 remained predictive for poor outcome. In addition to Ang 1-7 and Ang 1-5, the novel ACE (angiotensin-converting enzyme) independent Ang composite marker [Ang 1-7+Ang 1-5] was shown to predict adverse events. We conclude that Angs of the alternative renin-angiotensin system seem to play a role in HF with preserved ejection fraction and are linked to outcome in patients with HF and preserved ejection fraction. Ang 1-5 and the alternative renin-angiotensin system composite marker [Ang 1-7+Ang 1-5] are independent predictors of outcome.

EXPRESS: Riociguat for the treatment of transthyretin cardiac amyloidosis - Data from a named patient use program in Austria

Patients with transthyretin cardiac amyloidosis (TTR CA) suffer from impaired exercise capacity, have a poor quality of life (QoL), and approved treatments are lacking. Stimulators of the soluble guanylate cyclase are promising new pharmaceuticals in the treatment armamentarium of heart failure patients. The aim of the present study was to report on the safety and efficacy of riociguat administration in patients with TTR CA. TTR CA patients received riociguat for 4–6 months within the frames of a national named patient use (NPU) program. Parameters of interest included changes in submaximal exercise capacity, invasive hemodynamic parameters, and QoL. Between March 2012 and June 2017, 86 CA patients were screened for the NPU program, of whom 13 TTR CA patients were eligible for participation. In our study cohort, riociguat had an acceptable tolerability profile. At follow-up, we could detect slight improvements in median 6-min walk distance (396 m [interquartile range (IQR) = 340–518] vs. 400 m [IQR = 350–570], P  = 0.045), New York Heart Association class ≥ III (n = 7 [53.9%] vs. n = 0 [0.0%], P  = 0.031), cardiac output (4.3 L/min [IQR = 3.9–5.1] vs. 4.5 L/min [IQR = 4.2–5.1], P  = 0.022), diastolic pressure gradient (1.0 mmHg [IQR = −1.5–3.0) vs. −1.0 mmHg [IQR = −3.0–1.0], P  = 0.049), and QoL (50.0% [IQR = 40.0–58.0] vs. 60.0% [IQR = 50.0–75.0], P  = 0.021). Pulmonary arterial pressures were not altered. The present case series of TTR CA patients indicates that riociguat administration was safe and associated with minor clinical as well as hemodynamic improvements.

Three dimensional gait analysis in patients with symptomatic component mal-rotation after total knee arthroplasty

PURPOSE

Purpose of the present cohort study was the determination of lower body function and rotation in patients with symptomatic component mal-rotation after total knee arthroplasty using instrumented 3D gait analysis.

METHODS

A consecutive series of 12 patients (61.3 years ± 11.4 years) were included suffering under remaining pain or limited range of motion at least six months after total knee arthroplasty. A CT-scan according to the protocol of Berger et al. and instrumented 3D gait analysis were carried out including clinical examination, videotaping, and kinematic analysis using a Plug-in Gait model. Outcome variables were temporospatial parameters as well as kinematics in sagittal and transversal plane. Data for reference group were collected retrospectively and matched by age and gender.

RESULTS

Temporospatial parameters of the study group showed decreased velocity, cadence, and step length as well as increased step time. Single limb support was reduced for the affected limb. In sagittal plane, maximum knee flexion during swing phase was reduced for the replaced knee joint. In transverse plane, there was hardly any difference between affected and non-affected limb. Compared to the reference group, both limbs show significant increased internal ankle rotation and external hip rotation. There were significant strong linear correlations between ankle rotation and hip rotation as well as ankle rotation and radiological tibial mal-rotation.

CONCLUSIONS

Patients with symptomatic component mal-rotation after total knee arthroplasty showed typically functional deficits. The affected and non-affected limb showed significant increased internal ankle rotation and external hip rotation, while only the affected, replaced knee showed reduced internal knee rotation. Identification of rotational abnormalities of hip and ankle joints seems to be mandatory in TKA to identify the patient group with external hip rotation, internal ankle rotation, and an elevated risk for symptomatic rotational TKA component mal-alignment.

Echocardiographic assessment of right ventricular function: current clinical practice

Echocardiographic evaluation of right ventricular (RV) function is a challenge due to the complex anatomy of the RV. Several transthoracic echocardiographic methods have been suggested for the quantification of RV function. However, many of the parameters are time consuming and need dedicated hardware and software. We suspected that the majority of the established markers are not used on a wide basis. In a multinational online survey, we evaluated the use of current clinical standards for the quantification of RV function in clinical practice. Through the network of an Ultrasound Online Teaching Platform, echocardiographers were invited to participate in an open online survey. The participants were asked about the parameters (eyeballing, TAPSE, S', fractional area change, RIMP, 3D-EF, dp/dt, longitudinal strain) they used in clinical practice. A total of 1150 participants from 109 countries completed the survey. Only eyeballing (72%), TAPSE (69%), and S' (31%) were commonly used in clinical routine. These methods were applied significantly less common in low-income economies when compared to high-income economies. Twenty-three percent of all participants stated to rely on eyeballing only, when evaluating RV function in clinical routine. New technologies, such as global longitudinal strain (3%) and 3D echocardiography (1%) were rarely applied independent of region and economic strength. Eyeballing and TAPSE are the most widely used methods in echocardiography for the assessment of RV function. Although advanced parameters such as longitudinal strain and 3D echocardiography were shown to be highly accurate, they are rarely used in clinical routine.

The soluble guanylate cyclase stimulator riociguat reduces fibrogenesis and portal pressure in cirrhotic rats

In cirrhotic patients, portal hypertension (PHT) deteriorates survival, yet treatment options are limited. A major contributor to increased intrahepatic vasoconstriction in PHT is dysfunctional nitric-oxide signaling. Soluble guanylate cyclase (sGC) is the receptor of nitric-oxide and can be stimulated by riociguat. Riociguat is approved for pulmonary hypertension but has not been studied in liver cirrhosis. In this study we assessed the effects of riociguat on PHT and liver fibrosis in cholestatic (bile duct ligation, BDL) and toxic (carbon-tetrachloride, CCl4) rat models. In cirrhotic livers sGC expression was upregulated. In BDL rats, riociguat reduced liver fibrosis and decreased portal pressure without affecting systemic hemodynamics. In an early BDL disease stage, riociguat decreased bile duct proliferation, improved sinusoidal vascular dysfunction and inhibited angiogenesis. In advanced BDL riociguat exhibited anti-inflammatory effects. In CCl4 rats the beneficial effects of riociguat treatment were less pronounced and confined to an early disease stage. Similarly, in patients with cholestatic cirrhosis and PHT nitrates (that induce sGC activity) decreased portal pressure more effectively than in patients with non-cholestatic etiology. We also found an improvement of transaminases in patients with pulmonary hypertension receiving riociguat. Our findings support the clinical development of sGC stimulators in patients with cirrhotic PHT.