The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias

BACKGROUND

Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias.

METHODS

Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD.

RESULTS

Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation.

CONCLUSIONS

Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.

Left ventricle myocardial deformation in olympic athletes assessed by cardiac magnetic resonance: does the sex and discipline matter?

Funding Acknowledgements

Type of funding sources: None.

Background

Sport induces structural and functional cardiac adaptation with different entity related to several factors including type of training and gender. Cardiovascular Magnetic Resonance (CMR) is the gold standard for morpho-functional evaluation of athletes’ heart and commonly relies on ventricular volume, wall thickness and ejection fraction (EF) assessment. Data on myocardial deformation (MD) are limited to echocardiography and are scarce.

Purpose

To assess MD in Olympic athletes and to evaluate the possible influence of sport categories and gender.

Methods

A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed for volume and function evaluation and to assess global longitudinal strain (GLS) and global circumferential strain (GCS) by feature-tracking software. Athletes were divided in subgroups according to ESC sport classification. Male and female athletes were compared. Athletes were also divided based on EF (≤53% or >53%).

Results

93 elite athletes (33% power, 33% mixed, 33% endurance) and 18 controls were enrolled. No differences in terms of EF were observed, while endurance athletes showed the greater LV remodeling (Table). GLS and GCS values of the entire population were -22.5±2.7% and -30.7±3.4%, respectively. No significant differences were found comparing athletes of different sport categories and sedentary controls for GLS (p= 0.940) and GCS (p=0.072). Female athletes showed higher GLS compared to male (-23.5±2.8% vs-21.9±2.8%, p=0.002) but not differences in terms of GCS (-31.5±3.1% vs-30.2±3.5%, p=0.076). Athletes with EF≤53% had lower GLS values compared with those with >53% but within normal limits (Figure).

Conclusion

No differences were observed in MD assessed by CMR between different sport categories and controls. Female athletes showed higher longitudinal but not circumferential strain compared with male. Athletes with lower EF presented lower values of strain but within normal range with the potentiality to be used as a tool for differential diagnosis between normal adaptation and disease.

Cardiovascular screening in olympic athletes before and after SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, these data are mainly based on Troponin and imaging findings.

Purpose

Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in Olympic athletes, who had previously been screened in our pre-participation program.

Methods

Since November 2020, all consecutive Olympic athletes presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was also performed. All Athletes were previously screened in our Institute as part of their periodical pre-participation evaluation.

Results

Forty-seven Italian Olympic athletes were enrolled: 83% asymptomatic, 13% mildly asymptomatic, 4% had pneumonia. The evaluation was performed after a median of 9 days from negative SARS-CoV-2 swab. Uncommon premature ventricular contractions (PVCs) were found in 13% athletes, however, only 6% (n=3) were newly detected. All newly diagnosed uncommon PVCs were detected by CPET. One of these three athletes had evidence for acute myocarditis by CMR, along with Troponin raise; another had mild pericardial effusion. No one of the remaining athletes had abnormalities detected by CMR (Figure).

Conclusions

Cardiac abnormalities in Olympic athletes screened after COVID-19 resolution were detected in a minority and were associated with new ventricular arrhythmias. Only one had evidence for acute myocarditis (in presence of symptoms and elevated biomarkers). No one of the remaining athletes had abnormalities by imaging or laboratory test. Our data support the efficacy of the clinical assessment including exercise-ECG to raise suspicion for cardiovascular abnormalities after COVID-19. Instead, the routine use of CMR as a screening tool appears not justified.

Hemodynamic forces in olympic athletes assessed by cardiac magnetic resonance: a new non-invasive screening tool?

Funding Acknowledgements

Type of funding sources: None.

Background

Non-invasive evaluation of left ventricular hemodynamic forces (HDFs) by Cardiac Magnetic Resonance (CMR) is a promising tool to improve systolic and diastolic evaluation. No data are available on athletic population.

Purpose

To provide the range of normal values of HDFs in Olympic athletes and to evaluate the possible influence of different sport categories.

Methods

A group of Olympic athletes evaluated prior the Olympic games with unremarkable cardiovascular pre-participation screening tests underwent CMR without contrast administration. A group of sedentary subjects was enrolled as a control group. Cine-images were post-processed by a feature-tracking based software to estimate HDFs. HDFs were measured in apex-base (AB) and latero-septal (LS) directions, over the entire heartbeat, in systole and diastole. Athletes were divided in subgroups according to ESC sport classification for comparison. They were also divided according to the ejection fraction (EF ≤ or >53%).

Results

93 elite athletes (33% power, 33% mixed, 33% endurance) were enrolled. HDFs in AB and LS direction were 20.5%± 4.3 and 2.9%± 0.7 in the entire heartbeat, 32.6% ± 7 and 3.6%± 1 in systole, 11%± 4.1 and 2.3%± 0.8 in diastole. Comparing athletes of different sport category and sedentary controls no significant differences were found between groups (Table). Comparing athletes with ejection fraction (EF) £ 53% and > 53%, the former showed lower values of AB-HDFs assessed in the entire heartbeat and in systole (18.9 ± 4.6 % vs 20.9 ± 4.1; p= 0.024 and 29.6 ± 6.3 vs 33.3 ± 7; p= 0.024, respectively), but within the normal range.

Conclusion

We provide normal range for HDFs assessed by CMR in elite athletes and no differences were observed between sedentary controls and athletes involved in different sport categories. Comparing athletes with low-normal and normal ejection fraction, the former showed lower values of AB-HDFs but within the normal range.

Low prevalence of cardiac abnormalities in competitive athletes before the return-to-play after COVID-19 based on the italian strategy

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting results on the cardiovascular involvement after SARS-CoV-2 infection generated concerns on the safety of return-to-play (RTP) in the athletic population. However, data are limited to the approached based on Troponine, ECG and echocardiogram while the data on exercise test are scarce.

Purpose

Aim of the study was to evaluate the prevalence of cardiac involvement after COVID-19 in competitive athletes for the RTP applying a comprehensive cardiovascular evaluation.

Methods

Since October 2020, all consecutive competitive athletes (age≥14 years) presented to our Institute after COVID-19 prior RTP were enrolled. The protocol was dictated by the Italian governing bodies and comprised: 12-lead ECG, blood test, cardiopulmonary exercise test (CPET), 24-hours ECG monitoring, spirometry. Cardiovascular Magnetic Resonance (CMR) was performed based on clinical indication.

Results

219 competitive athletes were enrolled (59% male), age 23 years (19,27): 20% asymptomatic, 77% mildly asymptomatic, 2% had pneumonia. The evaluation was performed after a median of 10 days (6-17 days) from negative SARS-CoV-2 swab. All athletes had a good performance at CPET. Uncommon premature ventricular contractions (PVCs) were found in 10% (n=21) and were detected by CPET. Two athletes (1%) were finally diagnosed with acute myocarditis (confirmed by CMR) and another had newly diagnosed mild pericardial effusion (Figure). All the three athletes were temporally refrain from sport participation.

Conclusions

Cardiac abnormalities in competitive athletes screened after COVID-19 resolution were detected in a minority of the cases (1.4%). No one of the remaining athletes had abnormalities by imaging or laboratory test neither reduction in cardiopulmonary fitness. Our data are in line with those reporting low prevalence of cardiovascular complication in mildly symptomatic or symptomatic athletes.

Positive CMR findings are associated with polymorphic ventricle arrhythmias and ECG repolarization changes but not with exercises induced arrhythmias in competitive and non-competitive athletes

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) provides an effective contribution for the prevention of sudden cardiac death with its ability to provide accurate information on morpho-functional abnormalities and on myocardial tissue characterization. However, data on its utility in clinical scenario in the competitive athletes are limited to selected cohort of patients with complex arrhythmias.

Objective

To retrospectively analyze all the CMR performed at our center for evaluating the predictors of positive CMR findings in a large cohort of competitive and non-competitive athletes presenting with different clinical indications.

Methods

Over a period of 30 months all the CMR performed on athletes aged > 14 years and training for at least 5 hours per week at our Institutes were retrospectively recruited. The following data were also collected: medical history, ECG, echocardiography, exercise testing. CMR were categorized as "positive" or "negative" based on the presence or absence of late gadolinium enhancement (LGE, excluding RV insertion point) and/or morphological and/or functional abnormalities. Predictors of "positive" CMR were explored.

Results

503 CMR were recruited and the most frequent indications for CMR were: ventricular arrythmias (n= 213, 42%), ECG abnormalities (n= 140, 28%) followed by echocardiogram abnormalities, symptoms and family history (Figure A). 308 (61%) CMR were "negative" and 195 (39%) "positive" (Figure B). Uncommon ventricular arrythmias did not result associated with positive CMR (p= 0.43), while polymorphic ventricular beats are associated with positive CMR (p= 0.02). Among ECG abnormalities only T-waves inversion, particularly on lateral and infero-lateral leads, were associated with positive CMR (p= 0.04).

Conclusion

Ventricular arrhythmias represented the most common indication for require a CMR but in almost half the cases, the CMR was negative. Excises induced ventricular arrhythmias is not significantly associated with pathological findings on CMR, while the polymorphic morphology of arrhythmias and the presence of lateral and infero-lateral repolarization abnormalities on ECG were associated with positive CMR.

Cardio-vascular remodelling during sacubitril/valsartan therapy in patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan (S/V) benefits in patients with heart failure and reduced ejection fraction (HFrEF) are partially related to cardiac reverse remodelling, in terms of volumes reduction and function improvement.  Effects on vascular remodeling are less investigated.

Purpose

To evaluate cardiac and vascular remodelling in a cohort of patients with HFrEF after six months of therapy with S/V.

Methods

50 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. Clinical evaluation and standard and advanced echocardiography were performed at baseline and after six months of follow up (FU). Standard left ventricular dimension and function parameters, global longitudinal strain (GLS) were calculated. Non-invasive pressure-volume curves (P-V loop) estimation was assessed with an off-line dedicated software using ST-E derived time-resolved LV volumes and brachial pressure as input. The following hemodynamic parameters were calculated based on P-V loop curves: left ventricular elastance (Ees), arterial elastance (Ea) and ventricular-arterial coupling (VAC).

Results

At six months F/U, a reduction of NYHA class in the vast majority of patients was detected (NYHA Class ≥ II, baseline vs F/U = 100% vs 50%; p< 0,001). Systolic and diastolic blood pressure were lower, in comparison with baseline values (119 ± 16 vs 126  ± 11 mmHg; p = 0,002 and 71 ±  8 vs 78 ±  8 mmHg; p = 0,001, respectively). At echocardiographic evaluation, left ventricular end-diastolic and end-systolic volumes decreased (p< 0.001 and p< 0,001, respectively) and ejection fraction and GLS significantly improved (p< 0.001 and p < 0.001, respectively). Moreover, a significant reduction of Ea and a significant improvement of Ees and VAC were observed (p = 0.008, p< 0,001 and p< 0,001, respectively).

Conclusion

Therapy with S/V in HFrEF patients determines both cardiac and vascular remodelling reflecting the complex mechanisms behind clinical improvement. Abstract Figure.

Left ventricular forces distribution in patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Hemodynamic forces (HDFs) are the forces exchanged between the blood and the myocardium. Estimation of their magnitude and alignment could be a novel marker of cardiac dysfunction.

Purpose

To describe left ventricular (LV) HDFs values and distribution in patients with heart failure with reduced ejection fraction (HFrEF) and to compare them with those of a group of healthy controls.

Methods

A cohort of 26 non-ischemic patients with an initial diagnosis of HFrEF was enrolled. All of them underwent basal 2D echocardiography evaluation.  Off-line HDFs estimation using a dedicated software based on speckle-tracking echocardiography was conducted. HDFs were normalized for the LV volume and expressed as a percentage of the force of gravity. HDFs were assessed over the entire cardiac cycle, in systole and diastole, both in apex to base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio). HDFs of HFrEF patients were compared with those of 24 healthy volunteers.

Results

HFrEF patients showed smaller values of A-B HDFs during the entire cardiac cycle (5,2 ± 1,24% vs 12,3 ± 3,6%; p = 0,001), in systole (7,2 ± 2% vs 16,6 ± 6,3%; p = 0,001) and diastole (3,3 ± 0,8% vs 7,1 ± 3,6%; p = 0,001). Moreover, comparing HFrEF subjects with healthy volunteers , the former had lower L-S HDFs during the entire cardiac cycle (1,6 ± 0,4% vs 2 ± 0,7%; p= 0,022) and in systole (1,6 ± 0,5% vs 2,3 ± 0,8%; p = 0,003), while in diastole they showed inappropriate high values of L-S HDFs (1,7 ± 0,6% vs 1,8 ± 0,9%; p = 0,999). Consequently, HFrEF patients had higher  values of L-S/A-B ratio during the entire cardiac cycle (32 ± 6,9 vs 15 ± 7,7; p = 0,001), in systole (23,5 ± 7,4 vs 14,7± 4,2; p = 0,001), but particularly in diastole (52 ± 10,8 vs 28 ± 13,6; p = 0,001), showing an important HDFs misalignment.

Conclusion

When compared with healthy controls, HFrEF patients presented intraventricular fluid alterations characterized by lower HDFs magnitude and a significant HDFs misalignment, especially in diastole. Further studies are needed to confirm these initial results and to assess the effects of therapy on these new parameters. Abstract Figure.  Abstract Figure.

Natural history of right ventricle: longitudinal study in veteran athletes

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Right ventricular (RV) enlargement is a physiologic adaptation to long lasting athletic training. Its clinical implications for veteran athletes are poorly understood. In recent years, controversial data suggest an association between ultra-endurance exercise and a RV cardiomyopathy similar to arrhythmogenic cardiomyopathy (ACM). In this context, the effects of exercise detraining have not been extensively studied yet.

PURPOSE

The aim of this study was to assess the morphological and functional RV changes in veteran athletes and to evaluate the effect of a long period of detraining.

METHODS

This is a longitudinal study including 22 veteran rowers with at least 10 years of competitive career. We evaluated them with an echocardiographic assessment at baseline and after a minimum of 3 years of detraining (age: 23.2 ± 4.4 and 43 ± 7.4 years), by reducing the weekly training volume from 26 ± 0.7 to 3 ± 2 hours. In this second evaluation we also performed an RV strain analysis and a cardiac magnetic resonance (CMR) study.

RESULTS

RV end diastolic (ED) areas significantly reduced after detraining (31.48 ± 5.8 versus 28.59 ± 6.8; p = 0.001), although remaining larger than normal. RV enlargement was balanced: the ratio between inflow (IT) and outflow tract (OT) (RVIT/RVOT = 1.4 ± 0.1) and the ratio between RV and left ventricle (LV) (RV/LV = 0.81 ± 0.1) were within normal limits. The fractional area change (FAC%) was normal at baseline and increased significantly (41.5 ± 6% versus 45.8 ± 7%; p = 0.011). After detraining, RV longitudinal strain was normal (-19.7 ± 2.7%). CMR assessment showed enlarged RVED volumes (97.9 ± 14 ml/m2) but normal RV ejection fraction (55.5 ± 4.1%).

CONCLUSIONS

RV enlargement in endurance athletes persists after a long period of detraining. However, detraining results in a significant reduction of RV dimensions. Furthermore, the absence of RV dysfunction or disproportionate RV geometry are reassuring findings that suggest a physiological remodeling of the RV.

Significant echo findings. RV ECHO PARAMETERS BASELINE DETRAINING MEAN DIFF. (C.I. 95%) p VALUE RVOT plax (mm) 34.8 ± 4 33.7 ± 14 1.1 (0.18; 2.1) p = 0.011 RVOT psax (mm) 34.9 ± 3.3 33.09 ± 3.5 1.8 (0.9; 2.7) p < 0.001 RV basal diameter (mm) 47.31 ± 5.3 45.86 ± 6.4 1.4 (0.04; 2.8) p = 0.022 RV end-diastolic area (cm²) 31.48 ± 5.8 28.59 ± 6.8 2.8 (1.1; 4.6) p = 0.001 FAC% 41.5 ± 6 45.8 ± 7 0.04 (-0.07; -0.007) p = 0.011 RV inflow/outflow ratio 1.36 ± 0.1 1.36 ± 0.2 -0.003 (-0.06; 0.06) p = 0.454 RV/LV ratio 0.82 ± 0.07 0.81 ±0.1 0.01 (-0.01; 0.04) p = 0.219

Abstract Figure. Comparison in the same veteran athlete.

Misalignment of hemodynamic forces in the left ventricle is associated with adverse remodeling following STEMI

Funding Acknowledgements

Type of funding sources: None.

Background

Infarct size (IS), area at risk (AAR) and microvascular obstruction (MVO) are well known predictors of adverse remodeling (aLVr) following acute myocardial infarction, while the pathogenic role of left ventricular (LV) hemodynamic forces (HDFs) is still unknown. Recent evidence suggests the role of HDFs in negative remodeling after pathogenic events. 

Purpose

To identify LV HDFs patterns associated with aLVr in reperfused ST-segment elevation MI (STEMI) patients.

Methods

Forty-nine acute STEMI patients underwent CMR at 1 week (baseline) and 4 months (follow-up) after MI.  The following parameters were measured: left ventricular end-diastolic and end-systolic volume index for body surface area (LVEDVi and LVESVi), left ventricular ejection fraction (LVEF) and LV mass index, AAR and IS. LV HDFs were computed at baseline from cine CMR long axis datasets using a novel method based on LV endocardial boundary tracking. LV HDFs were calculated both in apex-base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs were evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio %). All HDFs parameters are computed over the entire heartbeat, in systole and diastole. aLVr was defined as an absolute increase in LVESV of at least 15% (ΔLV-ESV ≥15%).

Results

Patients with aLVr (n = 18; 37%) had significant greater value of AAR (32 ± 23 vs 22 ± 18; p = 0.03) and slightly larger IS (23 ± 16 vs 15 ± 11; p= 0.07) at baseline. In patients with aLVr at FU, baseline systolic L-S HDF were lower (2.7 ± 0.9 vs 3.6 ± 1; p = 0.027) while diastolic L-S/A-B HDF ratio was significantly higher (28 ± 14 vs 19 ± 6; p = 0.03), reflecting higher grade of diastolic HDFs misalignment. At univariate logistic regression analysis, higher IS [Odd ratio (OR) 1.05; 95% confidence interval (95% CI) 1.01-1.1; p= 0.04] L-S HDFs (OR 0.41; 95% CI 0.2-0.9; p= 0.04] and higher diastolic L-S/A-B HDFs ratio (OR 1.1; 95% CI 1.01-1.2; p= 0.05) were associated with aLVr at FU (Table).  At multivariate logistic regression analysis, L-S/A-B HDF ratio remained the only independent predictor of adverse LV remodeling after correction for other baseline determinants.

Conclusion

Misalignment of diastolic HDFs following STEMI is associated with aLVr observed after 4 months.

Predictors of adverse remodeling Univariate Multivariate Parameter OR (95% CI) P OR (95% CI) P IS (%) 1.05 (1.01-1.1) 0.042 - - Systolic L-S HDF 0.41 (0.2-0.9) 0.04 - - Diastolic L-S/A-B HDF Ratio 1.1 (1.01-1.2) 0.05 1.1 (1.01-1.2) 0.04 A-B:apex-base; L-S: latero-septal; HDFs: hemodynamic forces Abstract Figure. Diastolic HDFs distribution and aLVr

Improvement of left ventricular systolic performance during sacubitril/valsartan in a cohort of patients with heart failure and reduced ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan is a well-established therapeutic option for patients with heart failure with reduced ejection fraction (HFrEF). While it was clearly demonstrated to improve patients’ clinical conditions, its potential role in inducing left ventricle (LV) reverse remodeling is still under investigation. 

Purpose

to evaluate clinical and echocardiographic effect of sacubitril/valsartan on a cohort of patients with HFrEF after six months of therapy.

Methods

36 patients with HFrEF eligible to start a therapy with sacubitril/valsartan were enrolled. A standard and advanced echocardiographic evaluation was performed before starting the therapy and after six months of follow up (FU). Off-line analysis of left ventricle global longitudinal strain (GLS), longitudinal strain of the free wall of the right ventricle (RVFWSL) and left atrial strain (LAS) was conducted. Clinical and biochemical parameters were evaluated as well.

Results

At six months of FU NYHA class improved in the vast majority of patients (NYHA class III at baseline vs FU: 56% vs 5%, p 0.001). We observed a significant reduction in LV end-diastolic (99.62 ± 33.24 vs 91.54 ± 33.36, p 0.043) and end-systolic (69.99 ± 26.01 vs 58.68 ± 25.7, p 0.001) volumes and an improvement of LV ejection fraction (30.4 ± 5.02 vs 37.3 ± 6.4, p < 0.001). After six months of therapy, GLS significantly improved (-9.71 ± 2.87 vs -13.04 ± 3.14, p < 0.001). No differences in left and right atrial volumes (respectively 56.6 ± 29 vs 54 ± 30, p 0.349; 54.7 ± 23.7 vs 48.3 ± 19, p 0.157), RVFWSL (-16,5 ± 5,4 vs -16,8 ± 1,5) and LAS (14 ± 6 vs 19 ± 8, p 0.197) were found at FU. 

Conclusion

Left ventricular function evaluated with standard and advanced echocardiographic parameters improved after six months of therapy with sacubitril/valsartan in HFrEF patients. Reduction in LV volumes was found as well.

Echo Analysis Baseline Echo Analysis (n= 36) 6 Months FU Echo Analysis (n= 36) p LVEDVi, mL/m2 99, 62 ± 33,24 91,54 ± 33,36 0,043 LVESVi, mL/m2 69,99 ± 26,01 58,68 ± 25,7 0,001 LVEF, % 30,4 ± 5, 02 37,3 ± 6,4 < 0,001 E/E’ average 12,16 ± 3,74 9,71 ± 1,33 0,023 LS Endo Average ,% -9,71 ± 2,87 -13,04 ± 3,14 < 0,001 LVEF left ventricular ejection fraction, LVEDVi: left ventricular end diastolic volume indexed, LVESVi: left ventricular end systolic volume indexed; LS: longitudinal strain

Gender difference in extreme cardiac remodelling in endurance olympic athletes assessed by non-contrast CMR

Funding Acknowledgements

Type of funding sources: None.

Background

Male and female athletes present difference spectrum of cardiac remodelling related to their sport activity. However data in elite female athletes are scarce and mainly limited to echocardiography evaluation. 

Purpose

The aim of the study was to assess gender difference in extreme cardiac remodelling in Olympic athletes engaged in endurance sport assessed by non-contrast Cardiovascular Magnetic Resonance including Mapping.

Methods 

Olympic athletes engaged in endurance sport (rowing, canoeing, mid/long distance swimming) were examined with history, physical examination, 12-lead and exercise electrocardiogram, and echocardiography as part of their evaluation prior the Olympic games (Tokyo 2020). Athletes with unremarkable evaluation were undergone to non-contrast CMR including Mapping.  The following parameters were calculated: indexed left ventricle (LV) and right ventricle (RV) end-diastolic (EDVi) and end-systolic volumes (ESVi), stroke volume (SVi), ejection fraction (EF), left and right atria area (LAAi and RAAi), LV Mass (Massi) and maximum wall thickness (MWT), RV/LV EDV ratio, spericity index [SI=(long axis diameter/2)3 * 4,187], myocardial native T1 (nT1) and T2 Mapping. 

Results

51 caucasian elite athletes (without difference in term of age, years of training and hours of training/week) were enrolled and 59% were male. Male showed greater LV EDVi (123 ± 28 ml vs 103 ± 10, p = 0.003), ESVi (55 ± 14 ml vs 44 ± 7, p = 0.001), SVi (68 ± 15 ml vs 59 ± 7, p = 0.023), Massi (76 ± 19 vs 57 ± 10, p < 0.001), MWT (10 ± 1 mm vs 8 ± 1, p < 0.001) and RV EDVi (129 ± 48 ml vs 104 ± 13, p = 0.026), ESVi (57 ± 10 ml vs 45 ± 9, p < 0.001), SVi (68 ± 15 ml vs 59 ± 7, p = 0.018) compared to female, as expected. LVEF (p = 0.05) and RVEF (p = 0.17) did not show significant difference.  Despite greater volumes, SI (43 ± 12% vs 44 ± 8, p = 0.8) and RV/LV EDV ratio (0.99 ± 0.05 vs 1 ± 0.05, p = 0.405) did not differ between male and female athletes, as well as LAAi (13 ± 3 cm2 vs 13 ± 1.5, p = 0.86) and RAAi (13 ± 1.9 vs 13 ± 18, p = 0.56). Native T1 mapping was lower in male compared with female (934 ± 21 ms vs 956 ± 33, p = 0.028) while T2 Map values were slightly higher (53 ± 3.9 ms vs 50 ± 3.8, p = 0.027) . 

Conclusions

Male endurance Olympic athletes presented higher volumes and LV mass compared to their female counterparts, while atria dimension, systolic function and sphericity index did not differ. Ventricles showed balanced dilatation in both gender. Lower T1 value observed in male suggested cellular hypertrophy.

Figure 1 showed CMR images in a male (top row) and a female (bottom row) Olympic athletes: 4 chamber end-diastolic and end-systolic frame and end-diastolic basal short axis (SAX) showed balanced dilatation. Graphs showed higher EDVi and Massi in male compared o female, no difference in sphericity index and lower native T1 mapping.

Abstract Figure 1

HLM, a TNM-like classification for heart failure, compared with other nosologies at 12 months follow-up

Background

Heart failure (HF) is the pandemic of the third millennium with the highest mortality among general population, while lung cancer is the second most common cause of death. As cancer, HF can affect close organs, as lungs, or can reach peripheral organs (kidney, liver, brain), leading to multi-organ dysfunction, like cancer metastasis.

Purpose

We proposed a new staging system named HLM, analogous to TNM classification used in oncology, which refers to heart damage (H), lung involvement (L), and malfunction (M) of peripheral organs. The aim of this study is a comparison between HLM and NYHA, ACC/AHA and MAGGIC scores to assess the most accurate prognosis of HF patients in terms of rehospitalization for acute HF (AHF) or major adverse cardiac and cerebrovascular events (MACCE), and cardiac death.

Methods

We performed a single-center observational study of HF patients. All parameters for heart, lungs and peripheral organs function were examined. Each patient was classified according to HLM, NYHA, ACC/AHA and MAGGIC score at the entrance and at the discharge. Rehospitalization for MACCE or AHF and cardiac death were checked at 12 months follow up.

Results

We enrolled 2054 patients: 68.5% males, 31.3% females, mean age 70.18±7.48 years. Among them, overall survival curves regarding rehospitalization for MACCE, AHF and cardiac death at 12 months, show that HLM classification is as valid as the others (p<0.001). In particular, the area under the ROC curve (AUC) is greater for HLM than NYHA, ACC/AHA and MAGGIC score in terms rehospitalisation for MACCE (HLM=0.687; NYHA=0.642; ACC/AHA=0.604; MAGGIC=0.657) or AHF (HLM=0.662; NYHA=0.652; ACC/AHA=0.604; MAGGIC=0.662) and cardiac death (HLM=0.783; NYHA=0.712; ACC/AHA=0.623; MAGGIC=0.737).

Conclusion(s)

According to our results, HLM classification has greater prognostic power compared to other nosologies in terms of rehospitalization for MACCE, AHF and cardiac death for HF patients, thanks to a more accurate evaluation of the systemic impact of heart failure. Such a multivariable, holistic approach should be used in HF patients, rather than a “cardiocentric” approach, in order to address the pathophysiological mechanisms underlining heart abnormalities, improving clinical management and costs.

Funding Acknowledgement

Type of funding source: None

P1752 Prognostic role of Multilayer Strain Speckle Tracking Echocardiography in patients with severe aortic stenosis treated with Transcatheter Aortic Valve Implantation

Background

Myocardial Strain evaluation helps to assess the efficacy of therapeutic interventions and to predict the prognosis and clinical outcomes. The aim of the present study was to assess whether Multilayer Global longitudinal Strain (GLS) can be useful in estimation of left ventricle (LV) function in patients with severe symptomatic aortic stenosis (AS) who have undergone transcatheter aortic valve implantation (TAVI).

Methods

35 patients with severe AS who successfully underwent TAVI, were enrolled in the study. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function. Occurrence of cardiovascular (CV) events (rehospitalization for HF or CV death) were collected after 24 months follow-up.Results: CV events occurred in 7 patients (20%). Patients were divided in two groups accordingly with CV events occurrence. No differences in baseline, demographic, echocardiographic and procedural characteristics were found. Patients who developed CV events had a more impaired pre-procedural GLS (-10.2 ± 2.4% vs -12.6 ± 2.2%, p = 0.029), mostly due to his subendocardial layer (Endo-LS -10.8 ± 2 vs -13.9 ± 2, p = 0.003). Moreover, by ROC curve analysis, a cut-off value of -12.4% of endo LS was associated with CV events (sensitivity of 83% and specificity of 65 %, AUC 0.8, p = 0.024), with a log-rank p value assessed by survival analysis of 0.044.

Conclusion

Multilayer GLS analysis could provide additional information for prognosis stratification in patients with severe symptomatic AS before TAVI, above and beyond assessment of LVEF alone.

Parameter Event-group (7/35 pz= 20%) Non-event group (28/35 pz= 80%) p Age (y.o) 86 ± 4 80 ± 7 NS LVEDV (ml) 112 ± 34 94 ± 32 NS LVESV (ml) 51.2 ± 6 56.9 ± 6 NS LVEF(%) 55.7 ± 6 56.9 ± 6 NS AVA (cm2) 0.77 ± 0.2 0.73 ± 0.2 NS GLS (%) -10.2 ± 2.4 -12.6 ± 2.2 0.029 Endo-LS (%) -10.8 ± 2 -13.9 ± 2 0.003 Epi-LS (%) -10.2 ± 2 -11.9 ± 2 NS

Abstract P1752 Figure.

P1781 Cardio-protective role of dexrazoxane co-administered with anthracyclines: long-term echocardiographic follow-up in adult survivors of pediatric cancer

Background Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer treated with anthracyclines. A decrease in left ventricular (LV) ejection fraction (LVEF) and fractional shortening may be observed during follow-up. Previous studies reported non-negligible prevalence of subclinical systolic dysfunction assessed with deformation imaging at short-, mid- and long-term follow up. Co-administration of Dexrazoxane has been shown to significantly reduce short-term and mid-term cardiotoxicity. The usefulness of dexrazoxane in preventing late (>10 years) anthracycline cardiotoxicity remains under discussion.

Purpose Aim of this study was to assess cardiac function in long-term (>10 years) survivors of childhood tumors treated with dexrazoxane/anthracycline association.

Methods Twenty cancer survivors previously treated with co-administration of anthracyclines and dexrazoxane for childhood renal tumors or sarcoma and a control group of 20 healthy non-athletic subjects matched for age, sex and body surface area were enrolled in the study. Echocardiographic measurements included 3D LVEF and LV and right ventricular (RV) global longitudinal strain (GLS). Cancer survivors were evaluated at median follow-up time of 21.5 years (range 10-26).

Results No evidence of cardiac toxicity, as defined by current guidelines, was reported in all survivors. None of survivors presented LVEF < 50% or abnormal longitudinal strain, defined as a value >2 SDs below the mean using sex-specific and age-specific strain values. No significant differences in standard and deformation imaging parameters were observed between survivors and controls (3D LVEF 58 ± 3 % vs 60 ± 5 % p = NS; LV GLS -21 ± 1 % vs - 21 ± 2 % p= NS; RV GLS - 23 ± 2 % vs - 23 ± 5 % p= NS). Moreover, considering subjects who received a cumulative dose of anthracyclines above the median (doxorubicin-equivalent dose ≥208 mg/m2) no significant differences were found as compared to the group receiving a lower dose.

Conclusions No evidence of cardiac toxicity was detected in all survivors. Our findings support the cardio-protective role of dexrazoxane in children undergoing anthracycline-based treatment.

Parameters Cancer survivors (n= 20) Controls (n= 20) P 3D LVEF (%) 58 ± 3 60 ± 5 NS LV GLS (%) -21 ± 1 -21 ± 2 NS RV GLS (%) -23 ± 2 -23 ± 5 NS 3 D LVEF: Three-Dimensional Left Ventricular Ejection Fraction, LV GLS: Left Ventricular Global Longitudinal Strain; LV; RV GLS: Right Ventricular Global Longitudinal Strain.

Abstract P1781 Figure. LV strain analysis in a survivor

P1523 Impact of different techniques for mitral valve repair on left ventricular function: a 2D/3D echocardiographic analysis

Funding Acknowledgements

None

Aim

Different surgical techniques are available for mitral valve (MV) repair in patients with degenerative severe mitral regurgitation (MR). Leaflet resection (LR) and neochordoplasty (NP), both including ring annuloplasty (RA), are the most frequently performed techniques for posterior mitral leaflet prolapse/flail repair. Despite NP technique is supposed to preserve LV physiology more than LR, it is unclear which technique provides the best haemodynamic pattern. In the present study, the results of the two different surgical techniques in terms of left ventricular (LV) dimension and function are investigated.

Methods

23 consecutive patients who underwent MV surgical repair were enrolled. All patients underwent, before surgery and after 8 ± 2 months, 2D and 3D echocardiography with automatic (Heart Model, Philips) assessment of LV volumes and ejection fraction (EF), left atrial (LA) volume, right ventricular (RV) dimension and function, pulmonary artery systolic pressure (PASP), MR, tricuspid regurgitation (TR) and MVPG quantification. MR was corrected using 1) NP with polytetrafluoroethylene sutures and 2) triangular LR, both with RA. Patients were divided in 2 groups according to the surgical technique. Results: techniques were able to successfully correct MR. There were no significant differences in baseline echocardiogram and demographic characteristics between the two groups. There were no significant differences in terms of post-surgical MVPG between the two groups. In all patients a trend in reduction in LV dimension at follow-up was observed, but it was statistically significant only in NP patients (pre-surgical EDV 150 ± 41 VS post-surgical EDV 100 ± 27 ml, p = 0.03).

Conclusions

Both MV repair techniques showed a successful MV repair and an improvement in LV volumes at follow-up, especially in NP group. Further perspective studies are necessary to demonstrate the hypothesis of more physiological haemodynamic pattern associated with NP techniques.

Echo parameters pre VS post MV Repair Parameter pre post p value LVEDV RN (ml) 150 ± 41 100 ± 27 0.03 LVESV RN (ml) 58 ± 20 46 ± 14 NS LVEF RN (%) 58 ± 8 55 ± 7 NS LVEDV RR (ml) 160 ± 58 118 ± 31 NS LVESV RR (ml) 62 ±11 51 ±13 NS LVEF RR (%) 59 ± 8 57 ± 4 NS EDV: end-diastolic volume, ESV: end-systolic volume, EF: ejection fraction, RN = Ring + Neochordae; RR= Ring + Resect.

P795 Intraventricular fluid patterns during dobutamine stress echo in patients with significant coronary stenosis

Background

Dobutamine stress echo (DSE) is a useful tool for the evaluation of patients with suspected stable coronary artery disease (CAD). There has been no detailed investigation about the effects of exercise or pharmacological stress on intraventricular fluid dynamics. The possible association between significant CAD and abnormal fluid patterns has not been studied yet.

Purpose

Aim of the study was to evaluate the intraventricular vortices during dobutamine stress and to find fluid-dynamic patterns associated with the presence of significant CAD.

Methods

36 patients scheduled for coronary angiography (CA) and with clinical indication for DSE for suspected CAD were enrolled. Each patient underwent 2D, 3D and contrast echocardiography for Echo-PIV analysis and vortex quantification, both at rest and at peak stress. Vortex geometric and energetic parameters were evaluated using a post- processional software. Intraventricular pressure gradients were evaluated as well. Positive CA for significant CAD was defined as the presence of at least one epicardial coronary stenosis with ≥70% luminal narrowing.

Result

CA was positive in 58% of patients while DSE in 33%. In the whole population, at peak stress a reduction in vortex area (from 0.36 ± 0.01 to 0.21 ± 0.02; p= 0.001) and in absolute value of vortex intensity (from 0.36 ± 0.1 to 0.26 ± 0.12; p= 0.001) were detected. Vorticity fluctuation and kinetic energy (KE) fluctuation showed a significant increment at peak stress (respectively 0.84 ± 0.17 to 0.93 ± 0.07; p= 0.005; from 1.76 ± 0.37 to 2.47 ± 0.82; p= 0.001), as well as a deviation of flow force momentum angle (φ: from 36 ± 8 to 44 ±9; p= 0.001). Patients with positive CA showed during DSE an higher decrease of the absolute value of vortex intensity (Δ% |vortex intensity| -1.7 ± 0.39 vs -1.3 ± 0.56 vs; p= 0.021), and higher increase of flow force angle (Δ% φ 0.48 ± 0.6 vs 0.1 ± 0.27; p= 0.042). A reversal in the main direction of the vortical flow occurred in 9 patients (25%) at peak stress and 7 of them (64%) were found to have significant right coronary stenosis. This unexpected change in the vortical flow and the presence of right coronary artery stenosis were found significantly associated (X2 p= 0,02). Moreover, patients with circumflex artery stenosis were less likely to have a decrease of vortex length at peak stress (Δ% Vortex length - 0,06 ± 0, 36 vs - 0,34 ± 0,28, p= 0,034).

Conclusion

Significant changes in intraventricular vortices occur during DSE. The presence of significant CAD evaluated with CA was associated with different behavior of fluid dynamics during DSE. Further studies are needed to assess normal and pathological intraventricular flow patterns evaluated during DSE.

Abstract P795 Figure. Vortex reversal at peak stress

P1365 Different response of myocardial contractility by layer following acute pressure unloading after transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic option for severe symptomatic aortic stenosis (AS) with intermediate/high surgical risk. Aim of this study was to examine the acute effect of TAVI in terms of pressure unloading, on left ventricular (LV) mechanics using multilayer global longitudinal strain (GLS) by 2D speckle-tracking echocardiography (ST-E).

Methods

A total of 44 patients (mean age 81.8 ± 2, 34% male) with severe symptomatic AS and preserved LV ejection fraction (LVEF) underwent 2D echocardiography at baseline and 5 ± 2 days after TAVI. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before and after the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function.

Results

By dividing patients in two groups accordingly with LV geometry assessed with regional wall thickness measurement (concentric vs eccentric hypertrophy), better values of Endo-LS were recorded at baseline, in patients with concentric hypertrophy (-12.9 ± 2 vs -11 ± 3, p = 0.048). After TAVI, a significant improvement in Endo-LS was observed, but only in patients with concentric hypertrophy (-12.9 ± 2 vs -14.2 ± 2, p = 0.003).

Conclusion

The improvement in LS was more prominent in the endocardium, which was evident even immediately after TAVI only in patients with concentric hypertrophy. Evaluation of multilayer strain may provide new insights into the positive effects of unloading in patients with AS and may be potentially useful to predict patients with better outcome after TAVI.

Parameter RWT > 0.42 31 pz (70%) RWT ≤ 0.42 13 pz (30%) p Male sex (n, %) 8 (25%) 7 (53%) NS Age (y.o) 81 ± 6 83 ± 7 NS CAD (n, %) 3 (9%) 8 (61%) NS LVEDV (ml) 97 ± 29 134 ± 14 0.002 LVESV (ml) 43 ± 15 72 ± 38 0.001 LVEF(%) 56.2 ± 6 50 ± 12 NS AVA (cm2) 0.8 ± 0.2 0.8 ± 0.3 NS GLS (%) -11.4 ± 3 -10.5 ± 3 NS Endo-LS (%) -12.9 ± 2 -11 ± 3 0.048 Epi-LS (%) -10.8 ± 4 -9.9 ± 3 NS

Abstract P1365 Figure.

P874Role of Genetic Polymorphisms of ion channels in the pathophysiology of coronary microvascular dysfunction and ischemic heart disease: an update

Background

Ischemic heart disease (IHD) is classically associated with coronary artery disease (CAD) and conventional cardiovascular risk factors. However, IHD may exhibit in the absence of CAD, because of different pathophysiological mechanisms, such as the presence of specific genetic variants of ion channels, which act mainly in the microcirculation. Recently, we reported the correlation between some single nucleotide polymorphisms (SNPs) of ion channels genes and the presence of IHD, independently from the presence of conventional cardiovascular risk factors. The goal of this study is to confirm the results of the previous study on a bigger population and discover new SNPs of ion channels genes which may be associated with IHD.

Methods

A prospective, observational, single-center study was conducted on patients candidates for coronary angiography. Patients were divided in three groups: G1, coronary artery disease; G2, microvascular disfunction; G3, normal. Genetic polymorphisms relative to KCNJ11 encoding for the Kir6.1 and Kir6.2 subunits of K-ATP channels and KCNE1 encoding for the MinK subunit of IKs channels were analyzed.

Results

603 consecutive patients (G1: 409; G2:76; G3:118) were enrolled. Genetic analysis for the three groups showed a statistically significant difference for the SNP S38G of KCNE1 (p=0.001) and for the variants rs5215, rs5218, rs5219 of KCNJ11 (p<0.0001), as well as comparing G1-G3 (S38G p=0.006; rs5215, rs5218 and rs5219 p<0.0001). Regarding G1-G2 we confirmed differences only for the variants rs5215 (p<0.0001), rs5218 (p=0.005) and rs5219 (p=0.024), while regarding G2-G3 we found differences for the variants S38G, rs5215 e rs5219 (p<0.0001). A multivariate analysis was performed and highlighted that the SNP rs5215_GG of KCNJ11 may represent an IHD independent protective factor (p<0.0001; OR: 0.036; 95.0% CI: 0.018–0.069).

Conclusion

These results confirm the importance of genetic susceptibility and the role of SNPs of ion channels genes in the determinism of IHD, independently from the conventional cardiovascular risk factors. Moreover, these results may represent a future perspective for a genic therapy for IHD.

P6329123-Iodine Metaiodobenzylguanitidine imaging: a useful prognostic marker of cardiovascular death in heart failure patients

Background

According to guidelines, implantable cardioverter defibrillator (ICD) is recommended in prevention of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Guidelines have several limitations because ICD indication is based mainly on left ventricular ejection fraction (LVEF). Recently, 123-iodine metaiodobenzylguanidine imaging (123-I MIBG) seems to identify, independently from LVEF, pts at high risk of SCD: heart/mediastinum (H/M) ratio<1.6 and summed score (SS)>26.

Purpose

The aim is to assess the role of 123-I MIBG to predict malignant ventricular arrhythmias (VA) in HF pts

Methods

We enrolled 208 pts, admitted to our hospital with diagnosis of HF and LVEF≤35%, NYHA class II and III, who underwent 123-I MIBG imaging. H/M ratio of 1.6 was used as a cut-off to identify high risk (G1) versus low risk pts (G2). All pts underwent ICD implantation. Follow-up was performed at 24 months.

Results

138 patients were included in G1 and 70 patients in G2. All baseline characteristics were similar in the two groups (table 1). At 24 months follow-up VA events were recorded greater in G1 compared to G2 (21% vs 10%, p=0.04).

Table 1 G1 G2 P value H/M ≤1.6 (N=138) H/M >1.6 (N=70) Age (years) 65±12 63±14 0.28 Male, N (%) 108 (78) 64 (91) 0.02 Diabetes mellitus type II, N (%) 54 (39) 14 (20) 0.01 Dyslipidemia, N (%) 58 (42) 30 (42) 0.64 LVEF (%) 30±5 31±4 0.14 Ischaemic CM, N (%) 85 (62) 30 (42) 0.012 Malignant VA, N (%) 30 (21) 7 (10) 0.04 SS 38±9 16±7 0.0001 H/M: heart mediastinum ratio; LVEF: left ventricular ejection fraction; CM: cardiomyopathy; VA: ventricular arrhythmias; SS: summed score.

Conclusion

Our results seem to confirm that 123-I MIBG uptake is associated with the occurrence of life-threatening VA in HF pts independently from LVEF. The use of 123-I MIBG could be a useful tool in the future to increase the specificity of the pts selection for ICD therapy.

Echocardiographic long-term follow-up of adult survivors of pediatric cancer treated with Dexrazoxane-Anthracyclines association

AIMS

Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer treated with anthracyclines. Co-administration of Dexrazoxane has been shown to significantly reduce short-term and mid-term cardiotoxicity. Aim of this study was to assess cardiac function in long-term (>10 years) survivors of childhood tumors treated with dexrazoxane/anthracycline association.

METHODS AND RESULTS

Twenty cancer survivors previously treated with co-administration of anthracyclines-dexrazoxane for childhood renal tumors or sarcoma and a control group of 20 healthy subjects were enrolled in the study. Echocardiographic measurements included 3D left ventricular (LV) ejection fraction (LVEF) and LV and right ventricular (RV) global longitudinal strain (GLS). Among cancer survivors group the median age at diagnosis was 5 years (1-17) and they were evaluated at median follow-up time of 21.5 years (10-26). No evidence of cardiac toxicity, as defined by current guidelines, was reported in all survivors. No significant differences in standard and deformation imaging parameters were observed between survivors and controls (3D LVEF 58 ± 3% vs 60 ± 5% p = NS; LV GLS -21 ± 1% vs -21 ± 2% p = NS; RV GLS -23 ± 2% vs -23 ± 5% p = NS). No second tumor was registered in dexrazoxane-treated survivors.

CONCLUSIONS

Our findings may support the role of dexrazoxane as a useful strategy for cardio-protection in children undergoing anthracycline based treatment. However, large randomized trials are needed to confirm the cardio-protective role of dexrazoxane in pediatric setting at long-term follow-up.