P790 Bi-ventricular dysfunction in patients after bone marrow transplant: the value of strain imaging

Background

Cardiovascular events are a significant cause of morbidity and mortality in cancer survivors, particularly occurring at 5-10 years after their cancer therapy.

Purpose

To assess the utility of strain imaging by 2-dimensional (2D) speckle tracking echocardiography in detecting bi-ventricular dysfunction, as compared to traditional measures, in patients post bone marrow transplantation (BMT) with previous anthracycline (AC) therapy for haematological conditions.

Methods

50 consecutive patients post BMT + AC, reviewed at a long-term survivor clinic, were compared to 50 age and gender matched controls. 48/50 patients received AC doses below the recommended cumulative lifetime thresholds set by the European Society of Medical Oncology. 2D left ventricular global longitudinal strain (LV GLS) and right ventricle free wall strain (RV FWS) were compared to conventional measures of bi-ventricular function.

Results

The mean LVEF (58 ± 6% vs 63 ± 6%) and RV fractional area change (FAC) (39 ± 5% vs 44 ± 5%), although reduced in the BMT + AC group vs controls, were within normal limits. LV GLS was reduced in BMT + AC patients as compared to controls (-17.8 ± 3.1% vs -20.5 ± 2.2%, p < 0.01) while RV FWS was also reduced (-23.2 ± 4.0% vs -27.9 ± 2.7%, p < 0.001). In BMT + AC patients with a preserved LVEF (LVEF > 53%), 28% (11/40) had reduced GLS (GLS < -17%) while 52% (24/46) of those with preserved FAC (FAC > 35%) had reduced FWS (FWS < -25%). Major adverse cardiac events (MACE) occurred in 9/50 patients in the BMT + AC group and none in the control group. 8/9 patients had normal biventricular function as assessed by traditional parameters (LVEF and RV FAC) but 5/9 patients had reduced LV GLS and/or RV FWS.

Conclusions

Subclinical bi-ventricular dysfunction is common in patients post BMT + AC therapy, and can be detected using strain analysis, despite preserved LV and RV systolic function using conventional measures. MACE occurred at a significantly higher rate in BMT patients exposed to AC. More than half of MACE events occurred in patients with reduced LV or RV strain, with preserved bi-ventricular function by traditional measures. LV GLS and RV FWS should be utilised for early identification of subclinical dysfunction in BMT patients.

P309 The use of echocardiographic parameters to predict clinical outcomes in AL-amyloidosis cardiomyopathy

Background

AL-amyloidosis has a rapid clinical progression, with cardiac involvement associated with a particularly poor prognosis. Cardiac amyloidosis is diagnosed by either invasive biopsy or conventional echocardiographic parameters such as increased wall thickness, in the absence of other causes. More recently, novel parameters including 2D longitudinal strain have demonstrated diagnostic utility in a range of infiltrative cardiomyopathies including cardiac amyloidosis.

Aim/Method: We sought to evaluate traditional and novel echocardiographic parameters in their ability to predict adverse outcomes in a cohort of AL-amyloid patients. 80 patients who had transthoracic echocardiograms at a single centre were included. Comprehensive echocardiographic assessment was performed, including left ventricular ejection fraction (LVEF), LV Global Longitudinal Strain (GLS), LV mass (indexed to BSA). The primary endpoint was a composite of of major adverse cardiac events (MACE) and all-cause mortality, that was assessed by interrogation of the medical records on a specified censor date.

Results

At a mean follow-up (time from echo to censor date) of 5.4 ± 2.6years, 38/80 (47.5%) of patients experienced the primary endpoint of MACE or death, of which 25/80 (31%) were deaths. LVEF (59 ± 5.6%vs56 ± 6.4%, p = 0.04), GLS (17.4 ± 3.9%vs14.8 ± 4.9%, p = 0.01) basal longitudinal strain (12.3 ± 3.2%vs9.6 ± 3.9%, p = 0.002), indexed LV mass (107 ± 36g/m2vs130 ± 34g/m2, p = 0.06) and E/E’ (13.7 ± 4.9vs20.6 ± 9.6, p < 0.001) were all significantly different between patients who experienced the primary endpoint and those that didn’t. The strongest predictors of outcome were E/E’ (AUC 0.74), LV mass (AUC 0.73) and the ratio GLS:LV mass (AUC 0.73). An E/E’ of 15 had a sensitivity of 71% and specificity of 69%, while an indexed LV mass of 108 had a sensitivity and specificity of 74% and 67% respectively. GLS to LV mass as a cutoff of 0.16 had a sensitivity and specificity of 70% and 69% respectively.

Conclusion

In a cohort of 80 patients with AL-amyloid cardiomyopathy, almost half (47.5%) reached the primary composite endpoint. Diastolic dysfunction as expressed as E/E’, and LV mass were the most powerful predictors of outcome, while global longitudinal strain and LV basal strain were also reduced, and showed superiority over LV ejection fraction in predicting prognosis.

P1543 The assessment of regional myocardial strain in classifying amyloid cardiomyopathy

Background

An infiltrative cardiomyopathy is a common manifestation of AL-amyloidosis, with cardiac involvement associated with a poor prognosis. Wild-type transthyretin amyloidosis (wt-TTR), is a distinct clinical entity occurring predominantly in men > 65 yrs, that has gained interest recently due to novel treatment options. Regional strain analysis has been shown to discriminate both forms of cardiac amyloidosis from other causes of concentric left ventricular hypertrophy, with a characteristic pattern of ‘apical sparing’. Due to the significant difference in both the course of the disease and treatment options between groups, a non-invasive echocardiographic method of determining subtype would be valuable.

Aim/Method: We sought to compare traditional and novel echocardiographic parameters in a cohort of AL ( n = 80) and wild type (wt-TTR) amyloid ( n = 32) patients. All amyloid patients underwent comprehensive transthoracic echocardiography, including both conventional parameters and LV longitudinal strain. Further novel parameters were computed including the ratio of global longitudinal strain (GLS) to LV ejection fraction (LVEF), as well as GLS to indexed LV mass.

Results

wt-TTR patients had significantly greater LV mass (176 ± 59g/m2vs118 ± 37g/m2, p < 0.001), and worse diastolic dysfunction as expressed as E/E’ (21.5 ± 11vs17 ± 8, p = 0.04). LVEF was significantly lower in wt-TTR patients however remained in the normal range in both groups (53 ± 6%vs57 ± 6%, p = 0.001), whilst GLS was significantly reduced compared to AL-amyloid patients (11.5 ± 3.4%vs16.2 ± 4.6%, p < 0.001). LVEF:GLS was significantly higher in wt-TTR patients (4.93 ± 1.4vs3.87 ± 1.3, p = 0.001) reflecting a more profound reduction in strain with a relatively preserved ejection fraction. Similarly, the ratio of GLS to LV mass was significantly lower in wt-TTR amyloidosis (0.078 ± 0.05vs0.155 ± 0.07, p < 0.001), reflecting a more significant reduction in strain for a given wall thickness in wt-TTR patients. GLS:LV mass was the strongest discriminator between subtypes (AUC 0.82), with a cutoff of 0.09 giving a sensitivity and specificity of 71% and 80% respectively, for detecting wt-TTR.

Conclusion

In this cohort, patients with wt-TTR had significantly greater increase in LV wall thickness and diastolic dysfunction, which may in part reflect their increased age (77vs62). However, GLS was also significantly reduced compared to AL-amyloid, even when accounting for LV ejection fraction and LV mass, suggesting these composite parameters may have value in determining the subtype of cardiac amyloidosis.