Poster session 6: Saturday 6 December 2014, 08:30–12:30: Location: Poster area

doi:10.1093/ehjci/jeu271

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

GENERAL PRINCIPLES: P1232: "Fast" Left Atrial Volume measures validation and its comparison with echocardiographic results in a patient cohort

J Goirigolzarri Artaza ¹, M Gallego Delgado ¹, CP Jaimes Castellanos ¹, MA Cavero Gibanel ¹, MA Pastrana Ledesma ¹, LA Alonso Pulpon ¹, J Gonzalez Mirelis ¹

Abstract

Introduction: The increase of left auricular volume (LAV) is a robust cardiovascular event predictor. Despite that echochardiography is more often used, cardiac MRI is considered more accurate. Our objetives are to validate "fast" LAV measures by MRI vs the considered gold standard (GS) and to compare Echo and MRI in a wide spectrum of patients.

Methods: In a non-selected popullation with MRI study previously realized, we measured LAV by biplane method (BPMR) and by area-length in 4 chamber view (ALMR) and compared them with biplane (BPe) and discs method (MDDe) in 4 chamber view in echo. To validate MRI measurements, we measured LAV in short axis slices (Simpson Method, SM) in a group of patients and considered it the GS.

Results: 186 patients were included (mean age 51 ± 17 age; 123 male; 14 in AF) with clinical indication of cardiac MRI (Philips 1,5 T). In 24 patients SM was calculated. 29% of cardiac MRI were considered normal. Mean underlying pathologies were myocardiopathy (27%), Ischemic myocardiopathy (17%), myopericarditis (10%), prior to AF ablation (4%), valvular disease (6%) and miscellaneous (7%). Excellent correlation was obtained between "fast" MRI measurements and SM in MRI (SM vs BPMR interclass correlation coefficient ICC=0.965 and SM vs ALMR, ICC=0.958; P<0.05) with low interobserver variability (ICC=0.983 for SM; ICC=0.949 for BPMR; ICC=0.931 for ALMR). "Fast" measurements by MRI showed stadistical correlation between them (CCI=0.910) (Figure). Correlation between Echo and MRI measures was only moderate. (BPRM vs BPe CCI=0,469 mean difference -30 ml; ALMR vs MDDe ICC=0,456 mean difference -24 mL).

Conclusions: ‘fast’ LAV measures by MRI are comparable with the MRI GS and also between them. Echo values seem to underestimate compared to MRI, so its use may not be suitable.

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

THE IMAGING EXAMINATION: P1233: Right ventricular dysfunction in patients with end-stage renal disease on regular hemodialysis

R Z Al Ansi ¹

Abstract

Purpose: Although there are considerable data on the changes in left ventricular function in hemodialysis (HD) patients, only a few studies on right ventricular (RV) function can be found in the literature. We investigated the changes in RV function in HD patients.

Methods: We examined 74 individuals grouped as follows: healthy controls (n =24) and HD patients (n =50). Echocardiography including tissue Doppler imaging (TDI) of the RV was performed in all patients.

Results: HD patients had significantly lower RV systolic indices than control participants in right ventricle fractional area change (37.54 ± 9.86 vs. 43.5 ± 4.8%,P<0.001), tricuspid plane systolic excursion (2.09 ± 0.49 vs. 2.61 ± 0.36 cm, P<0.001),Septal TDIS'(peak systolic velocity at septal tricuspid annulus) (7.99 ± 1.37 vs. 9.66 ± 1.86 cm/s,P<0.001), and Lateral TDIS' wave (peak systolic velocity at lateral tricuspid annulus) (11.86 ± 2.86 vs.16.04 ± 3.60 cm/s, P<0.001). HD patients had statistically significantly higher systolic pulmonary pressure compared with those in the control group (32.75 ± 10.11 vs. 25.23 ± 3.99 mmHg, P<0.001). There were no statistically significant correlations between systolic pulmonary pressure and RV dimensions or RV function indices.

Conclusion: Subclinical RV dysfunction – as estimated by RV function indices; tricuspid plane systolic excursion, right ventricle fractional area change, and Lateral TDIS' – is increased among HD patients. A high prevalence of pulmonary hypertension was found among HD patients and this was not associated significantly with RV or left ventricular dysfunction in these patients.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1234: Atrial septal aneurysm in adults: a case series study

S Sokolovic ¹

Abstract

Introduction: Atrial septal aneurysm (ASA) is a defect mainly in fossa ovalis that penetrate into the right or left atrium or both. The prevalence with TTE is about 1% and with TEE from 2% - 10%. Five types of ASA are recognized: 1R, 2L, 3RL, 4LR and 5 depending on the protrusion and excursion of the aneurysm. The excursion of anerysm from the midline of the atrial septum >10 mm into the right or left atrium or if the sum of both is criteria for diagnosis. ASA may be associated with PFO, MVP, ASD, VSD and cause arrythmias and thromboembolic events.

Material and Method: The retrospective clinical analysis was done in total 1080 patients from June 2008 to February 2014. Only 14 patients had ASA. TTE was done in all, and TEE in 4 pts. Among 14 patients, 12 had either arrythmia or palpitations. Two were asymptomatic. No cerebrovascular event seen.

Results: Total of 14 patients (1,29%) were found to have ASA among 1080 examined by TTE. There was a women predominance with 11 females (78,5%) and 3 males (21,5%). Average age of total was 41,9 years (20-67y), For female the average age was 36,4 years and 52 years for males. Average dimension of ASA was 15,5 mm (range from 11-19mm). Majority of patients had 1R type (11), followed by 2 patients with 3RL type and 1 with type 5. Two patients had a MVP and 2 had PFO. Left atrium was mildly enlarged with 4,2 cm in 4 patients.

Conclusion: ASA are usually found by TTE in individuals as a part of routine examination, and many patient are either asymptomatic or with some palpitations or arrythmia. In our study, 1,29 % of examined individuals had ASA with a women prevalence in 78,5%, compared to other other authors that reported the prevalence 2,2%, the mean age 65 yrs, and women predominance with 63%.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1235: Is 2D-echocardiographic left atrial volume assessment reliable?

G Cerin ¹, W Szychta ², B A Popa ¹, D Botezatu ¹, D Benea ¹, S Manganiello ¹, A Corlan ³, A Jabour ¹

Abstract

Background: Enlargement of left atrium (LA) reflects the severity of heart disease and is associated with adverse cardiac events. In mitral regurgitation (MR), LA dilatation is associated with onset/recurrence of atrial fibrillation (AF) and the degree of LA enlargement is nowadays object of debate for surgical / catheter ablation. Moreover, guidelines concerning valve diseases recommend considering LA dilatation as one of indications for mitral valve repair (MVR). Therefore, 2D-echocardiographic volumetric assessment of LA remodeling becomes more important in the everyday practice, but may be challenging.

Purpose: To compare the LA volume assessed by 64-multislice CT (MSCT) to 2D-transthoracic echocardiography (2D-TTE).

Methods: 22 pts (11♂, 40 ± 11y) with severe MR and indications for MVR underwent a preoperative MSCT study for the evaluation of coronary arteries. LA three dimensional volume reconstruction following MSCT was performed and compared with 2D-TTE LA volume in apical 4- and 2-chamber views (4C, 2C).

Results: Correlations between MSCT and 2D-TTE LA assessment were found (R=0.55, p=0.007 for 4C and R=0.4, p=0.06 for 2C), but 2D-TTE measurements rendered significantly lower LA volumes than MSCT, the differences being 19 ± 41ml for 4C and 38 ± 63ml for 2C measurements. While the average differences can be corrected, the broad dispersion of the differences from the reference MSCT measurements implies that 2D-TTE values may be unreliable for predictive purposes.

Conclusion: Due to geometric assumptions, 2D-TTE has limited accuracy in measuring LA volume. Therefore, a direct volumetric calculation method (3D-TTE, MSCT, magnetic resonance) should be used for LA evaluation when the degree of LA dilatation is conclusive in decision-making as MVR, catheter or surgical ablation. New echocardiographic methods for the estimation of the atrial volumes, especially for atrial dilatation in MR, need to be developed.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1236: Reliability of left atrial volume calculation using new segmentation algorithms in no triggered Cardiac Magnetic Resonance angiographic sequences.

B Igual Munoz ¹, JOA Osaca Asensi ², AALH Andres La Huerta ², AMG Maceira Gonzalez ³, JEE Estornell Erill ³, OCP Cano Perez ², MJSTDC Sancho-Tello ², PAF Alonso Fernandez ², PSS Sepulveda Sanchez ⁴, AMA Montero Argudo ²

Abstract

New segmentation methods allows to study with cardiac magnetic resonance (CMR) angiographic sequences the volume (3DVol) of selected structures easily with only one click, but its reliability compared to standard methods has not been tested so far. We aim is to assess the reliability of this measure compared with reference methods.

Methods: Patients who underwent CMR scan with angiographic sequences were prospectively included. Left atrial volume was obtained in volume rendered reconstructions with specific tools and also in 8-10 slices of cine sequences prescribed orthogonal to atrial septum. Maximum, minimum and mean left atrial volume (Max V, Min V, Mean V) were derived in cine sequences by Simpson method. Bland altman test and intraclass correlation coefficient (ICC) were used in this setting . RESULTS : 35 patients 27 males (35 %), Max V ranged 154 to 49ml, mean V ranged 138- 35ml, Min V ranged 124- 21ml and 3DVol 154-49 ml . The ICC of individual measures, significance, mean of differences an confidence interval are shown in the table.

Conclusions: (1)-3D Vol is a valid parameter to asses left atrial volume. (2).-3D Vol correlates better with maximum atrial volume derived by Simpson and can be used interchangeably.

Reliability of Vol3D

	ICC	Significance	Mean of differences	Confidence
Max V	0,80	<0,001	0,02 (NS)	(29, -29)
Mean V	0,78	<0.001	32,9 (S)	(2.8, -68)
Min V	0,63	<0.001	34,6 (S)	(79,-3)

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ANATOMY AND PHYSIOLOGY OF THE HEART AND GREAT VESSELS: P1237: Large artery remodeling and dynamics following simulated microgravity by prolonged head down tilt bed rest in humans

C Palombo ¹, C Morizzo ¹, M Baluci ², M Kozakova ³

Abstract

Introduction: The effects of simulated microgravity on the static and dynamic properties of large arteries are still largely unknown.

Aim of the Study: To evaluate, using an integrated vascular approach, changes in structure and function of the common carotid and femoral arteries (CCA and CFA) after prolonged 6-degree head-down tilt bed rest (HDTBR), known to simulate microgravity effects on the cardiovascular and muscular system.

Methods: Ten healthy men, age 23 ± 2, were enrolled in a 5-week HDTBR study endorsed by the Italian Space Agency and studied twice, the day before and the day after HDTBR. Arterial diameter and intima-media thickness (IMT) were assessed by radiofrequency-based system (QIMT®) implemented on a MyLab30 US scanner (Esaote, Florence). Volumetric flow (systolic and diastolic) was estimated from arterial diameter and flow velocity integral. Calibrated applanation tonometry (Pulsepen®, Diatecne, Milan) was used to estimate central (carotid) pulse pressure (cPP), wave reflection (Augmentation index, AIx), carotid to brachial pulse pressure amplification (PPA: PPbrachial/PP carotid) and pulse pressure index (PPI: local PP divided by mean BP). LV stroke volume (SV) was also estimated by aortic root Doppler. Aortic stiffness was estimated from carotid-femoral pulse wave velocity (PWV, Complior, Alam).

Results: After 5 weeks of HDTBR, CCA geometry did not change, while CFA showed a decrease in lumen diameter (10 ± 4%) without significant changes in wall thickness (IMT), resulting in an inward remodeling (IMT/luminal radius ratio from 0.14 ± 0.04 to 0.16 ± 0.3, P=0.05). The ratio of systolic-to-diastolic flow significantly decreased in CFA (from 5.8 ± 2.1 to 3.9 ± 0.6, p<0.01), while it did not change in CCA. The relationships between mean volumetric flow per beat in CCA or CFA and SV were also tested. In CCA but not in CFA the mean flow per beat at baseline was strongly related to baseline SV (r=0.75; P=0.01), and the changes in mean flow per beat during HDTBR were related to changes in SV (r=0.70; P<0.05).

Local carotid PP and PPI decreased (from 44 ± 11 to 36 ± 7 mmHg, and from 0.55 ± 0.11 to 0.44 ± 0.09, respectively, P<0.05), and brachial/carotid PP amplification increased (from 1.24 ± 0.11 to 1.31 ± 0.10, P<0.05). AIx and PWV were unchanged.

Conclusions: Prolonged HDTBR is associated with a decrease in the pulsatile compared to the steady central BP component; CFA shows a significant remodeling and change in flow pattern, by contrast with CCA where flow is strictly related to stroke volume. No significant changes in either arterial stiffness or wave reflection are detected.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ASSESSMENT OF DIAMETERS, VOLUMES AND MASS: P1238: Atrial anatomy shows a strong heritability in a classical twin study

A Panajotu ¹, J Karady ¹, G Szeplaki ¹, T Horvath ¹, DL Tarnoki ², AL Jermendy ¹, L Geller ¹, B Merkely ¹, P Maurovich-Horvat ¹, MTA-SE "Lendület" Cardiovascular Imaging Research Group

Abstract

Purpose: Recently it has been described that left atrial size is associated with an increased cardiovascular mortality and morbidity. Whether the atrial anatomy depends on environmental influences or determined by genetic factors is unclear. We sought to determine the heritability of left atrial dimensions in a classical twin study.

Methods: We studied 50 asymptomatic twin subjects (14 monozygotic [MZ] and 11 dizygotic [DZ] twin pairs) with no history of coronary artery disease. All participants underwent coronary CT angiography (CCTA) exam using a 256-slice CT-scanner. Atrial measurements were performed using a dedicated software. We measured the left atrial volume (LAV) and the average area of the pulmonary venous ostia (PVOA). We calculated the correlation between MZ and DZ twins with bootstrapped maximum likelihood estimation, rMZ and rDZ, respectively.

Results: The average age of the MZ and DZ twins was 55.6 ± 9.2 vs. 61.0 ± 7.9 years, p=0.161, the average height was 164 ± 9 vs. 167 ± 8 cm, p=0.284, the average weight was 72.1 ± 20.4 vs. 77.1 ± 18.1 kg, p=0.506. The mean LAV was 60.6 ± 17.9 cm³ and the mean PVOA was 194.0 ± 52.9 mm² after correction to the body surface area. The correlations within each MZ and DZ pairs were the following, LAV: 0.51 (95%CI:-0.02-0.77) vs. 0.29 (95%CI:-0.40-0.79); PVOA: 0.60 (95%CI:-0.35-0.87) vs. 0.14 (95%CI:-0.72-0.83), respectively.

Conclusion: The rMZ/rDZ ratios suggest that atrial geometry is driven by genetic effects rather than environmental influences.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1239: Gender influence on atrial performance explored by speckle-tracking echocardiography

S Moustafa ¹, F Mookadam ¹, M Youssef ², H Zuhairy ², M Connelly ³, T Prieur ³, N Alvarez ³

Abstract

Purpose: We assessed the hypothesis that gender difference might have an impact on atrial function.

Methods: Two-dimensional speckle-tracking echocardiography was acquired from the apical 4-chamber view in 100 normal subjects (50 men/50 women). Both right/let atrial (RA/LA) subendocardial surfaces were traced to obtain atrial volumes, strain (ɛ) and strain rate (SR). The maximum volume (Vmax), minimal volume (Vmin) & volume before atrial contraction (Vpre-a) were used to compute global atrial function.

Results: Mean age was 38.77 ± 14.73 years. There were no significant differences regarding demographics. Reservoir, conduit and booster pump functions showed no statistical significance among study groups (TABLE).

Conclusions: The results demonstrate no statistical significant differences between men and women concerning RA and LA function. This is in keeping with matching bi-atrial function which accommodate and propel identical cardiac output.

Aspects of atrial function.

		Men (N=50)	Women (N=50)	P-Value
(A)- ATRIAL RESERVOIR FUNCTION
Filling Volume (ml) (Vmax- Vmin)	LA	35.3 ± 10.3	34.66 ± 10.26	0.7
Filling Volume (ml) (Vmax- Vmin)	RA	27.66 ± 11.95	27.32 ± 12.22	0.22
(B)-ATRIAL CONDUIT FUNCTION
Passive emptying (%) of total emptying ([Vmax-Vpre-a]/[Vmax-Vmin])×100	LA	34.73 ± 10.33	34.11 ± 10.27	0.76
	RA	27.02 ± 12.01	26.67 ± 12.27	0.22
(C)-ATRIAL BOOSTER PUMP FUNCTION
Active emptying (%) of total emptying ([Vpre-a-Vmin]/[Vmax-Vmin]) × 100.	LA	11.24 ± 5.6	10.76 ± 5.13	0.13
	RA	10.63 ± 5.92	10.19 ± 5.71	0.7
(A)-ATRIAL RESERVOIR FUNCTION
SR_pos	LA	1.57 ± 0.51	1.55 ± 0.52	0.8
SR_pos	RA	1.89 ± 0.74	1.79 ± 0.69	0.4
(B)-ATRIAL CONDUIT FUNCTION
ɛ_Pos	LA	46.18 ± 16.75	44.91 ± 16.36	0.06
ɛ_Pos	RA	60.03 ± 30.74	57.22 ± 30.67	0.07
(C)-ATRIAL BOOSTER PUMP FUNCTION
SR_LateNeg	LA	−1.34 ± 0.65	−1.25 ± 0.64	0.48
SR_LateNeg	RA	−1.52 ± 0.82	−1.39 ± 0.73	0.08

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1240: Left atrial contractile function and atrial fibrosis in patients with paroxysmal atrial fibrillation

Y Ashikhmin ¹, O Drapkina ¹

Abstract

Aim: To investigate atrial contractile function and myocardial fibrosis in patients with paroxysmal atrial fibrillation (AF) using transthoracic echocardiography (EchoCG).

Methods: 35 patients with paroxysmal AF and arterial hypertension [AH] (mean age 62 ± 10 yrs, 43% males) were enrolled in the study. Control group was composed of comparable patients with AH without arrhythmias. EchoCG was performed in sinus rhythm according extended protocol, which include ejection fraction (EF) of left atrium (LA), and tissue Doppler measurements. Myocardial fibrosis was assessed quantitatively by echo-videodensitometry in intraventricular (IVS) and intraatrial (IAS) septa using original image postprocessing algorithm.

Results: Left and right ventricles volume and systolic function were normal in all patients. We found significant depression of atrial contraction function in patients with AF in sinus rhythm expressed as decrease in left atrium EF, A' velocity, and increase in A/A' ratio, whereas peak A velocity was not affected (see table). Degree of atrial function decrease was similar in AF patients with both LA dilation, and normal LA index (n=7). Echo-videodensitometry display significant increase in fibrosis fraction in IAS (but not in IVS) in AF group.

Conclusion: Patients with AF has markedly depressed atrial contractile function in sinus rhythm, to improve measurements accuracy we propose to use A/A' ratio as LA contractile function marker minimally dependent from LV diastolic function. Echo-videodensitometric analysis reveal 2.3-fold increase in intraatrial septum fibrosis fraction in AF patients compared with controls. This inexpensive method might be served as fair alternative to MRI in measurement of atrial fibrosis in AF.

LA contractile function & fibrosis

Parameter	AF (mean ± SD)	Control (mean ± SD)	p-level
Left atrium volume, ml	86 ± 31	66 ± 17	< .05
Left atrium EF, %	34 ± 14	54 ± 17	< .05
Peak A velocity, m/s	0.4 ± 0.1	0.51 ± 0.1	N/S
Peak A’ velocity, m/s	0,17 ± 0,04	0,22 ± 0,04	< 0,05
A/A’ ratio	2.7 ± 0.2	1.9 ± 0.1	< .01
E/A ratio	1.9 ± 0.2	1.6 ± 0.1	< .05
Volume fibrosis fraction in IVS, %	21.4 ± 15.3	23.7 ± 17.5	N/S
Volume fibrosis fraction in IAS, %	32.7 ± 15.6	13.9 ± 8.4	< .01

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1241: Structural and functional abnormalities of the left atrium in pts with atrial fibrillation: Speckle tracking analysis and prognosis of successful cardioversion

M Boutsikou ¹, E Demerouti ¹, E Leontiadis ¹, E Petrou ¹, G Karatasakis ¹

Abstract

Introduction: Our hypothesis is that structural abnormalities and functional impairment of the LA in pts with atrial fibrillation (AF), are related to the probability of successful cardioversion and maintenance of sinus rhythm (SR).

Purpose: To prove our hypothesis atrial volumetric indices, longitudinal 2D speckle tracking atrial parameters, and left atrial appendage emptying velocity (LAAV) have been correlated and used to predict cardioversion outcome and maintenance of SR in pts with chronic AF.

Methods: In 23 patients (12 males, aged 64 ± 13 years) who had complete 2D transthoracic (TTE), Doppler and transesophageal (TEE) study prior to cardioversion, we measured by TTE maximum LA volume prior to mitral opening (LA max), minimum LA volume at mitral closure (LAmin) and calculated LA ejection fraction (LAEF) as LAmax-LAmin/LAmax %. LAAV was measured by TEE. For 2D speckle tracking of global longitudinal strain (LAGS) and strain rate (StR) measurement, we performed manual delineation of LA endocardium adjusting the ROI to avoid inclusion of areas outside the LA. LAGS and SR values were defined as the highest value of the average strain and strain rate curves.

Results: In 8 pts DC cardioversion, performed within 2 days from echo evaluation, was successful and they maintained SR throughout a 2 months follow up. Overall, LAGS and StR were related to LAEF (r=0,667, p=0.001 and r=0,719, p<0.001). LAGS was also related to LAAV (r=0.421, p=0.045). Furthermore, patients who underwent successful cardioversion had higher LAGS values than the rest of the group (14.33 ± 8.1 vs 8.3 ± 4.09, p=0.028).

Conclusion: Volumetric and deformation parameters of the LA are closely related in pts with AF. LAAV also correlates to LAGS. Pts to be successfully cardioverted can be depicted prior to cardioversion because they have higher LA deformation indices.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1242: Body composition and vascular adaptation in adolescents

M Kozakova ¹, C Morizzo ², V Bianchi ¹, B Marchi ¹, G Federico ¹, C Palombo ²

Abstract

Background: Increase in body mass index is accompanied not only by metabolic alterations but also by increased stroke volume and hyperdynamic circulation due to a higher metabolic demand in expanded adipose tissue and in increased fat-free mass (FFM). Therefore, the alterations in vascular biomarkers of cardiovascular risk can not reflect simply preclinical atherosclerosis but physiologic adaptation to body composition-related changes in central hemodynamics.

Aim: To evaluate the relationships between body composition and arterial structure and function without the confounding impact of atherosclerotic risk factors, we assessed carotid intima-media thickness (IMT), luminal diameter (LD), carotid wave speed (WS), local carotid pulse pressure (cPP) and endothelial function (reactive hyperemia index, RHI) in 80 children-adolescents with wide range of age (8-16 years) and BMI (15-40 kg/m2).

Methods: Carotid variables were obtained by radio-frequency based ultrasound (QIMT® and QAS®, MyLab70, Esaote), RHI by EndoPAT (Itamar), body composition was assessed by bioimpedance technique, visceral fat (VF) by ultrasound, and stroke volume (SV) by Doppler echocardiography. Plasma lipids, glucose and insulin levels were also evaluated.

Results: In univariate correlations (p<0.05, at least), body weight (BW) and FFM were related to IMT (r=0.61 and 0.50), LD (r=0.54 and 0.53), WS (r=0.43 and 0.56) and cPP (r=0.36 and 0.49), whereas fat mass (FM) was related to IMT and LD (r=0.40 and 0.29), and VF to IMT and RHI (r=0.41 and -0.23). SV was more strongly related to FFM than to FM (r=0.70 and 0.24). In multivariate models, IMT was determined by BW and triglycerides (R²=0.44), LD by BW and male sex (R²=0.37), WS by FFM and systolic BP (R²=0.39), cPP by FFM (R²=0.24), and RHI by total cholesterol (R²=0.11). When SV was included into the models, it replaced FFM in model of cPP.

Conclusion: Adiposity-related changes in carotid function, mainly in local pressure, are depending on FFM-related increase in SV. Changes in carotid geometry, above all in IMT, seem to reflect also an increase in body fat and plasma lipids. Endothelial function is influenced only by lipids.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1243: Carotid plaques in middle-aged hypertensive patients

E Chatzistamatiou ¹, G Moustakas ², G Memo ¹, D Konstantinidis ¹, I Mpampatzeva Vagena ¹, K Manakos ¹, K Traxanas ¹, N Vergi ¹, A Feretou ¹, I Kallikazaros ¹

Abstract

Objective: Essential hypertension is an established risk factor for carotid atherosclerosis. This study sought to assess the prevalence, location and morphology of carotid plaque(s) as well as determinants of calcification in middle-aged hypertensive patients.

Design and Methods: A total of 756 consecutive newly diagnosed, never treated, non-diabetichypertensives without known cardiovascular disease (52 ± 13 years, 53% males) referred to the outpatient antihypertensive unit of our institution were studied in accordance to the European Society of Hypertension guidelines. All participants under went a carotid ultrasound: the far wall common carotid intima-media thickness (IMT) was measured 1cm before carotid bulb while carotid plaque(s)prevalence, location, and echogenicity and the degree of stenosis were determined.

Results: The median and maximal IMT were 0.67 mm (0.59-0.79) and 0.82 mm (0.73-0.96), respectively. Increased IMT (>0.9mm) was found in 32.4% of patients. The prevalence of carotid plaque(s)presence was 45.6% (21.6%, 16.1% and 7.9% for 1, 2 and >2 plaque(s), respectively) and it was higher (p<0.05) in patients with IMT>0.9 (63.1%) than in those with IMT≤0.9mm (37.4%). The majority of plaques were located at the posterior surface of the carotid bulb (64.3%) followed by multiple locations (13.2%), internal carotid arteries (9.7%), anterior surface of the carotid bulb (9.4%) and common carotid arteries (1.9%). Moreover, the majority of plaques were isoechogenic (41.5%) followed by hyperechogenic (22.9%), mixed echogenic (21.6%) and hypoechogenic (14%). Logistic regression analysis indicated sedentary lifestyle (OR 2.7, 95%CI 1.3-5.9, p=0.011), less milk product consumption (OR 2.8, 95%CI 1.1-7.1, p=0.030), lower plasma calcium concentration (OR 2.86 95%CI 1.2-6.7, p=0.021) and increased carotid compliance (OR 1.13, 95%CI 1.02-1.25, p=0.022) as independent predictors of higher echogenicity after adjustment for age, gender, smoking, LDL-cholesterol, body surface area, 24-hour blood pressure and 24-hour heart rate. Besides, the median degree of stenosis was 20% (10-30%) while the prevalence of stenosis>50% was 2%.

Conclusions: Non-stenotic plaques of low echogenicity, predominantly located at the posterior surface of the carotid bulb are commonin middle-aged newly diagnosed hypertensives. Physical activity, milk product consumption, plasma calcium levels and carotid wall stiffness emerge as independent determinants of calcification.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ASSESSMENTS OF HAEMODYNAMICS: P1244: A new method for imaging two-dimensional flow propagation in the Left Ventricle

M Goto ¹, T Uejima ¹, K Itatani ², G Pedrizzetti ³

Abstract

Purpose: Flow propagation of left ventricular (LV) inflow reflects LV relaxation and can be assessed using colour M-mode Doppler. However, this method does not account for regional variations. In this abstract, we expand the simple 1-dimensional assessment into 2-dimensional (2D) displays of LV flow propagation.

Methods: In 14 patients with systolic heart failure (SHF, 67 ± 14years old) and 5 patients with diastolic heart failure (DHF, 57 ± 22years old) and 14 normal subjects (N, 40 ± 13years old), 2D structure of blood transport inside LV was assessed, by first estimating flow vectors with Vector Flow Mapping (Hitachi-Aloka, Tokyo) and then solving a governing equation of fluid transport in fluid mechanics with MATLAB (MathWorks, Massachusetts). Virtual ink was added intermittently at the mitral valve to delineate LV inflow wave propagating toward the apex.

Results: In N group, the front wave propagated fast toward the apex; the subsequent wave accelerated and merged with the front wave at the apex, suggesting a facilitated blood transport during early diastole (figure A). In DHF group, there was a slow propagation in the LV without consecutive wave lines merged during early diastole; the flow wave lines became distorted in later phase (figure B). These images suggested a passive LV filling and subsequent disorganised flows. In SHF, LV filling waves moved slowly and formed into large round mushroom-shape and then the flows swirled around as a whole (figure C).

Conclusion: This new method illustrated a facilitated blood transport in the normal LV and a passive and disorganised LV filling in the LV with heart failure.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ASSESSMENT OF SYSTOLIC FUNCTION: P1245: How to define end-diastole?

RO Mada ¹, AM Daraban ¹, J Duchenne ¹, JU Voigt ¹

Abstract

The exact definitions of end-diastole (ED) and –systole (ES) are crucial for correct myocardial deformation measurements as they influence the baseline and ES measurements. This study aims to investigate which surrogate parameters characterize ED and ES best.

Methods: 20 healthy volunteers (Normal), 20 patients with ischemic heart disease (Ischemic) and 20 patients with typical left bundle branch block (LBBB) underwent echocardiography. ED and ES references were defined by observing mitral and aortic valve closure in the apical three chamber views. M-modes through the mitral valve were acquired using each of the three ECG leads. In all apical images, we investigated the following potential surrogate parameters for ED: peak R, automatic ECG trigger (Trigger), peaks of the single plane and averaged speckle tracking based volume (vol) and global longitudinal strain curves (GLS), and the mitral valve Doppler. For ES, we used the respective curve nadirs and the aortic valve spectral Doppler.

Results: Depending on the QRS morphology, the timing of peak R and Trigger differed considerably between the three leads (>23 millisec. (ms)). Analysis of the relation between ED reference and the surrogate parameters showed that spectral Doppler was most accurate under all conditions (p<0.05) while tracking derived parameters differed considerably from ED reference, particularly in Ischemic and LBBB (up to 48ms, see Figure). Similar observations were made for ES.

Conclusion: ECG-derived time markers are highly dependent on the selected ECG lead as well as on the QRS morphology. Spectral Doppler is a reliable time marker while speckle tracking based surrogates are unreliable in certain pathologies and are therefore less suited for timing measurements in myocardial function imaging.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1246: Tissue motion mitral valve annular displacement, measured using two-dimensional speckle tracking, correlates with global longitudinal strain in haemodialysis patients with preserved ejection fraction

D Y Y Chiu ¹, D Green ¹, L Johnstone ², S Sinha ², PA Kalra ², N Abidin ³, Salford Vascular Research Group

Abstract

Background: Assessment of tissue motion mitral valve annular displacement (TMAD) using 2D speckle tracking echocardiography is simple, quick to perform and reproducible. There has been reported correlation between TMAD and left ventricular ejection fraction (LVEF) in the general population. However, this has not been investigated in patients with end stage kidney disease, where left ventricular hypertrophy is prevalent and many patients have an asymmetrically sized left ventricle. The aim of this study was to investigate the association of TMAD with left ventricular function in patients undergoing haemodialysis with preserved LVEF.

Methods: 2D transthoracic echocardiography was performed in 194 haemodialysis patients on a non-dialysis day. LVEF was determined by Teichholz method in M-mode. Peak systolic longitudinal strain (Sl) in apical 4-, 2- and 3- chamber views, and TMAD (in apical 4- and 2- chamber views) was measured using speckle tracking software (QLAb; Philips Medical System). The average value of Sl from the 3 apical views was defined as global longitudinal strain (GLS). An average of the midpoint value of TMAD in both 4- and 2- chamber views was also calculated. Linear regression was utilized to explore the correlation between TMAD and other parameters.

Results: 166 patients had LVEF>50%. In this group, mean age was 61.1 (standard deviation, SD=14.6) years, 65% were male, 10% had history of myocardial infarction. Mean LVEF was 67.4 (9.32)%, mean left ventricular mass index was 114.3 (34.7) g/m2 and 42% had left ventricular hypertrophy.

Mean average TMAD was 10.2 (2.5) mm. Apical 4-, 2- chambers and average TMAD was poorly correlated with LVEF (r=0.04, 95% confidence interval, CI, -0.11 to 0.19, p=0.61; r=-0.07, 95%CI -0.22 to 0.08, p=0.36; r=-0.02, 95%CI -0.17 to 0.13, p=0.79, respectively).

Mean GLS was -13.80 (3.5)%. Apical 4-, 2- chamber and average TMAD showed a good correlation with GLS (r=-0.60, 95%CI -0.69 to -0.49, p<0.01; r=-0.53, 95%CI -0.63 to -0.41, p<0.01; r=-0.62, 95%CI -0.71 to -0.51, p<0.01, respectively).

Conclusions: TMAD showed poor correlation with LVEF in this population, this might be due to the high prevalence of left ventricular hypertrophy associated with depressed left ventricular longitudinal motion. Mean GLS was also depressed in this group despite preserved LVEF. However, TMAD showed good correlation with GLS. Therefore it may be a useful technique that does not depend on endocardial definition, in rapidly detecting subclinical longitudinal strain abnormalities in haemodialysis patients with preserved ejection fraction.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1247: Myocardial performance index before and after percutaneous coronary intervention in patients with stable coronary artery disease with or without diabetes mellitus type 2

M Sikora-Frac ¹, B Zaborska ¹, P Maciejewski ¹, B Bednarz ¹, A Budaj ¹

Abstract

Myocardial performance index (MPI) is a valuable parameter of combined systolic and diastolic left ventricular (LV) function. The effects of percutaneous coronary intervention (PCI) on LV function in pts with stable coronary artery disease (SCAD) and preserved LV ejection fraction (EF) are not well known, particularly in patients with coexisting diabetes mellitus type 2 (DM t.2).

Aim: To evaluate the effects of PCI on the LV function using MPI in relation to DM t.2.

Methods: To assess LV function, MPI was calculated before and 3 months after PCI. PCI was performed for significant lesions (stenosis >70%). Extent of CAD was assessed with SYNTAX and EXTENT scores. To evaluate impact on MPI multivariate linear regression analyses were performed. DM t.2 diagnosis, SYNTAX and EXTENT scores, BMI>30 and high molecular weight adiponectin/total adiponectin ratio were included into the models.

Results: Consecutive 66 pts with SCAD and LVEF >50% undergoing PCI were enrolled in the study; 34 pts had SCAD and DM t.2 (age 67 ± 8.6 years, mean duration of DM 6 years) and 32 pts had SCAD without DM t.2 (age 66.2 ± 7.7 years). Baseline MPI was significantly higher in diabetic vs non diabetic pts. MPI improved in the whole group and in pts with or without DM t.2 three months after PCI (table). Improvement in MPI was significantly greater in diabetic pts compared to non-diabetics (Δ MPI 0.17 ± 0.07 vs 0.12 ± 0.05; p=0.0025). On multivariate linear regression analysis, DM t.2 and EXTENT score were independent factors negatively related to the baseline MPI (β=0.06; p=0.02 and β=0.27; p=0.01, respectively). No significant impact on the degree of MPI improvement post PCI in any of the studied groups for any tested factor was revealed.

Conclusions: PCI had significant positive impact on LV function, expressed as MPI, in diabetic and non-diabetic pts with preserved LV function. The degree of improvement was significantly greater in diabetics. It may suggest that coronary revascularization in this group of patients may be particularly useful.

MPI before and after PCI

	Total group	CAD	CAD+DM t.2	P*
MPI ( ± SD) before PCI	0.57 ( ± 0.09)	0.53 ( ± 0.06)	0.6 ( ± 0.1)	<0.001
MPI ( ± SD) after PCI	0.42 ( ± 0.08)	0.4 ( ± 0.05)	0.44 ( ± 0.1)	0.18
P**	<0.0001	<0.0001	<0.0001

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*CAD vs CAD+DM t.2;**before vs after PCI

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1248: Relationship between early videodensitometric blush parameters following invasive treatment of ST-elevation myocardial infarction and late cMRI-derived myocardial loss index

A Nemes ¹, V Sasi ², H Gavaller ³, A Kalapos ¹, P Domsik ¹, A Katona ², T Szucsborus ², T Ungi ⁴, T Forster ¹, I Ungi ²

Abstract

Introduction: Tissue level myocardial perfusion is one of the most important prognostic factors after successful recanalisation of the occluded coronary artery in patients suffering acute ST-elevation myocardial infarction (STEMI) to determine myocardial injury. The objective of the present study was to examine the relationship between videodenzitometric myocardial blush parameters assessed on coronary angiograms directly following successful recanalization therapy and cardiac magnetic resonance imaging (cMRI)-derived myocardial lost tissue level late after STEMI.

Methods: The study comprised 29 STEMI patients (mean age: 59.1 ± 10.9 years, 21 males). Quantitative myocardial perfusion was assessed by videodensitometry on coronary angiogram following successful recanalisation of the occluded vessel. Perfusion was characterized by the ratio of maximum density (Gmax) and the time-to-reach maximum density (Tmax). Parameters were calculated on time-density curves over myocardial areas supplied by the occluded vessel. Epicardial coronary arteries were digitally masked out. Blush measurements were compared to a cMRI-derived index (MLI=myocardial loss index) based on extent of infarction, affected segments and transmurality following 376 ± 254 days after STEMI.

Results: Mean MRI-derived MLI proved to be 0.65 ± 0.23, Gmax was 11.53 ± 5.64, while Gmax/Tmax was 2.64 ± 1.12. Significant correlations could be demonstrated between MLI and Gmax (R=0.36, p=0.05) and Gmax/Tmax (R=0.40, p=0.03) using vessel masking. Using ROC analysis Gmax/Tmax ≤2.17 predicted best MLI=0.3, 0.4, 0.5 and 0.6 with good sensitivity (100%, 100%, 89%, 70%, p <0.05 for all, respectively) and specificity data (69%, 75%, 85%, 79%, p <0.05 for all, respectively), while Gmax/Tmax ≤3.25 proved to have a prognostic role in the prediction of MLI=0.7 (sensitivity 81%, specificity 62%, p=0.05) (higher MLI value means less myocardial loss).

Conclusions: There is a relationship between early parameters asessed by selective densitometric quantitative blush method and cMRI-derived MLI following invasive treatment of STEMI.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1249: Left and right ventricular deformation indexes in neonates

FR Pluchinotta ¹, C Arcidiacono ¹, A Saracino ¹, M Carminati ¹, C Bussadori ¹

Abstract

Purpose: To evaluate cardiac maturation through direct quantification of left ventricular (LV) and right ventricular (RV) systolic function in healthy newborns measuring longitudinal peak systolic strain (PSS) and peak systolic strain rate (PSSR) of both ventricles, LV circumferential PSS and PSSR, and LV systolic rotation (LV rot°).

Methods: The study included 31 healthy newborns (1 to 5 day-old). All subjects were born at term and free from any cardiac abnormalities. Echocardiographic exams were performed with a multi-frequency 5– 7.5 MHz transducer. 2D harmonic cine-loop with a frame rate of 40-64 fps cine video clips from apical 4 chamber and LV short axis views at mitral and apical levels were acquired and stored for off-line analysis. Off-line computer based analysis were performed using a software based on speckle tracking technology (XStrain™, Esaote - Florence) installed on a Windows™ based computer workstation. Parameters computed were longitudinal PSS and PSSR of both ventricles, LV circumferential PSS and PSSR, and LV rot° at basal and apical level. Two sided p-values and 95% CI were used.

Results: LV longitudinal PSS (-18,66 ± 7,62) and PSSR (-1,52 ± 0,29) values are similar to what previously derived in children and young adult with a significant increasing of the values from the base to the apex in the septal wall (p≤0.05), while differences between segments were not significant in the lateral wall. The LV circumferential PSS and PSSR increased from the base to the apex in all subjects (p≤0.05). RV PSS (40,42 ± 3,52) and PSSR (-4,05 ± 0,55) were consistently higher than those of the LV without significant difference by segments. LV rot° at the apex was positive and uniform (+8 ± 0,82) conversely basal rotation was negative with a not uniform direction of the segments (-1,40 ± 3,03).

Conclusion: LV longitudinal and circumferential PSS and PSSR showed patterns of values similar to what we reported for children and young adults. High values of RV PSS may represent the expression of an accentuate activity of the RV longitudinal function in neonate. Low values of LV basal rotation compared to the apex express a lack of coordination in the rotational mechanism in the newborns compared to children and adults. This could be due to incomplete maturation of the myocardial fibers orientation but also pulmonary resistance and ventricular interdependence may play a role. The definition of specific reference values for newborn is essential for a better understanding of myocardial maturation and to define LV and RV dysfunction in this population.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1250: IABP improves function in severly hypokinetic and akinetic segments during cardiogenic shock

T Dahlslett ¹, S Karlsen ¹, B Grenne ², B Sjoli ², B Bendz ³, H Skulstad ³, OA Smiseth ³, T Edvardsen ³, H Brunvand ¹

Abstract

Purpose: Intra-aortic balloon pump (IABP) has been used for mechanical circulatory support in patients with cardiogenic shock for the last 40 years. Recently its use has been questioned by the lack of supportive evidence in clinical studies. Our aim was to investigate the cardiomechanical and physiological effect of IABP on left ventricular function in patients with cardiogenic shock after acute myocardial infarction (AMI).

Methods: 45 patients with AMI and cardiogenic shock treated with IABP were included. Echocardiography with synchronised intra-aortic pressure recordings were performed during IABP support and repeated after 5 minutes of standby position of the IABP. Longitudinal peak systolic strain was measured using speckle-tracking echocardiography. Global peak systolic longitudinal strain (GLS) was calculated as the average strain in a 16 LV segment model. Left ventricular ejection fraction (LVEF) was measured.

Results: After 5 minutes standby of the IABP, mean systolic aortic pressure had increased from 83 mmHg to 92 mmHg (p<0.01), mean aortic diastolic pressure decreased from 87 mmHg to 79 mmHg (p<0.01) and aortic end diastolic pressure increased from 66 mmHg to 71mmHg (p<0.01). Mean aortic pressure did not change significantly 85 mmHg vs. 84 mmHg (p=0.32). GLS and LVEF slightly improved -9.3 ± 4.5% vs. -8.7 ± 4.3% (p=0.01) and 35 ± 10% vs. 33 ± 10% (p<0.05), an improvement of 0.5% (CI 0.1 to 0.9) and 2.6% (CI 0.1 to 5.2) respectively. In a segmental analysis (Table 1), the segments were grouped according to their average function on and off IABP. The results show that segmental systolic function only significantly improved in severely hypokinetic or dyskinetic LV segments with IABP.

Conclusion: In patients with cardiogenic shock after AMI, IABP reduces mean systolic and increases mean diastolic pressure, but does not change the overall mean aortic pressure. Regional systolic function was improved in severely hypokinetic and dyskinetic LV segments with slightly improved global LV function measured by GLS and LVEF.

Pooled segmental analysis

Segment group	No. segments	Mean change (CI)	Significance level
−15% or better	396	−0.3% (-0.7 to 0.1)	0.11
−15% to -5%	138	−0.2% (-1.0 to 0.5)	0.52
−5% or worse	144	−1.2% (-2.1 to -0.2)	0.02*

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1251: New routine echocardiographic parameter for the detection of subtle left ventricular systolic dysfunction in heart failure with preserved ejection fraction and its precursor conditions

A Vereckei ¹, ZS Szelenyi ², G Szenasi ³

Abstract

Purpose: To find a routine echocardiographic left ventricular (LV) systolic function parameter suitable for the detection of subtle LV systolic dysfunction revealed by imaging studies measuring myocardial deformation in patients with heart failure with preserved ejection fraction (HFPEF) and its precursor conditions such as hypertension.

Methods: To this end, ≥60-year-old 18 control and 94 hypertensive patients with normal ejection fraction (EF) were studied with echocardiography. Detailed assessment of systolic and diastolic LV function, LV myocardial mass (LVM) and online mitral annular velocity, offline LV myocardial strain (S) and strain rate (SR) measurements by tissue doppler (TDI) and speckle tracking imaging (STI) were done.

Results: LV diastolic dysfunction was not found in 38/94(40%) hypertensive patients (HTDD- group) and mild LV diastolic dysfunction was verified in 56/94(60%) hypertensive patients (HTDD+ group). No between-groups difference was found in EF and mitral annular velocities. The body mass index (BMI) increased (p<0.05 for HTDD- and p<0.01 for HTDD+ groups) and the absolute values of mean peak longitudinal LV systolic S (p<0.05 for both groups) and SR (p<0.001 for both groups) with TDI and global longitudinal LV peak systolic S (GLS) with STI (p<0.05 for HTDD- and p<0.001 for HTDD+ groups) decreased in both patient groups vs. controls. The LVM and LVM/BMI increased (p<0.001 and p<0.01 respectively) in the HTDD+ group, the EF/LVM/BMI decreased in both patient groups (p<0.05 for HTDD- and p<0.001 for HTDD+ groups) vs. controls. LVM increased (p<0.05) and EF/LVM/BMI decreased (p<0.05) in the HTDD+ group vs. HTDD- group, and in the HTDD- group (p<0.05 for both) vs. controls. Using ROC analysis EF/LVM/BMI proved to be the best parameter of LV systolic function [with an area under the curve (AUC) of 0.8039, p<0.0001], and its cutoff value <15.73 m2/kg2 indicated LV systolic dysfunction as accurately (sensitivity: 75.56%, specificity: 82.55%) as the best myocardial deformation parameters: mean peak longitudinal LV. systolic SR/BMI with TDI (AUC: 0.7903, p=0.00011) and GLS/BMI with STI (AUC: 0.7904, p=0.0001284).

Conclusions: In contrast to EF, the routine echocardiographic parameter EF/LVM/BMI detects subtle LV systolic dysfunction as accurately as myocardial deformation parameters in patients with hypertension, the most common HFPEF precursor state, regardless whether LV diastolic dysfunction, representing transition of hypertensive heart disease to HFPEF, is present or not.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1252: Regional longitudinal strain correlates with TIMI frame count and extension of myocardial damage after acute anterior STEMI

C Santoro ¹, M Galderisi ¹, T Niglio ¹, M Santoro ¹, E Stabile ¹, A Rapacciuolo ¹, L Spinelli ¹, G De Simone ¹, G Esposito ¹, B Trimarco ¹

Abstract

Purpose: Regional and global longitudinal strain (GLS) derived by Speckle Tracking Echocardiography (STE) has been succesfully used after STEMI for predicting left ventricular (LV) infarct size and prognosis. We evaluated the relationship between regional and GLS with currently available coronary angiographic scores and myocardial markers after anterior STEMI .

Methods: Nineteen patients with acute anterior STEMI underwent standard echocardiography and STE-derived Automated Function Imaging early after coronary angiography. A group of 19 normal subjects, matched for age and sex were the control group for echocardiographic parameters. LV ejection fraction (EF), the ratio of transmitral E velocity to annular tissue-Doppler e' velocity (E/e' ratio) and GLS (average of 18 regional longitudinal strain in the apical views) were calculated. Longitudinal strain of left anterior descending territory (LSlad) was also generated as the average of 8 myocardial segments (middle and apical posterior septum, basal, middle and apical anterior septum, basal, middle and apical anterior wall). By coronary angiography TIMI flow grade and TIMI frame count (TFC) were calculated. Laboratory cardiac biomarkers were also determined.

Results: The two study groups were comparable for blood pressure, heart rate and body mass index . STEMI patients had lower EF and high E/e' ratio (both p<0.0001) than controls. GLS was -10.9 ± 3.3% in STEMI and -19.9 ± 2.2% in controls (p<0.0001). LSlad was -7.1 ± 3.8% in STEMI and -21.0 ± 2.6 in controls (p<0.0001). In STEMI patients, LSlas was negatively related with TFC (r=-0.58, p<0.01) and troponin levels (r=-0.48, p<0.05) but not to TIMI flow grade. TFC was also marginally related to E/e' ratio (r=0,40, p<0.05) but not to EF or GLS.

Conclusions: We demonstrate that STE-derived analysis can detect non invasively the ischemic territory of the culprit lesion after acute STEMI. In particular, the determination of longitudinal strain of the left anterior descending artery might be useful to identify the extent of myocardial damage and the degree of myocardial perfusion before performing coronary angiography.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1253: Imaging myocardial fibrosis in pulmonary arterial hypertension: comparison between echocardiography, deformation imaging, MRI, and serum biomarkers of myocardial fibrosis

S Hubert ¹, A Jacquier ¹, J Fromonot ¹, C Resseguier ¹, A Tessier ¹, R Guieu ¹, S Renard ¹, J Haentjiens ¹, C Lavoute ¹, G Habib ¹

Abstract

Background: Evaluation of right ventricle function is crucial but difficult in pulmonary arterial hypertension (PAH). Right ventricular myocardial fibrosis has been correlated with right ventricular function and prognosis and can be evaluated by several methods, including late gadolinium enhancement (LGE) detected by cardiovascular magnetic resonance (CMR), deformation imaging (2D strain) and serum markers of collagen turnover. Myocardial fibrosis imaging based on T1-mapping and extracellular volume fraction (ECV) has not been systematically assessed for right ventricle evaluation.

Objectives: To compare ECV, echo longitudinal strain, and serum markers of collagen turnover in the assessment of myocardial fibrosis in a population of adults with PAH.

Methods: Twelve patients with PAH (6 male) were prospectively included and underwent on the same day

- TTE including measurement of right ventricular fractional shortening (RVFS) (%)by 2D echo, TAPSE by M-mode (mm), maximal tricuspid annulus velocity S (m/s) by tissue Doppler, RV global deformation RVD (%) and segmental (septal and lateral) RV deformations (%) by 2D strain

- Right ventricular ejection fraction and global right ventricular myocardial ECV by CMR. T1 mapping and ECV were quantified in areas where RV wall thickness were >=5mm and

- Measurements of 2 biomarkers of collagen turnover: TIMP-1 (Tissue Inhibitor of MetalloProteinase 1) and PIII-NP (Procollagen III N-Propeptid).

Results: Right ventricular ECV was abnormal (> 25%) in all patients and was significantly correlated with RVFS (r=0.6, p=0.026), S' velocity (r=0.7, p=0.009), TAPSE (r=0.6, p=0.04), and RV ejection fraction measured by MRI (r=0.6, p=0.04).

Septal ECV correlated well with septal 2D strain (r=0.7, p=0.013).

There was no significant relationship between ECV or RV strain and serum levels of biomarkers, but a trend was observed between PIIINP values and right ventricular ECV (p=0.064).

Conclusion: In patients with PAH, RV myocardial ECV (T1 mapping CMR) is a potential additional quantitative tool for accurate detection of right ventricular fibrosis and correlates well with other markers of RV dysfunction.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1254: Novel paediatric and adult normative strain values for the left and right ventricle using 2D speckle-tracking echocardiography

M E Menting ¹, LP Koopman ², JS Mcghie ¹, B Rebel ², D Gnanam ², WA Helbing ², AE Van Den Bosch ¹, JW Roos-Hesselink ¹

Abstract

Purpose: Strain measurements using speckle-tracking echocardiography (STE) are associated with clinical outcome in congenital heart disease and play an increasing role in clinical practice. However, strain measurements depend on the ultrasound system. No normative data exist for QLAB software (Philips). We aimed to provide normative strain values for children (4-18 years) and adults (19-60 years), and to determine the influence of sex and BSA.

Methods: Global and segmental peak systolic longitudinal strain (LS) and strain rate of the left ventricle (LV) consisting of LV lateral wall and septum, and of the RV lateral wall were measured from the apical four-chamber view with STE (QLAB 9.0).

Results: We included 150 healthy subjects: 75 children (age 11.6 ± 3.6 years, 51% male, BSA 1.35 ± 0.35m2) and 75 adults (age 33.7 ± 10.8 years, 52% male, BSA 1.88 ± 0.16m2). Feasibility of LV LS was 99% and of RV LS 72%. Mean LV LS was similar in children (-19.7 ± 2.7%) and adults (-19.5 ± 2.5%, p=0.669), as well as RV LS (-28.6 ± 4.9% vs. -28.3 ± 4.6%, p=0.729). Strain measurements of the three walls separately show that sex difference is only present in the LV lateral wall of adults (Figure 1). In children, BSA was correlated with LV LS (r=0.25, p=0.032) and with RV LS (r=0.41, p=0.001). Strain rate of the LV midseptal (-1.33 ± 0.35%/s vs. -1.23 ± 0.25%/s), apical lateral (-1.44 ± 0.59%/s vs. -1.18 ± 0.41%/s), and midlateral wall (-1.65 ± 0.62%/s vs. -1.29 ± 0.38%/s) was significantly higher in children than adults, but not affected by sex.

Conclusions: Mean LV and RV LS are similar in children and adults, and sex difference is only found in adults regarding LV lateral wall LS. Strain rate was higher in children than adults. Furthermore, BSA influences LV and RV strain in children, which is important for interpreting results.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1255: Usefulness of right ventricular basal free wall strain by two-dimensional speckle tracking echocardiography in patients with chronic thromboembolic pulmonary hypertension

K Shiino ¹, A Yamada ¹, K Sugimoto ², K Takada ¹, Y Takakuwa ¹, M Miyagi ¹, M Iwase ¹, Y Ozaki ¹

Abstract

Purpose: Recently two-dimensional (2D) speckle tracking echocardiography (STE) derived from right ventricular (RV) free wall has been shown to be a very useful tool for the estimation of RV performance. The purpose of this study was to examine whether RV basal free wall strain can detect increased mean pulmonary arterial pressure (mPAP) in patients with chronic thromboembolic pulmonary hypertension (CTEPH).

Methods: We investigated a total of 126 patients with CTEPH (mean age: 56 ± 12 years). They underwent echocardiography and right heart catheter examination. 2D STE-derived longitudinal strain was measured by placing 2 regions of interests (ROIs) on the RV basal free wall in RV-focused apical four-chamber view. Peak strain (RV-PS) was acquired between the 2 ROIs. Conventional echocardiographic RV parameters (RV fractional area change, RV myocardial performance index, tricuspid annular plane systolic excursion, and tricuspid annular peak systolic velocity) were evaluated as well. Right heart catheterization was performed on the following day of echocardiographic evaluation.

Results: Among RV echo parameters, RV-PS showed the best correlation with mPAP (R=0.75, P < 0.0001). Receiver operating characteristic analysis revealed that a cut-off value of RV-PS -20.8% could detect mPAP > 25mmHg (sensitivity 78%, specificity 93%, area under the curve 0.90, P < 0.001).

Conclusions: RV basal free wall strain was a useful tool for the non-invasive detection of increased mPAP in patients with CTEPH.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ASSESSMENT OF DIASTOLIC FUNCTION: P1257: Dissipative energy loss within the left ventricle during diastole reflects left ventricular diastolic function

T Hayashi ¹, K Itatani ², R Inuzuka ¹, T Shindo ¹, Y Hirata ¹, N Shimizu ¹, K Miyaji ³

Abstract

Purpose: Dissipative energy loss (EL) has been increasingly applied in cardiovascular medicine as an indicator of blood flow efficiency. EL within the left ventricle can be echocardiographically estimated by vector flow mapping (VFM) analysis and is thought to reflect the superfluous cardiac workload caused by turbulent flow in the left ventricle. The aim of this study was to explore the correlation between diastolic EL and echocardiographic indices of diastolic function.

Methods: VFM analysis and EL calculation were performed using apical 5-chamber view echocardiographic images of 29 children (26 children without a congenital heart defect, 1 with patent ductus arteriosus, 1 with a ventricular septal defect, and 1 with coarctation of the aorta). The z-score of diastolic EL was obtained using the previously published normative reference value of diastolic EL that was adjusted to body surface area, age, and heart rate. In addition to widely used echocardiographic indices of diastolic function such as the transmitral E/A ratio, peak myocardial velocity at the septal mitral annulus in early diastole (e'), and E/e' ratio, we measured the transmitral color M-mode Doppler flow propagation velocity (FPV) and E/FPV ratio, which reflect the time constant of isovolumic relaxation and the left ventricular filling pressure, respectively.

Results: The mean subject age was 7.8 ± 4.1 years. The diastolic EL z-score ranged from -1.92 to 2.49 and was significantly correlated with the E/e' ratio (r=0.46, p < 0.05), FPV (r=-0.47, p < 0.01), and the E/FPV ratio (r=0.65, p < 0.001). There were no significant correlations between diastolic EL z-score and the E/A ratio or e'. The E/FPV ratio was the only significant predictor of diastolic EL z-score on multivariate analysis.

Conclusions: We found a strong positive correlation between diastolic EL z-score and the E/FPV ratio, suggesting that an increased diastolic EL would be associated with elevated left ventricular filling pressure. Diastolic EL, which reflects transmitral flow-induced turbulence and vortex in the left ventricle, might be more appropriate for estimating left ventricular diastolic function than the E/FPV and E/e' ratios. Further studies that compare diastolic EL and the invasive indices of diastolic function are warranted.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1258: Relationship between Left Atrial deformation and B-type natriuretic peptide activation in asymptomatic Aortic Stenosis

C Henri ¹, R Dulgheru ¹, J Magne ², S Kou ¹, L Davin ¹, A Nchimi ¹, C Oury ¹, L Pierard ¹, P Lancellotti ¹

Abstract

Purpose: ESC guidelines emphasize the usefulness of B-type natriuretic peptide (BNP) measurements in aortic stenosis (AS). The purpose of the present study was to determine the relationship between BNP activation and left atrial (LA) volumes and strain parameters.

Methods: We studied asymptomatic patients with ≥ moderate AS who underwent concomitant BNP level measurement and echocardiography. LA volumes were measured using Simpson method and strain parameters using speckle-tracking of the mid septal and lateral segments in apical 4-chamber view. Patients (n=23) were divided into 2 groups according to the median of BNP level (65pg/mL).

Results: Patients in the high BNP level group had a significantly lower peak negative strain, peak positive strain, late peak positive strain rate and early diastolic negative strain rate (Table). Significant correlations were found between peak negative strain (r=0.60, p<0.01), peak negative strain rate (r=0.47, p=0.02), peak positive strain (r=-0.45, p=0.03), late peak positive strain rate (r=-0.49, p=0.02), early diastolic negative strain rate (r=0.47, p=0.03) and BNP level. However, there was no difference for LA volumes according to BNP level group and no significant correlations with BNP level.

Conclusion: In AS, BNP activation is determined by LA functional changes as assessed by deformation imaging. Conversely, LA structural changes are not related to BNP release.

LA volumes and strain parameters

	Low BNP group	High BNP group	p-value
Indexed systolic LA vol, mL/m²	30.8 ± 12.7	32.9 ± 9.3	0.65
Indexed diastolic LA vol, mL/m²	11.9 ± 6.6	13.7 ± 5.6	0.49
Indexed pre-A wave LA vol, mL/m²	19.3 ± 11.2	23.1 ± 7.4	0.36
Indexed LA stroke vol, mL/m²	18.8 ± 7.1	19.2 ± 6.1	0.90
Indexed LA passive vol, mL/m²	11.4 ± 4.5	9.8 ± 2.8	0.31
Indexed LA active vol, mL/m²	7.4 ± 5.0	9.4 ± 4.2	0.33
Peak negative strain, %	−16.2 ± 3.7	−12.6 ± 2.8	0.02
Peak negative strain rate, s^-1	−2.0 ± 0.9	−1.7 ± 0.5	0.37
Peak positive strain, %	14.9 ± 7.2	8.0 ± 3.6	0.01
Early peak positive strain rate, s^-1	0.78 ± 0.36	0.69 ± 0.38	0.57
Late peak positive strain rate, s^-1	1.66 ± 0.44	1.16 ± 0.41	0.01
Early diastolic negative strain rate, s^-1	−1.53 ± 0.54	−0.91 ± 0.33	0.01

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1259: Interleukins 33 and 1B serum levels are connected to Left Ventricular geometry and diastolic filling in patients with hypertension and obesity

O Kovalyova ¹, O Honchar ¹

Abstract

Purpose: To investigate interrelations between interleukin 33 (IL-33) and 1β (IL-1β) serum levels, left ventricular (LV) structural and functional remodeling in hypertensive patients with obesity.

Method: 80 hypertensive patients (34 male, 46 female), aged 59,2 ± 8,2 years, with preserved LV systolic function had been observed, including 51 obese patients. Transthoracic echocardiography was performed with estimation of LV geometric pattern by A.Ganau, E/A and E/E' ratios, pulmonary wedge pressure (PWP) by S.Nagueh. IL-33 and IL-1β serum levels were estimated using ELISA.

Results: Both levels of IL-33 and IL-1β were elevated in all groups of hypertensive patients (p<0,001), independently of BMI. Cluster analysis revealed 4 clusters of IL-33 and IL-1β values (p=0,128). Prominent increase of both cytokines (IL-33>73 pg/ml, IL-1β>25 pg/ml) was associated with the highest LV myocardial mass index (MMI) (160,5 (142,8; 185,8) g/m2, p<0,05), highest prevalence of LV hypertrophy (LVH) (100,0%, 90,0% of concentric LVH), moderate decrease in E' velocity (9,95 (8,32; 10,60) cm/sec), relatively low PWP (9,23 (8,83; 13,03) mm Hg) and 70,0% prevalence of LV DD (60,0% of type I). Prevalent increase in IL-1β (>20 pg/ml with IL-33<71 pg/ml) was characterized by relatively low LV MMI (116,9 (104,4; 163,1) g/m2), 55,0% prevalence of LVH plus 30,0% of concentric remodeling, lowest E' (7,68 (6,50; 9,67) cm/sec, p<0,01), highest PWP (12,26 (10,72; 13,12) mm Hg, p<0,05) and highest rate of DD (85,0%, 70,0% of type I). Prevalent increase in IL-33 (>71 pg/ml with IL-1β<25 pg/ml) was associated with MMI of 121,4 (111,7; 140,5) g/m2, 66,7% rate of LVH (equal for concentric and eccentric variants), highest values of E' (11,04 (9,49; 12,00) cm/sec), lowest PWP (9,07 (7,04; 11,51) mm Hg) and lowest prevalence of LV DD (66,7%, 50,0% of type I). Cluster with no differences vs control group (IL-33<71 pg/ml, IL-1β<20 pg/ml) had intermediate characteristics: LV MMI of 137,4 (121,3; 157,8) g/m2, 78,9% prevalence of LVH (50,0% of concentric variant), E' of 9,95 (8,30; 12,20) cm/sec, PWP of 11,20 (9,55; 12,33) mm Hg, and 71,1% rate of DD (50,0% of type 1).

Conclusion: Significant increase in IL-33 and IL-1β serum levels in patients with hypertension has been revealed independently of presence of obesity. A pronounced increase in both cytokines' levels was associated with the highest rates of LVH and DD. Prevalent increase in IL-1β was connected to the worst state of diastolic function despite low rates of hypertrophy. Prevalent increase in IL-33 had the most favorable influence on the severity of LVH as well as diastolic filling.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1260: M-mode pattern of Left Atrial slope as parameters of Left Ventricular diastolic function

WINDA Tengku ¹, ANDRE Ketaren ¹

Abstract

Background: M-mode of cardiac chambers throughout the cardiac cycle can detect structural and functional abnormalities. Left atrial (LA) wall has a motion pattern that associated with left ventricle (LV) diastolic filling phase, but M-mode examination of the left atrium has not yet been used to determine left ventricle diastolic function.

Aim: To validate M-mode pattern of left atrial slope, as a simple parameter in determining left ventricle diastolic function.

Methods: This is a cross-sectional study using echocardiography examination. M-mode pattern of left atrium wall was assessed by measuring left atrial filling and emptying slope. This measurement was compared with the regular assessment tissue doppler imaging on septal and Doppler method on mitral inflow. Correlation between heart rate and both LA slope also analyzed. Inter-observer and intra-observer variability also analyzed

Results: This study involved 98 subjects that underwent trans thoracal echocardiography, 46 subjects with normal diastolic function and 52 subjects with diastolic dysfunction. The incidence and ROC analysis of LA slope indicated that LA filling slope with cut off point value of < 28 mm/s for LV diastolic dysfunction and > 28 mm/s for normal LV diastolic function had 71% sensitivity, 96% specificity, 95% positive predictive value, 75% negative predictive value. LA emptying slope with cut off point value of < 47mm/s for LV diastolic dysfunction and > 47mm/s for normal LV diastolic function had 98% sensitivity, 96% spesificity, 96% positive predictive value, and 98% negative predictive value. Correlation between heart rate and LA filling slope is weak positive but not significant (p=0,419) and there was no correlation between heart rate and LA emptying slope (p=0,223). Intra-observer and intra-observer variability of LA filling and emptying slope is fair to good (Kappa value 0,616-0,834) and significant (p < 0,001). Conclusion - This study showed that LA anterior wall slope measurement during both filling and emptying can be used as a parameter in determining LV diastolic function especially LA emptying slope with high sensitivity and specificity

Diagnostic Test of LA Slope

Parameter	Sens (IK 95%)	Spes (IK 95%)	ND + (IK 95%)	ND − (IK 95%)
LA filling slope	71 (59 - 83)	96 (90 - 100)	95 (88 - 100)	75 (63 - 86)
LA emptying slope	98 (94 - 100)	96 (90 - 100)	96 (91 - 100)	98 (93 - 100)

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1261: Follow-up of transplanted heart: evolution of diastolic function two years after heart transplantation

S Mingo Santos ¹, V Monivas Palomero ¹, A Restrepo Cordoba ¹, E Rodriguez Gonzalez ¹, J Goirigolzarri Artaza ¹, I Sayago Silva ¹, I Garcia Lunar ¹, C Mitroi ¹, M Cavero Gibanel ¹, J Segovia Cubero ¹

Abstract

Heart transplantation (HT) is an accepted therapy for end-stage heart failure. At early post-HT period high filling pressures and restrictive pattern are ussually present. Objective: To describe the normal evolution of diastolic function along the 2 first years after HT and to compare it with controls. Methods: We included 29 consecutive patients since 2009 followed at least 1 year (20 patients completed 2 years of follow-up) and 13 healthy controls. To evaluate diastolic function, mitral E and A wave ratio (E/A), deceleration time (DT), isovolumic relaxation time (IVRT), Tissue Doppler E' (lateral and medial) and the annular E/E' ratio (E/E' lat and E/E'med) were measured. Studies with a rejection degree ≥ 2R were excluded.

Results: HT patients showed diastolic dysfunction in the the early phase after transplant, with abnormal diastolic indexes compared to controls. These indexes improved progressivelly along the 2 years of follow-up in the HT group, and no differences were observed at the end of the follow-up compared to controls. Only E/A index remained pathological twenty four months after HT. (Results of our study are shown in the table)

Conclusion: Most of dyastolic measures improved early during HT follow-up, as also did NT-proBNP until allmost its normalization. Although the LV filling pattern (E/A) seems to remain restrictive, TDI measures unmask a prompt normalization of dyastole. Their evaluation is a non invasive tool to monitorize normalization of filling pressures.

Evolution of dyastolic parameters

Parameter	Controls	Basal Echo	3 month Echo	6 month Echo	1 year Echo	2 year Echo	ANOVA of the Trend
E/A	1.3 ± 0.5	2.4 ± 0.8 ¤	2.0 ± 0.7 ¤	1.9 ± 0.6 ¤	1.9 ± 0.7 ¤	1.8 ± 0.6 ¤	0.15
DT	187.5 ± 47.5	140.8 ± 56.2 ¤	150.4 ± 49.7¤	153.6 ± 32.4 ¤	154.5 ± 36.8 ¤	170.1 ± 37.5	0.39
IVRT	97.3 ± 9	82.2 ± 15.8 ¤	94.3 ± 14.2	100.0 ± 18.9	95.5 ± 20.1	98.7 ± 13.3	0.001
E/Émed	7.8 ± 1.5	12.9 ± 4 ¤	10.0 ± 3.1 ¤	10.0 ± 3.5 ¤	9.0 ± 3.4	8.9 ± 3.4	0.027
E/É lat	5.9 ± 1.5	8.4 ± 2.9 ¤	6.9 ± 2.2	6.8 ± 2.9	6.2 ± 2.7	6.3 ± 2	0.16
Ém	10.8 ± 2.6	6.7 ± 1.7*	8.6 ± 1.9*	8.9 ± 2.4	9.4 ± 2.6	9.4 ± 2.5	0.009
ÉL	14.8 ± 3.1	11 ± 3.4*	12.9 ± 3.8	13.5 ± 4	14.1 ± 3.9	13.8 ± 3.1	0.4
NTproBNP		8932.0 ± 8021.1	1259.1 ± 914.9 ¤	890.3 ± 881.4 ¤	591.6 ± 414.3 ¤	355.9 ± 238.9 ¤	0.027

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DT: Deceleration time, IVRT: Isovolumic Relaxation Time.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

ISCHEMIC HEART DISEASE: P1262: Is progression of preclinical diastolic dysfunction different according to involved coronary artery?

SK Ryu ¹, JY Park ¹, SH Kim ¹, JW Choi ¹, CW Goh ², YS Byun ², JH Choi ³

Abstract

Background: Previous studies reported that coronary artery disease (CAD) is related to early diastolic dysfunction and diastolic function is prognostic factor of CAD. Significant stenosis of left anterior descending artery (LAD) is supposed to involve larger area of left ventricle (LV) than left circumflex(LCX) or right coronary artery(RCA). There was no data which compared early diastolic dysfunction according to involved artery in single vessel disease.

Method: From 2004 to 2014 consecutive patients diagnosed as single vessel disease by coronary angiography in single general hospital were enrolled. Echocardiography including tissue Doppler study at mitral valve annulus(MVA) was done just before coronary angiography. Patients with acute or recent myocardial infarction, atrial fibrillation, systolic dysfunction(LVEF < 50%), regional wall motion abnormality and significant valve disease were excluded. Total 382 patients was enrolled.

Results: Proportion of involved artery was 56.5%, 17.5%, and 25.9 in each LAD, LCX, and RCA. Mean age, left ventricular diastolic dimension (LVDD), LV mass index, early mitral inflow peak velocity (E), and early filling MVA peak velocity(e') were 62.1 ± 10.5 vs. 62.0 ± 10.1 vs. 63.1 ± 8.6 year (NS), 47.5 ± 4.2 vs. 47.9 ± 3.9 vs. 47.4 ± 3.9mm (NS), 102.5 ± 23.26 vs. 104.1 ± 20.6 vs. 101.2 ± 21.4 g/m2 (NS), 59.9 ± 13.5 vs. 61.9 ± 13.1 vs. 58.9 ± 14.1 cm/s (NS), and 5.3 ± 1.8 vs. 5.2 ± 1.6 vs. 5.2 ± 1.8 cm/s (NS) in each LAD vs. LCX vs. RCA involvement. There was no significant difference in prevalence of hypertension, diabetes, and smoker according to involved vessel.

Conclusion: In single vessel disease patients in coronary angiography, involvement of LAD is not associated with earlier deterioration of diastolic function. There was no difference in progression of preclinical diastolic dysfunction according to involved vessel.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1263: The state index, a new timing based diagnostic tool for identifying patients with acute coronary syndrome

C Westholm ¹, J Johnson ², T Jernberg ¹, R Winter ²

Abstract

Background: Our aim was to evaluate the diagnostic value of the state index in a NSTEMI population without previously known heart disease and compare with expert Wall motion score index (WMSI).

Methods: The State index is derived from the state diagram software that registers the longitudinal myocardial velocities from the six basal segments of the left ventricle (LV), This software gives us timing information regarding the different phases of the cardiac cycle and from this the Myocardial performance index (MPI), both global and also the standard deviation of the MPI from the different segments, MPI_SD. The state index is given by MPIxMPI_SD. The upper panel of the image is from a healthy person and the lower from a patient with NSTEMI, from left to right are the different phases starting with the atrial contraction and each row represents one segment of the LV starting with the anteroseptal segment. In the NSTEMI patients we see an intersegmental variation of the timing of the different phases which will give a higher value of the state index. We compared the results from the state index and WMSI with Area under curve from receiver operator characteristics (ROC)

Results: 49 patients and 21 controls were included. AUC for the state index was 0.87 and for WMSI 0.66 with a significant difference (p=0.008).

Conclusion: The state index, based only on timing, seems to be a very sensitive marker for acute ischemia in patients without previously known heart disease and better compared to WMSI and all other parameters tested in this study.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1264: Global Longitudinal Strain for risk assessment in patients with a first ST segment elevation Myocardial Infarction

P Rio ¹, L Moura Branco ¹, A Galrinho ¹, P Pinto Teixeira ¹, A Viveiros Monteiro ¹, G Portugal ¹, T Pereira-Da-Silva ¹, M Afonso Nogueira ¹, J Abreu ¹, R Cruz Ferreira ¹

Abstract

Introduction: Assessment of left ventricular systolic function is crucial to determine the outcome after ST-segment elevation myocardial infarction (STEMI).

Aim: to study the influence of the clinical baseline characteristics (CBC) in global longitudinal strain (GLS) with prognostic significance in patients after STEMI and to compare GLS with left ventricular ejection fraction (LVEF) and end-systolic volume index (LVESVi).

Methods: A retrospective study on 237 consecutive patients (pts) who underwent primary PCI, between January and December 2012, in a single center. Pts with previous MI or previous heart failure (HF) were excluded from the analysis. CBC and echocardiographic parameters (EP) 72h post STEMI, were evaluated and semiautomatic GLS was calculated offline. Pts that did not have adequate images for this calculation were also excluded. Statistic methods used were chi-square and student t-test, logistic regression analysis, Roc and Kaplan-Meier curves.

Results: Total of 69 pts (84% males, 59.1 ± 13.3 years old) were included with a median time of 490 days of follow up.

GLS had good correlations with LVEF (r=-0.50, p<0.001), LVESVi (r=0.24, p<0.05), BNP (r=0.36, p<0.01). The best GLS cut off value for all-cause mortality and/or hospitalization for HF was > - 13.5% with area under the curve (AUC) of 0.741 and HR=9.25, 95% CI=1.01-84.7, p<0.05. LVESVi and LVEF had AUC of 0.731 and 0.38, respectively. Either parameters had no significant association with adverse events.

Total cholesterol, LDL cholesterol and brain natriuretic peptide (BNP) levels were significant associated with GLS > -13.5%. Total cholesterol and BNP levels were independent predictors of it.

Conclusion: GLS shows good correlations with LVEF, LVESi and BNP levels. GLS was superior to LVEF and LVESVi for early risk assessment in patients after STEMI. Total cholesterol and BNP were independent predictors of higher GLS (> -13.5%).

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1265: Admission clinical, imaging and laboratory parameters are predictors of new onset atrial fibrillation in myocardial infarction with ST elevation patients undergoing primary PCI

A Mazzone ¹, N Botto ¹, U Paradossi ¹, A Chabane ¹, M Francini ¹, E Cerone ¹, M Baroni ¹, S Maffei ¹, S Berti ¹

Abstract

Purpose New Onset Atrial Fibrillation (NOAF) is a common arrhythmia in the setting of Acute Myocardial Infarction with ST Elevation (STEMI) and its worst outcomes. The aim of the study was to detect value of simple integrated clinical, imaging and laboratory markers in prediction of New-Onset Atrial Fibrillation (NOAF) in a large STEMI population undergoing primary PCI.

Methods: We retrospectively examined admission clinical, echocardiographic and laboratory data of 1112 consecutive STEMI patients (ranging from 21 to 99 years) admitted to our Heart Care for primary PCI from 2006 to 2011. The NOAF was defined as atrial fibrillation that occurred during the index hospitalization.

Results: New Onset AF was documented in 89 patients with STEMI (8.0%; mean age 73.9 ± 9.9 years; 67% men). The NOAF group was older (p < 0.0001), presented hypertension (p=0.009). At admission trans-thoracic echocardiography the NOAF patients had increased Left Atrial dimension (mm) (37.5 ± 5.1vs39.1 ± 5.6; p=0.004) and Left Atrial area (mm2) (49.1 ± 14.3 vs 55.5 ± 15.2;p=0.001), mitral regurgitation (%)(78.0 vs 86.4; p=0.06),severe mitral regurgitation (%) (2.4 vs 4.5; p=0.007) and systolic dysfunction (EF%)(45.2vs 40.3; p<0.001). Among the acute laboratory parameters, Troponin-I (ng/ml) (40.2 ± 63.7vs57.9 ± 85.6; p=0.02), BNP (ng/L) (259.3 ± 469.3 vs 469.6 ± 494.1; p< 0.0001), Neutrophil/Lymphocyte ratio (6.7 ± 6.0 vs 9.2 ± 5.3; p<0.0001), creatinine (mg/dl) (1.0 ± 0.5 vs1.2 ± 0.5;p<0.0001) glucose(mg/dl) (129 ± 54.5vs150.3 ± 62.8; p=0.001) resulted significantly higher in the NOAF group. After multivariate adjustment, admission independent predictors of NOAF were old age (OR=4.3, p=0.001), higher N/L ratio (OR=3.3, p=0.004) and BNP (OR=2.9, p=0.01).

Conclusions: Age, inflammatory status and cardiovascular remodeling seem be strong predictors of NOAF. An integrated assessment of simple clinical, imaging and laboratory parameters, at the admission of STEMI patient, may be effective in the prevention of NOAF.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1267: Monocyte subpopulation counts association with LV ejection fraction and global longitudinal strain post ST elevation myocardial infarction

A Ghattas ¹, E Shantsila ¹, H Griffiths ², GY Lip ¹

Abstract

Introduction: The three monocytes subsets are implicated in atherosclerotic plaque instability and rupture. Mon1 are inflammatory, whilst Mon3 have a reperative role. The function of the newly described Mon2 subset is not yet clear. In PCI era, fewer patients have globally impaired LVEF, hence the importance of studying regional wall deformation using longitudinal strain. This is the first study to assess the role of the monocyte subpopulations in determining subclinical global strain post STEMI.

Methodology: STEMI patients (n=196, mean age 62 ± 13 years; 72% male) were recruited within the first 24 hours post infarction. Peripheral blood monocyte subpopulations were enumerated and characterized using flow cytometry after staining for CD14, CD16 and CCR2. Phenotypically, monocyte subpopulations are defined as: CD14++CD16CCR2+ (Mon1), CD14++CD16+CCR2+ (Mon2) and CD14+CD16++CCR2(Mon3) cells. Monocytes function was measured by phagocytic activity. TTE was performed within 7 days and at 6 months to assess ventricular volumes, mass, LVEF as well as global longitudinal strain.

Results: Using linear regression analysis higher counts for Mon1, and Mon2 were significantly associated with the baseline LVEF within 7 days post infarct. At 6 months higher counts of Mon2 remained positively associated with a decrease in LVEF (p value=0.002). STEMI patients with EF ≥50% (n=112) had GLS assessed. Using multivariate regression analysis higher counts of Mon1 and Mon2 and phagocytic activity of Mon2 were significantly associated with reduced GLS (after adjusting for age, time to hospital presentation, and peak troponin) at 7 days and after remodelling.

Conclusion: Mon1 and Mon2 independetly predicted LVEF after STEMI. In patients with mildly impaired EF, higher counts of Mon1 and Mon2 predicted lower GLS within 7 days as well as an impaired convalescent GLS at 6 months of remodelling. This supports an inflammatory role for Mon2 leading to impaired healing.

Monocyte subsets and GLS

Monocytes mean florescence intensity(cells/ μl)	GLS (%) 7 days post infarct			GLS (%) 6 months post infarct
Mon 1	R value	R2 value	P- Value	R value	R2 value	P- Value
Mon 1	0.88	0.77	0.001	0.85	0.73	0.001
Mon 2	0.71	0.50	0.03	0.74	0.54	0.02
Phago Mon1	0.58	0.33	0.24	0.52	0.27	0.53
Phago Mon 2	0.32	0.12	0.03	0.5	0.25	0.69

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

HEART VALVE DISEASES: P1268: Prevalence and determinants of right ventricular dysfunction in severe Aortic Stenosis

E Galli ¹, Y Guirette ¹, M Daudin ¹, V Auffret ¹, P Mabo ¹, E Donal ¹

Abstract

Introduction: Systolic pulmonary artery pressure (sPAP) is a well known predictor of outcome in patients with valvular heart disease. In spite of this fact, limited data are available regarding the assessment of RV function in patients with aortic stenosis (AS).

Purpose of the study is therefore to evaluate the prevalence and the determinants of RV dysfunction in severe AS patients

Methods: 201 patients (mean age:79.7 ± 8.7, males 55.5%) with severe AS underwent 2D echocardiography and speckle tracking echocardiography (STE) for the evaluation of left ventricular (LV) and RV function, aortic valve gradients and sPAP. A tricuspid annular plane systolic excursion (TAPSE) was used to define reduced RV ventricular function.

Results: RV dysfunction was observed in 48 patients (24%). Patients TAPSE ≤17 mm had impaired LV ejection fraction (LVEF) (49.2 ± 15.4 vs 57.9 ± 10.9%, p<0.0001), significantly altered STE parameters (GLS: -10.3 ± 3.9 vs -13.2 ± 3.5%, GCS: -7.0 ± 3. vs -10.4 ± 4.9%, GRS: 18.7 ± 11.6 vs 28.4 ± 15.6%, all p<0.001) and a higher sPAP (48.4 ± 15.8 vs 40.9 ± 12.7 mmHg, p=0.002). Correlates of TAPSE were: LVEF (β=0.35, p<0.0001), LV global longitudinal, circumferential and radial strain (β=-0.40, β=-0.40, β=0.37 respectively, all p<0.0001), LV indexed stroke volume (β=0.44, s<0.0001), lnNT-proBNP (β=-0.51, p<0.0001) and sPAP (β=-0.27, p<0.0001). At Kaplan-Meier survival curve, a TAPSE ≤17 mm was associated with a reduced survival in patients with AS (LogRank test, p=0.03).

Conclusions: In patients with severe AS, RV dysfunction is frequent and is associated with a poor prognosis. The correlates of TAPSE highlight the RV-LV interdependence in AS patients. Further studies will clarify the real and independent prognostic value of RV function in severe AS patients and test for the RV reverse remodelling after AS treatment.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1269: Speckle tracking imaging identifies myocardial fibrosis in patients with aortic stenosis and preserved ejection fraction: potential role for correct surgical timing and reverse Left Ventricular remode

I Fabiani ¹, L Conte ¹, C Scatena ², V Barletta ¹, S Pratali ¹, A De Martino ¹, U Bortolotti ¹, AG Naccarato ², V Di Bello ¹

Abstract

Background: Myocardial fibrosis is an adverse correlate of Aortic Valve Stenosis (AVS), determining diastolic and systolic functional impairment. Non-invasive estimation of fibrosis, using speckle-tracking imaging (STI), could beuseful in determining sub-clinical myocardial damage prior to symptoms development and overt systolic dysfunction.

Materials and methods: 24 consecutive patients (Age 75.2+/-8 years; 63% Female; NYHA functional class: 2.06+/-0.6) with AVS (iAVA<0.6 cm2/m2) and preserved EF underwent to surgical aortic valve replacement (AVR) (Euroscore II 2.28+/-1.13%). We performed clinical examination, ECG, standard echocardiography, including TDI and 2D STI for evaluation of global longitudinal strain (GLS), global systolic longitudinal (GLSrS) and proto-diastolic strain rate (GLSrE). We also performed an acquisition limited to basal septum to derive septal longitudinal strain (LSs) and sisto/disatolic strain rates (SrSs/SrEs).

During AVR, 15 patients performed septal biopsy at the basal inter-ventricular septum level for quantitative evaluation of myocardial fibrosis %.

Results: Patients with AVS (iAVA 0.33+/-0.1 cm2/m2; V max 4.4+/-0.4 m/sec; Max Grad 80.2+/-16.7 mmHg; Mean Grad 50+/-9mmHg; Velocity ratio 0.18+/-0.04) presented increased Left ventricular mass (iLVM 139.5+/-20.7 g/m2), concentric hypertrophy (RWT 0.51+/-0.07), increased left ventricular filling pressures (E/E'18.37+/-8.7) and afterload (ZVA: 5.9+/-2.3 mmHg/ml/m2).

Despite preserved ejection fraction (EF 66+/-11%) patients showed severe reduction of deformation parameters (GLS -13+/-6.1; GLSrS -0.8+/-0.2; GLSrE 1+/-0.35). Septal analysis confirmed severe reduction of speckle tracking derived indices (SLs -8.6+/-2.8; SrSs -0,6+/-0.1; SrEs: 0.6+/-0.29).

Histological analysis showed various degrees of myocardial fibrosis (0.151+/-0.09). Correlation analysis revealed strong association between fibrosis and cardiac output (r=-0.5; p=0.05), end-diastolic pressure (r=0.55; p=0.05), septal strain rates (SrSs r=-0.64; p=0.010/SrEs r=-0.74; p=0.008) and global longitudinal strain (GLS r=-0.64; p=0.012). No significative association was found between fibrosis, SLs, GLSrS and GLSrS and other indices of systolic function, including EF, MAPSE and TDI derived (all p>0.05).

Conclusions: STI allows non-invasive estimation of myocardial fibrosis, and its impairment identifies patients with early systolic dysfunction and still preserved EF.

The opportunity of estimate the amount of myocardial fibrosis could be relevant for the identification of a correct surgical timing, with a better reverse remodeling in patients with aortic stenosis.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1270: Risk stratification in asymptomatic severe aortic stenosis: new insights from 3D Speckle-Tracking and exercise stress echocardiography in the evaluation of the left ventricular function

G Falanga ¹, E Alati ¹, G Di Giannuario ¹, C Zito ², M Cusma' Piccione ², S Carerj ², G Oreto ², G Dattilo ², O Alfieri ¹, G La Canna ¹

Abstract

Purpose: To investigate the value of Three Dimensional (3D) Speckle-Tracking and exercise stress Echocardiography for the assessment of left ventricular (LV) function in patients with asymptomatic severe aortic stenosis (AS).

Methods: Twentytwo asymptomatic patients (16 M, mean age 70.4 ± 9.6 years) with severe AS and without concomitant more than moderate valvular diseases, with sinus rhythm and preserved LV ejection fraction (EF>55%) were enrolled and underwent at rest transthoracic/transesophageal echocardiogram, and stress echocardiography with bicycle ergometer. LV volumes, EF, stroke volume (SV), LV mass, LV global and regional strain parameters (longitudinal-LS, radial-RS, circumferential-CS, and area strain-AS), rotations, twist and torsion were calculated at rest using 3D Speckle Tracking echocardiographic analyses (undertaken offline in a dedicated workstation). At the peak of exercise, transaortic peak (PPG) and mean pressure gradients (MPG), systolic pulmonary arterial pressure (SPAP), SV, AVA, and valvulo-arterial impedance (ZVA) was evaluated. The exercise was stopped for dyspnea in up one-third of patients and for muscle exhaustion in the remaining two-thirds.

Results: At the peak of exercise a rapid increase in transaortic PPG and MPG (respectively 80.2 ± 14.09 vs 94.9 ± 8.46 mmHg, p=0.003 and 50.2 ± 8.77 vs 62.95 ± 9.46 mmHg, p<0.001) was underlined in all the patients, whereas an increased SPAP (27.04 ± 6.36 mmHg vs 45.4 ± 12.31 mmHg, p<0.001) was found in two-thirds of them. Both exercise PPG and MPG were inversely related with resting LS of basal segments (r=-0.442, p=0.03; r=-0.586, p=0.003); in addition, MPG was also positively related with resting CS of basal segments (r=0.42, p=0.04). Moreover, a direct relation between peak exercise SPAP and resting apical rotation (r=0.58, p=0.003), twist (r=0.48; p=0.02) and apical segments' CS (r=0.63, p=0.001) was found.

Conclusions: In patients with asymptomatic severe AS, a rapid increase in transaortic gradients and SPAP during exercise may indicate a more severe disease with inefficient pulmonary vascular function adaptation. Moreover an important increase of rest apical rotation, twist and torsion were particularly evident in patients with pulmonary hypertension during exercise (p=0.01, p=0.003, p=0.01 respectively), suggesting an association between these indices and a greater hemodynamic compromise during exercise. Therefore, the assessment of these parameters could be useful for risk stratification of the asymptomatic patients.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1271: Pathophysiology of exercise in Aortic Stenosis: the Right Ventricle stage

G Generati ¹, F Bandera ¹, M Pellegrino ¹, E Alfonzetti ¹, V Labate ¹, M Guazzi ¹

Abstract

Background: Cardiac output (CO) increase is the mainstay of exercise (Ex) physiology. A prerequisite for adequate increase is that flow through the cardiac valves is unimpeded. Aortic stenosis (AS) allows to investigate how Ex physiology changes when left ventricular (LV) output is impeded.

Methods and Results: Twentyseven moderate – severe AS subjects performed semisupine bicycle ergometry (ramp protocol) with baseline and peak Ex respiratory gases and echo-Doppler measurements. They were divided according to linear VO2/WR (O2 uptake/work rate) relationship (ΔVo2/ΔWR=10.7, which is normal) throughout the test (63% Group A), or decline in the latter part (25% Group B). At peak Ex, Group B, compared to A, despite similar transaortic gradient increase and Ex gas exchange respiratory ratio, developed functional mitral regurgitation, lower peak VO2 (63.2% vs 82.3% predicted) and VO2/heart rate, steeper ventilation to CO2 production slope and, consistently, decline in stroke volume (-36% vs +21%) and inadequate increase of CO (+ 44% vs + 90%). Global LV afterload (Zva) rose similarly and LV ejection fraction (EF) remained constant in both groups. Oppositely, changes in pulmonary pressure (PASP + 65% vs + 33%), effective pulmonary artery elastance (PEAE +79% vs +19%) and tricuspid annular plane systolic excursion (TAPSE)/PASP (-51% vs -43%) were definitely greater in group B; right ventricular (RV) area also slightly augmented in this group.

Conclusions: Some AS subjects showed nearly normal aerobic capacity. Some did not, due to defective CO. In them, the raised Zva did not depress LVEF, whereas the excessive hemodynamic load markedly reduced RV contractile performance. All the LV-pulmonary circulatory- RV apparatus is involved in AS patients with altered Ex physiology and the RV is predominant in disrupting CO.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1273: Subclinical left ventricular systolic dysfunction in patients with severe aortic stenosis : a speckle tracking echocardiographic study

B Cengiz ¹, S T Sahin ², S Yurdakul ², S Kahraman ², A Bozkurt ¹, S Aytekin ¹

Abstract

Background: In patients with aortic stenosis (AS), left ventricular (LV) geometry alters due to increased LV afterload. However, sub-clinical myocardial dysfunction may develop despite normal LV EF. In the present study, we aimed to evaluate sub-clinical LV systolic dysfunction in patients with severe AS, without any cardiovascular disease and with normal LV EF, by using tissue Doppler imaging (TDI), a strain imaging method, "speckle tracking echocardiography" (STE) and its correlation with changes in LV geometry.

Methods : We studied 38 patients (56 % male, 71,7 years) with AS and 25 age and sex-matched controls, without any cardiac disease and with preserved LV EF. Conventional echocardiography, TDI, and STE- based strain imaging were performed to analyse sub-clinical LV systolic function. Novel indices (energy loss index'' (ELI), valvulo-arterial impedance, systemic arterial compliance (SAC), etc.) were also measured in addition to conventional methods.

Results: Conventional echocardiographic measurements (LV end diastolic diameter, LV end systolic diameter, LV EF) were similar between the groups. Interventricular septum and posterior wall thickness were increased, compared to controls. (1.28 ± 0.05 cm to 1.08 ± 0.21 cm, p=0.04; 1.23 ± 0.23 cm to 0.9 ± 0.01 cm, p=0.01, respectively). In TDI analysis, we observed significant reduction in LV peak systolic velocity (Sa) (0.06 ± 0.009 m/s to 0.14 ± 0.025 m/s, p=0.0001). LV longitudinal peak systolic strain (9.63 ± 1.18 % to 19.68 ± 3.48 %, p=0.0001) and strain rate (0.21 ± 0.07 1/s to 1.65 ± 0.05 1/s, p=0.0001) were significantly impaired in patients, compared to controls, demonstrating sub-clinical ventricular systolic dysfunction. Significant positive correlation was obtained between energy loss index and LV strain/strain rate (r=0.598, p=0.0001; r=0.678, p=0.0001 respectively). Aortic valve area was also positively correlated with LV strain (r=0.332, p=0,04).

Conclusions: Patients with severe AS develop LV systolic dysfunction, despite preserved EF. Changes in LV geometry are correlated to impairment in LV function. Strain imaging-based novel echocardiographic techniques may provide additional data for detecting early myocardial systolic deterioration in patients with severe AS.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1274: Inoue versus single Balt balloon technique in mitral valvuloplasty - Long-term follow-up of 25 years

I P Borges ¹, ECS Peixoto ², RTS Peixoto ², RTS Peixoto ³, VF Marcolla ¹

Abstract

Objectives: This study aimed to demonstrate that mitral balloon valvuloplasty (MBV) with the Balt single balloon (BSB) has similar outcome and long-term follow-up (FU) than MBV performed with the Inoue worldwire accepted technique.

Methods: From 1987 to 2013 a total of 526 procedures were performed, being 312 with a FU, 56 (17,9%) with Inoue balloon (IB) and 256 (82,1%) with BSB. The mean FU in IB group was 33 ± 27 (2 to 118) and 55 ± 33 (1 to 198) months, p<0.0001. Univariate analysis (UA) and multivariate Cox analysis (MVA) were utilized to determine independent predict variables of survival and event free survival (EFS) in both techniques groups. The major events (ME) were death, cardiac surgery and new MBV.

Results: In IB and BSB groups there were, respectively: female 42 (75.0%) and 222 (86.7%); mean age 37.3 ± 10.0 (19 to 63) and 38.0 ± 12.6 (13 to 83) years, p=0.7138; sinus rhythm 51 (91.1%) and 215 (84.0%), p=0.1754; echo score (ES) 7.6 ± 1.3 (5 to 10) and 7.2 ± 1.5 (4 to 14) points, p=0.0528; echo mitral valve area (MVA) pre-MBV 0.96 ± 0.18 and 0.93 ± 0.21 cm², p=0.2265; post-MBV mean MVA (Gorlin) were 2.00 ± 0.52 and 2.02 ± 0.37 cm², p=0.9554; MBV dilatation área 6,09 ± 0,27 and 7,02 ± 0,30, p<0,0001. At the end of the FU, there were in IB and BSB groups, respectively: echo MVA 1.71 ± 0.41 and 1.54 ± 0.51 cm², p=0.0552; new severe mitral regurgitation in 5 (8.9%) and 17 (6.6%) patients, p=0.5633; new MBV in 1 (1.8%) and 13 (5.1%), p=0.4779; mitral valve surgery in 3 (5.4%) and 27 (10.4%), p=0.3456; deaths 2 (3.6%) and 11 (4.3%), p=1.000; cardiac deaths 1 (1.8%) and 9 (3.5%), p=1.000; ME 5 (8.9%) and 46 (18.0%), p=0.1449.

In UA and MCA the BSB or IB technique do not predict survival or EFS. The independent risk factors to survival (MCA with 2 models with 5 and 6 variables) were: age <50 years (p=0.016, HR=0.233, 95% IC 0.071- 0.764), ES≤8 (p<0.001, HR=0.105, 95% IC 0.34 - 0.327), MBV dilatation area (p<0.001, HR 16.838, 95% IC 3.353 - 84.580) and no mitral valve surgery in the FU (p=0.001, HR0.152, 95% IC 0.050 - 0.459). Independent risk factors to EFS: no prior commissurotomy (p=0.012, HR=0.390, 95% IC 0.187 - 0.813) and post-MBV MVA≥1.50 cm² (p=0.001, HR=7.969, 95% IC 3.413-18.608).

Conclusions: MBV with BSB and IB were equally efficient, there were similar survival and EFS in the FU. Independent predictors of survival were: age <50 years, ES≤8 points, MBV dilatation area > 7 mm2 and no mitral valve surgery in the FU. Independent risk factors of EFS were no prior commissurotomy and post-MBV MVA≥1.50 cm².

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1275: 3D assessment of mitral annular dynamics in mitral stenosis: novel parameters associated with stenosis severity

A Venkateshvaran ¹, S Sola ², P K Dash ², P Thapa ², A Manouras ², R Winter ², LA Brodin ², S C Govind ²

Abstract

Background: Mitral stenosis (MS) severity is traditionally assessed by examining leaflets, commissures and sub valvular apparatus. Though the mitral annulus (MA) is an important component of the mitral apparatus, there is little data on how it is influenced by MS. Current advances in 3DTTE permit a comprehensive evaluation of MA dynamics. We hypothesized that MA dynamics are impacted in MS. We aimed to study the relationship between variables associated with MA dynamics and stenosis severity using 3D echocardiography.

Methods: We prospectively enrolled consecutive subjects with rheumatic MS in sinus rhythm. 41 MS subjects (36 ± 6 years; 70% female) comprising mild (MVA ≥ 1.5 cm2; n=10), moderate (MVA=1.1 to 1.49cm2; n=13) and severe (MVA ≤ 1.0cm2; n=18) MS subgroups were analyzed. Subjects with > grade 1 MR, mitral annular calcification, hypertension, multi-valve or coronary artery disease, and LV dysfunction were excluded. All subjects underwent 2DTTE and 3DTTE in keeping with current guidelines. 3D parameters including MA dimensions, antero-posterior and intercommissural diameters, annular area, annular height, systolic annular displacement and displacement velocity were measured offline. Subjects were also stratified based on mean value of annular displacement into low MA (≤ 6.3mm; n=20) and high MA (> 6.3mm; n=21) subgroups.

Results: Subjects with severe MS showed reduced annular displacement (4.7 ± 2 vs. 9.8 ± 1.5mm; p<0.01) and displacement velocities (26.2 ± 8 vs. 41.6 ± 7mm/s; p<0.01) as compared to mild MS, in addition to demonstrating higher mean gradient, LA volume and RVSP (p<0.001 for all variables). MA dimensions and orthogonal diameters were not significantly different between subgroups, though with increasing stenosis severity, a tendency towards increased annular flattening was observed. MA displacement was strongly correlated with valve area (r=0.74; p<0.001), mean gradient (r=-0.60; p<0.001) and RVSP (r=-0.62;p<0.001). Subjects with low MA displacement demonstrated significantly smaller MVA (0.8 ± 0.2vs. 1.3 ± 0.4cm2; p<0.001), higher mean gradient (18 ± 7 vs. 10 ± 7mmHg; p=0.03) and RVSP (64 ± 29 vs. 35 ± 10mmHg; p=0.001) as compared to the high MA subgroup.

Conclusion: Mitral annular displacement and velocity are decreased in severe MS. Progressive reduction in mitral annular dynamics are associated with increasing disease severity. 3D TTE derived MA dynamics demonstrate potential as novel additional parameters to quantify MS severity.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1276: Speckle-tracking echocardiography in evaluation early left ventricular diastolic dysfunction in asymptomatic aortic regurgitation patients

V Mizariene ¹, R Verseckaite ¹, M Bieseviciene ¹, R Karaliute ², R Jonkaitiene ², J Vaskelyte ², R Arzanauskiene ¹, J Janenaite ¹, R Jurkevicius ²

Abstract

Background: Chronic aortic regurgitation (AR) patients remain asymptomatic for a long time. Early detection of left ventricular (LV) systolic or diastolic dysfunction can help to improve further management of these patients.

The goal of our study was to find early diastolic LV dysfunction using speckle-tracking echocardiography in patients with chronic AR with preserved LV ejection fraction.

Methods: The study population consisted of 45 asymptomatic AR patients, 16 symptomatic patients and 40 healthy controls. Patients underwent a standard transthoracic echocardiographic study. LV diastolic longitudinal, circumferential and radial strain rate (Sr) (early diastolic and at atrial contraction) were measured off – line by 2 dimentional speckle -tracking imaging.

Results: Asymptomatic AR patients had reduced early diastolic LV longitudinal Sr in all LV walls as well as global longitudinal Sr compared to controls (1.36 ± 0.251/s vs 1.59 ± 0.301/s respectively, p<0.05). Early diastolic circumferential Sr at midventricular and apical levels were reduced in symptomatic AR patients compared to controls (p<0.05). Asymptomatic patients had reduced global early diastolic circumferential Sr (p<0.05). Late diastolic circumferential Sr was reduced at basal, midventricular level in symptomatic patients compared to controls (p<0.05). Radial Sr analysis showed reduced global radial Sr at atrial contraction in symptomatic patients compared to controls (-0.92 ± 0.351/s vs-1.41 ± 0.561/s, p<0.05). ROC analysis showed, that diastolic Sr at atrial contraction were good predictors of clinical symptoms (Figure 1).

Conclusions: Speckle-tracking echocardiography helps to find impaired diastolic function in chronic asymptomatic AR patients. Reduced diastolic indices can predict the onset of clinical symptoms.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1277: Quantitative and semiquantitative parameters in the classification of aortic insufficiency: a 3D-echocardiography and magnet resonance imaging study

S Rosner ¹, M Orban ², J Nadjiri ³, H Lesevic ¹, M Hadamitzky ³, C Sonne ¹

Abstract

Background: The purpose of this study was to evaluate the value of echocardiographic semiquantitative parameters, including enddiastolic flow reversal (EFR) in the upper descending aorta, in the assessment of aortic regurgitation (AR) severity.

Methods: 36 patients (81% men, 51 ± 15 years) with mild to severe AR were included. In all patients echocardiography was perfomed for assessment of AR, including EFR-velocity. Ejection fraction (EF), enddiastolic, endsystolic volumes (EDV, ESV) and global longitudinal strain (GLS, normal < -20%) were assessed by 3D-echocardiography. Magnet resonance imaging (MRI) was performed to quantify EDV, ESV and EF.

Results: AR, as determined by MRI, was mild in 10, moderate in 10 and severe in 16 patients. Interestingly, VC and velocity of EFR in echocardiography were significantly different between the groups. In all groups GLS was reduced despite only mildly reduced EF.

Conclusion: Semiquantitative parameters help to discriminate between mild, moderate and severe AR. The additional discriminative value of EFR-velocity needs to be adressed in a larger study. Interestingly, GLS was abnormal in these patients with mild to severe AR despite only mildly reduced EF and may help to identify patients with subclinical LV dysfunction.

	Mild AR (n=10)	Moderate AR (n=10)	Severe AR (n=16)	Significance
PHT (ms)	484 ± 165	385 ± 101	376 ± 89	0,78
VC (mm)	4 ± 1	5 ± 1	6 ± 2	0,014
EROA (mm2)	10 ± 6	24 ± 10	32 ± 12	0,001
AR-Vol (ml)	21 ± 10	52 ± 19	78 ± 32	0,003
EFR-velocity (cm/s)	15,5 ± 5,2	15,3 ± 3,9	19,7 ± 5,1	0,013
3D-GLS (%)	−14 ± 5	−14 ± 3	−12 ± 6	0,62
3DE-LV-EDV (ml)	148 ± 88	173 ± 20	187 ± 75	0,51
3DE-LV-ESV (ml)	57 ± 33	68 ± 12	88 ± 49	0,33
3DE-EF (%)	56 ± 7	59 ± 4	54 ± 8	0,71
MRI-EDV(ml)	174 ± 42	221 ± 56	261 ± 68	0,002
MRI-ESV (ml)	73 ± 23	84 ± 38	126 ± 63	0,013
MRI-EF (%)	60 ± 7	61 ± 6	54 ± 12	0,20

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3DE: 3D-echocardiography; EDV: enddiastolic volume; EFR: enddiastolic flow reversal; ESD: endsystolic volume; GLS: global longitudinal strain; PHT: pressure half time; VC: vena contracta

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1278: Prognostic value of left ventricular recoil in primary chronic mitral regurgitation

R Manganaro ¹, S Carerj ¹, MC Cusma-Piccione ¹, A Caprino ¹, I Boretti ¹, MC Todaro ¹, G Falanga ¹, L Oreto ¹, MC D'angelo ¹, C Zito ¹

Abstract

Purpose: To evaluate the prognostic value of abnormalities of left atrial (LA) and/or ventricular (LV) mechanics as predictors of cardiovascular events during follow-up in asymptomatic patients with chronic primary mitral regurgitation (MR).

Methods: 68 patients (mean age 57 ± 17 years) with mitral valve prolapse, MR and normal LV ejection fraction were prospectively enrolled. Patients were divided into three groups according to the severity of MR: mild (n=24), moderate (n=21) and severe (n=23). Two-dimensional echocardiographic images were acquired for speckle tracking analysis. At the end of follow-up, patients were subdivided into two group according to the occurrence of events (death, dyspnea/palpitations and MV surgery).

Results: Compared to patients with mild MR, those with moderate MR showed increased LV mass index (p< 0.001), E/E' (p=0.01), PAPs (p=0.007), basal rotation (p=0.04), twist (p=0.004), reduced longitudinal LV strain (p=0.04) and LA strain (p=0.005); furthermore LV mass index (p<0.001), LV volumes (EDV p<0.001, ESV p=0.007), sphericity index (p=0.003), E/A (p=0.005), E/E' (p=0.003), LA volume (p=0.002) and PAPs (p=0.01) were higher in pts with severe than in those with moderate MR, whereas LA strain (p<0.001)and LV recoil (p<0.001) were lower in pts with severe than in those with moderate MR. After a mean follow-up of 23.8 months ± 17.5, 39 (57%) patients remained asymptomatic whereas 29 (42%) developed events (17=MV surgery, 9=dyspnea/palpitations, 5=deaths). Compared to asymptomatic patients, those with events showed: higher LV sphericity index (0.65 ± 0.06 vs 0.60 ± 0.08, p=0.028) and LV global circumferential strain (-23.2 ± 4.8 vs -20.7 ± 4.7, p=0.043) and decreased: LA strain (25.5 ± 8.1% vs 31.9 ± 7.9%, p=0.003), LV global longitudinal strain (-19.1 ± 4.7 vs -21.1 ± 2.5, p=0.030), LV recoil (-69.7 ± 34.6 vs -86.8 ± 23.2, p=0.024). On univariate Cox regression analysis, mitral E/A ratio (HR=2.4, CI 1.2-4.8, p=0.010), LA volume (HR=1.02, CI 1.00-1.05, p=0.025), LA strain (HR=0.92, CI 0.87-0.97, p=0.003) and LV recoil (HR=1.02, C.I. 1.00-1.03, p=0.012) were associated with increased risk of events. On multivariate regression analysis, only LV recoil was independent predictor of events (HR=1.03, CI 1.00-1.04, p=0.024). The ROC analysis showed that a cut-off recoil=-77.5°/sec had the higher sensitivity and specificity to identify patients at major risk (AUC=0.73; Sensitivity 73%, Specificity 72%).

Conclusions: Impaired LA and LV mechanics are associated with the occurrence of events in asymptomatic patients with MR, however LV recoil is the only independent predictor of a worse prognosis.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1279: Relation of functional tricuspid regurgitation to right and left ejection fraction in organic mitral regurgitation

T Le Tourneau ¹, C Cueff ¹, M Richardson ², C Hossein-Foucher ², G Fayad ², JC Roussel ¹, JN Trochu ¹, A Vincentelli ²

Abstract

Objective: To assess the determinants of functional tricuspid regurgitation (TR) and the relation of TR to right (RV) and left ventricular (LV) ejection fraction (EF) in chronic organic mitral regurgitation (MR).

Methods: Three-hundred twenty-five patients (63 ± 12 years, 206 males) with organic MR (82% degenerative etiology) referred to surgery and who underwent a preoperative gradation of TR were included in this study. Radionuclide angiography was carried out in 237 patients.

Results: Fifty patients had a TR ≥ grade 2. Patients with TR ≥ 2 were older, had more AF (54 vs 24%, P<0.0001) and were more symptomatic. Mean LV EF and RV EF were lower, and LV septal function and RV free wall function were impaired in those with TR ≥ 2. By echocardiography, LV-RV, left and right atrial remodeling were worse, PASP was higher and inter ventricular systolic pressure was lower whereas the severity of MR was similar. RV S velocity was also significantly decreased. Ventricular function was stratified in normal RV-LV (Normal), isolated RV dysfunction (RVdysf, RV EF≤35%), isolated LV dysfunction (LVdysf, LV EF<60%), and biventricular impairment (BiV, LV EF<60% and RV EF≤35%). TR ≥ 2 was found mainly in either BiV (33%) or LVdysf (22%) but almost never in RVdysf (3%) nor Normal (3%) groups. In BiV TR ≥ 2 was associated with overall impairment of the right heart while only the RA-tricuspid annulus-RV base were enlarged in LVdysf. By contrast RV EF alteration in RVdysf was likely linked mainly to compression and flattening of the RV by the severely enlarged LV owing to severe volume overload. Moreover, in RVdysf volume overload was higher, RV S wave velocity was not reduced, and RV EF improvement after surgery was greater suggesting limited impairment of RV myocardial function. These specific features probably explain the absence of TR in this subgroup of patients.

Conclusions: In patients with organic MR referred to surgery TR ≥ 2 is associated with the longstanding consequences of chronic organic MR. Significant TR occurs mainly in patients with BiV or LVdysf but is almost absent in RVdysf or Normal groups. Finally RVdysf group exhibits features suggesting a direct reversible effect of volume overload on the RV.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1281: Relationships between the severity of the regurgitation and the geometry of the tricuspid annulus in patients with functional tricuspid regurgitation

G Cavalli ¹, D Muraru ¹, MH Miglioranza ², K Addetia ³, F Veronesi ⁴, U Cucchini ¹, S Mihaila ⁵, M Tadic ¹, RM Lang ³, L Badano ¹

Abstract

Background: Tricuspid annulus (TA) remodeling plays an important role in the development of functional tricuspid regurgitation (FTR). However, difficulties in assessing the complex three-dimensional geometry of the TA coupled with difficulties in measuring the severity of TR using conventional echocardiography have hampered the ability to assess the relationship between the magnitudes of TA changes in geometry and the severity of the FTR .

Objective: We sought to study the relationships between the severity of FTR and TA geometry using three-dimensional transthoracic echocardiography (3DE).

Methods: We prospectively performed a cross-sectional study in 24 patients (66 ± 15 years, 58% women) with FTR (30% severe TR) who underwent a 3DE study to evaluate TA geometry using a prototype custom software. FTR severity was quantified using 3D eSie PISA (Acuson SC2000, Siemens) to obtain quantitative parameters of FTR severity independent of geometric assumptions regarding the shape of the regurgitant orifice area. TA geometry and FTR quantification were performed at the same time point during cardiac cycle (i.e. tricuspid valve closure).

Results: Significant correlations (p<0.0001) were found between all parameters describing FTR severity and the various TA geometry indexes (Table). 3D TA surface area seems to be the parameter more closely related to all indexes of FTR severity (Table).

Conclusion: In patients with FTR, severity of the regurgitation is closely correlated with the extent of TA geometry and size. Due to the high RV loading dependence of FTR, assessment of the extent of TA remodeling may improve assessment of FTR severity in doubtful cases.

Correlations between TA and TR severity

TA geometry parameters	3D effective ROA (mm2)	3D PISA (cm2)	3D regurgitant volume (ml)
Perimeter (cm)	0.697	0.680	0.754
Surface area (cm2)	0.719	0.679	0.750
Long axis (mm)	0.734	0.649	0.715
Short axis (mm)	0.685	0.665	0.707

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PISA, proxymal isovelocity surface area; ROA, regurgitant orifice area; TA tricuspid annulus. Values are reported as Pearson's r coefficients.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1282: Multimodality imaging for sizing of aortic annulus for transapical heart valve implantation: an agreement analysis of three-dimensional transoesophageal echocardiography and cardiac CT scan

V Polizzi ¹, PG Pino ¹, G Luzi ¹, D Bellavia ², R Fiorilli ¹, C Chialastri ¹, A Madeo ¹, J Malouf ³, V Buffa ¹, F Musumeci ¹

Abstract

Background and Aims: Aortic annulus dimension is critical in the assessment of patients undergoing trans-apical aortic valve implantation (TAAVI). At the current state of art multidetector computed tomography (MDCT) is the referenced imaging method in aortic annulus sizing. MDCT, using a virtual ring method, has shown the high accuracy in determining size of the aortic annulus (Cross sectional area –CSA-). Our aim was to test agreement in CSA values obtained by three-dimensional transesophageal echocardiograpy (3DTEE) and CT-Scan in patients undergoing TAAVI.

Methods: Twenty-five patients (81 ± 5 yo, 13 Females) underwent pre-TAAVI 3DTEE Annulus size by 3DTEE was determined by 3 methods: direct annular planimetry, virtual ring CSA (assessed at the level of the most basal attachment points of all three aortic cusps joined by a virtual ring), computation (by two axial diameters). Linear regression, variation coefficients (VC) intra-class correlation coefficients (ICC) and concordance correlation coefficients (CCC) were used to test agreement with MDCT measures obtained at level of virtual basal ring

Results: CSA calculated either by virtual ring or computed methods was lower than that measured at CT (p=0.003 and p=0.04 respectively, Table 1) while negligible difference was obtained by the direct annulus planimetry method (p=0.31). Planimetry also provided the highest agreement with CT according to R2, ICC or CCC. Procedures were uneventful with no significant aortic regurgitation.

Conclusions: Pre-operative CSA assessment using the direct annulus planimetry method by 3DTEE has optimal agreement with CT-Scan, without the well known risks related to the use of contrast. Further studies are warranted to test usefulness of 3DTEE in predicting short- and long-term outcomes.

Agreement measures for CSA

Variable	CSA (cm)	Mean Diff ± SE	R2	β ± SE	VC (%)	ICC	CCC
CSA by Cardiac CT	4.68 ± 0.9
CSA by 3DE - Measured	4.55 ± 0.9	− 0.09 ± 0.4	0.80	0.9 ± 0.1	5.2	0.89	0.88
CSA by 3DE - Virtual Ring	4.19 ± 1.0	− 0.45 ± 0.7	0.53	0.8 ± 0.2	10	0.63	0.64
CSA by 3DE - Computed	4.40 ± 0.9	− 0.23 ± 0.5	0.66	0.8 ± 0.1	7.7	0.79	0.78

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CSA=Cross sectional Area, R2=Coefficient of Determination, ICC=Intra-class Correlation CoefficientCCC=Concordance Correlation Coefficient, VC=Variation Coefficient

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1283: Comprehensive 3D TTE evaluation of right and left heart chamber remodeling following percutaneous mitral valve repair

P Gripari ¹, G Tamborini ¹, V Bottari ¹, F Maffessanti ², C Carminati ³, M Muratori ¹, C Vignati ¹, A Bartorelli ¹, F Alamanni ¹, M Pepi ¹

Abstract

Purpose: Percutaneous mitral valve repair (PMVR) is an alternative treatment in patients (pts) with significant mitral regurgitation (MR) denied surgery. While in surgical pts the outcome has been related both to the acute hemodynamic favorable results and to the positive cardiac remodeling in the mid-term, in case of PMVR, the effect on cardiac chamber remodeling has never been extensively studied. The aim of this study was to evaluate the immediate and short-term remodeling induced by PMVR of the left (LV) and right ventricles (RV), as well as left (LA) and right atrium (RA) using 3D and 2D transthoracic echocardiography (TTE).

Methods: 3D and 2D TTE was performed in 43 pts (76 ± 8 years, 19 women) with functional (20) or degenerative (23) severe MR before, 30 days and 6 months after PMVR (MitraClip). LV and RV volumes and ejection fraction (EF), and LA volumes were measured using 3D TTE, while RA volumes were derived from 2D TTE. Moreover, 3D LV sphericity and conicity indices (ranging between 0 and 1, with higher values for better similarity with sphere/cone) were calculated at end-diastole and end-systole.

Results: In all pts a significant reduction of MR was obtained and the analysis was feasible. Results are summarized in the Table. At 30 days after PMVR, a favorable remodeling was observed: 1) reduction in volumes of all chambers 2) no LVEF decrement after MR reduction (but a slight improvement in LV EF); 3) LV remodeled toward a more physiological condition (less spherical and more conical). At 6 months, the remodeling process continued, adding further improvement of both morphological and functional parameters.

Conclusion: A comprehensive 2D and 3D TTE analysis allows to investigate the entity and modality of double perspective (volume-morphology) changes involved in PMVR outcome. In high risk pts undergoing PMVR, post procedural heart remodeling involves all cardiac chambers, occurs at short term and improves at mid-term follow-up.

Parameters of cardiac chamber remodeling

Mean ± std				LV				LA	RV			RA
	EDV[ml/m2]	ESV[ml/m2]	EF[%]	Sphericity		Conicity		ESV [ml/m2]	EDV[ml/m2]	ESV[ml/m2]	EF[%]	ESV[ml/m2]
				ED	ES	ED	ES
pre PMVR	91.6 ± 27.3	49.8 ± 28.3	49.03 ± 16.93	0.73 ± 0.06	0.69 ± 0.06	0.73 ± 0.03	0.75 ± 0.03	62.10 ± 18.01	64.34 ± 22.87	33.72 ± 18.64	49.66 ± 11.41	35.73 ± 25.08
30 days	79.97 ± 26.85 (*)	44.39 ± 26.73 (*)	48.46 ± 15.39	0.69 ± 0.06 (*)	0.65 ± 0.07 (*)	0.76 ± 0.04 (*)	0.78 ± 0.03 (*)	58.52 ± 20.80 (*)	59.21 ± 16.35	29.17 ± 12.96 (*)	51.87 ± 17.99	35.09 ± 23.35
6 months	76.11 ± 28.34 (*)	39.29 ± 24.78 (*)	52.05 ± 13.39 (*,º)	0.68 ± 0.05 (*)	0.64 ± 0.06 (*)	0.77 ± 0.03 (*)	0.79 ± 0.03 (*)	57.37 ± 18.18 (*)	58.13 ± 17.99	28.49 ± 13.53	52.08 ± 8.37	31.78 ± 18.29 (*)

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*:p<0.05 vs Pre °: p< 0.05 30 Days vs 6 Months

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1284: Transfemoral vs transapical aortic valve implantation: effects on left ventricular systolic and diastolic function

S Polymeros ¹, A Dimopoulos ¹, K Spargias ², G Karatasakis ¹, G Athanasopoulos ¹, G Pavlides ¹, N Dagres ³, E Vavouranakis ⁴, C Stefanadis ⁴, DV Cokkinos ¹

Abstract

Purpose: To prospectively assess the impact of transcatheter aortic valve implantation (TAVI) performed either with transfemoral (TF) or transapical (TA) approach on left ventricular systolic and diastolic function.

Methods: We investigated 91 patients with severe aortic stenosis who underwent TAVI (59 patients with TF and 32 with TA approach). Echocardiographic parameters of left ventricular function were evaluated 48 hours before and 3 months after the procedure. The echocardiographic assessment included the standard 2-dimensional and Doppler analysis, tissue Doppler and speckle tracking for deformation imaging.

Results: At 3 months, TAVI with TF approach induced significant improvement of the systolic parameters including left ventricular ejection fraction (p<0.001), pulsed tissue Doppler systolic wave of the mitral valve annulus (p<0.001), global longitudinal peak systolic strain (p<0.001), segmental peak values of longitudinal systolic strain (p<0.05) with the exception of the basal lateral wall, mean longitudinal systolic strain rate (p<0.001), mean circumferential systolic strain (p=0.02), mean circumferential systolic strain rate (p=0.001) and all the segmental values of the radial systolic strain (p<0.05). These favourable echocardiographic findings were not observed in the TA group of patients. Furthermore, the TA approach resulted in significant deterioration of the apical lateral peak systolic strain (p=0.05), probably related to local myocardial injury. Regarding the echocardiographic parameters of diastolic function, TAVI with TF approach induced significant improvement of the E/E' ratio (p=0.024), not observed in the TA group.

Conclusions: At 3 months, TAVI with TF approach resulted in significant improvement of echocardiographic parameters of left ventricular systolic and diastolic function.These positive results were not observed in the patients undergoing the TA approach.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1285: Prevalence and prognostic significance of left-sided valvular thickening in patients with systemic light-chain amyloidosis

S Pradel ¹, D Mohty ¹, J Magne ¹, N Darodes ¹, D Lavergne ¹, T Damy ², C Beaufort ³, V Aboyans ¹, A Jaccard ¹

Abstract

Background: Left-sided valvular thickening (LVT) has been described in patients with light-chain amyloidosis (AL) reflecting probable heavy infiltration of valvular endocardium by amyloid proteins. However, the prevalence at initial diagnosis and the prognostic significance of LVT have never been investigated in patients with AL.

Methods and results: transthoracic echocardiography was performed in 150 patients with confirmed AL (Mean age 68 ± 11 years; 59% of male). The presence of mitral and/or aortic valve thickening was assessed visually. Overall, 42% had LVT-AL at baseline. Compared to patients without LVT, those with LVT were significantly older, with more advanced NYHA functional class. They also had higher left ventricular (LV) wall thickening, left atrial size, mitral E/E' ratio and systolic pulmonary artery pressures and lower LV ejection fraction (all p < 0.01). Patients with advanced Mayo Clinic stage had more frequently LVT: 58% in stage III vs. 45% in stage II and 5% in stage I, p<0.0001. In addition, LVT was more present in patients with severe symptoms (63% in NYHA III-IV vs. 33% in NYHA I-II, p=0.0008).

During a mean follow-up of 2.9 years, 79 deaths occurred. Presence of LVT was significantly associated with reduced 5-year survival: 32 ± 7% vs. 64 ± 6% in no-LVT group (figure). In multivariable analysis, after adjusting for age, gender, NYHA and LV ejection fraction, LVT remained significantly associated with mortality (Hazard Ratio=1.90, 95%CI: 1.10-3.43, p=0.02).

Conclusion: The presence of LVT in patients with AL is common and associated with impaired LV systolic and diastolic functions, worse functional status and advanced stage of the disease. In addition, LVT is a powerful marker of mortality in these patients. These results may improve risk stratification in AL patients.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

CARDIOMYOPATHIES: P1286: Right ventricular deformation in patients with non-ischemic dilated cardiomyopathy

K Mzoughi ¹, I Zairi ¹, M Jabeur ¹, F Ben Moussa ¹, A Ben Chaabene ¹, S Kamoun ¹, K Mrabet ¹, S Fennira ¹, A Zargouni ¹, S Kraiem ¹

Abstract

Background: Right ventricular (RV) functional assessment is difficult and not done routinely because of its complex anatomy and high load dependence. Many indices have been developed for quantifying RV function, among which strain and strain rate is relatively new.

Objectives: The study aims were to assess RV function in patients with non-ischemic dilated cardiomyopathy by strain and strain rate analysis; and to determine if the RV dysfunction has prognostic significance.

Methods: Forty patients with non-ischemic dilated cardiomyopathy were assessed for RV function by two dimensional (2D) logitudinal strain and strain rate imaging.

Results: The mean age was 60 years ± 10. Eighty percent of the population was male. Sixty percent of patients were smokers. Half of patients has hypertension. Only thirty percent of them have diabete mellitus which was insulino-dependant in the majority of cases. The average fractional ejection of left ventricle (SIMPSON BP) was 35,7% ± 9. Seventy percent of the polpulation have presented a complication during six months of follow.

Comparing the group that presents a complication to the group that did not present a complication, we note that there is no significant différence on the usual parmeters of the right ventricle study : tricuspid annular plane systolic excursion (TAPSE=15mm ± 3 vs. 15,6 ± 3, p=0,8), Vmax of S (DTI)=11 ± 2,6 cm/s vs. 11 ± 3 cm/s, p=0,88).

Patients with non-ischemic dilated cardiomyopathy had significantly lower global RV systolic strain (the mean peak of contraction of RV=-14,34 ± 4,88, p=0,005). But, there is no significant difference between the two groups (the mean peak of contraction of RV (group with complication)=-14,5 vs. -14,2 (group without complication), p=0,78). The segmental RV function was not significantly decreased.

In addition, the non uniformity of contraction of the RV is correlated to complications (70% of patients in the group that has presented complication vs. 50% of patients in the group that ha not presented a complication, p=0,01).

Conclusion: The non-uniformity of contraction of the RV is a prognostic parameter in non-ischemic dilated cardiomyopathy.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1287: LV assessment with speckle tracking echocardiography in non-sichemic dilated cardiomyopathy

S Jovanova ¹, F Arnaudova-Dezjulovic ¹

Abstract

Background: Speckle tracking is a new echocardiographic advance modality for assessing LV performances .The modality is integrated in novel echocardiographic systems as automated functional imaging (AFI) and allows quick and accurate assessment of LV longitudinal deformation or strain.

Aim: The aim of the study was to evaluate the LV performances in patients with non-ischemic dilated cardiomyopathy, using speckle tracking strain.

Methods: Two-dimensional echocardiography and tissue Doppler examination were performed in 31 patients with non-ischemic dilated cardiomyopathy and 16 healthy controls. GLS was obtained from apical 2, 3 and 4 chamber views. GLS was compared to 2D echocardiographic parameters of LV global systolic function (EF(%), FS (%) and parameters of LV diastolic function (E/A ratio, deceleration time od E wave, E/e' ratio)

Results: GLS was significantly different between two groups, respectively -8.1+/-2.5%, and -16.3+/-1.2% (p<0.01). Strong correlations were observed between GLS and LVEF (r=0.78) in patients with dilated cardiomyopathy. There was a good correlation between GLS and NYHA functional class (r=81) as with E/e' of lateral mitral annulus (r=0.77) in patients with dilated cardiomyopathy.

Conclusion:Speckle tracking is a promising and accurate method for assessing LV function in patients with non-ischemic cardiomyopathy and can predict the patients with poor prognosis.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1288: Echocardiographic predictors of nonsustained ventricular tachycardia in hypertrophic cardiomyopathy

C E Correia ¹, I Cruz ², N Marques ³, M Fernandes ⁴, D Bento ³, D Moreira ¹, L Lopes ², O Azevedo ⁴, SUNSHINE GROUP

Abstract

Introduction: Despite all the techniques at our disposal for the evaluation of patients with hypertrophic cardiomyopathy (HCM), echocardiogram continues to have a central role in the management of these patients.

In our work, we studied which echocardiographic parameters could predict the occurrence of NSVT in patients with HCM

Methods: We studied a population of patients with HCM (N=242, 56% male, mean age 59 ± 15 years) with 24-hour Holter and echocardiogram, from four hospitals.

NSVT was present in 34 (14%) of patients. Two groups were created: those with -NSVT(+) -and those without NSVT- NSVT(-).

Resultas: Patients with NSVT had increased maximum left ventricular wall thickness (LVMWT) 22,3 ± 5,4 vs 18,1 ± 4,5mm (p=0,007). NSVT+ was associated with decreased global longitudinal strain (−12,0 ± 3,2 vs -15,4 ± 3,5%) and increased left atrium área (28,2 ± 7,2 vs 26,3 ± 6,4) but without statistical significance. TDI values were no different between groups (Table 1). The presence of left ventricular outflow tract gradient, a cut off value of 30mm for LVMWT and <-10% for global longitudinal strain did not reach statistical significance between groups.

Conclusions: Maximum left ventricular wall thickness remains the most powerful echocardiographic parameter for predicting NSVT in patients with hypertrophic cardiomyopathy.

Variable	NSVT (+)	NSVT (−)	p
Maximum left ventricular wall thickness (mm)	22,3 ± 5,4	18,1 ± 4,5	0,007
LV mass (g)	332 ± 102	309 ± 92	0,345
Septal Em (cm/s)	5,4 ± ,92	5,1 ± 1,9	0,853
Lateral Em (cm/s)	8,3 ± 3,3	8,1 ± 3,7	0,878
Septal E/Em	5,2 ± 1,9	5,1 ± 2,0	0,896
Global longitudinal strain (%)	−12,0 ± 3,2	−15,4 ± 3,5	0,078
Left atrium area (cm²)	28,2 ± 7,2	26,3 ± 6,4	0,179
Left atrium volume (cm³)	116,1 ± 35,5	95,4 ± 47,5	0,210
LV telediastolic diameter (mm)	48,1 ± 6,4	45,3 ± 7,0	0,830
LV ejection fraction (%)	60 ± 7	59 ± 9	0,287

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Table 1: Echocardiographic parameters and NSVT in HC

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1289: Clinical application of 2D speckle tracking echocardiography in the diagnostic work-up of patients with left ventricular hypertrophy

K Keramida ¹, N Kouris ¹, V Kostopoulos ¹, G Psarrou ¹, V Giannaris ¹, CD Olympios ¹

Abstract

Estimation of myocardial deformation by two-dimensional (2D) speckle tracking echocardiography (STE) is a relatively new method for evaluating regional function of the cardiac chambers. The aim of this study was to assess left ventricular (LV) and left atrial (LA) function with 2DSTE in patients with LV hypertrophy (LVH) and to investigate any relation between strain analysis and the possible cause of hypertrophy.

Methods: We studied 82 consecutive patients (pts) (42 men, mean age 67 ± 13y) with LVH and 20 controls (11 men, mean age 39 ± 11y). From the pts with LVH, we proved by the appropriate diagnostic work-up that 36 had hypertensive cardiomyopathy (Group A), 31 had LVH because of aortic stenosis (Group B) and 15 had idiopathic hypertrophic cardiomyopathy (HCM) (Group C). All pts underwent a transthoracic echocardiography for evaluation of LV and LA functions with 2DSTE.

Results: Left ventricular global longitudinal strain (LVGLS) and left atrial peak longitudinal strain (LAPLS) were significantly lower in patients with LVH compared with controls (-11.94 ± 4.80 vs -19.77 ± 1.90%, p<0.001 and 15.35 ± 10.54 vs 35.61 ± 10.41%, p<0.001, respectively). LVGLS and LAPLS of pts with LVH according to their underlying factor are presented in Table 1.Pts of Group C had significantly decreased LVGLS (p=0.002) and especially later wall strain (p=0.009) compared to pts of Group A, while pts of Group A had higher LAPLS and better strain of the later wall compared to Group B (p=0.027 and p=0.033, respectively). Groups B and C presented no difference in longitudinal strain.

Conclusion: LV and LA function is impaired in patients with LVH. 2DSTE is useful in assessing the impairment of myocardial mechanics due to hypertrophy and may help to determine the underlying cause by the chamber and the myocardial wall that is mostly affected.

	Group A	Group B	Group C	p value
LVGLS (%)	−13.49 ± 5.27	−11.44 ± 4.13	−9.26 ± 3.62	0.011
LAPLS (%)	17.99 ± 10.21	11.94 ± 11.26	15.67 ± 9.09	0.070
Lateral wall (%)	−9.23 ± 9.31	−5.00 ± 6.46	−4.20 ± 3.82	<0.001
Septal wall (%)	−11.65 ± 10.12	−11.84 ± 9.79	−10.40 ± 4.39	<0.001

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1290: Circulating mesencymal stem cells correlate with left ventricular mass index in patients with hypertrophic cardiomyopathy

M Marketou ¹, F Parthenakis ¹, N Kalyva ¹, CH Pontikoglou ¹, S Maragkoudakis ¹, E Zacharis ¹, A Patrianakos ¹, K Roufas ¹, H Papadaki ¹, P Vardas ¹

Abstract

Purpose: Stem and progenitor cells are implicated in ventricular remodelling and have great clinical significance in the pathophysiology of heart failure. However, there are limited data regarding the involvement of mesenchymal stem cell (MSCs) in the pathogenesis of left ventricular hypertrophy (LVH). The aim of this study is to investigate MSCs circulation in patients with hypertrophic cardiomyopathy (HCM).

Methods: We included 28 patients with HCM (14 males, aged 54 ± 12 years) and 17 healthy individuals (8 males, aged 55 ± 14 years). All subjects underwent a complete echocardiographic study. In addition, peripheral blood samples from all participants were immunostained with antibodies against the cell surface markers CD34, CD45 and CD90. Using flow cytometry, we have measured MSCs as a population of CD45-/CD34-/CD90+ cells and also as a population of CD45-/CD34-/CD105+ cells. The resulting counts were translated into the % percentage of MSCs in the total cell number of peripheral blood.

Results: Patients with HCM were shown to have increased circulating CD45-/CD34-/CD90+ and CD45-/CD34-/CD105+ cells (0.005 ± 0.002% and 0.024 ± 0.002%, respectively), compared to control group (0.001 ± 0.002% and 0.01 ± 0.006%, respectively), (p < 0.05 for both comparisons). Both CD45-/CD34-/CD90+ and CD45-/CD34-/CD105+ cell populations revealed a strong positive correlation with left ventricular mass index (r=0.620, p< 0.05 and r=0.54, p< 0.05, respectively).

Conclusions: Patients with HCM were shown to have increased circulating MSCs compared to healthy individuals and this is correlated with the severity of LVH. Our findings contribute to the understanding of pathogenesis of HCM and might offer a future therapeutic target.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1291: Prediction of cardiovascular events by speckle tracking in left ventricular non compaction

F Dominguez Rodriguez ¹, V Monivas Palomero ¹, S Mingo Santos ¹, B Arribas Rivero ¹, S Cuenca Parra ¹, I Zegri Reiriz ¹, J Vazquez Lopez-Ibor ¹, P Garcia-Pavia ¹

Abstract

Left ventricular non compaction (LVNC) is a rare cardiomyopathy which has different morphologic diagnostic criteria with low correlation, and 2D strain analysis has proven to be useful in diagnosis. Prognostic value of 2D Strain has not been studied. The aim of this study is to demonstrate the usefulness of speckle tracking in prediction of cardiovascular events (CVE) among patients with LVNC.

Methods: 26 patients with LVNC were included. Diagnosis was established by Chin, Jenni, Jacquier and Petersen criteria. 2D Strain analysis included Longitudinal Strain (Slong), basal/apical rotation and torsion. Patients were prospectively followed from diagnosis to detect CVE.

Results: After a mean FU of 38 ± 13.3 months, 6 CVE were observed: 2 sustained VT, 1 embolic TIA and 3 admissions for HF. Slong value was significantly reduced in patients with events, with an AUC ROC of 0.82 (0.54 to 1, p=0.047. Best cut-off -8,7; S : 75%, E: 95%). Patients with ≥ -8.7 Slong values had a lower event-free survival. Among patients admitted for HF, torsion was significantly decreased compared to non-admitted patients (0.7 ± 1.5 vs 4.6 ± 3.3, p=0.02)

Conclusions: Low Slong and torsion values emerge as good CVE predictors in LVNC, and routine measurements could complement classic parameters.

Event predictors in LVNC

	CV event (n=4)	No CV event (n=22)	p
LVEF (%)	26,25 ± 13,7	47,5 ± 13,1	0,007
Atrial fibrillation	25 %	9,1 %	<0,001
Slong ≥ -8,7%	75%	4,5%	<0,001

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1292: Left ventricle in the diagnosis of Brugada syndrome

M Szulik ¹, W Streb ¹, A Wozniak ¹, R Lenarczyk ¹, A Sliwinska ¹, Z Kalarus ¹, T Kukulski ¹

Abstract

Rationale: The role of abnormal electrical activation, myocardial dispersion measured by longitudinal strain and exercise-induced changes in Brugada syndrome (BS) has not yet been thoroughly studied.

Aim of the Study: To explore the role of left ventricle in the diagnosis of BS.

Methods: 14 patients underwent rest and bicycle stress echocardiography. SD of time to maximum myocardial longitudinal strain (shortening) – measured by speckle tracking (STI) – was calculated as a parameter of mechanical dispersion for LV: in a 16-segment model; for RV – the SD of 6 RV segments (in apical 4-chamber view). 13 healthy individuals served as controls. Global longitudinal strain (GLS) for LV and RV was also analyzed.

Results: Are presented in table and in figure (only significant table results).

The most valuable parameters for BS recognition were as follows:

(1). LV dispersion at rest (SD STI rest LV) of more than 32 ms: sensitivity – 87%, specificity – 79%, (2). GLS LV of more than ‘−18,75%’: 87%, 71%, (3). RV dispersion during stress (SD STI stress RV 6) of more than 28ms: 71%, 92%, respectively.

Conclusions: (1). LV mechanical dispersion together with LV global longitudinal strain measured at rest – may play an important role in Brugada syndrome diagnosis. (2). Concerning RV – its dispersion might contribute, but only when induced by exercise.

ROC - LV and RV STI parameters

	AUC	95% CI
REST
GLS LV strain	0,836	0,652 to 0,946
GLS RV strain	0,643	0,444 to 0,811
SD STI rest LV	0,905	0,737 to 0,980
SD STI rest RV 6	0,748	0,553 to 0,889
STE RV med. strain	0,752	0,558 to 0,800
STRESS
GLS LV strain stress	0,604	0,399 to 0,785
GLS RV strain stress	0,681	0,475 to 0,846
SD STI stress LV	0,758	0,556 to 0,900
SD STI stress RV 6	0,808	0,611 to 0,932

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AUC - area under curve; CI - confidence interval; other abbreviations - see text.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1293: Left atrial volumetric and strain analysis by three-dimensional speckle tracking echocardiography in noncompaction cardiomyopathy

A Nemes ¹, P Domsik ¹, A Kalapos ¹, T Forster ¹

Abstract

Introduction: Noncompaction cardiomyopathy (NCCM) is a rare cardiomyopathy characterized by a distinctive 2-layered appearance of the myocardium, hypertrabecularization and deep intertrabecular recesses due to arrest of the compactation process of the embryonal endomyocardial morphogenesis. Three-dimensional (3D) speckle tracking echocardiography (3DSTE) seems to be a promising non-invasive imaging tool for the accurate evaluation of global and regional left atrial (LA) function. 3DSTE allows volumetric and strain measurements at the same time. The present study was designed to assess LA volumetric and strain-based functional properties by 3DSTE in NCCM.

Methods: The study comprised 9 consecutive NCCM patients. Due to low image quality one patient has been excluded from the analysis (mean age: 60.2 ± 8.2 years, 3 males). Their results were compared to 20 age- and gender-matched healthy controls (mean age: 50.8 ± 14.6 years, 11 males). Complete two-dimensional Doppler echocardiography and 3DSTE have been performed in all cases.

Results: Calculated LA maximum (90.3 ± 19.1 ml vs. 35.8 ± 6.3 ml, p <0.0001) and LA minimum (71.3 ± 19.5 ml vs. 16.3 ± 4.7 ml, p <0.0001) volumes and LA volume before atrial contraction (81.6 ± 19.8 ml vs. 24.0 ± 6.5 ml, p <0.0001) were significantly increased in NCCM patients. Total (21.8 ± 6.7% vs. 54.8 ± 10.0%, p <0.0001), active (10.2 ± 4.6 vs. 33.4 ± 12.0%, p <0.0001) and passive (12.8 ± 6.5% vs. 32.0 ± 9.2%, p <0.0001) LA emptying fractions proved to be decreased in NCCM. Global radial (-8.0 ± 6.8% vs, -21.4 ± 11.5%, p=0.005), circumferential (9.7 ± 7.7% vs. 28.7 ± 9.7%, p <0.0001), longitudinal (8.4 ± 4.1% vs. 24.5 ± 6.6%, p <0.0001), 3D (-5.7 ± 5.2% vs. -13.7 ± 10.5%, p=0.05) and area (17.7 ± 12.5% vs. 58.2 ± 17.3%, p <0.0001) strains were significantly reduced in NCCM patients as compared to matched controls.

Conclusions: 3DSTE allows detailed evaluation of LA dysfunction in NCCM. Increased LA volumes, reduced LA emptying fractions respecting cardiac cycle and decreased LA strain parameters could be demonstrated by 3DSTE in NCCM.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1294: ESC/ERS Guidelines and DETECT Algorithm Raccomandation in Pulmonary Artery Hypertension associated to Scleroderma. A real life comparison

W Serra ¹, FL Lumetti ², FM Mozzani ², GDS Del Sante ², AA Ariani ²

Abstract

Background: Pulmonary arterial hypertension (PAH) is one of the most common Sistemic Sclerosis (SSc) related cause of death.

Right heart catheterisation (RHC) is the gold standard to detect a PAH. Nevertheless RHC is an invasive diagnostic procedure not always accepted by patients. The European Society of Cardiology/European Respiratory Society (ESC/ERS) has suggested several consensus guidelines to identify high risk PAH subjects . ESC/ERS RHC recommendation are based on patients' syntoms and echocardiographic parameters such as tricuspid regurgitant jet (TR) velocity and right atrium (RA) area. Recently the DETECT study has presented an evidence-based detection algorithm for PAH in SSc. The DETECT algorithm is divided in two steps determining

referral to RHC. In the first one non ecocardiographic tests (FVC/DLCO ratio, current/past telangiectasias, serum ACA, serum NTproBNP, serum urate and right axis deviation on ECG) are taken into account. TR velocity and RA are the echocardiographic parameters assessed in step 2.

Objectives: To compare RHC recommendations according to ESC/ERS guidelines and DETECT algorithm in a group of SSc patients followed up in our rheumatological clinic.

Methods: We included 39 consecutive patients admitted to the Unit of Internal Medicine and Rheumatology of the University Hospital Parma (Italy) between April and October 2013. Each patient had a SSc diagnosis (according to the EULAR/ACR classification criteria) established three or more years ago and was assessed with the above mentioned nonechocardiographicand echocardiographic tests.

Results: Table 1 shows patients with RHC recommended (or not) according to ESC/ERS guidelines and DETECT algorithm. A concordant recommendation was found in 61,5% of patients; 20,5% of patients had a RHC recommended only by ESC/ERS guidelines while 18,0% of patients had a RHC referral according to DETECT algorithm. Moreover 15,4% of patients met ESC/ERS criteria for RHC but had not a referral to echocardiography conforming to DETECT algorithm. Pretty much the same ESC/ERS RHC referral was noticed in patients with a DETECT Step2 score > 44.

Conclusions: In our cohort of patients we observed a RHC recommendation concordace between ESC/ERS guidelines and DETECT algoritm in less than two-thirds of patients. In the near future DETECT algorithm validity should be carefully assessed to have unambiguous evidence-based guidelines to identify PAH high-risk SSc patients

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1295: Echocardiography in patients with end-stage liver disease

C Corros ¹, S Colunga ¹, A Garcia-Campos ¹, E Diaz ¹, M Martin ¹, ML Rodriguez-Suarez ¹, V Leon ¹, A Fidalgo ¹, C Moris ¹, JM De La Hera ¹

Abstract

Background and Purpose: Involvement of the cardiovascular system in patients with end-stage liver disease (ESLD) is well recognized and may be seen in several scenarios in adult liver transplantation (LT) candidates. Patients with hepatopulmonary syndrome (HPS) have higher cardiorespiratory mortality than those without. Pre-operative assessment of the cardiac status of LT candidates is thus critically important for risk stratification and management. Cardiac imaging plays an integral role in the assessment of LT candidates. The purpose of our study is to evaluate the echocardiographic findings and the prevalence of HPS in patients with ESDL previous to hepatic transplant.

Methods: A total of 104 chronic liver disease patients aged 48(SD 11) years fulfilled the criteria for this study and were subjected to clinical examination, laboratory investigations, and agitate saline contrast transthoracic echocardiography.

Results: Alcohol abuse was the main cause of liver disease (50%), followed by hepatitis C virus infection (26%). The prevalence of HPS was 17%, mild hypoxemia was observed in 74% of these patients and moderate in 24%. Left ventricle (LV) was dilated in 10% (ETDV 100 ml, SD 33) and LV hypertrophy was found in 2%. LVEF was 69% (SD 6) and LV systolic dysfunction was observed in only 2%, however diastolic dysfunction was present in 76% of patients (type I 57% and type II in 19%) with elevated LV filling pressures in 8% of cases. Aortic calcification was present in 34% of patients and mitral calcification in 36%. Aortic stenosis was observed in 6% (severe in 1 case and mild in the rest), aortic regurgitation in 11% (moderate in 1 case) and mitral regurgitation in 46% (all mild except for 3% moderates). Left atrium was enlarged in 57% of patients. RV was dilated in 21% of cases but RV systolic dysfunction was observed in only 2%. Systolic arterial pulmonary pressure was 32 mm HG (SD 7) with PHT in 24% of cases (mild in all patients). Pericardial effusion was present in 6% of patients and pleural effusion and free abdominal fluid in 5% of cases.

Conclusions: The presence of echocardiographic findings, especially diastolic dysfunction and valvular calcification are common in patients with ESLD. The echocardiographic study should be a routine test to evaluate the possible causes and repercussions of hepatic diseases besides the evaluation of HPS.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1296: Assessment of early myocardial dysfunction in type I diabetes by tissue Doppler strain rate imaging

M M Kylmala ¹, M Rosengard-Barlund ², P H Groop ², J Lommi ¹

Abstract

Purpose: We tested whether echocardiography with strain rate imaging could detect subclinical changes in left ventricular function in type I diabetes.

Methods: We included 33 patients (28 ± 5 years, 17 male) and 9 healthy controls (27 ± 5 years, 5 male). The patients had suffered from type I diabetes for 8.6 ± 1.7 years (GHbA1C 7.5 ± 0.9) but were otherwise healthy, with no diabetes-related complications. The patients had BMI 25.7 ± 5.3, mean arterial pressure 93.6 ± 10.4 mmHg, and heart rate 61.3 ± 7.6 bpm; for no value differing significantly from controls. Color tissue Doppler images were acquired for all standard LV apical views. Longitudinal strain- and strain-rate (SR) values came from basal, mid, and apical segments of each myocardial wall. Serum proBNP was measured in all patients and controls.

Results: Segmental late diastolic SR (SR A) was significantly higher in patients than in controls: mean 0.93 ± 0.54 vs. 0.81 ± 0.47 1/s (p=0.021), with no difference in systolic SR, early diastolic SR, or end-systolic strain between patients and controls. ProBNP was significantly higher in patients: mean 53.4 ± 29.3 vs. 33.6 ± 35.6 ng/l (p=0.012). Global SR A values are in Figure for healthy controls (group 1) and patients, the patients divided into two groups by the median value of proBNP (group 2, proBNP <46 ng/l; group 3, proBNP 46≥ ng/l).

Conclusions: An increase in SR A and serum proBNP may serve as markers of subclinical myocardial dysfunction in type I diabetes after 6 to 10 years of disease duration.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1297: Low stroke volume and sigmoid septum are associated with the development of reversible wall motion abnormalities in patients with aneurysmal subarachnoid hemorrhage

HACM Bruin De- Bon ¹, IA Bilt Van Der ¹, AA Wilde ¹, RBA Brink Van Den ¹, AJ Teske ², GJ Rinkel ², BJ Bouma ¹

Abstract

Purpose: Several patients with aneurysmal subarachnoid hemorrhage(aSAH) have temporary reversible wall motion abnormalities (WMA). We sought to determine which patients are prone to develop reversible WMA.

Methods: All 301 consecutive patients admitted with an aSAH in 5 university medical centers in the Netherlands underwent transthoracic echocardiography on day1, 4 and 8 after the aSAH. 59 Patients had WMA in the time frame day 1 to 4. In 13 of these patients LV function was recovered on day 8, these were used in the study. Left ventricular dimensions and volumes were measured. Stroke volume was measured using the Simpson rule at the 4 and 2 apical chamber view and was corrected for BSA. We evaluated 13 aSAH patients without WMA as controls.

Results: 13 Patients with aSAH and WMA (2 male, mean age 60 years ± 11.3) and 13 patients with aSAH but without WMA(2 males, mean age 55 years ± 11.8) were analyzed. Patients with WMA had a lower LV diastolic (65.2 ml ± 12 ml) and systolic volume (30.6 ml ± 8ml) and a lower stroke volume 34,5 ml ± 12.3 ml compared to patients without WMA had LV diastolic (87.2ml ± 15 ml)and systolic volume(38.7ml ± 7 ml) (p 0.0001) and a stroke volume 49,4 ml ± 11.3 ml (p 0.004). This remained significant after correction for BSA (16.9 ml/m² ± 6,1 ml/m² VS 26.9ml/m² ± 5.3 ml/m² (p. 0.001). The septum thickness at the base was 13.7 ± 2 mm in patients with WMA and 10.5 mm ± 1.7 mm (p 0.0001) in those without WMA. The ratio between basal and mid septum dimensions in patients with WMA was 1,31 ± 0.10 and in patients without WMA 1,07 ± 0.09 (p 0.0001)

Conclusions: Patients with aSAH and WMA have lower stroke volumes and a more pronounced sigmoid septum compared to controls. These findings may in part explain pathophysiology.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

SYSTEMIC DISEASES AND OTHER CONDITIONS: P1298: Aortic arch mechanics in hypertensive patients versus controls, a two dimensional speckle-tracking study

R Teixeira ¹, R Monteiro ², J Garcia ³, A Silva ³, M Graca ³, R Baptista ¹, M Ribeiro ³, N Cardim ⁴, L Goncalves ¹

Abstract

Our group has reported that 2D-ST echocardiography is a feasible methodology for the analysis of the aortic arch mechanics. Our previous data supported the use of mechanics as a surrogate for vascular stiffening.

Purpose: to study aortic arch vascular mechanics in hypertensive patients (HP) versus controls (CT).

Methods: We included 50 CT and 33 HP and performed a complete echocardiographic exam. We included a short axis view of the aortic arch, after the emergence of the brachiocephalic artery. The 2D-ST methodology was used to off-line calculate aortic arch mechanics (EchoPAQ, GE Healthcare®). The analysis was performed for circumferential aortic strain (CAS) and for early circumferential aortic strain rate (eCASR). We divided our population in three groups, in accordance to the age distribution (<30y;30-42y;≥42y).

Results: HP had a mean age of 45 ± 13 years and a gender balance. They had hypertension for a mean of 5.2 ± 3.1years. The mean systolic and diastolic blood pressure was 149 ± 21 and 88 ± 14mmHg. Of the 480 aortic wall segments, 92% had adequate waveforms for 2D-ST analysis. The mean CAS for CT was 11.3 ± 3.2%; versus 6.6 ± 2.0% for HP (p<0.01). For CASR it was 1.5 ± 0.4 for CT and 1.0 ± 0.3 for HP (p<0.01). In both CT and HP we found a significant negative correlation between vascular mechanics and age. In all age groups, CT had higher values for both aortic strain and strain rate (Table). There were no differences between genders.

For HP, we found a significant correlation between CAS and the LA indexed volume (r=-0.42, p<0.01), LV early (e') relaxation (r=0.55, p<0.01) and the estimated LV filling pressures (r=-0.59, p<0.01). Similar significant associations were identified for CASR.

Conclusions: Aortic arch mechanics assessed with 2D-ST were significantly lower for the HP, for all age groups; the indexes correlated significantly with LV diastolic performance.

Aortic arch mechanics

		Controls	Patients	P
< 30y	CAS	12.6 ± 2.7	8.9 ± 1.2	<0.01
< 30y	CASR	1.6 ± 0.4	1.4 ± 0.3	<0.01
30-42y	CAS	10.9 ± 3.2	7.0 ± 2.0	<0.01
30-42y	CASR	1.5 ± 0.5	1.0 ± 0.3	<0.01
≥42y	CAS	8.7 ± 2.8	5.7 ± 1.6	<0.01
≥42y	CASR	1.3 ± 0.5	0.9 ± 0.3	<0.01

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1299: Echocardiographic markers of cardiogenic shock in patients with acute Pulmonary Embolism

A Duszanska ¹, I Skoczylas ², T Kukulski ¹, L Polonski ², Z Kalarus ¹

Abstract

Objective: We sought to determine echocardiographic markers of cardiogenic shock in patients with acute pulmonary embolism (PE).

Methods: 243 patients (132 M, mean age 55.4 ± 15.4 years) were admitted into our centre with acute PE. In all the patients clinical assessment, ECG, transthorasic echocardiography (TTE), arterial blood gases, biochemistry and coagulation screening were performed on admission.

Results: 14 (5.7%) patients with acute PE presented with cardiogenic shock (systolic blood pressure 75 ± 11 mmHg, HR 123 ± 20/min.). On univariate analysis right ventricular antero-posterior end-diastolic diameter (RV) [OR 1.15, 95% (1.05-1.27), p=0.004], Left Ventricular Ejection Fraction (LVEF) [OR 0.89, 95% (0.84-0.95) p=0.0001], Tricuspid Annular Plane Systolic Excursion (TAPSE) [OR 0.85, 95%(0.73-0.98), p=0.03], Right Ventricular Systolic Pressure (RVSP) [OR 1.03, 95% (1.0-1.07), p=0.05] were associated with cardiogenic shock. On multivariate analysis RV(p=0.01) was identified as an independent marker of cardiogenic shock in patients with acute PE (RV>43 mm, sensivity 60%, specificity 96 %).

Conclusions: Reduced LV ejection fraction, tricuspid annular plane excursion and increased RV antero-posterior diameter and RV systolic pressure on transthorasic echocardiogram are associated with cardiogenic shock in patients with acute pulmonary embolism. RV end-diastolic diameter was identified as an independent marker of cardiogenic shock with an excellent specificity.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1300: Incidence of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism in Korea: The predictive value of echocardiography

J-H Choi ¹, JS Park ¹, JH Ahn ², JW Lee ¹, SK Ryu ³

Abstract

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication after acute pulmonary embolism (APE) and is associated with substantial morbidity and mortality. This study aimed to investigate the incidence of CTEPH after APE in Korea and to determine echocardiographic predictors of CTEPH.

Methods and Results: Among patients with APE confirmed by chest computed tomography (CT) between January 2007 and July 2013, 246 consecutive patients with available echocardiographic data were enrolled in this study. CTEPH was defined as a persistent right ventricular systolic pressure (RVSP) greater than 35 mmHg on echocardiography after at least 6 months' follow-up and persistent pulmonary embolism on the follow-up CT. Fifteen patients (6.1%) had CTEPH. The rate of right ventricular (RV) dilatation (66.7% vs. 28.1%, P=0.002) and the RVSP (75.5 mmHg vs. 39.0 mmHg, P<0.001) were significantly higher in the CTEPH group. D-dimers, RV dilatation, RV hypertrophy, RVSP, and intermediate-risk APE were associated with the risk of CTEPH after APE (odds ratio [OR] 0.59, 5.11, 7.82, 1.06, and 4.86, respectively) on univariate analysis. RVSP remained as a significant predictor of CTEPH on multivariate analysis (OR 1.056, 95% confidence interval 1.006–1.109, P=0.029).

Conclusions: This study showed that the incidence of CTEPH after APE in Korea was 6.1% and that initial RVSP by echocardiography was a strong prognostic factor for CTEPH

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1301: Echocardiographic evaluation of heart in chronic obstructive pulmonary disease patient: co-relation with the severity of disease and exercise capcity

J Ahn ¹, DH Kim ¹, HO Lee ¹

Abstract

Background: As a result of increased pulmonary resistance, right ventricular structure and function can be changed in chronic obstructive pulmonary disease (COPD) patients. The aim of study is to assess the cardiac changes secondary to COPY by echocardiography and to find out the relationship between echocardiographic parameters and severity of COPD and exercise capacity.

Methods: Clinical data, echocardiography, pulmonary function, 6 minutes walking test were obtained in 56 patients with COPD patints. Linear regression analysis was performed to evaluate the association between echocardiograpic parameters and not only FEV1/FVC but also six minute walk distance.

Results: All subjects had preserved left ventricular (LV) systolic function (EF=64.2 ± 4.6%) and the mean six minute walk distance was 380 ± 124 meters. FEV1/FVC was correlated with TR dp/dt (r=-0.369, P < 0.009) and E'/A' (r=0.372, P < 0.008). Six minute walk distance was correlated with TR dp/dt (r=-0.417, P < 0.003) and E'/A' (r=0.327, P < 0.022). Especially pulmonary arterial systolic pressure (PASP) was well correlated with six minutes walk distance (r=-0.490, P < 0.000).

Conclusions: Echocardiographic right ventricular function test was correlate with disease severity and exercise capacity of COPD patients. Also pulmonary hypertension has a linear relationship with exercise capacity of COPD patients.

Relationship between echocardiographic p

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1302: Effect of endurance exercise training on Left Atrial functional and structural characteristics in previously untrained subjects

M Przewlocka-Kosmala ¹, J Mlynarczyk ¹, A Rojek ¹, A Mysiak ¹, W Kosmala ¹

Abstract

Endurance exercise training (EET) has been shown to elicit structural and functional LV and RV remodeling, however data on the adaptive changes of atrial myocardium are scarce. We sought to investigate the effect of EET on left atrial (LA) function and morphology in amateur individuals preparing for triathlon competitions.

Methods: Twenty-one subjects aged 33 ± 6 yrs underwent conventional and speckle tracking echocardiography at rest before and after a high-intensity 12-month EET, with measurement of LA longitudinal deformation.

Results: Post-training evaluation revealed significant decrease in LA strain and increase in LA volume index, and no change in LA ejection fraction (Table). Significant effect of EET was evidenced for LV diastolic function (improvement in tissue e' velocity - 12.0 ± 3.2 vs 13.5 ± 3.0 cm/s, p<0.01, and E/e' ratio - 6.5 ± 1.2 vs 5.7 ± 1.4, p<0.01), but not for global LV systolic performance (longitudinal strain -21.4 ± 1.9 vs 20.8 ± 2.0%, p=0.27, and LV ejection fraction - 69.5 ± 4.8 vs 70.2 ± 3.4%, p=0.55). No significant correlations were shown between changes from baseline to follow-up in LA strain and analogous changes in LA size and LV functional parameters.

Conclusions: In previously untrained subjects, EET induces LA enlargement and decrease in LA deformation at rest, with LA hemodynamic function (LA ejection fraction) remaining preserved. The reduction in LA myocardial strain may be associated with a lesser myofibre stress and more efficient functioning, and should be considered as a physiologic adaptive response to exercise.

Results

	Pre	Post	p
Total LA strain, %	41.0 ± 7.6	35.0 ± 8.2	0.001
LA strain at atrial contraction, %	14.9 ± 3.5	12.7 ± 2.9	0.03
Peak positive LA strain, %	26.1 ± 5.7	22.3 ± 7.1	0.01
LA volume index, ml/m²	25.3 ± 5.0	29.0 ± 3.9	0.01
LA ejection fraction, %	58.0 ± 10.4	60.8 ± 8.5	0.28

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1303: Cardiac remodeling in American-style football players is associated with subclinical systolic dysfunction as shown by intraventricular pressure gradient

A Pellissier ¹, E Larochelle ¹, L Krsticevic ¹, E Baron ¹, V Le ¹, A Roy ¹, A Deragon ¹, M Cote ¹, D Garcia ¹, F Tournoux ¹

Abstract

American-style football players, especially linemen, are known to develop hypertension and concentric cardiac remodeling during training. It is unclear whether such cardiac remodeling is linked to hypertension or to the development of an athlete's heart. The goal of this study was to demonstrate whether such cardiac remodeling was associated with subclinical cardiac dysfunction.

Twenty-five line position football players were scanned using a Vivid q echo machine (General Electrics). For each participant, left ventricular mass, ejection fraction (Simpson's method), longitudinal strain, intraventricular pressure gradient (IVPG)) and diastolic function (diastolic longitudinal strain rate) were assessed. IVPG was estimated by processing color M-mode Doppler data using the Euler equation of fluid dynamics and indexed by the systolic arterial pressure of the participant. These echo data were compared to the following clinical characteristics: blood pressure, weight, medical history and current training.

Among this group, only two players (8%) had normal blood pressure while the others were diagnosed with either pre-hypertension (n=17, 68%) or confirmed hypertension (n=6, 24%). Increased relative wall thickness was significantly associated with hypertension status (P=0.001) but unrelated to past or current training load. However, higher LV mass was correlated with lower systolic function as assessed by IVPG (R=-0.6, P=0.004). Other parameters for systolic or diastolic function were not able to highlight such relationship.

Cardiac remodeling in American-style football players is associated with hypertension and subclinical systolic function. Careful evaluation of remodeling and consideration of hypertension should be performed in these athletes before assigning the diagnosis of athlete's heart.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1304: Comparison of diastolic function of the left ventricle between elite athletes and the general population,with the use of tissue doppler imaging,left atrial volume index and velocity flow propagation

K Yiangou ¹, C Azina ², A Yiangou ¹, M Zitti ¹, M Ioannides ³

Abstract

Purpose: The morphological and structural changes that take place in the left ventricles of elite athletes, are expected to influence the physiologic characteristics, contributing to the entity known as athletic heart. The aim of this study is to have an insight in the changes of diastolic function of the left ventricle of elite athletes and to compare them with the general population, with the use of tissue doppler imaging, left atrial volume index and velocity flow propagation.

Method: 24 professional football players of a first division league team, who train intensively daily (subgroup a) and 24 subjects that do not have regular physical activity (subgroup B, as control group) have been matched in pairs. A comprehensive echo study has been conducted and the intraventricular septal and posterior wall thickness, left ventricular end diastolic diameter (LVEdD), E wave, A wave of the mitral inflow have been measured. The mean value of E' at the level of the mitral annulus both in the lateral and in the intraventricular septal wall has been calculated. Moreover left atrial volume index was calculated by using both the biplane-area method and the anteroposterior – transverse diameter. Velocity flow propagation was measured from the slope of the first aliasing velocity by the use of color / m-mode.

Results: In athletes the E' in interventricular septum was increased in a statistically significant degree (0.21 +/- 0.04 vs 0.19 +/- 0.04 p< 0.05) as it was in the lateral wall (0.23+/- 0.03 vs 0.18 +/- 0.02) The E/E' both in the interventricular septum and the lateral wall was statistically significant reduced in athletes group than in the control group (4,73 +/- 1.1 vs 5,9 +/- 1,4 p=0,08 and 4,21 +/- 0.8 vs 5,42 +/- 1.3 p=0,02) respectively. Higher values of velocity flow propagation were recorde in athletes (61,49+/-6.84 vs 55.81 +/- 4.29 in control group). Left atrial volume index was increased in the athletes group compared to the control group (26 +/- 7 mm/m² vs 22 +/- 5 mm/m²).

Conclusion: The intensive training benefits diastolic function through the morphological and functional changes that creates. Increase of left atrium is considered to be an expected change during the adaptation of the heart to these conditions.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1305: Utility of ultrasound lung comets in the early diagnosis of Acute Heart Failure in post-cardiac surgery: the LUCE study

F Ricci ¹, G Dipace ², R Aquilani ³, F Radico ¹, V Cicchitti ¹, F Bianco ¹, E Miniero ³, F Petrini ², R De Caterina ¹, S Gallina ¹

Abstract

Purpose: Acute heart failure (AHF) after cardiac surgery is associated with a very poor prognosis. Early diagnosis of AHF is key to ensure prompt and effective treatment. Lung ultrasonography (LUS) have been proposed as a reliable diagnostic tool for the assessment of pulmonary congestion by means of ultrasound lung comets (ULCs). The aim of this study is to assess the diagnostic performance of ULCs, alone or in combination with transthoracic echocardiography (TTE), compared with chest-X-ray (CXR) and NT-proBNP, for the early diagnosis of AHF in a cohort of patients admitted to the cardiac surgery intensive care unit (CSICU) of our hospital.

Methods: We enrolled 42 consecutive patients (mean age: 71.1 ± 8.8 years; mean EuroSCORE: 5.7 ± 2.9 [ ± SD]), who were studied before and immediately after cardiac surgery with LUS, TTE, CXR and NT-proBNP. Final diagnosis of AHF, satisfying ESC guidelines recommendations, was adjudicated by 2 independent investigators blinded to the results of LUS. ROC-curve analyses were performed to compare diagnostic accuracy and predictive values of LUS ( ± TTE-derived LV systolic and diastolic function), CXR and NT-proBNP with reference to the adjudicated final diagnosis.

Results: The adjudicated final diagnosis of postoperative AHF was done in 18 patients (42.9%). Mean postoperative ejection fraction was 49%. Decompensation was detected in 59% of patients when estimated by LUS ( ± TTE), 28% by CXR, and 26% by NTproBNP. At the time of admission in CSICU, a number of ULCs <5 safely ruled out postoperative AHF with both sensitivity and negative predictive value of 94%. In ROC analyses, ULCs yielded a C-statistic of 0.81 (95% CI: 0.69-0.92) compared with 0.74 (95% CI: 0.61-0.87) for CXR, and 0.56 (95% CI: 0.42-0.70) for NT-proBNP. LUS allowed significantly shorter average time to diagnosis (107 min) when compared with CXR and NT-proBNP (261 and 165 min; p<0.0001).

Conclusions: In post-cardiac surgery LUS allows rapid and reliable ruling-out of AHF. LUS represents an attractive, radiation-free, bedside, non-invasive tool for early detection of extravascular lung water.

Diagnostic strategy	Sensitivity	Specificity	NPV	PPV	AUC (95% CI)
ULCs	94.4	66.7	94.1	68.0	0.81 (0.69-0.92)
CXR	55.6	91.7	73.3	83.3	0.74 (0.61-0.87)
NT-proBNP	33.3	79.2	61.3	54.5	0.56 (0.41-0.70)

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1306: Right atrial reservoir phase strain and tricuspid regurgitation, a pilot study

R Jardim Prista Monteiro ¹, R Teixeira ², J Garcia ², R Baptista ³, M Ribeiro ², N Cardim ⁴, L Goncalves ³

Abstract

Introduction: The influence of tricuspid regurgitation (TR) on right atrial (RA) mechanics has not been demonstrated.

Purpose: The aim this study was to assess the influence of chronic functional TR on the RA reservoir phase strain (rɛR).

Methodology: We included 55 consecutive individuals referred for transthoracic echocardiography. The sample was divided into three groups, according to the tricuspid regurgitation volume (TRV), calculated with the PISA method: Group A (n=20) VRT ≤ 21 ml, Group B (n=19) TRV > 21 and ≤ 31 ml, Group C (n=16) TRV > 31 ml. rɛR was assessed with 2D-speckle tracking echocardiography (QRS reference frame).

Results: Patients had a median age of 78,0 (64,0 – 84,0) years with a female predominance (64%). For the 55 patients, rɛR had a median value of 16% (12.7 – 24.0). A significant positive correlation was observed between rɛR, right ventricular (RV) longitudinal systolic function (TAPSE: r=0.53, p<0.01; S' RV: r=0.60, p<0.01), and left ventricular ejection fraction (r=0.35, p=0.01). On the contrary, there was a negative correlation between rɛR and RV diastolic diameter (r=-0.57, p<0.01), RA systolic and diastolic dimensions (RADA [r=-0.51, p<0.01}, RASA [r=-0.65, p<0.01]), estimated pulmonary vascular resistance (PVRs) (r=-0.61, p<0.01) and PASP (r=-0.34, p=0.01). A progressive decrease of rɛR was documented with an increase in TRV (23 [16-28] vs 16.8 [13-20] vs 11 [8.3-13.8]%, p<0.01), r=-0.71; p<0:01). The rɛR was lower in patients with atrial fibrillation compared to patients in sinus rhythm [AF: 14.0 (10.5-16.9)% vs SR: 19.9 (15.5-27.0)%, p<0.01]. Two multivariate linear regression models were created to estimate rɛR either for the AF or for the SR patients. The following variables were included: RA systolic area (RASA), TRV, RV S' and estimated RVP. For the AF patients, TRV (β -0.52; p<0.03) was the only independent predictor of rɛR. For the SR patients, besides TRV (β -0.44; p<0.01), both RASA (β -0.34; p<0.03), and RV S' (β 0.35; p=0.01) were considered independent predictors of rɛR.

Conclusions: According to this study, rɛR decreased significantly with increasing values of TRV. The underlying rhythm, chamber dimensions, RV systolic function and PVR were also important variables to explain rɛR variability.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1307: Left Atrial volume index predicts recurrence of stroke in patients with Non-Sustained Atrial Tachycardia

H Chung ¹, JY Kim ¹, B Joung ², JS Uhm ², HN Pak ², MH Lee ², KY Lee ¹

Abstract

Background: Non-sustained atrial tachycardia (NSAT) is known to appear more frequently in patients with paroxysmal AF. Additionally enlarged LA is considered to be an independent risk factor for newly diagnosed AF. We hypothesized that those patients who presented with NSAT and enlarged LA would have a higher incidence of stroke recurrence.

Methods: 214 patients (102 males, mean 70 ± 11 years) with acute ischemic stroke and NSAT were subject to 24-hour Holter monitoring. During follow-up patients were assessed for stroke recurrence and echocardiographic parameters.

Results: During a mean follow-up period of 36 ± 34 months, the recurrence rate of stroke was 11.8% (25 of 214). Those patients with recurrence had a larger LA diameter (34.73 ± 5.04 vs. 40.64 ± 3.45mm, p<0.001), LA volume index (LAVI, 22.56 ± 5.86vs. 33.81 ± 7.80 ml/m2, p<0.001and increased E/E' (12.27 ± 4.86 vs. 14.49 ± 4.38, p=0.032) compared to patients without recurrence (n=189). A Kaplan-Meier survival rate was significantly lower in patients with enlarged LA size (LAVI>28 mm3/m2) compared with patients without enlarged LA size (LAVI≤28 mm3/m2) (p<0.001 by log-rank test). Cox regression analysis revealed that left atrial volume index hazard ratio (HR: 1.148, 95% CI: 1.092-1.206, p<0.001) was an independent predictor for stroke recurrence in patients with NSAT. Areas under the Receiver Operating Characteristics (ROC) curve of LAVI for recurrence of stroke was 0.876 (95% CI: 0.791-0.960, p<0.001).

Conclusion: In patients with acute ischemic stroke and NSAT, increased LAVI predicts an increased risk of stroke recurrence. This study supports the potential use of anticoagulants in stroke patients with NSAT and increased LAVI without documented AF to reduce recurrent stroke.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1308: Echocrdiographic characteristics of 60 non cardiac patients with false tendon and their electrocadiographic significance

AM Ragab ¹, AMIR Abdelwahab ¹, YASER Yazeed ¹, WAEL El Naggar ¹

Abstract

Background: False tendons are (FT) fibromuscular bands that transverse the left ventricular cavity and often contain conduction tissue which proved in some case reports to cause ventricular tachycardia.

Objectives: To investigate the echocrdiographic characteristics of patients with false tendon and their electrocadiographic significance.

Methods: We studied 60 non cardiac patients with FTs . False tendons were defined (by 2D TTE) as bands stretching across the left ventricle (LV) from the ventricular septum to the papillary muscle or LV free wall but not connecting, like the chordae tendinae, to the mitral leaflet. Site and number of FTs were identified and length& thickness & volume (calculated as volume of cylinder) of FT were measured. FTs were classified according to their points of attachment as type 1 (longitudinal), type 2 (diagonal), type 3 (transverse) and type 4 (weblike). ECG intervals were calculated and analysis of ST segment was done.

Results: Patients were 42 males and mean age was 33 ± 15.19, 20 patients were completely healthy and 40 patients with systemic non cardiac diseases. Four patients (6.7%) of the 60 had multiple FTs, the horizontal (From the apical septum to lateral free wall) had been the most common site of FT(6%), length (mm) 27.88 ± 9.23, thickness (mm) 1.98 ± 0.67 and volume (mm3) 102.03 ± 78.14. Early repolarization pattern (ERP) was present in 29 patients (48.3%) of patients with FTs.Horizontal ST segment elevation was found in 15 patients (60%) of patients with ERP. Infrolateral ST segment elevation was the most common site of ERP (48%).

Conclusion: In our sample of adult non cardiac Egyptian patients FTs tend to occur more in males and horizontal type is the most common type and our results suggest that FTs may play a role in genesis of ERP.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1309: Is insulin resistance a link between obesity and subclinical Left Ventricular dysfunction in obese women?

K Spahiu ¹, E Spahiu ¹, A Doko ²

Abstract

Prolonged obesity predisposes to heart failure and premature cardiovascular death. Obese women are at increased risk for the development of heart failure because of left ventricular (LV) hypertrophy, systolic and diastolic dysfunction. However, coexistence of insulin resistance and obesity in women may enhance the development of heart failure.

Purpose: The aim of this study was to investigate subclinical alterations of LV structure and function in obese women with insulin resistance.

Methods: Sixty consecutive asymptomatic, sedentary obese women (body mass index [BMI] ≥30 kg/m2), mean age 48 ± 13 years, were enrolled. A total of 62 age-matched non-obese healthy women (body mass index [BMI] < 30 kg/m2) were recruited as control subjects. Left ventricular structure, systolic and diastolic function were assessed by two-dimensional echocardiography and tissue Doppler imaging at mitral annulus level. The homeostasis model assessment insulin resistance index (HOMA-IR) was used to assess insulin resistance.

Results: The HOMA-IR values in the obese group were significantly higher than in the control group (13.4 ± 5.2 vs 4.2 ± 1.25, p < .0001). Obese women had higher end-diastolic septal and posterior wall thickness, LV mass, and relative wall thickness than non-obese women. Obese women had a greater LV mass index by height (61.808.5 ± 14 g/h2.7) than did control subjects (36.67 ± 8 g/h2.7, p < .0001). BMI values showed significant correlations with HOMA-IR (r=0.78, p=0,001), with left atrium area (r=0.81, p < 0.0001) and posterior wall thickness (r=0.7, p < 0.0002). Moderate positive correlation was observed between BMI and RWT (r=0.55, p <0.001) also between BMI and LV mass (r=0.4, p < 0.005). The Sm and Em values (average of lateral+septal velocity) were lower in obese women, suggesting an impairment of systolic and diastolic function of LV.

Conclusions: This study demonstrates that insulin resistance could be a link between obesity and subclinical alterations of LV structure and function in obese women.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1310: Relation of 2D- and 3D-echocardiography and cardiac MRI in patients with HER2Neu positive breast cancer treated with chemotherapy and HER2Neu-receptor blocking agents

C Liesting ¹, JJ Brugts ², MJM Kofflard ¹, JJEM Kitzen ¹, E Boersma ², M-D Levin ¹

Abstract

Purpose: Chemotherapy has proved to be a helpful and efficient modality of treatment in advanced malignant disease in both adjuvant and palliative settings. With the advent of monoclonal antibodies directed against tumor antigens newer strategies are explored to further improve remission and survival rates. As such, Trastuzumab and Lapatinib have evolved as promising agents in the treatment of breast cancer over-expressing the human epidermal growth factor receptor 2 protein (HER2Neu). A well-known downside of chemotherapeutic agents has always been the increased incidence of cardiotoxic side effects. The incidence of these effects vary between <1% to >10% in different series treated with HER2Neu-receptor blocking agents. The cardiac function in these patients is regularly measured by MUGA-scan or 2D-echocardiography (2DE). The reliability of 3D-echocardiography (3DE) is often discussed in literature and is unknown in patients treated with HER2Neu-receptor blocking agents.

Methods: In this prospective single centre study, successive HER2Neu positive breast cancer patients starting with chemo-immunotherapy are included in the HERBAS study. Trastuzumab in with chemotherapy are prescribed in two different groups: early-stage or advanced-stage. Systolic function by 3D- and 2D-echocardiography for start and during treatment are assessed even as systolic function by 3D-echocardiography compared to cardiac MRI as golden standard.

Results: From January 2008 to December 2013 103 patients are included in the study. The mean age was 52.3 ( ± 11.7) years. The mean LVEF by 3DE and 2DE at time point 1 were respectively 60.5% and 62.3% (p=0.001) versus 58.5% and 58.0% at time point 2 (p=0.560). The mean LVEF by 3DE and cMRI at time point 1 was respectively 60.1% and 52.0% (p < 0.001) versus 58.1% and 51.5% (p=0.002) at time point 2. More results will be presented.

Conclusions: The LVEF measured by 3DE is also in this population closer to the values measured by cMRI. But in clinical practice, the 3D ultrasound for this population is no real added value, because of the lack of expertise and availability.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

CONGENITAL HEART DISEASE: P1311: Target therapy in oncology. Trastuzumab cardiomyopathy is prevented by ranolazine: in vitro and in vivo study

C Coppola ¹, G Piscopo ¹, D Rea ¹, C Maurea ¹, A Caronna ¹, I Capasso ¹, N Maurea ¹

Abstract

Purpose: Trastuzumab (T), an anti-ErbB2 inhibitor, is the foundation of care for patients with HER2-positive breast cancer. Cardiovascular complications due to T are a growing problem in clinical practice that may frustrate modern oncological outcome of therapy (asymptomatic left ventricular dysfunction and heart failure). The mechanisms of cardiotoxicity of T have not been fully elucidated and can include changes in Ca2+ regulation related to blockade of ErbB2 and PI3K-Akt and MAPK pathways. Here, we aim at assessing whether RAN, modulating intracellular calcium, through its inhibition of late INa, blunts T cardiotoxicity in vitro and in vivo.

Methods: To assess for toxicity in vitro, rat H9C2 cardiomyoblasts were pretreated with RAN (1 and 10 μM) for 72 hours and then treated with T (200 nM) for additional 72 hours. To evaluate cardiac function in vivo, fractional shortening (FS) and ejection fraction (EF) were measured by echocardiography M-Mode in C57BL6 mice, 2-4 mo old, pretreated with RAN (305 mg/Kg/day, dose comparable with that used clinically in humans of 750 mg twice) per os for 3 days. RAN was then administered for additional 7 days, alone and together with T (2.25 mg/kg/day ip), according to our well established protocol.

Results: Our in vitro studies demonstrate that RAN reduces cardiotoxicity due to T in rat H9C2 cardiomyoblasts as evidenced by higher viability rate of cells treated with RAN+T than cells treated with T alone. In our in vivo studies, after 7 days with T, FS decreased to 49 ± 1.5%, p<0.01 vs 60 ± 0.5% (sham), and EF to 81+2%, p<0.01 vs 91+1% (sham). RAN alone did not change FS (59 ± 2%) nor EF 89+1%. Interestingly, in mice treated with RAN and T, the reduction in cardiac function was milder: FS was 58 ± 1%, EF was 90+1%, p=0.01 and p<0.01 respectively, vs T alone.

Conclusions: In our mouse model, T produces left ventricular dysfunction and RAN blunts T cardiotoxic effects. We plan to test RAN as a cardioprotective agent with other target therapy drugs in our experimental models and to define the mechanisms of cardioprotection.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1312: Diabetic cardiomyopathy in young normotensive patients with type 1 diabetes mellitus: evaluation of left ventricular diastolic function by strain analysis by speckle tracking

O Azevedo ¹, I Tadeu ², M Lourenco ¹, J Portugues ¹, V Pereira ¹, A Lourenco ¹

Abstract

Introduction: Diabetic cardiomyopathy is defined as ventricular dysfunction secondary to diabetes mellitus (DM) that is not explained by arterial hypertension or coronary heart disease. Diastolic dysfunction has been suggested as the earliest marker of diabetic cardiomyopathy. Most echocardiography studies have been performed in patients with type 2 DM and there are few studies about myocardial deformation in patients with type 1 DM.

Purpose: To evaluate the impact of diabetes in left ventricular diastolic function of young normotensive patients with type 1 DM and without other comorbidities, through echocardiography with longitudinal strain analysis by speckle tracking.

Methods: Prospective study including 30 young normotensive patients with type 1 DM and without other comorbidities and 24 healthy controls. Demographic and clinical data were obtained. All participants underwent a transthoracic echocardiogram that included evaluation by conventional echocardiography and tissue Doppler imaging (TDI) and strain analysis by speckle tracking.

Results: Patients with type 1 DM were mainly males (63%). They were young (mean age 26 years) and presented diabetes for a mean duration of 10 years (mean glycosylated hemoglobin 9.3%). Systolic function, evaluated by ejection fraction and TDI, was normal and did not differ between diabetic patients and controls. Diastolic function parameters, obtained by conventional Doppler and TDI, were also normal and did not differ between diabetic patients and controls. However, early diastolic strain rate (SRe) was lower in patients with type 1 DM than in controls (1.91 ± 0.4 vs. 2.12 ± 0.32 /s; p=0.026). This study found an inverse correlation between diabetes duration and SRe (r=-0.443; p=0.026) and between the levels of glycosylated hemoglobin and SRe (r=-0.427; p=0.019).

Conclusions: Young normotensive patients with type 1 DM with only 10 years of evolution already present a reduction of SRe. Strain analysis seems to be more sensitive than conventional Doppler and TDI to detect diabetic cardiomyopathy. SRe was inversely correlated to the DM duration and degree of glycemic control.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1313: Evaluation of left ventricular global systolic deformation in patients with cardiomyopathy

E Nesukay ¹, V Kovalenko ¹, S Cherniuk ¹, O Danylenko ¹

Abstract

Purpose: To study parameters of speckle-tracking echocardiography (STE) in patients with inflammatory cardiomyopathy (ICM) and dilated cardiomyopathy (DCM) and their correlation with immunologic markers.

Methods: We examined 33 patients: 17 – with ICM (1st group) and 16 – with DCM (2nd group). By the use of STE we studied the values of left ventricular (LV) systolic deformation parameters: longitudinal global systolic strain (LGSS), circumferential global systolic strain (CGSS), radial global systolic strain (RGSS), rate of LGSS (LGSSR), rate of CGSS (CGSSR) and rate of RGSS (RGSSR). Both groups were matched on LV ejection fraction (LVEF), LV end diastolic volume index (LVEDVI) that were measured by 2D-echocardiography and on heart rate. We also detected serum titers of antimyocardial antibodies (ATm) and levels of proinflammatory cytokines - interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α).

Results: In the 1st group in comparison with the 2nd we didn't find any significant differences in the values of LVEF - (34,3 ± 2,7 vs 32,7 ± 2,8) % (P>0,05) and LVEDVI – (114,5 ± 9,3 vs 113,3 ± 8,0) ml/m² (P>0,05). On the other hand in the 1st group there were higher values of LGSS - (-9,3 ± 1,1 vs -5,3 ± 1,1) % (P<0,01), CGSS - (-9,2 ± 1,3 vs -5,4 ± 1,0) % (P<0,05), CGSSR - (-0,64 ± 0,07 vs -0,41 ± 0,05) s-1 (P<0,02) than in the 2nd group. This may indicate more severe LV contractile dysfunction in DCM than in ICM. In the 1st group we detected reliably higher on 34,6% ATm titer (P<0,05), as also higher serum levels of IL-1β on 37,6% (P<0,02) and TNF-α on 45,4% (P<0,01) compared with those in the 2nd. The inverse correlation was found in the 1st group between CGSS, LGSSR and ATm titers - r=-0,57, (P<0,02); r=-0,42, (P<0,05) respectively; CGSS, CGSSR and IL-1β concentrations - r=-0,41, (P<0,05); r=-0,56 (P<0,01) respectively and also between LGSS, CGSS and TNF-α concentrations - r=-0,42, (P<0,05); r=-0,53 (P<0,02) respectively. In the 2nd group we didn't find any correlation between STE parameters and cytokine concentrations. This may provide an evidence for more pronounced inflammatory reaction in ICM than in DCM and association of its activity with the impairment of the LV systolic function.

Conclusions: We defined STE parameters such as LGSS, CGSS and CGSSR that have additional diagnostic value for the assessment of LV systolic function in patients with ICM and DCM which have no significant differences in LVEF and LVEDVI. We suppose the association of LV systolic dysfunction with inflammation activity in ICM but not in DCM.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1315: Changes in mitral annular morphology and function in young patients with type 1 diabetes mellitus - a three-dimensional speckle tracking echocardiographic study

A Nemes ¹, P Domsik ¹, A Kalapos ¹, C Lengyel ², TT Varkonyi ², A Orosz ³, T Forster ¹

Abstract

Introduction: Alterations in mitral annular (MA) size and function could be demonstrated in cardiomyopathies and in ischaemic heart disease. The present study was designed to evaluate MA morphology and function in young type 1 diabetes mellitus (T1DM) patients by three-dimensional speckle tracking echocardiography (3DSTE) and to compare their results to matched healthy controls.

Methods: The study comprised 17 subcutaneous insulin pump-treated non-obese patients with T1DM without cardiac symptoms (mean age: 33.5 ± 8.2 years, 8 males, duration of T1DM: 17.0 ± 11.1 years, body mass index: 23.3 ± 3.0 kg/m2, HbA1c: 8.1 ± 1.5%, daily insulin dose: 39.0 ± 7.3 IU). Their results were compared to 20 age- and gender-matched healthy controls (mean age: 37.9 ± 11.4 years, 9 males, body mass index: 25.3 ± 1.2 kg/m²). Complete two-dimensional Doppler echocardiography (2DE) and 3DSTE have been performed in all cases.

Results: No significant differences could be demonstrated in demographic and standard echocardiographic parameters between groups. None of T1DM patients or healthy controls showed significant (≥ grade 1) mitral regurgitation. No calcification could be demonstrated in any of T1DM patients. Significantly enlarged diastolic MA diameter (2.83 ± 0.29 cm vs. 2.58 ± 0.32 cm, p=0.02), diastolic MA diameter index (1.58 ± 0.20 cm/m² vs. 1.30 ± 0.39 cm/m², p=0.01), diastolic MA area index (4.73 ± 0.89 cm²/m² vs. 3.91 ± 1.35 cm²/m², p=0.04) and augmented MA fractional shortening (27.46 ± 10.50% vs. 20.35 ± 12.50%, p=0.05) could be demonstrated in T1DM patients as compared to healthy controls by 3DSTE. 2DE- and 3DSTE-derived diastolic MA diameter correlated well both in T1DM patients and in controls (R=0.79, p <0.01 and R=0.83, p <0.01, respectively). 3DSTE-derived MA fractional shortening correlated with left ventricular ejection fraction as assessed by 2DE in control subjects (r=0.53, p=0.02).

Conclusions: Early alterations in MA size and function could be demonstrated in young patients with T1DM by 3DSTE.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1316: Bicuspid aortic disease – are there differences between the type of aortic valve lesions?

M Castro ¹, J Abecasis ¹, H Dores ¹, S Madeira ¹, E Horta ¹, R Ribeiras ¹, M Canada ¹, MJ Andrade ¹, M Mendes ¹

Abstract

Bicuspid aortic valve(BAV) is the most common adult congenital heart disease, with frequent progression to valve dysfunction, both as stenosis and/or regurgitation. The factors determining either type of dysfunction and its evolution are not completely defined. We tried to identify predictors valve dysfunction and disease progression in BAV.

Methods:Retrospective analysis of 53 patients (pts) with BAV and aortic valve dysfunction. Patients were classified according to group 1)predominant stenosis (17), group 2) predominant regurgitation(34) or group 3)both dysfunction of similar grade of severity (2).Clinical(risk factors, coronary artery disease(CAD), age at diagnosis, disease presentation) and echocardiographic(morphology, dilation and dysfunction of left ventricle and ascending aorta pathology) data were compared among groups. Clinical events (death, cardiovascular death, cardiovascular readmission) and surgery were assessed in a follow-up period(Fup) of 75 ± 149 months.

Results: The prevalence of cardiovascular risk factors and CAD was higher in-group 1(17 pts, 7 severe, 7 moderate and 3 mild), with significant difference for dyslipidaemia and CAD when compared with pts with predominance of regurgitation(41 % vs. 9 %, p=0.007 and 24 vs. 0 %, p=0.004, respectively). There were no differences among groups both concerning the age at diagnosis and the incidence of aortic dilatation(70% and 69% in group 1 and 2, respectively) and left ventricular dilatation and systolic dysfunction. BAV type 1 morphology(right and left cusp fusion) was the most common abnormality in both group 1 and 2(71% vs.% 72, p=NS). Type 2 BAV(non-coronary and right cusp fusion)was more prevalent in pts with aortic stenosis(28 % vs. 12 %, p=NS) and type 3 BAV (non-coronary and left cusp fusion)was only present in pts with aortic regurgitation(0 % vs. 12 %, p=NS). During the Fup pts with predominant aortic stenosis were more frequently submitted to aortic valve replacement(56 % vs. 29%, p=0.068), at the mean age of 53 years(37-68) although ascending aorta intervention did not differ among the groups. The occurrence of cardiovascular events(all pts alive at the Fup) did not differ between the groups.

Conclusion: In BAV, the presence of valve stenosis occurred in pts with higher prevalence of traditional cardiovascular risk factors, as in tricuspid valves, but at an earlier age of presentation. However neither type of bicuspid valve morphology nor aorta involvement was associated with a specific type of valve dysfunction.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1317: Bicuspid aortic valve: clinical and echocardiographic predictors of a long term outcome

M Morosin ¹, R Piazza ², V Leonelli ², E Leiballi ², R Pecoraro ², M Cinello ², L Dell' Angela ¹, M Cassin ², G Sinagra ¹, GL Nicolosi ²

Abstract

Purpose: Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation. There is still uncertainty about the management of patients (pts) with BAV. The aim of this retrospective study was to determine clinical and echocardiographic prognostic factors of a large population with BAV.

Methods: Inclusion criteria was the presence of a BAV at ultrasound examination. We considered aortic valve replacement (AVR), aortic surgery and cardiovascular (CV) death as a clinical combined end-point and focused on prevalence, determinants and evolution of complications. Predictors for the progression of the disease and predictors of outcome were determined by logistic regression.

Results: Our population study included 338 pts with BAV (0.42%) referred for echocardiographic examination to our cardiology department from 1/1/93 to 30/4/14. Mean duration of follow-up was 9.6 ± 6.6 years (yrs), range 0 - 20.5 yrs. At baseline 176 pts (52.1%) were ≤ 30 yrs of age and 257 pts (76%) were males. Mean age at first examination was 29.4 ± 19.9 yrs. BAV was associated with other congenital cardiac malformation in 31 cases (9.2%). 138 pts (40.8%) were with hypertension (Hy). Prevalence of complications at baseline were: 25 pts (7.4%) with at least moderate aortic stenosis (AS) 73 pts (21.6%) with at least moderate aortic regurgitation (AR). Baseline mean ascending aortic diameter (AAD) was 3.54 ± 0.95 cm. 68 pts (20.2%) underwent AVR and/or aortic surgery during follow-up. 12 pts died (7 due to CV causes: 2 of them for endocarditis, 2 for aortic dissection, 2 for heart failure and 1 for Eisenmenger disease); mean age at death was 66.2 ± 21 yrs. At univariate analysis, baseline predictors of the combined endpoint were: an older age at enrollment (p<0.001), a higher body mass index (p<0.001) and hystory of Hy (p<0.001), a larger AAD (<0.001), moderate to severe AR (<0.001) and moderate to severe AS (<0.001). At multivariate analysis, baseline predictors were: history of Hy (HR 2.026, 95% CI 1.068 – 3.841, p=0.031), a larger AAD (+1 cm,HR 1.883, 95% CI 1.324 – 2.678, p<0.001), moderate to severe AR (HR 2.832, 95% CI 1.547 – 5.186, p<0.001) and moderate to severe AS (HR 4.583, 95% CI 2.287 – 9.185, p<0.001).

Conclusions: BAV has a prevalence of 0.42% in our community. Different from other reports, our series was composed mostly by young pts. At enrollment, history of Hy, a wider AAD, moderate to severe AR and moderate to severe AS were independently correlated to AVR, aortic surgery or CV death during follow-up. Long term follow-up showed low CV mortality (2.1%) and a high prevalence of cardiac surgery (20.2%).

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

STRESS ECHOCARDIOGRAPHY: P1318: Delayed longitudinal strain recovery after dobutamine challenge as a presentation of subclinical diabetic myocardial dysfunction

K Wierzbowska-Drabik ¹, P Hamala ¹, JD Kasprzak ¹

Abstract

Purpose: Diabetes (DM) represents an important risk factor for coronary artery disease (CAD) and heart failure development. Whereas diabetic myocardial dysfunction at rest may be subtle, the assessment during dobutamine stress echocardiography (DSE) may be more sensitive for detection of the subclinical myocardial involvement. We analysed global peak systolic longitudinal strain during baseline, peak and recovery phase of DSE to assess if it may reveal subclinical dysfunction in diabetic patients.

Methods: In a DSE study of 238 consecutive patients with coronary anatomy verified by angiography we analyzed a subset of 25 subjects without significant CAD (mean age 62 ± 8, 17 F) selected from 67 diabetic patients. We compared them with an age- and sex-matched group of 85 controls without DM and CAD (C) (mean age 60 ± 9, 50 F/35M). Global peak systolic longitudinal strain (PSLS) of the left ventricle (LV) was obtained using speckle-tracking based modality, automated function imaging (AFI) at rest, peak and recovery phase of DSE by averaging of 18 LV segments.

Results: Heart rate at baseline, peak and recovery were: 68 ± 10, 146 ± 11, 90 ± 13 bpm in DM and 66 ± 10, 143 ± 13 and 91 ± 12 bpm in C, respectively, and did not differ significantly. Although diabetic patients were characterized by similar PSLS value of the LV measured by AFI at rest and during peak stage of DSE, they had significantly lower absolute value of PSLS in recovery phase, assessed 6 minutes after discontinuation of dobutamine infusion, see Table.

Conclusions: Left ventricular peak systolic longitudinal strain measured by AFI method during recovery phase of DSE is impaired in diabetic patients without CAD. This phenomenon may reflect a longer time needed for full restoration of myocardial systolic function in this group of subjects due to subclinical longitudinal fibers dysfunction.

Comparison of global PSLS values

Global PSLS value	Diabetes n=25	Controls n=85	p value
baseline [%]	−17.34 ± 4.02	−18.71 ± 3.37	ns
at peak DSE [%]	−16.38 ± 4.54	−17.88 ± 4.24	ns
at recovery [%]	−15.33 ± 3.21	−17.17 ± 3.33	=0.016
PSLS change peak-baseline	0.96 ± 3.83	0.84 ± 3.73	ns
PSLS change recovery-peak	1.06 ± 3.65	1.11 ± 4.44	ns
PSLS change recovery-baseline	2.01 ± 2.44	1.49 ± 2.87	ns

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1319: The prognostic value of Dobutamine Stress Echocardiography among different ethnic groups

J O'driscoll ¹, C Rossato ¹, P Gargallo-Fernandez ¹, M Araco ¹, S Sharma ¹, R Sharma ¹

Abstract

Background: Cardiovascular disease mortality is different among ethnic groups. Populations referred for dobutamine stress echocardiography (DSE) are increasingly diverse and whether the prognostic information obtained from DSE provides differential information based on ethnicity is unknown. The aim of this study was to investigate the prognostic utility of DSE on non-fatal cardiac events (NFCE) and all-cause mortality in different ethnic groups.

Methods: We studied 5329 consecutive patients referred for DSE, of whom 8.1% were black, 41.6% were European white, and 50.2% were Indian Asian. End points included NFCE and all-cause mortality.

Results: In total 1174 (22%) patients had a positive DSE, 859 (16.1%) had fixed wall motion abnormalities and 3645 (68.4%) patients had a normal study. During a mean follow-up time of 4.6 ± 1.3 years there were 849 (15.9%) NFCE and 1365 (25.6%) deaths. Among the three ethnic groups, ischaemia on DSE was associated with 2 to 2.5 times the risk of NFCE and 1.2 to 1.4 times the risk of all-cause mortality. Peak wall motion score index was the strongest independent predictor of NFCE and all-cause mortality in all groups. The C statistic for the prediction of NFCE and all-cause mortality were significantly higher when DSE parameters were added to the standard risk factors.

Conclusions: DSE is a strong predictor of NFCE and all-cause mortality and provides predictive information beyond that provided by standard risk factors in three major racial and ethnic groups. No major differences among racial and ethnic groups in the predictive value of DSE was detected.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1320: Does mechanical dispersion occur with inducible ischaemia on dobutamine stress echocardiography ? A 2D-speckle tracking study

N Jakus ¹, Z Baricevic ², J Ljubas Macek ², B Skoric ¹, I Skorak ², V Velagic ², J Separovic Hanzevacki ¹, D Milicic ¹, M Cikes ¹

Abstract

Purpose: Mechanical dispersion was recently established as an indicator of greater susceptibility to fatal arrhythmias in patients after myocardial infarction. Mechanically, it suggests the presence of post-systolic shortening (PSS), which has been demonstrated in patients with inducible ischaemia on dobutamine stress echocardiography (DSE). Furthermore, PSS has also been suggested in patients developing an LV intracavity gradient during DSE. Thus, we sought for a potential increase in mechanical dispersion in patients undergoing full dose DSE for inducible ischaemia.

Methods: DSE was acquired in 30 patients (17 male, mean age 58 ± 12 years). The procedure included ultrasound acquisition of apical 2, 3 and 4 chamber views during a gradual increase of dobutamine up to a full dose of 40 mcg/kg/min or reaching target heart rate. According to the result, we divided the patients to 3 groups: DSE negative patients, who developed an intracavitary gradient (Grad+, 10 pts), DSE negative, gradient negative pts (DSE-, 10 pts) and DSE positive, gradient negative pts (DSE+, 10 pts). None of the DSE positive pts developed the gradient. Images acquired during baseline and peak dobutamine dose were analyzed using 2D-speckle tracking, obtaining a 17-segment LV model. The time from peak R wave on ECG to peak strain was measured and mechanical dispersion (MD) was calculated as the standard deviation of the time to peak strain between the 17 segments. To compare the groups, we calculated the ratio of MD at peak dose to MD at baseline (MDp/MDb) in each patient, expressing the increase in MD.

Results: All three groups showed an increase in MD at peak dose, with the greatest increase occuring in the DSE+ group: MDb 38.04 vs. MDp 81.64, p≤0.002 (MDp/MDb=2.25 ± 1.22). Both DSE negative groups showed similar results - Grad+: MDb 38.94 vs MDp 55.51, p≤0.001 (MDp/MDb=1.47 ± 0.41); DSE-:MDb 46.69 vs. MDp 63.86, p≤0.01 (MDp/MDb=1.45 ± 0.51). The MDp/MDb of the DSE+ group was significanlty greater compared to the Grad+ group (P=0.04), as well as to the DSE- group (P=0.05).

Conclusions: Patients with inducible ischaemia on DSE demonstrated a greater increase in MD compared to the patients who did not develop inducible ischaemia, regardless of the development of an intracavitary gradient. This suggests that the potential occurence of post-systolic shortening with an inducible intracavitary gradient is less extensive than with inducible ischaemia. Moreover, the data confirm the role of MD in detecting patients at risk, also suggesting it may be used as an adjunct in the interpretation of DSE data.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1321: Relationship between increase of pulmonary arterial pressure during stress echocardiography and markers of endothelial function in patients with chronic obstructive pulmonary disease

M Deljanin Ilic ¹, S Ilic ², G Kocic ³, R Pavlovic ³, V Stoickov ², V Ilic ¹, LJ Nikolic ¹

Abstract

Background: Endothelial dysfunction is believed to be an early event in pulmonary hypertension, and is characterized by overproduction of vasoconstrictor compounds, and by insufficient production of vasodilators, which may induce unfavorable changes in pulmonary vascular tone, and hence might contribute to impair endothelial function and increase of pulmonary arterial pressure (PAP) during exercise.

Purpose: To evaluate if there is an relationship between increase in PAP during exercise stress echocardiography (ESE) and values of circulating blood markers of endothelial function: the stable end product of nitric oxide (NOx), asymmetric dimethylarginine (ADMA) and symmetric dimethylarginine (SDMA) (endogenous compounds which impair NO synthesis), in patients (pts) with chronic obstructive pulmonary disease (COPD).

Methods: 38 pts with COPD (27 men) without pulmonary arterial hypertension (PAP at rest <25mmHg) were enrolled in the study. In all pts submaximal or symptom limited ESE was performed. Venous blood samples were taken before ESE and values of NOx, ADMA and SDMA were determined in all pts as well. At baseline and after ESE, PAP was estimated using transthoracic Doppler. Patients were classified according to the value of PAP after ESE: PAP less than 30mmHg (Group I, N=23pts, mean age 56 years) and PAP greater than 31mmHg (Group II, N=15pts, mean age 57 years).

Results: In all pts basal echocardiographic findings, were in normal range. In both groups PAP increased after ESE: in Group I from 18.5 ± 3.7 to 22.0 ± 2.9 mmHg, increase by 19%; P< 0.005, and in Group II from 22.4 ± 2.1 to 36.1 ± 2.7 mmHg, increase by 61%;P<0.0001. Value of NOx was higher in Group I than in group II (40.8 ± 7.1 vs 36.2 ± 6.0 μmol/l,P<0.05), while values of ADMA and of SDMA were significantly lower in Group I than Group II: ADMA 0.310 ± 0.040 μmol/l vs 0.357 ± 0.041 μmol/l; P<0.005; SDMA 0.317 ± 0.036 vs 0.346 ± 0.030 μmol/l; P<0.02). Markers of myocardial ischemia were not detected during ESE and exercise capacity was similar in both groups.

Conclusions: Our results show a relationship between more pronounced increase in PAP during ESE and higher baseline values of ADMA and SDMA, and lower values of NO. This finding confirm the role of endothelial dysfunction in induction of unfavorable changes in pulmonary vascular tone and increase of PAP during exercise.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1322: Ventilatory inefficiency, diastolic dysfunction, mitral regurgitation and pulmonary hypertension during exercise: the culprit interaction in heart failure reduced ejection fraction

G Generati ¹, F Bandera ¹, M Pellegrino ¹, E Alfonzetti ¹, V Labate ¹, M Guazzi ¹

Abstract

Background: Dyspnea and exercise intolerance are landmark manifestations of heart failure (HF). An impaired efficiency in ventilation (VE) as indicated by a steep increase in VE vs CO2 output during exercise provides remarkable prognostic indications. We aimed at defining the role of different hemodynamic components that may determine the most unfavorable ventilatory phenotype and worse clinical status.

Methods: 71 HF reduced ejection fraction patients (mean age 67 ± 11; male 72%; ischemic etiology 61%; NYHA class I, II, III and IV 13%, 36%, 39% and 12%, mean ejection fraction 33 ± 9%) underwent cardiopulmonary exercise test evaluation on tiltable cycle-ergometer combined with simultaneous echocardiographic assessment.

Results: Patients were divided in 4 ventilatory classes (VC) according to the VE/VCO2 slope classification focusing on peak exercise variables. We observed a VC related increase in E/e' ratio, mitral regurgitation and pulmonary artery systolic pressure and a progressive reduction in TAPSE and peak VO2. The best correlation with VC groups was found for E/e' ratio and peak VO2.

Conclusions: A remarkable culprit interaction emerged between the degree of diastolic dysfunction, mitral regurgitation, pulmonary hypertension and right heart dysfunction with inefficient VE during exercise. A systematic analysis of these hemodynamic determinants by stress echo combined with gas exchange analysis may become a valuable addition for appropriately refining therapeutic interventions.

Peak exercise variables	VC I (n=23)	VC II (n=18)	VC III (n=21)	VC IV (n=9)	P coeff. Anova
Mitral Regurgitation ≥3/4+, %	30	44	62	67	0.05
Rest E/e’, ratio	18 ± 9	28 ± 13	30 ± 15	32 ± 10	0.006
Tricuspid annular systolic excursion (TAPSE), mm	22 ± 4	20 ± 4	18 ± 6	18 ± 3	0.05
Pulmonary artery systolic pressure, mmHg	51 ± 15	61 ± 16	64 ± 24	65 ± 17	0.04
Cardiac Output, l/min	8.3 ± 3	6.6 ± 2	5.8 ± 2	5.2 ± 2	0.002
Cardiac Power Output, Watt	1.9 ± 0.6	1.6 ± 0.6	1.3 ± 0.6	1.1 ± 0.5	0.001
Oxygen consumption (VO₂), ml/kg/min	14.8 ± 3.1	13 ± 2.4	12.3 ± 3.6	8.9 ± 2	0.000

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1323: Exercise ventilatory power in heart failure patients: functional phenotypes definition by combining cardiopulmonary exercise testing with stress echocardiography

V Labate ¹, F Bandera ¹, G Generati ¹, M Pellegrino ¹, V Donghi ¹, E Alfonzetti ¹, M Guazzi ¹

Abstract

Exercise Ventilatory Power (EVP; peak systolic blood pressure/exercise ventilation to CO2 production slope) is a new powerful prognostic marker that combines ventilator abnormalities with systemic hemodynamic during exercise. The phenotype and clinical relevance of patients with a worse EVP is broadly undefined and we aimed at this definition across a population of heart failure reduced ejection fraction (HFrEF) of different severity.

Methods: 77 HFrEF patients (mean age 65 ± 11; male 70%; ischemic etiology 59%; NYHA class I, II, III and IV 23%, 33%, 31% and 13%, respectively; mean LVEF 34 ± 9 %) underwent cardiopulmonary exercise test (CPET) evaluation (ramp protocol on performed on a tilt-table cycleergometer) combined with simultaneous echocardiographic assessment.

Results: Patients were divided in 2 EVP classes (cutoff 3) focusing on peak exercise echocardiographic variables.

Conclusions: A low EVP translates in a very unfavorable phenotype characterized by a lower peak VO2 and CO response at peak exercise. Remarkable impairment in right heart function and pulmonary hemodynamics were also peculiar of a low EVP. All the LV-pulmonary circulation- RV apparatus is abnormally involved in the exercise response of the EVP HFrEF phenotype.

	EVP≥3.5 (n=61)	EVP < 3.5 (n=16)	P value
Peak oxygen consumption (VO2), ml/kg/min	13.8 ± 3.29	9.9 ± 2.68	0.002
Rest LVEF (%)	33 ± 8	28 ± 10	0.03
Peak LVEF (%)	35 ± 9	31 ± 13	0.10
Rest cardiac output, (CO) l/min	3.85 ± 1.18	3.20 ± 1.50	0.12
Peak cardiac output, (CO) l/min	7.34 ± 2.46	4.59 ± 1.86	0.00006
Rest tricuspid annular systolic excursion (TAPSE), mm	18.5 ± 4.06	13.6 ± 3.18	0.00002
Peak tricuspid annular systolic excursion (TAPSE), mm	20.8 ± 4.03	15.5 ± 4.32	0.003
Rest pulmonary artery systolic pressure (PASP), mmHg	31.6 ± 9.20	56.5 ± 19.43	0.0001
Peak pulmonary artery systolic pressure (PASP), mmHg	54.3 ± 14.36	74.5 ± 23.47	0.004

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

REAL-TIME THREE-DIMENSIONAL TTE: P1324: Real-time three-dimensional transesophageal echocardiography (RT 3DTEE) for guiding of off-pump transapical implantation of artificial chordae to correct mitral regurgitation

D Zakarkaite ¹, R Kramena ², S Aidietiene ¹, V Janusauskas ¹, K Rucinskas ¹, R Samalavicius ³, I Norkiene ¹, G Speciali ¹, A Aidietis ¹

Abstract

Objective: Minimally invasive transapical implantation of artificial mitral valve (MV) chordae tendineae (neochordae) in a beating heart is possible using the NeoChord DS1000 device under intraoperative TEE guidance. The aim of our study is to evaluate the possibilities and advantages of RT 3DTEE during this procedure.

Methods: From June 2012 to March 2014 the 42 consecutive patients with severe mitral regurgitation due to prolapse and/or rupture of chordae were selected for neochordae implantation operation after TEE examination using Philips iE33 system (Philips Healthcare) with X7-2t TEE transducer.

For the first 13 patients (group I) operation was performed using just 2D TEE image guidance, for the remaining 29 patients (group II) 2D TEE imaging was used only for selecting the location of ventriculotomy and navigation of the device to the MV. When the device approached MV plane the imaging was switched to the one beet RT 3D Zoom mode. Crossing of MV plane, capture of the leaflets and deployment neochordae were performed.

Results: (a) Crossing MV oriface by device under 2D TEE in Ist group of patient was complicated in 7 (54%) cases. One patient from this group had on table conversion to conventional MV repair after perforation of posterior MV leaflet. In all group II cases the coming tip of the device was perfect seen through the opened MV orifice in the left ventricle on 3D view. It really helps to control entry of the instrument to the left atrium.

(b) 3D imaging allows determining required depth of the device entry and his position in relation of prolapsing segments. Better visualization enables quicker and more precise implantation of neochordae. The average number implanted chordae has increased after implementing RT 3DTEE from 2.7 ± 0.8 in Ist group to 3.9 ± 1.1 in group II (p <0.001). In group I neochordae were implanted just in P2 segment (which is easiest to approach with the device). In group II patients neochordae were implanted in different MV segments, including anterior MV leaflet (11 patients).

(c) Neochordae was hardly seen on ultrasound. 3D views enables precise determination of the position of implanted neochordae. It was determined visualizing invagination seen on MV leaflet after tensioning neochordae.

(d) In cases if 4 or more neochordae were implanted 3D view of MV was useful in determining precise and equal tensioning of each of them and regaining normal anatomy of the MV.

Conclusion: RT 3DTEE provides significant benefits over 2D TEE only during minimally invasive implantation of artificial chordae and has become an indispensable intraprocedural guidance tool.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1325: The advantages of live/real time three-dimensional transesophageal echocardiography in the assesment of Pulmonary valve Stenosis

T Kemaloglu Oz ¹, F Ozpamuk Karadeniz ¹, S Akyuz ¹, S Unal Dayi ¹, A Esen Zencirci ¹, I Atasoy ¹, A Osken ¹, M Eren ¹

Abstract

Purpose: Pulmonary valve stenosis(PS) is a common isolated cardiac abnormality representing almost %10 of all congenital cardiovascular malformations. Two-dimensional echocardiography and Doppler imaging are the techniques of choice to measure the severity of PS. Typically only one or two leaflets of pulmonary valve (PV) are visualized and en face view could not be acquired by 2D echocardiography. Thus, the aim of the study was to compare live/real time three-dimensional transesophageal echocardiography (3D-TEE) and two-dimensional transesophageal echocardiography (2D-TEE) findings and to evaluate whether the advantages of 3D TEE in patients with PS.

Methods: Ten patients with PS who have indication for TEE were prospectively enrolled. After initial 2D-TEE, 3D-TEE was performed and 3D TEE images were analyzed by using off-line Q lab software system.

Results: In the present study, we have obtained the en face view and area of the PV in nine patients (90%). Also, we could detect the type of PV (unicuspid, bicuspid or tricuspid) in all except one patient (10%). Severity and localization of the stenosis were determined more precisely by 3D-TEE in five patients (%50). The other information are outlined in Table 1.

Conclusions: The present study showed that 3D-TEE provided several advantages over 2D-TEE. According to our knowledge, this study is the first one which compared the 2D-TEE and 3D-TEE in patients with PS.

Age (years)/Sex	2D TEE	3D TEE	Cathaterization (Peak-to-peak gradient)	Treatment	The advantages of 3D TEE
42/F	Severe PS(peak gradient 94 mmHg)	Unicuspid PV, severe PS, PVA=0.29 cm²	80 mmHg (valvular)	Valvuloplasty	En face visualization, quantification of the PVA, detection of the type of PV
47F	Bicuspid aortic valve, secundum ASD, moderate PS (peak gradient 43 mmHg)	Bicuspid aortic valve, secundum ASD, bicuspid PV,mild PS, PVA=1.96 cm²	17mmHg (valvular)	Operation:Bicuspid aortic valve and PV, secundum ASD, mild PS	En face visualization, quantification of the PVA, detection of the type of PV
47/M	Moderate PS (peak gradient 49 mmHg), mild-to-moderate PR, pulmonary artery aneurysm (50mm)	Tricuspid PV, mild PS, PVA=1.71 cm², moderate PV regurgitation, (VCA is 0.35 cm²), pulmonary artery aneurysm (48 mm)	40 mmHg (valvular)	Medical treatment Pulmonary artery CT angiography: PA 47 mm	En face visualization, quantification of the PVA, detection of the type of PV, accurate classification of the stenosis severity because of gradient can be effected by regurgitation.
31/M	Supravalvular severe PS(peak gradient 65 mmHg)	Hypoplastic pulmonary artery,moderate valvular PS, PVA=1.28 cm²	40 mmHg (valvular), 80 mmHg (supravalvular)	Operation: Hypoplastic pulmonary artery	En face visualization, quantification of the PVA, accurate classification of the stenosis severity and localization
22/M	Severe PS(peak gradient 110 mmHg)	Tricuspid PV, severe PS, PVA=0.73 cm²	100 mmHg (valvular)	Valvuloplasty	En face visualization, quantification of the PVA, detection of the type of PV
19/F	Severe PS(peak gradient 65 mmHg)	Tricuspid PV, moderate PS, PVA=1.44 cm²	Not performed because of the pregnancy.	Medical treatment	En face visualization, quantification of the PVA, classification of the stenosis severity and localization. Transpulmonary gradient may be affected by volume overload in pregnancy.
21/M	Secundum ASD, moderate PS (peak gradient 52 mmHg)	Secundum ASD, tricuspid PV, PV area=2.8 cm², no PS	16 mmHg (valvular)	Operation:No PS, tricuspid PV, large secundum.	En face visualization, quantification of the PVA, classification of the stenosis severity and localization. Transpulmonary gradient may be affected by left-to-right shunt.
18/F	Secundum ASD, moderate PS (peak gradient 48 mmHg)	Secundum ASD, tricuspid PV, mild PS, PVA=1.93 cm²	Not performed because of the pregnancy	She was pregnant, after delivery the peak gradient reduced to 30 mmHg.	En face visualization, quantification of the PVA, classification of the stenosis severity . Transpulmonary gradient may be affected by overload in pregnancy.
33/M	Moderate PR, moderate PS (peak gradient 71mmHg)	Poor image quality	Not performed	Medical treatment	none
43/F	Severe PS (peak gradient 106 mmHg)	Tricuspid PV, severe PS, PVA=0.78 cm²	69 mmHg (valvular)	Valvuloplasty	En face visualization, quantification of the PVA, detection of the type of PV

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ASD:Atrial septal defect,PS: Pulmonary stenosis,PR:Pulmonary regurgitation, PV:Pulmonary valve,PVA:pulmnary valve area, VCA:Vena contracta area.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1326: Tridimensional echocardiography in aortic valve area assessment

P R Fazendas ¹, D Caldeira ¹, B Stuart ¹, I Cruz ¹, L Rocha Lopes ¹, A R Almeida ¹, P Sousa ¹, I Joao ¹, C Cotrim ¹, H Pereira ¹

Abstract

Background: Planimetry by transoesophageal echocardiography (TOE) of aortic stenosis is seldom used, BUT when Doppler measurements are inadequate, or sub-aortic obstruction is present, it is indicated. The continuity equation (CE) measures the effective, not anatomic, orifice area and has been established as the primary predictor of clinical outcome. Anatomic and functional areas are not exactly equivalent and a cut-off of severity specific for 3D planimetry should be used.

Purpose: Establish a cut-off for severe aortic stenosis (AS) in aortic valve planimetry by 3D echo by comparison with the CE corrected with left ventricular outflow (LVOT) planimetry.

Methods: 51 patients (pts), 36 males, age 74,2 ± 6.7 years, with significant aortic stenosis by transthoracic echocardiography (TTE) underwent TOE. 3D planimetry of aortic valve and LVOT was performed. The CE was corrected with LVOT 3D planimetry to avoid errors introduced by its calculation from the LVOT diameter.

Results: AS was considered severe in 31 patients (pts) by TTE, with the 3D corrected continuity equation (CCE), it was classified as severe in only 18 pts. We found significant differences in the 2 methods: CCE 1,07+-0,30, AV3D planimetry 0,93+-0,32 (p<0.001). Considering the criteria for severe aortic stenosis an AVA<1cm² by CCE, we observed a good performance of 3D planimetry for the diagnosis of severe AS with an area under the ROC curve of 0,89 (95% CI 0,79-0,98), with the best discriminator of AVA 0,77 cm².

Conclusions: Significant differences in functional and anatomic areas exist that should be considered when assessing AS severity. We propose that when 3D planimetry of aortic valve orifice is necessary a lower cut-off for severe AS should be considered. The 0,77 cm² threshold should be validated in a larger population.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1327: Tridimensional echocardiography in the evaluation of aortic stenosis

P R Fazendas ¹, D Caldeira ¹, B Stuart ¹, I Cruz ¹, L Rocha Lopes ¹, A R Almeida ¹, I Joao ¹, C Cotrim ¹, H Pereira ¹

Abstract

Planimetry of anatomic valve area in aortic stenosis is rarely used due to technical difficulties and is recommended only when Doppler measurements are unavailable.

Purpose: To compare the performance of 3D and 2D planimetry of the aortic valve in aortic stenosis (AS) with the the Doppler functional area as reference.

Population and methods: 47 patients (pts), 33 males, age 74 ± 6.9 years, with moderate or severe aortic valve stenosis by the continuity equation (CE) underwent transoesophageal echocardiography (TOE). 2D planimetry of the aortic valve orifice at midsystole and Real-time 3D zoom TOE of the aortic valve were performed. Post-processing quantification software allowed to choose the plane of the anatomic valve area in midsystole for planimetry of 3D images.

Results: Planimetry by 2DTOE wasn't possible in one patient (excessive calcification of aortic valve). AS was classified as severe in 28 patients (pts) by CE, 17 by 2DTOE and 24 by 3DTOE. We found significant differences in the areas evaluated by the three methods: CE: 0.89 ± 0.25; 2DTOE: 1.19 ± 0.46; 3DTOE: 0.96 ± 0.31 (One-way ANOVA p<0.001). 3DTOE was able to detect severe aortic stenosis better than 2D TOE, with overestimation of the AVA by 2DTOE. 3DTOE had lower intra-observer variability (mean difference -0.14 cm2, C.I. 95%: -0.19; -0.08; p<0.001): 3DTOE (0.067cm2 ± 0.060; 47 pts) 2DTOE (0.202cm2 ± 0.181; 46 pts). In the Bland-Altman analysis of the 2D and 3D planimetry methods with the CE, 3D was superior.

Conclusions: Planimetry by 3D TOE in aortic valve stenosis was feasible in all patients, with lower intra-observer variability than 2D planimetry and better agreement with the continuity equation than 2D. We propose that when planimetry of aortic valve orifice is necessary, the 3D method should be preferred.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1328: Acute and late effects of percutaneous atrial septal defect closure to right atrial and right ventricular deformation in adult patients: a two dimensional speckle tracking echocardiography study

SC Sinem Cakal ¹, EE Elif Eroglu ², O Baydar ³, BC Beytullah Cakal ¹, MVY Mehmet Vefik Yazicioglu ¹, MB Mustafa Bulut ¹, CD Cihan Dundar ¹, KT Kursat Tigen ¹, BO Birol Ozkan ¹, A Ali Metin Esen ¹

Abstract

Background: Atrial septal defect (ASD) is a relatively common congenital heart defect causing chronic volume overload of the right heart chambers. This study aimed at evaluating the early and late changes in right atrial (RA) and right ventricular (RV) deformation after ASD closure.

Methods: We studied 20 ASD patients before, early (within 24 hours) and one month after percutaneous closure. Twenty age-matched normal subjects were served as control group. The analysis for atrial deformation was performed on the lateral wall mid segment of the RA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during RA reservoir, passive emptying (conduit) and atrial contraction phases were measured. RV global longitudinal systolic S (SRV) and (SRRV) were measured from apical four-chamber view.

Results: Peak S and SR at RA reservoir, conduit and late contraction phases in ASD patients were significantly higher than controls. All of these parameters decreased immediately after the closure of the defect. Similarly, SRV and SRRV in ASD patients were significantly higher than controls and significantly decreased after the closure. Moreover, RA S,SR and RV S, SR results decreased more one month after closure (Table 1).

Conclusion: Chronic volume overload of right heart chambers in patients with ASD causes an increase in RA and RV longitudinal deformation, related to the severity of left to right shunting. Correction of this volume overload with percutaneous ASD closure, results in significant reduction of RA and RV longitudinal deformation parameters in the acute and late phase.

	Controls	Pre-closure	Post 24 hrs	Post 1 month	P1-value	P2-value	P3-value
RA reservoir S(%)	36,7 ± 4	69,2 ± 9,2	55,2 ± 8,6	37,8 ± 6,8	<0,001	<0,001	<0,001
RA conduit S(%)	13,4 ± 2,1	29,7 ± 6,1	24,1 ± 5,9	16,2 ± 2.9	<0,001	<0,001	<0,001
RA pump S(%)	−1,9 ± 0.9	−3,6 ± 1,2	−2,6 ± 0,7	−2,4 ± 0,7	<0,001	0,002	<0,001
RA reservoir SR(s^-1)	2,1 ± 0,2	3.5 ± 0,5	3,2 ± .0,4	2,5 ± 0,4	<0,001	<0,001	<0,001
RA conduit SR(s^-1)	−2.2 ± 0.2	−3.2 ± 0.3	−2.8 ± 0.4	−2,1 ± 0,3	<0,001	<0,001	<0,001
RA pump SR(s-1)	−2.0 ± 0.1	−3.4 ± 0.5	−2.9 ± 0.5	−2,1 ± 0.3	<0,001	<0,001	<0,001
RV global S(%)	−22,7 ± 3,2	−27,5 ± 3	−23 ± 3	−21,9 ± 1,6	<0,001	<0,001	<0,001
RV global SR(s^-1)	−1.5 ± 0.1	−1.9 ± 0.3	−1.7 ± 0.5	−1,3 ± 0,6	<0,001	<0,001	<0,001

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P1; preclosure vs. controls, P2; preclosure vs. post 24 hrs, P3; preclosure vs. post 1 month

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1329: Noninvasive assessment of left ventricular systolic properties in hypertension using novel automated one-beat real-time 3-dimensional speckle tracking echocardiography with high volume rates

H Yagasaki ¹, M Kawasaki ², R Tanaka ¹, S Minatoguchi ², H Houle ³, S Warita ¹, K Ono ¹, T Noda ¹, S Watanabe ¹, S Minatoguchi ²

Abstract

Background: Left ventricular (LV) systolic properties in hypertension (HTN) may be impaired by pressure overload, resulting in heart failure with reduced or preserved ejection fraction (HFpEF). LV strain rate (SR) at systole (S) by 2-D speckle tracking echocardiography (2D-STE) was reported as index of contractility. The mechanics of heart in multiple dimensions seem to be best represented by 3D-STE. We examined LV systolic properties in HTN including contractility by global SR using novel 3D-STE with high volume rates.

Methods: We measured LV strain and SR at S and isovolumic contraction (IC) as index of contractility in HTN with preserved EF > 50% (n=107, age 69 ± 7) and control (n=60, age 69 ± 9) by the 3D-STE. HTN was divided to 5 groups according to LV geometry and presence of HF {normal geometry, concentric remodeling, concentric hypertrophy (LVH), eccentric LVH, and HFpEF}. We measured LV EF and calculated stroke work (SW) and LV stress as radius x systolic blood pressure / thickness.

Results: LV mass increased in HTN with LVH and HFpEF. Global myocardial SR at S and IC by novel 3D-STE in concentric remodeling already reduced despite no reduction in LV EF and SW. Although LV EF in HFpEF remained within normal, LV EF and SW in HFpEF reduced compared to eccentric LVH associated with increased stress despite no difference in LV SR (Table).

Conclusions: LV contractility even in concentric remodeling may be already deteriorated before LV EF and SW are decreased. LV EF and SW in HFpEF decreased associated with increased LV mass and systolic stress despite no reduction in contractility compared to eccentric LVH, suggesting that to reduce LV systolic stress and mass is important in HTN to prevent HFpEF as there is currently no appropriate treatment for diastolic dysfunction.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1330: Relationship between segmental longitudinal strain and symptomatic status in severe aortic stenosis: three-dimensional speckle-tracking echocardiography

E J Cho ¹, S J Park ¹, H J Lim ¹, S A Chang ¹, S C Lee ¹, S W Park ¹

Abstract

Background: The aim of this study was to evaluate the relationship between strain by 3-dimensional (3D) speckle tracking echocardiography (STE) and symptomatic status in patients with severe aortic stenosis (AS) and normal left ventricular ejection fraction (LVEF≥50%).

Methods: Conventional and 3D STE were performed in 69 patients (mean age 69.3 ± 8.4 yrs) with severe AS (aortic valve area <1 cm2, AV Vmax >4 m/sec or mean PG >40mmHg) and normal LVEF but without overt coronary artery disease. Severe AS patients were divided into two groups: asymptomatic (n=55) and symptomatic group (n=14).

Results: Global longitudinal strain (GLS) measured by 2D and 3D was not different in asymptomatic and symptomatic AS group. In 3D segmental LS analysis, basal LS was reduced in both. Interestingly, mild anterial, mid anteroseptal and apical anterial 3D LS were significantly decreased in symptomatic AS group compared to asymptomatic (Figure). 2D STE also showed the same results (Table).

Conclusions: Three-dimensional segmental strain was related to symptomatic status in severe AS. Three-dimensional STE may give additional information in the decision-making process for patients with severe asymptomatic AS.

Clinical, 2D and 3D STE variables

	Asymptomatic AS group (n=55)	Symptomatic AS group (n=14)	p-value
2D global LS	−14.97 ± 3.12	−14.11 ± 2.93	0.352
3D global LS	−12.93 ± 2.64	−12.62 ± 4.11	0.733
2D basal LS	−14.97 ± 3.12	−14.11 ± 2.93	0.352
3D basal LS	−13.20 ± 2.66	−12.86 ± 3.84	0.697

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1331: Correlate of global longitudinal, radial and area strain in severe aortic stenosis with normal Left Ventricular ejection fraction: a three-dimensional speckle-tracking echocardiography

E J Cho ¹, S J Park ¹, H J Lim ¹, S A Chang ¹, S C Lee ¹, S W Park ¹

Abstract

Background: The aim of this study was to the capability of real-time three-dimensional echocardiography (RT3DE) in characterizing early abnormalities of left ventricular (LV) structure and function in patients with severe aortic stenosis (AS) and normal LV ejection fraction (EF≥50%).

Methods: Conventional and 3D STE were performed in 69 patients (mean age 69.3 ± 8.4 yrs) with severe AS and normal LVEF but without overt coronary artery and 12 healthy controls. Global longitudinal strain (GLS), global circumferential strain (GCS), global area strain (GAS), and global radial strain (GRS) were calculated by RT3DE.

Results: Severe AS group had lower 3D GLS, GAS, GRS and 2D GLS compared controls. But, 3D GCS was not significantly different between two groups. In 3D segmental LS analysis, basal and mid LS were decreased in severe AS group compared to controls. (Table, Figure)

Conclusions: Three-dimensional STE identifies early functional LV changes in severe AS patients with normal LVEF. GAS, GLS, and GRA impaired, while circumferential strain is still preserved, supporting a normal LV chamber systolic function. Therefore, 3D STE may give additional information in the decision-making process for severe AS patients with normal left ventricular function.

2D, 3D STE variables

	healthy control (n=12)	severe AS (n=69)	p-value
3D GLS	−18.08 ± 8.54	−12.87 ± 2.96	< 0.001
3D GRS	55.80 ± 6.73	43.74 ± 10.25	< 0.001
3D GAS	−33.90 ± 2.69	−28.04 ± 4.70	< 0.001

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

TISSUE DOPPLER AND SPECKLE TRACKING: P1332: Prognostic value of a new Tissue Doppler index in patients with Non-revascularized Coronary Artery Disease

C Mornos ¹, D Cozma ¹, A Ionac ¹, A Mornos ², I Popescu ¹, G Ionescu ¹, S Pescariu ¹

Abstract

A value >1.6 for a new parameter, E/(E'×S'), is a powerful predictor of clinical outcome in patients with heart failure (E=early diastolic transmitral velocity, E'=early diastolic mitral annular velocity and S'=systolic mitral annular velocity).

Purpose: To evaluate the prognostic value of E/(E'×S')>1.6 in patients with non-revascularized coronary artery disease (NCAD).

Methods: We determined E/(E'×S') in 234 patients with NCAD, in sinus rhythm, at hospital discharge and after 1 month. Worsening of E/(E'×S') was defined as any increase of baseline value. The average of septal and lateral mitral annular velocities was used. The primary study end-point was definite as cardiac death or hospital readmission due to myocardial ischemia or heart failure worsening.

Results: At hospital discharge, 97 patients (41.5%) presented E/(E'×S')≤1.6 (group I) while 137 patients (58.5%) presented E/(E'×S')>1.6 (group II). During the follow-up period (36 ± 8 months) cardiac events occurred in 128 patients (54.6%): 16 cardiac deaths (6.8%) and 112 hospital readmissions (47.8%). Mean left ventricular ejection fraction was 39 ± 13% in these patients, while it was 47 ± 14% in the rest (p<0.001). The composite end-point was significantly higher in group II than in group I (112 events, 81.7% vs. 16 events, 16.5%, p<0.001). One month after hospital discharge we identified worsening of E/(E'×S') in 64 patients (27.3%). Of this patients, 38 presented the initial value of E/(E'×S') greater than 1.6. Patients with E/(E'×S')>1.6 at discharge and its worsening after 1 month have presented the worst prognosis (all p<0.05), as showed by Kaplan–Meier analysis (figure 1).

Conclusions: In patients with NCAD, E/(E'×S')>1.6 at hospital discharge is a powerful predictor of clinical outcome particularly if it is associated with worsening.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1333: Feasibility and limitations of 2D-speckle tracking in daily practice: a prospective study in 406 patients

L Melzer ¹, A Faeh-Gunz ¹, B Seifert ², C H Attenhofer Jost ¹

Abstract

Background: Two-dimensional speckle tracking echocardiography (2DSTE) has been recommended as a helpful tool to diagnose coronary artery disease (CAD), to assess myocardial function in cardiomyopathies, valvular or congenital heart disease, or to detect amyloid heart disease. A GLS value of >16-18% has been recommended as the normal cut-off. Little is known about feasibility, impact as well as interobserver variability in daily practice.

Method: Between Oct 2013 and Jan 2014; in 406 consecutive patients (pts) undergoing transthoracic echocardiography, 2DSTE was attempted from the 3 apical views (resulting in average global longitudinal strain GLS values). All diagnoses, echocardiographic parameters and image quality (excellent, average, bad) were prospectively collected and analyzed. GE Vingmed System E9 4D BT12: all was analyzed during the study (or offline for interobserver variability on the Echopac system). Results: The mean age was 64 ± 16 years; body mass index 25.4 ± 4.8kg/m2. The average ejection fraction (EF) was 57 ± 10%; regional wall motion abnormalities (RWMA) were present in 32%, left ventricular hypertrophy (LVH) in 20%, abnormal diastolic function (DF) in 45%. Feasibility of 2DSTE in was 93%. Interobserver variability was acceptable in good and average image quality, only. The most important reasons for inability to do 2DSTE was echoquality (p<0.0001), a higher body mass index (p=0.002). In patients with severely diminished echoquality, GLS could be done in 65%. The average GLS was -16.7 ± 5.9%. The results are shown in the Table (LBBB=left bundle branch block).

Conclusion: Assessment of GLS by 2DSTE is feasible in most pts. Feasibility and interobserver variability are critically dependent on image quality. A cut-off value great -18% or even greater than -16% may not reasonable as many “abnormal”, puzzling results can occur – especially in the presence of diminished image quality and diastolic dysfunction. For every day practice, a cut-off of average GLS of -14% would be advisable.

	No. pts	Normal LV, abnormal DF (42 pts)	Normal LV and normal DF (20 pts)	EF, %	RWMA (129 pts)	LVH (80 pts)	LBBB (29 pts)
GLS <-18%	188	28 pts	14 pts	53 ± 12	90 pts	60 pts	29 pts
GLS <-16%	122	11 pts	5 pts	49 ± 13	57 pts	49 pts	28 pts
GLS <-14%	77	3 pts	1 pt	44 ± 13	51 pts	40 pts	22 pts
GLS <-10%	33	0	0	36 ± 12	29 pts	23 pts	9 pts

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Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1334: Automatic real-time measurement of echocardiographic indices of left ventricular systolic and diastolic function

S Storve ¹, BO Haugen ², H Dalen ³, JF Grue ¹, S Samstad ², H Torp ¹

Abstract

Purpose: We have previously developed a fully automatic algorithm for detection of the AV-plane in 4CH view TDI images and measurement of mitral annular excursion (MAE) and the mitral annular peak velocities: systolic (S'), early diastolic (e') and late diastolic (a'), at both the septal and lateral positions. The motivation is automatic assessment of global systolic and diastolic left ventricular function.

Methods: The population consisted of 200 patients from the outpatient clinic and echo-lab at the region's university hospital and 200 healthy volunteers from the Nord-Trøndelag Health Study (HUNT). Measurements performed by three cardiologists experienced in echocardiography served as reference for the comparison with the automatic measurements. The correlation coefficients were computed for all indices. To assess the utility to automatically detect systolic dysfunction we dichotomized average septal and lateral MAE ≤ 9mm.

Results: Preliminary results from 78 healthy controls (22-75 years) and 40 patients (21-87 years) are shown below. Septal (lateral) correlation r-values were MAE: 0.70 (0.61), S': 0.81 (0.69), e': 0.89 (0.88), and a': 0.85 (0.68) The figure demonstrates the high correlations for septal e' and S'. Dichotomization of automatically assessed MAE resulted in 9 true positive, 5 false positive, 1 false negative, and 103 true negative, corresponding to a sensitivity of 90%, specificity of 95%, and PPV and NPV of 64% and 99%.

Conclusion: The automatically measured indices were accurate and highly correlated with reference measurements. The somewhat higher correlation for measurements at the septal position may be related to image quality. Classification by average MAE is promising. Future work will investigate detection of systolic and diastolic dysfunction based on all indices.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1335: Additional value of right atrial strain in pulmonary hypertension diagnosis: correlation with clinical and invasive parameters and prognostic implications

L Ferrarotti ¹, E Maggi ¹, C Piccinino ¹, D Sola ¹, F Pastore ¹, PN Marino ¹

Abstract

Objectives: Increased right atrium (RA) size is related to adverse prognosis in patients with pulmonary hypertension. The aim of the study was to evaluate the potential incremental value of RA 2-dimensional-speckle tracking strain echocardiography (2d-SpTr) in assessing global RA performance and correlation with hemodynamic and clinical parameters.

Methods: Successive, unselected, naïve patients with suspected PH based on clinical and echo parameters underwent cardiac catheterization (RHC) to confirm PH according to international guidelines. All patients had standard 2D and Doppler echocardiography evaluation in < 48 hrs of admission. Specially RA function was assessed with RA 2D-SpTr from standard apical views. Healthy subjects matched for age and gender were included as controls.

Results: The study involved 37 patients (mean age 69 ± 12 years, 84% women) and 7 controls. RA global strain was significantly higher in healthy subjects compared to patients (p=0.0002). Regression analysis indicated that RA strain significantly correlated with RHC measurements of cardiac index (p<0.001) and pulmonary artery compliance (p<0.014) whereas no correlation was found between RA area and hemodynamic parameters. Clinically, RA strain correlated negatively with functional class (p=0.02) and BNP (p=0.04) and positively, although non-significantly, with 6-minute walking test.

Conclusions: RA strain is accurate and reliable tool for diagnosis and assessment of patients with PH and provides additional prognostic value to standard non-invasive parameters.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1336: A 3D mathematical modeling of the left ventricular myocardium

S Ranjbar ¹, M Karvandi ¹, SA Hassantash ¹

Abstract

Purpose: Currently, an echocardiogram presents the left ventricle (LV) based on images obtained from ultrasound methods. Utilizing mathematical equations, specific echocardiographic data may provide more detailed, valuable and practical information for physicians. In our project using appropriate mathematically based softwares, we have attempted to create a novel software capable of demonstrate LV model in normal hearts.

Methods: Echocardiography was performed on 50 healthy volunteers. Data evaluated included: velocity (radial, longitudinal, rotational and vector point), displacement (longitudinal and rotational), strain rate (longitudinal and circumferential) and strain (radial, longitudinal and circumferential) of all 16 LV myocardial segments. Using these data, force vectors of myocardial samples were estimated by MATLAB and LSDYNA softwares, interfaced in the echocardiograph system. Dynamic orientation contraction (through the cardiac cycle) of every individual myocardial fiber could be created by adding together the sequential steps of the multiple fragmented sectors of that fiber. This way we attempted to mechanically illustrate the global LV model.

Results: LV Myocardial modeling: Our study shows that in normal cases myocardial fibers initiate from the posterior-basal region of the heart, continues through the LV free wall, reaches the septum, loops around the apex, ascends, and ends at the superior-anterior edge of LV.

Conclusion: We were able to define the whole LV myocardial model mathematically, for the first time, by MATLAB software and LSDYNA software in normal subjects. This will enable physicians to diagnose and follow-up many cardiac diseases when this software is interfaced within echocardiographic machines.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1337: A novel calculated formula of right ventricular rotation using echocardiographic velocity vector imaging

M Karvandi ¹, S Ranjbar ¹

Abstract

Background: Right ventricular rotational (RV) deformation is a sensitive index for RV performance but difficult to measure. Having assumed RV as a conic shape (no ellipsoid), the present study serves a novel formula of right ventricular rotation that uses velocity vector imaging for quantifying RV.

Method: After a clinical standard echocardiographic examination, the RV cross section was made as ellipse as possible. Optimal 2D images for velocity vector imaging analysis were recorded with electrocardiogram synchronization. After storing optimal 2D images, velocity vector imaging offline analysis was performed using X-Strain software. We calculated right ventricular rotation by integrating the rotational velocity, determined from velocity vector imaging global velocities of the septal and free wall regions of the right ventricle, and correcting for the right ventricular diameters a(t) and b(t) as an ellipse over time . Data used included: global velocities and rotational velocities of referred regions 1, 2, 3 (as septum) and 4 (as RV free wall) respectively. "a" sub 0 and "b" sub 0 are end diastolic diameters of ellipse.

Result: The numerical calculations showed that RV rotated with basal and apical RV rotation of -3.1 ± 1.2 degree and 8.2 ± 2.7 degree, respectively (p<0.001), and resulting torsion of 11.4 ± 2.6.

Conclusion: The present study has shown that velocity vector imaging can quantify right ventricular rotational deformation over time. This novel method may facilitate noninvasive quantification of right ventricular torsion in clinical and research settings.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

COMPUTED TOMOGRAPHY & NUCLEAR CARDIOLOGY: P1338: In vivo quantification of the longitudinal expression profile of the macrophage mannose receptor after myocardial ischemia reperfusion injury in rats

S Tierens ¹, I Remory ¹, G Bala ², K Gillis ², S Hernot ³, S Droogmans ², B Cosyns ², T Lahoutte ⁴, N Tran ⁵, J Poelaert ¹

Abstract

Introduction: Improving the management of acute myocardial ischemia (MI) has led to a substantial decrease of its early mortality in Europe. Nonetheless, ischemic heart diseases remain the most important cause of morbidity and mortality in developed countries. Studies have shown that the complex inflammatory process after the acute injury might be of particular interest for future diagnosis and therapy. Therefore, new methods for the in vivo assessment of different subsets of immune responses after MI are warranted.

In this study, we aimed to image the expression profile of M2-mediated inflammation over time, using radionuclide labeled single domain antibodies (nanobodies, Nbs), targeting the macrophage mannose receptor (MMR, CD206+) in a myocardial ischemia/reperfusion injury (IRI) rat model.

Methods: Myocardial IRI was obtained by ligating the left anterior descending coronary artery for 60 minutes followed by reperfusion in 16 Wistar rats. Six animals were sham operated. Infarct size was assessed by a 99mTc-Tetrofosmin scan on day 2. Pinhole-SPECT/CT acquisitions of 99mTc-MMR Nb and a 99mTc-control Nb were taken at baseline, day (D) 5, 9, 12, 16, 21 and 28 after IRI or sham operation. Quantification of the retention of 99mTc labeled Nbs in the infarct zone (IZ) was performed by placing fixed sized volume of interest at the anterolateral segment of the myocardium. Immunofluorescent staining was performed for MMR and CD68. Statistical analysis was conducted using repeated measures ANOVA, paired student-T and student-T test with Bonferroni post hoc corrections. Data are presented as mean ± standard deviation.

Results: Four animals died during the procedure and 3 shortly thereafter. IZ, expressed as total perfusion deficit (TPD), was 11.11 ± 9.06 and did not differ between IRI groups (p=.277). The retention of the MMR-Nb in IRI (n=5), MMR-Nb in sham-operated rats (n=6) and control Nb in IRI (n=4) was significantly different over time (F(12,72)=4.45, p < .001). Only the IRI group that was imaged with MMR Nbs showed an increased retention from D5 until D16 in comparison to their baseline values (p < .008). Immunofluorescent staining demonstrated the presence of MMR in the IZ and surrounding pericardium, in accordance with the localization of in vivo retention and co-localized well with the anti-CD68 signal.

Conclusion: The expression profile of M2-mediated inflammation using radionuclide labeled Nbs in an IRI rat model can be imaged in vivo. This opens new opportunities to follow the impact of various treatment strategies on inflammation modulation in acute ischemic heart disease.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1339: The role of coronary CT angiography in patients with normal SPECT MPI and persistent chest pain

M Al-Mallah ¹, A Alsaileek ¹, K Nour ²

Abstract

Background: The aim of this analysis is to investigate the role of coronary computed tomography angiography (CCTA) in patients with normal single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) and persistent chest pain.

Methods: We included 53 patients (Mean age 53 years, 53% males) without known coronary artery disease (CAD) who had a normal SPECT MPI (Sum stress score<3). Univariate and multivariate logistic regression were performed to identify the independent predictors of obstructive CAD on CCTA.

Results: A total of 17 (32%) patients had evidence of obstructive CAD in at least one vessel. Patients with obstructive CAD had higher Framingham risk score (12 ± 9, 6 ± 5, p=0.007), but there was no difference in the prevalence of traditional risk factors (hypertension, diabetes, hyperlipidemia) between the two groups. Patients with obstructive CAD had higher coronary calcium score (336 ± 334 vs. 62 ± 122, p<0.001). A calcium score of 50 has 77% sensitivity and 73% specificity for detection of obstructive CAD. Using multivariate analysis, the Framingham risk score (OR 1.2, p=0.008) and exercise ability (odds ratio 5.4, p=0.047) were the independent predictors of CAD after adjusting for con-founders.

Conclusions: Our analysis suggests that CCTA provides incremental diagnostic information in patients with normal SPECT MPI and persistent chest pain

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1340: Feasibilty of semiautomatic transluminal attenuation gradient assessment in the detection of hemodynamically significant stenosis in coronary CT angiography

CS Celeng ¹, T Horvath ¹, M Kolossvary ¹, M Karolyi ¹, A Panajotu ¹, P Kitslaar ², B Merkely ¹, P Maurovich Horvat ¹, MTA-SE "Lendület" Cardiovascular Imaging Research Group

Abstract

Background: To date, coronary computed tomography angiography (CCTA) is the only diagnostic imaging technique that allows non-invasive visualization and robust assessment of coronary artery plaque and stenoses. However, the assessment of hemodynamic relevance of a coronary luminal narrowing with CCTA remains challenging.

Purpose: The aim of this study was to assess the feasibility of semiautomated transluminal attenuation gradient (TAG) measurements in CCTA in order to determine the lesion specific ischaemia.

Methods: CCTA scans were performed with a 256-slice CT-scanner. CCTA images of left anterior descending coronary artery (LAD) were analyzed in eight patients (age: 37-70). Four patients with significant LAD stenosis were compared with four patients with normal coronary arteries (controls). The CCTA diagnosis of significant stenosis was confirmed by cardiac catheterization. The coronary lumen was segmented and the TAG was measured with semiautomatic method using a dedicated software. The mean luminal HU values were recorded in 0.5 mm increments. The HU values were smoothed over 20 cross-sections using a moving average filter. The distal thirds of the LADs were excluded. Linear least square regression line was fitted to the TAG. Trendline slopes were compared between the stenosis group and controls.

Results: The average length of the analyzed coronary segments was 158.8 ± 42.5 mm and 164.0 ± 14.5 mm for the stenosis and for the control groups, respectively. The stenosis group showed a greater attenuation gradient (-7.8 HU/10mm) compared to the control group (+2.0 HU/10mm), p<0.05.

Conclusion: The semi-automated measurement of TAG is feasible. The assessment of TAG with 256-slice CT-scanner may add a functional aspect to the evaluation of the coronary artery stenosis.

Eur Heart J Cardiovasc Imaging. 2014 Dec 5;15(Suppl 2):ii235–ii264.

P1341: Diagnostic and therapeutic profitability of isolated invasive coronary angiography vs guided by computed tomography angiography in patients with low/intermediate cardiovascular risk

S Aguiar Rosa ¹, R Ramos ¹, H Marques ¹, G Portugal ¹, T Pereira Da Silva ¹, P Rio ¹, M Afonso Nogueira ¹, A Viveiros Monteiro ¹, L Figueiredo ¹, R Cruz Ferreira ¹

Abstract

Introduction: The diagnostic profitability (DP) (rate of patients (PTS) diagnosed coronary artery disease (CAD)) and therapeutic profitability (TP) (rate of revascularized PTS) of invasive coronary angiography (ICA) are low in patients (PTS) with low to intermediate cardiovascular (LICV) risk and positive or inconclusive non-invasive diagnostic methods (NIDM) for CAD.

Objective: Evaluate the increase of DP and TP in ICA with the use of systematic coronary computed tomography angiography (CCTA) after positive or inconclusive NIDM for CAD in PTS with LICV risk.

Methods: Retrospective analysis of ICA's DP and TP after introduction of CCTA (64-multislice spiral) in diagnostic algorithms, for 6 months. All PTS with no known CAD with LICV risk (Framingham score < 20%), and at least one positive or inconclusive NIDM for CAD were included. The control group was a population with similar clinical characteristics, whom underwent ICA in the 5 years previous to the introduction of CCTA in diagnostic approach. CAD was defined as coronary stenosis > 70% (>50% in left main). All angioplasty attempts were considered revascularization non regarding the final result.

Results: Of 250 CCTA performed in the study period, 60 presented inclusion criteria. In control group 1835 consecutive PTS were analysed. Groups differed in sex (male 42% vs 59%, p=0.005), with no difference in remaining basal characteristics, mean age (62 ± 10 vs 62 ± 9 years), diabetes (18% vs 17%), hypertension (66% vs 66%), (p=NS). Of 60 PTS with CCTA, 10 PTS (16.7%) underwent ICA due to CAD in CTA. In this subgroup, the angioplasty was performed in 6 PTS (60%). In 4 PTS angioplasty was not performed, because 1 PTS underwent coronary artery bypass grafting, in 1 PTS fractional flow reserve was > 0.80, in 1 PTS the vessel was too small and in 1 PTS CAD was not confirmed. Of 1835 in group control, 813 PTS (44.3%) presented CAD and 518 (28.2%) were revascularized. Comparing to control, in the CCTA group DP increased from 43% (813/1835) to 90% (9/10) (p=0.025) and TP increased from 28.8% (518/1835) to 60% (6/10) (p=0.026).

Conclusion: In a population with LICV risk and positive or inconclusive NIMD, CCTA introduction in diagnostic algorithms raised ICA DP by 104% and TP by 113%.

PERMALINK

Poster session 6

GENERAL PRINCIPLES: P1232: "Fast" Left Atrial Volume measures validation and its comparison with echocardiographic results in a patient cohort

J Goirigolzarri Artaza

M Gallego Delgado

CP Jaimes Castellanos

MA Cavero Gibanel

MA Pastrana Ledesma

LA Alonso Pulpon

J Gonzalez Mirelis

Abstract

THE IMAGING EXAMINATION: P1233: Right ventricular dysfunction in patients with end-stage renal disease on regular hemodialysis

R Z Al Ansi

Abstract

P1234: Atrial septal aneurysm in adults: a case series study

S Sokolovic

Abstract

Figure.

P1235: Is 2D-echocardiographic left atrial volume assessment reliable?

G Cerin

W Szychta

B A Popa

D Botezatu

D Benea

S Manganiello

A Corlan

A Jabour

Abstract

P1236: Reliability of left atrial volume calculation using new segmentation algorithms in no triggered Cardiac Magnetic Resonance angiographic sequences.

B Igual Munoz

JOA Osaca Asensi

AALH Andres La Huerta

AMG Maceira Gonzalez

JEE Estornell Erill

OCP Cano Perez

MJSTDC Sancho-Tello

PAF Alonso Fernandez

PSS Sepulveda Sanchez

AMA Montero Argudo

Abstract

Figure.

ANATOMY AND PHYSIOLOGY OF THE HEART AND GREAT VESSELS: P1237: Large artery remodeling and dynamics following simulated microgravity by prolonged head down tilt bed rest in humans

C Palombo

C Morizzo

M Baluci

M Kozakova

Abstract

ASSESSMENT OF DIAMETERS, VOLUMES AND MASS: P1238: Atrial anatomy shows a strong heritability in a classical twin study

A Panajotu

J Karady

G Szeplaki

T Horvath

DL Tarnoki

AL Jermendy

L Geller

B Merkely

P Maurovich-Horvat

Abstract

P1239: Gender influence on atrial performance explored by speckle-tracking echocardiography

S Moustafa

F Mookadam

M Youssef

H Zuhairy

M Connelly

T Prieur

N Alvarez

Abstract

P1240: Left atrial contractile function and atrial fibrosis in patients with paroxysmal atrial fibrillation

Y Ashikhmin

O Drapkina

Abstract

P1241: Structural and functional abnormalities of the left atrium in pts with atrial fibrillation: Speckle tracking analysis and prognosis of successful cardioversion

M Boutsikou

E Demerouti

E Leontiadis

E Petrou

G Karatasakis

Abstract

P1242: Body composition and vascular adaptation in adolescents

M Kozakova