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(searched for: The Left Atrial Function as a Marker for the Severity of Heart Failure with Preserved Ejection Fraction)
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Mingxue Sun, Zhiyuan Shui, Yunzhi Wang, Yiqun Gao, Shunji Liang, Yiran Wang, Qin Yu, Li Liu
Cardiology and Cardiovascular Medicine, Volume 05, pp 300-314; doi:10.26502/fccm.92920203

Background: Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome characterized by heart failure symptoms and signs, but normal or near-normal left ventricular ejection fraction (LV-EF). There are objective evidences of left ventricular systolic/diastolic dysfunctions and alteration of left atrial (LA) structure and functions. However, limited data are available on the association of LA functions with the severity of HFpEF. Methods: We assessed and analyzed LA/LV structure and functions in 61 patients with HFpEF with 2D echocardiography and two-dimensional speckle tracking echocardiographic technology (2D-STE). LA triphasic functions in subgroups with different classification of cardiac functions (NYHA II – IV) were compared. The correlation analysis of LA triphasic functions with LV systolic/diastolic functions was made with Pearson test. Results: Patients with HFpEF had impaired LV systolic/diastolic functions, and impaired LA triphasic functions compared with control subjects. LA global longitudinal strain (LA-GLS) and the left atrial systolic strain rate (LA-mSRs, reflecting LA reservoir function) were positively correlated with global LV longitudinal strain (LV-GLS) and E/e’; the longitudinal strain rate of the left atrium at the early diastole (LA-mSRe, reflecting LA conduit function) and the longitudinal strain rate of the left atrium at the late diastole (LA-mSRa, reflecting LA pump function) were inversely correlated with the LV-GLS and E/e’. The LA function is closely related with the NYHA classification in patients with HFpEF. Conclusion: LA phasic functions were significantly impaired in patients with HFpEF. It can be used as a marker for scaling the severity of HFpEF.
C Baehr, C Angermann, J Albert, S Stoerk, C Morbach, S Frantz, G Ertl
European Heart Journal, Volume 41; doi:10.1093/ehjci/ehaa946.0901

Background To date, there are few prospective studies which characterize left ventricular diastolic dysfunction (LVDD) in patients with acute heart failure (AHF) using contemporary echo- and Doppler-techniques and take heart failure (HF) phenotype into account. Furthermore, prevalence and clinical correlates of different degrees of LVDD are unknown. Purpose To determine prevalence and echo characteristics of LVDD and identify clinical and biomarker correlates in patients hospitalized for AHF with either preserved (HFpEF, LVEF ≥50%) or reduced (HFrEF, LVEF <50%) LV systolic function. Methods The AHF Registry Würzburg enrols consecutive patients hospitalized for AHF. For the current analysis, patients with complete high-quality echo- and Doppler studies performed during the index hospitalization allowing for full quantitative analysis were eligible. Left ventricular ejection fraction (LVEF) was determined using Simpson's biplane method. LVDD was graded according to 2016 ESC recommendations based on the E/A-ratio and markers of left ventricular (LV) filling pressure: E/E'-ratio, LA volume, and estimated systolic pulmonary artery pressure (sPAP, derived from peak tricuspid regurgitant flow velocity and estimated right atrial pressure). E/A-ratio <0.8 or E/A-ratio 0.8–2.0 without evidence of increased LV filling pressure was classified as LVDD°I, an E/A-ratio between 0.8–2.0 with evidence of elevated filling pressure as LVDD°II, and an E/A-ratio >2.0 as LVDD°III. LVDD prevalence rates were determined overall and in patients with HFrEF and HFpEF, respectively. Furthermore, other echocardiographic, clinical, and biomarker characteristics were studied. Results Overall, 155 patients were eligible (37.4% female, mean age 71.6±12.0 years, LVEF 45.7±17.8%, 49.7% HFpEF, 50.3% HFrEF). Most patients (83.9%) had Doppler evidence of increased filling pressures, with either LVDD°II (48.4%, LVEF 48.6±18.6%) or LVDD°III (35.5%, LVEF 40.3±15.4%). Overall, HFrEF-patients had higher rates of LVDD°III (47.4 vs 23.4%, p=0.002), while HFpEF-patients had higher rates of LVDD°II (58.4 vs 38.5%, p=0.013) (Figure). LVDD°I was present in only 16.1% of all patients (HFpEF: n=14, HFrEF: n=11, LVEF 48.9±15.4%). Compared to patients with LVDD°II-III, this subgroup had lower E/E'-ratio (11.7 vs 19.5 p<0.001), sPAP (30.9±15.8 vs 44±12.5 mmHg, p<0.001) and LA volume index (36.4±17.67 vs 53.5±21.0 ml/m2, p<0.001). Furthermore, NT-proBNP-levels were lower (median [IQR] 2236 [1336; 5204] vs 4125 [2390; 4125] pg/ml, p=0.042) and heart failure (HF) history shorter (56.0 vs 33.1% HF known <1 year, p=0.029). Conclusion Among patients hospitalized for AHF, the majority had significant LVDD, irrespective of LVEF. However, LVDD°II was more common in HFpEF, whereas HFrEF patients had more LVDD°III. Furthermore, the small subgroup with LVDD°I had less severe sPAP elevation, lower LA volume and NT-proBNP and a shorter HF history indicating a less advanced HF stage. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Bundesministerium für Bildung und Forschung
T Van Loon, C Knackstedt, T Delhaas, K.D Reesink, H.P Brunner-La Rocca, V.P.M Van Empel, J Lumens
European Heart Journal, Volume 41; doi:10.1093/ehjci/ehaa946.0868

Background Left ventricular (LV) diastolic dysfunction, i.e. impaired LV relaxation function and/or increased LV stiffness, has been hypothesized to be responsible for at least part of the exercise intolerance in heart failure with preserved ejection fraction (HFpEF). Yet the mechanisms remain largely unknown. Purpose To determine in silico if and how abnormal LV diastolic function causes reduction in maximum cardiac output (COmax), i.e. exercise intolerance. Methods We used a cardiovascular model (CircAdapt) to simulate the effects of impaired LV relaxation and increased LV myocardial stiffness on cardiac hemodynamics. The model was initialized using a reference simulation with hypertension (systolic blood pressure: 150 mmHg) and concentric LV hypertrophy (LV wall mass: +25%). Impaired LV relaxation was introduced by increasing tau from 35 ms to 65 ms. LV stiffness was increased by increasing LV end-diastolic elastance from 0.15 mmHg/ml to 0.60 mmHg/ml and 2.00 mmHg/ml (moderate and severe LV stiffness, respectively). In each simulation, LV ejection fraction (LVEF), E/A ratio and mean left atrial (LA) pressure (mLAP) was assessed. To evaluate the effect on exercise tolerance, COmax was determined by gradually increasing cardiac output and heart rate in a predefined manner until mLAP exceeded 35 mmHg. Results In all simulations, LVEF remained unchanged and preserved (i.e. 60%). In rest, impaired LV relaxation decreased E/A ratio from 1.1 to 0.8 (impaired filling pattern) and increased mLAP from 7.2 mmHg to 8.0 mmHg (Figure top: gray vs. orange). Total LV filling time was reduced at rest, reducing diastolic reserve capacity and thereby of COmax, by 15% compared to the reference (Figure bottom: gray vs. orange). Moderate LV stiffness increased E/A ratio to 1.1 (pseudo-normal filling pattern) and mLAP to 15.0 mmHg (Figure top: gray vs. red). COmax was reduced by 40% due to a steep increase of mLAP with exercise intensity. Severe LV stiffness increased E/A ratio to 2.2 (i.e. restrictive filling pattern), but resulted in a non-physiological mLAP of 40 mmHg at rest. However, when combining moderate LV stiffness with LA dysfunction (i.e. reduced LA contractility and increased LA stiffness) also led to restrictive filling pattern (E/A ratio >2.0) with mLAP 19 mmHg (Figure top: red vs. dashed blue). COmax reduced most severely by 53%, emphasizing the importance of LA function in LV diastolic dysfunction (Figure bottom: gray vs. dashed blue). Conclusions Through variations in LV and LA function, we linked the progression of LV diastolic dysfunction to LV and LA properties. Increased LV stiffness, more than impaired LV relaxation, is associated with substantially reduced exercise tolerance. The combination of LV and LA dysfunction led to the most severe exercise intolerance. Our unique in silico framework enables future studies to investigate other potential cardiac and vascular mechanisms underlying exercise intolerance in HFpEF. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was funded by the Netherlands Organisation for Scientific Research and the Dutch Heart Foundation.
T. P. Gizatulina, L. U. Martyanova, T. I. Petelina, E. V. Zueva, N. E. Shirokov
Journal of Arrhythmology, Volume 27; doi:10.35336/va-2020-3-25-33

Introduction. Growth Differentiation Factor 15 (GDF-15) is known to be an independent predictor of cardiovascular and all-cause mortality, as well as major bleeding in patients (pts) with non-valvular atrial fibrillation (AF). Since GDF-15 is expressed by a wide array of cells in response to inflammation and myocardial stress, it is interesting to study which clinical and functional parameters are most associated with the level of GDF-15 in pts with non-valvular AF and preserved left ventricular ejection fraction. Aim. To study the relationship of GDF-15 level in blood serum with parameters of clinical and functional status and to determine independent predictors of GDF-15 level in pts with non-valvular AF. Material and methods. 87 pts with non-valvular AF were studied, with an average age of 56.9±9.2 years. A general clinical examination, echocardiography and laboratory tests were performed, including fasting serum glucose (mmol/l),highly sensitive C-reactive protein (h/s CRP) (mg/l), creatinine level (mkmol/l) and subsequent calculation of glomerular filtration rate (ml/min/1.73m2), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) (pg/ml). The level of GDF15 (pg/ml) in blood serum was determined using an enzyme immunoassay with the help of the human GDF-15/MIC-1 ELISA analytical kit (BioVender, Czech Republic). Results. The increase in the GDF-15 level was associated with ageing, ischemic heart disease, severity of arterial hypertension and heart failure, raising the risk of stroke, according to the scale CHA2DS2-VASc, disturbances of carbohydrate metabolism and obesity, increasing the levels h/s CRP and NT-proBNP, enlargement of the right and left atria, signs of diastolic left ventricular dysfunction and structural remodeling in the form of eccentric hypertrophy. Multiple linear regression analysis revealed 2 independent predictors of GDF-15 levels: age and fasting glucose. Conclusion. GDF-15 appears as an integral biomarker of age-related metabolic disorders and structural and functional changes in the heart, which opens up prospects for further study of its prognostic significance in pts with non-valvular AF.
, , Evgeny Belyavskiy, Aravind‐Kumar Radhakrishnan, Martin Kropf, Marijana Tadic, Lothar Roessig, Carolyn S.P. Lam, Sanjiv J. Shah, Scott D. Solomon, et al.
Published: 2 July 2020
ESC Heart Failure, Volume 7, pp 1956-1965; doi:10.1002/ehf2.12820

Aims The purpose of this retrospective analysis was to examine the association of left atrial (LA) strain (i.e. LA reservoir function) with left ventricular diastolic dysfunction (DD) in patients with heart failure with reduced and preserved left ventricular ejection fraction (LVEF). Methods and results We analysed the baseline echocardiographic recordings of 300 patients in sinus rhythm from the SOCRATES‐PRESERVED and SOCRATES‐REDUCED studies. LA volume index was normal in 89 (29.7%), of whom 60.6% had an abnormal LA reservoir strain (i.e. ≤23%). In addition, the extent of LA strain impairment was significantly associated with the severity of DD according to the 2016 American Society of Echocardiography recommendations (DD grade I: LA strain 22.2 ± 6.6, rate of abnormal LA strain 62.9%; DD grade II: LA strain 16.6 ± 7.4, rate of abnormal LA strain 88.6%; DD grade III: LA strain 11.1 ± 5.4%, rate of abnormal LA strain 95.7%; all P < 0.01). In line with these findings, LA strain had a good diagnostic performance to determine severe DD [area under the curve 0.83 (95% CI 0.77–0.88), cut‐off 14.1%, sensitivity 80%, specificity 77.8%], which was significantly better than for LA volume index, LA total emptying fraction, and the mitral E/e′ ratio. Conclusions The findings of this analysis suggest that LA strain could be a useful parameter in the evaluation of DD in patients with heart failure and sinus rhythm, irrespective of LVEF.
I Lupasteanu, A Vijan, C Delcea, C Stanescu, S Bari, I Daha, G A Dan
Published: 1 June 2020
Europace, Volume 22; doi:10.1093/europace/euaa162.292

Background Recent data has acknowledged atrial induced functional mitral valve regurgitation (MR) in the setting of atrial fibrillation (AF) and/or heart failure with preserved ejection fraction (HFpEF) as a distinct type of secondary MR, holding prognostic significance. However, evidence on its prevalence is still scarce, especially in the phenotype of mid-range ejection fraction heart failure (HFmEF). Purpose The aim of this study is to evaluate the occurrence of left atrial (LA) enlargement and MR in AF patients with or without heart failure with preserved or mid-range ejection fraction. Methods This retrospective study included 750 consecutive patients with AF admitted to a tertiary hospital from January 2018 to June 2019. We excluded patients with primary valvular disease and HF with reduced EF. MR presence and severity were assessed by evaluating the valve morphology, colour flow imaging and, when feasible, vena contracta and PISA methods. We measured LA anteroposterior diameter and used LA dilatation as a surrogate marker for mitral annulus dilatation. Results We evaluated 584 AF patients: mean age 72.22 ± 10.10 years; 58,73% females; 79.75% had HF: 73.13% of them had HFpEF and 26.87% had HFmEF. Compared to those without HF, patients with HF had a relative risk (RR) of associating LA enlargement of 5.37 (95%CI = 3.05-9.48, p < 0.001) and a RR of associating MR of 1.47 (95%CI 1.08-2.00, p = 0.01). Mean LA diameter was higher in the HF group, compared to non-HF (47.06 ± 7.26 mm vs 40.91 ± 7.10 mm, p < 0.001). MR severity was more likely associated with HF (RR = 1.68, 95%CI = 1.46-1.94, p < 0.001). When comparing results between the two HF subgroups, patients with HFmEF had a higher mean LA diameter than those with HFpEF (48.52 ± 5.68 mm vs 46.36 ± 7.57 mm, p = 0.011), without associating a significant difference in the MR prevalence (72.97% vs 73.98%, p = 0.94). The presence of a dilated LA was directly correlated with MR in the HF group (RR = 1.94, 95%CI = 1.18-3.20, p = 0.023), but not in those without HF (RR = 1.04, 95%CI = 0.57-1.90, p = 0.89). In HF patients, permanent AF associated the highest prevalence of LA dilatation (96.67%) and MR (81.73%) in contrast to paroxysmal AF (81.10%, p < 0.01, respectively 63.43%, p = 0.0002). Conclusions LA dilatation, the presence and severity of MR correlated with AF and HF, especially in permanent AF patients. In patients without HF, LA dilatation did not correlate with the presence of MR. MR prevalence was similar in patients with HFmEF and HFpEF, irrespective of a higher degree of LA dilatation in HFmEF. Our results suggest that the pathophysiological mechanisms involved in LA enlargement and MR are different for different phenotypes of AF in patients with or without HF.
Mohammed A. Chamsi-Pasha, , Dany Debs,
Published: 1 January 2020
JACC: Cardiovascular Imaging, Volume 13, pp 283-296; doi:10.1016/j.jcmg.2019.02.031

Heart failure with preserved ejection fraction presents a challenging diagnosis given a heterogeneous patient population and limited therapeutic options. Diastolic function assessment using echocardiography has been a cornerstone in the work-up and is as important as systolic functional assessment. There has been increased awareness to the potential utility of cardiac magnetic resonance (CMR) imaging over the past decade as a promising, radiation-free, robust imaging modality providing an unrestricted field of view and high-resolution images for global and regional functional assessment. CMR provides early markers for detecting myocardial disease using tissue characterization imaging, which might prove useful to improve diagnosis and management. Over the years, several studies have examined CMR-derived diastolic functional indices, including transmitral and pulmonary venous velocities, left ventricular and left atrial strain using myocardial tagging, and, more recently, feature tracking. The relevance of imaging-based diastolic function indices and their clinical application across different modalities is increasingly recognized.
M Ledwidge, Rb Pharithi, F Ryan, J Dodd, D Murphy, J Gallagher, C Watson, M Barrett, K McDonald, M Ferre
Published: 16 October 2019
by BMJ
General Poster Abstracts 1, Volume 105; doi:10.1136/heartjnl-2019-ics.20

Background Elevated B-type NP (BNP) in asymptomatic patients with cardiac abnormalities can provide a protective, endogenous response to fibro-inflammation. The PARABLE study is investigating the hypothesis that augmenting BNP pharmacologically with the neutral endopepdidase inhibitor sacubitril can modulate progression of LAVI over 18 months measured using cardiac Magnetic Resonance Imaging (cMRI). In addition, all patients in PARABLE undergo Doppler-echocardiography at baseline, 9 months and 18 months. The purpose of this report is to evaluate overall, blinded progression of cardiac structural and functional abnormalities over 9 months in the first 100 and 18 months in the first 74 patients. Methods PARABLE is an investigator-led, prospective, randomised, double blind, double dummy, phase II trial comparing treatment with sacubitril/valsartan versus valsartan. PARABLE will enroll 250 patients aged over 40 years with hypertension and/or diabetes, with BNP from 20–280 pg/mL or NTproBNP from 100 to 1000 pg/mL) and LAVI above 28 mL/m2. Excluded are patients with a history of heart failure, left ventricular systolic dysfunction, haemodynamically significant mitral and/or aortic valve disease, persistent atrial fibrillation, hepatic dysfunction and severe chronic kidney disease. The primary endpoint is change in LAVI measured by cMRI over 18 months. We evaluated blinded Doppler-echocardiographic measures of left ventricular structure, systolic function and diastolic function at baseline, 9 months and 18 months. Results In the first 100 patients to complete the study, 35% were female, average age 72.7±8.0 years, 94% had hypertension and 22% had Type 2 diabetes. Sub-population blood pressure was 136/78±21/13 mmHg, heart rate was 63.5±10.8 bpm and body mass index was 28.8±4.9 kg/m2. Other baseline medical history included dyslipidaemia (83%), coronary artery disease (52%), other vascular disease (5%), stroke/TIA (10%), paroxysmal atrial fibrillation n (7%) and chronic kidney disease (2%). Median BNP was 79 pg/mL [interquartile range (IQR) 47, 117] and Baseline Doppler-echocardiography showed average ejection fraction was 68.5±6.5%, LVMI was 113.3±28.2%, E/e’ was 11.3±3.2 and LAVI was 34.3±4.9 mL/m2. There were no significant changes from baseline in Doppler-echocardiography measures at 9 months. At 18 months, in the subgroup who had completed the study, the only observed change was a significant increase in LAVI from 34.0±4.6 mL/m2 to 36.0±5.0 mL/m2 (p<0.01). Conclusions Participants in the PARABLE clinical trial with elevated BNP and LAVI at baseline show significant progression of LAVI abnormalities over an 18-month time period. The PARABLE study is on target to define the impact of preserving circulating BNP using sacubitril on LAVI progression as a personalised therapy for prevention of progression of left ventricular diastolic dysfunction.
, C Acatrinei, C Neagu, S Onciul, D Zamfir, R Onut, M Stoian, S Iancovici, I Petre, M Dorobantu
European Heart Journal, Volume 40; doi:10.1093/eurheartj/ehz748.0923

Background The left atrium (LA) is a highly dynamic chamber that has 3 mechanical functions (reservoir, conduit, booster pump), as well as additional endocrine and regulatory properties. It is a marker of both the severity and chronicity of diastolic dysfunction and its remodelling has been shown to be a reliable predictor of clinical outcome in patients with heart disease. While LA function has been extensively studied in chronic heart failure, information about LA mechanics in patients with acute heart failure and preserved left ventricular ejection fraction (EF) are scarce. Purpose We sought to assess LA mechanics in a cohort of patients with acute pulmonary edema and preserved EF and compare it with a normal reference group. Methods We included 50 consecutive patients (22 men) with acute pulmonary edema, preserved EF and sinus rhythm in our study. Patients with significant mitral or aortic valve disease were not considered eligible. The control group consisted of 30 subjects (18 men) with no previous cardiovascular disease. We performed conventional transthoracic echocardiography for all patients and we assessed various parameters of LA mechanics. To evaluate the reservoir function, we determined the total ejection volume (EV), the total EF, the LA expansion index (LAEI) and the LA function index (LAFI). To evaluate the conduit function, we determined the passive EV and passive EF. For the booster pump function, we determined the active EV, active EF, the atrial filling fraction, the ejection force and the LA kinetic energy (LAKE). We used T-test to compare the parameters between the two groups. Results The mean age in the study group was 72±14 years, while in the control group the mean age was 56±16 years (p=0.06). The total EV did not differ significantly between groups (p=0.44). The total LA ejection fraction was lower in the study group: 29±10% vs. 51±9% (p Conclusion All three integrated phases of left atrial mechanics (reservoir, conduit, booster pump) are impaired in patients with acute pulmonary edema and preserved left ventricular EF. These findings highlight the importance of diastolic dysfunction in the pathogenesis of acute heart failure for these patients and they suggest that LA dysfunction might be a potential therapeutic target in this clinical setting. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC-A2- cofinanced by the ERDF
, Omar F. AbouEzzeddine, Margaret M. Redfield
Published: 16 August 2018
PLOS ONE, Volume 13; doi:10.1371/journal.pone.0201836

Microvascular inflammation may contribute to the pathogenesis of both heart failure with preserved ejection fraction (HFpEF) and pulmonary hypertension (PH). We investigated whether the inflammation biomarker C-reactive protein (CRP) was associated with clinical characteristics, disease severity or PH in HFpEF. Patients in the Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Diastolic Heart failure (RELAX) trial had baseline high-sensitivity CRP levels measured (n = 214). Clinical characteristics, exercise performance, echocardiographic variables and biomarkers of neurohumoral activation, fibrosis and myocardial necrosis were assessed. Patients with normal (≤3mg/L) versus high (>3mg/L) CRP levels were compared. The median CRP level was 3.69mg/L. CRP was elevated in 57% of patients. High CRP levels were associated with younger age, higher body mass index (BMI), chronic obstructive pulmonary disease (COPD), lower peak oxygen consumption and higher endothelin-1 and aldosterone levels. CRP increased progressively with the number of comorbidities (0.7mg/L per increment in comorbidity number, P = 0.02). Adjusting for age, BMI and statin use, high CRP levels were additionally associated with atrial fibrillation, right ventricular dysfunction, and higher N-terminal pro-B-type natriuretic peptide levels (P<0.05 for all). CRP was not associated with PH or left ventricular function. CRP did not identify responders to sildenafil(P-value for interaction 0.13). In HFpEF, high CRP is associated with greater comorbidity burden and some markers of disease severity but CRP was normal in 40% of patients. These findings support the presence of comorbidity-driven systemic inflammation in HFpEF but also the need to study other biomarkers which may better reflect the presence of systemic inflammation.
Mirela Zaharie, Doina Carstea, Costin Teodor Streba, Paul Mitrut, Adina Dorina Glodeanu, Andrei Puiu Carstea, Sorin Ioan Zaharie, Ionela Teodora Dascalu, Mihaela Jana Tuculina, Adina Bunget, et al.
Published: 15 July 2018
Revista de Chimie, Volume 69, pp 1435-1440; doi:10.37358/rc.18.6.6341

Heart failure (HF) and renal dysfunction are frequent associated in the same patient. The purpose of our study was to assess the prevalence of renal dysfunction and the clinical status in admitted patients for decompensated HF. Material and Methods. 397 patients succesively hospitalized for decompensated HF, NYHA III or IV functional class, with left ventricular ejection fraction (LVEF) � 45% were included in the study. Renal dysfunction was defined by glomerular filtration rate (GFR) [ 60 mL/min/1.73 m 2. The mean GFR in patients with HF was 63.89 � 21.5 mL/min/1.73 m2 .The prevalence of renal dysfunction was 49.6%. Patients with GFR [ 60 mL/min/1.73m2, compared with those with preserved renal function were significantly more frequent older (75.37 � 6.84 vs. 71.33 � 8.08 years; p [0.001), females (53,8% vs. 43.5%; p = 0.04), had a significantly higher prevalence of diabetes mellitus (50.2% vs. 28.5%; p [0.001), atrial fibrillation (53.8% vs 46.2%, p = 0.04) and anemia (47.7% vs. 29.5% ; p [0.001). Also, patients with renal dysfunction had more severe HF than those without renal dysfunction (NYHA class IV: 65% vs 45%, p [0.001, clinical congestion: 78.2% vs 68%, p = 0.02, LVEF [35%: 47.21% vs � 35%, p [0.001). Renal dysfunction can be considered an additional marker of severe cardiac dysfunction along with NYHA IV class and low LVEF. The presence of both renal dysfunction and anemia could represent prognostic markers in HF patients with reduced LVEF.
Thomas H. Marwick
ESC CardioMed pp 1768-1773; doi:10.1093/med/9780198784906.003.0407

Imaging is helpful for the evaluation of myocardial structure and function, valvular disease, and haemodynamics in heart failure (HF). The assessment of ejection fraction is probably the most important step, as distinction of preserved, reduced, and mid-range ejection fraction has implications for management. In enlarged ventricles, quantification of mitral regurgitation and assessment of left ventricular (LV) shape are important as markers of HF severity. However, it should be remembered that haemodynamic evaluation and the assessment of right ventricular function are of value, independent of ejection fraction. The evaluation of diastolic dysfunction is based on estimation of LV filling pressure and assessment of severity of LV diastolic dysfunction, on the basis of left atrial volume, diastolic stage, and estimation of LV filling pressure (E/eʹ). Diastolic assessment is of value in patients with HF with preserved ejection fraction. LV responses to stress can identify an ischaemic aetiology, as well as left or right ventricular contractile reserve, a prognostic marker in both ischaemic and non-ischaemic cardiomyopathy. In patients with risk factors for HF, the evaluation of myocardial deformation and classification of LV morphology on the basis of relative wall thickness and LV mass, into normal, concentric remodelling, concentric hypertrophy, and eccentric hypertrophy has prognostic value. Cardiac imaging is indispensable in the management of HF, and echocardiography is the most widely used test for this purpose. However, no single test satisfies all imaging requirements in HF.
S. Gunter, C. Robinson, L. Tsang, P.H. Dessein, A.M. Millen
Rheumatoid arthritis – comorbidity and clinical aspects, Volume 77, pp 1367-1367; doi:10.1136/annrheumdis-2018-eular.5124

Background We recently reported that apelin concentrations are associated with reduced atherosclerosis and plaque vulnerability as well as improved aortic function in rheumatoid arthritis (RA)1,2. These relations were influenced by RA characteristics1,2. Besides protecting against atherosclerosis, apelin is also a vasoactive peptide that improves cardiac contractility. In this regard, patients with RA experience a 2-fold increased risk of developing heart failure3. RA patients often demonstrate diastolic dysfunction and heart failure with a preserved ejection fraction (HFpEF). Traditional cardiovascular risk factors do not fully explain the increased heart failure incidence in this population. Metabolic risk factor driven inflammation is highly implicated in HFpEF. Objectives This study aimed to determine whether apelin can impact left ventricular function in RA and whether disease characteristics can modify this potential effect. Methods Relationships of apelin concentrations with echocardiographically determined markers of systolic and diastolic function including stroke volume, endocardial fractional shortening, midwall fractional shortening, ejection fraction, relative wall thickness, left ventricular mass, mitral inflow (E/A), filling pressure (E/e’) and left atrial volume index (LAVI) were determined in multivariable regression models among 169 patients without established cardiovascular disease. Results In demographic characteristic adjusted analysis, rheumatoid factor (RF) positivity, joint deformity counts, and CRP were associated with increased apelin concentrations (p=0.01, 0.02 and 0.05, respectively). Apelin was associated with a reduced LAVI [β(SE)=-4.6 (2.2); p=0.04] but not with E/A, lateral e’ or E/e’ (p>0.05 for all). RA characteristics including disease duration, CRP, erythrocyte sedimentation rate (ESR), RF positivity, and joint deformity counts did not impact apelin concentration-diastolic function marker relationships (interaction p values>0.05). Apelin levels were associated with increased endocardial fractional shortening [β(SE)=5.99 (2.97); p=0.04] and midwall fractional shortening [β(SE)=6.92 (3.0); p=0.03]. The ESR and anti-citrullinated peptide antibody (ACPA) status impacted the apelin level-endocardial fractional shortening relationships (interaction p=0.05 and 0.01, respectively). In stratified analysis, apelin concentrations were associated with improved endocardial fractional shortening in those with [β(SE)=14.1 (3.9); p=0.001] but not without an ESR >12 mm/hr (median value), and in those with [β(SE)=8.2 (3.7); p=0.03] but not without ACPA positivity. Conclusions In RA, apelin concentrations are associated with a reduced LAVI irrespective of RA activity and severity characteristics. Apelin concentrations are also associated with improved endocardial fractional shortening in patients with RA, particularly in those with high-grade inflammation and ACPA positivity. Whether apelin can improve left ventricular systolic and diastolic function in RA merits further exploration in longitudinal studies. References [1] Gunter S, et al. Atherosclerosis2017;256–75.81. [2] Gunter S, et al. Clinical Rheumatology2018:in press. [3] Nicola PJ, et al. Arthritis Rheum2005:52;412–20. Disclosure of Interest None declared
, Erik Michaëlsson, , , Jean-Claude Daubert, ,
Circulation: Cardiovascular Genetics, Volume 10; doi:10.1161/circgenetics.116.001633

Background— Underlying mechanisms in heart failure (HF) with preserved ejection fraction remain unknown. We investigated cardiovascular plasma biomarkers in HF with preserved ejection fraction and their correlation to diastolic dysfunction, functional class, pathophysiological processes, and prognosis. Methods and Results— In 86 stable patients with HF and EF ≥45% in the Karolinska Rennes (KaRen) biomarker substudy, biomarkers were quantified by a multiplex immunoassay. Orthogonal projection to latent structures by partial least square analysis was performed on 87 biomarkers and 240 clinical variables, ranking biomarkers associated with New York Heart Association (NYHA) Functional class and the composite outcome (all-cause mortality and HF hospitalization). Biomarkers significantly correlated with outcome were analyzed by multivariable Cox regression and correlations with echocardiographic measurements performed. The orthogonal partial least square outcome-predicting biomarker pattern was run against the Ingenuity Pathway Analysis (IPA) database, containing annotated data from the public domain. The orthogonal partial least square analyses identified 32 biomarkers correlated with NYHA class and 28 predicting outcomes. Among outcome-predicting biomarkers, growth/differentiation factor-15 was the strongest and an additional 7 were also significant in Cox regression analyses when adjusted for age, sex, and N-terminal probrain natriuretic peptide: adrenomedullin (hazard ratio per log increase 2.53), agouti-related protein; (1.48), chitinase-3–like protein 1 (1.35), C–C motif chemokine 20 (1.35), fatty acid–binding protein (1.33), tumor necrosis factor receptor 1 (2.29), and TNF-related apoptosis-inducing ligand (0.34). Twenty-three of them correlated with diastolic dysfunction (E/e′) and 5 with left atrial volume index. The IPA suggested that increased inflammation, immune activation with decreased necrosis and apoptosis preceded poor outcome. Conclusions— In HF with preserved ejection fraction, novel biomarkers of inflammation predict HF severity and prognosis that may complement or even outperform traditional markers, such as N-terminal probrain natriuretic peptide. These findings lend support to a hypothesis implicating global systemic inflammation in HF with preserved ejection fraction. Clinical Trial Registration— URL: ; Unique identifier: NCT00774709.
HIT Poster session 2P479Strain concordance in a real-world setting: experience in our laboratory after equipment upgradeP4803D echocardiography is a fast-learning and reliable method for the measurements of left atrial volumesP481Echocardiographic parameters associated with long-term appropriate antiarrhythmic therapies in cardiac resynchronization therapy defibrillator patientsP482Noninvasively measured global wasted myocardial work allows for quantitative assessment of typical left ventricular mechanical dyssynchrony pattern in patients with left bundle branch blockP483The impact of adherence to physical exercise on the improvement of cardiovascular remodeling and metabolic status in healthy untrained postmenopausal womenP484The impact of the latest chamber quantification recommendations on the prediction of left atrial appendage thrombus presenceP485The cardiac-enriched miRNAs plasma levels (miR-1, miR-133a, miR-499) reflect the impaired left ventricular systolic function and correlate with cardiac necrosis markers in early phase of NSTE-ACSP486Acute regional myocardial deformation changes in patients with severe aortic stenosis and preserved ejection fraction after isolated aortic valve replacementP487Left ventricular rotational deformation in asymptomatic patients with chronic aortic regurgitation and normal left ventricular ejection fraction P488The appropriate use of transthoracic echocardiography for the exclusion of infective endocarditisP489In patients with hypertrophic cardiomyopathy, left ventricular mass and shape by three-dimensional echocardiography are related with dynamic obstruction and functional capacityP490Mitral leaflet sizing in hypertrophic cardiomyopathy: impact of method and timingP491Echocardiographic predictors of atrial fibrillation in obese womenP492Echocardiographic risk factors for 30 day mortality after the hybrid procedure for hypoplastic left heart syndromeP493Left ventricular mass is an independent predictor of coronary flow reserve: insights from a single centre stress echo cohortP494Transesophageal echocardigoraphy uner conscious sedation for guiding cryoballoon pulmonary vein isolation in paroxysmal atrial fibrillation - the safety and feasibility studyP495Transesophageal echocardigoraphy under conscious sedation for guiding cryoballoon pulmonary vein isolation in paroxysmal atrial fibrillation - the safety and feasibility studyP496Three-dimensional trans-esophageal echocardiography assessment of the immediate morphological changes of the mitral annulus after percutaneous mitral edge-to-edge repairP497Clinical value of global and regional longitudinal strain in prediction of myocardial ischemia in asymptomatic diabetes type 2 patientsP499Comparison of prognostic operative risk impact on the global longitudinal strain right ventricle (GLS RV) and tricuspid annular plane systolic excursion (TAPSE) values in patients with ischemic cardioP498Right heart function in early diastolic dysfunction: 2D...
Jf. Cueva Recalde, A. Velcea, S. Aguiar Rosa, V. Bucciarelli, V. Reskovic Luksic, R. Verseckaite, N. Jillott, A. Borizanova, S. Caroli, S. Guerreiro, et al.
European Heart Journal - Cardiovascular Imaging, Volume 17; doi:10.1093/ehjci/jew246

Background: Myocardial deformation imaging by speckle tracking (ST) represents one of the latest improvements in echocardiography. Clinical application has been limited by the lack of agreement between different companies. When a laboratory is equipped with new technology, the concordance between vendors should be analyzed. Methods: We performed echocardiographic studies in 36 patients (men: 55,6%, age: 55,8 ± 15,9 years) with several indications (coronary artery disease: 22,2%, heart failure: 16,7%, normal subjects: 36,1%). All images were acquired in the same machine (EPIQ7, Philips®). Afterward we used two software packages to conduct myocardial deformation analysis, first with raw data (QLAB v.10.3, Philips®) and later with images stored in DICOM format (VVI v.2.0, Siemens®), always by the same operator. After checking appropriate identification and tracking of the endocardium, either manual or automatically, values of GLS (global longitudinal strain), LS4C (longitudinal strain in apical 4C), LVEF (left ventricle ejection fraction) and LVEDV (left ventricle end-diastolic volume) were obtained. To assess concordance we used intraclass correlation coefficients (ICC) and Bland-Altman analysis with bias (mean difference) and 95% limits of agreement (LOA).Results: Values of ICC for GLS and LS4C show moderate concordance (Table), meanwhile LVEF and LVEDV have coefficients > 0,90. Bland-Altman plot for GLS (Figure) show a wide range of LOA, which in the understanding of the authors, represents a clinical meaningful difference; particularly in the follow-up of patients (cardiotoxicity, asymptomatic valvular disease, etc), setting in which is often used GLS.Conclusions: Myocardial deformation parameters obtained by ST using different vendors show limited concordance, even when the same operator performs the analysis; whereas echocardiographic data as LVEF and LVEDV has better agreement. All laboratories should be aware of this variation when new equipment is acquired. View this table:Enlarge tableConcordance analysisICC (CI95%)p valueBland-Altman:mean difference (LOA95%)GLS (%)0,63 (0,11-0,86)< 0,05-3,92 (-11,11 a 3,27)LS4C (%)0,74 (0,15-0,91)< 0,05-3,77 (-9,39 a 1,85)LVEF (%)0,90 (0,68-0,96)< 0,053,99 (-7,47 a 15,45)LVEDV (mL)0,94 (0,88-0,97)< 0,05-3,87 (-43,63 a 35,89)ICC: intraclass correlation coefficients, LOA95%: 95% limits of agreement, GLS: global longitudinal strain, LS4C: longitudinal strain in apical 4Ch, LVEF: left ventricle ejection fraction, LVEDV: left ventricle end-diastolic volume.Download figureOpen in new tabDownload powerpoint P479 Figure. Infective endocarditis (IE) is a potentially lethal disease, which is associated with high mortality and severe morbidity. According to the ESC Guidelines transthoracic echocardiography ( TTE ) is the first imaging choice for investigation for IE. The major echocardiographic findings for identifying IE include direct visualization of a vegetation or other hallmarks of the disease such as pseudoaneurysm or abscess formation. Sensitivity for the in native and prosthetic valves is 70% and 50%, respectively for TTE.The modified Duke criteria were proposed as a standardised method of assessing the likelihood of the presence of IE. According to this classification, patients can be categorised in three ways: "definite", "possible", and "rejected". Systematic reviews have shown that TTE is largely over utilised and often provides little additional clinical information.In order to review this hypothesis, 680 patients referred for TTE for possible endocarditis from October 2014 to October 2015 were analysed in a single tertiary referral centre. All patients over 16 years of age that had been referred as an inpatient TTE for endocarditis were included. All patients underwent standard TTE with images and measurements taken according to the British Society of Echocardiography minimum dataset.Statistical analysis was carried out using SPSS version 22, with a p value of < 0.05 considered significant. 91 patients were excluded as they were below the age cut off. In the remaining 589 patients, evidence of IE was seen in 7 (1.18%) patients. The mean age of the population was 60.8 years (range 16 – 98 years), and 54% were male. Univariate analysis was performed. The significant independent predictors for a positive TTE were central venous access, injected drug use and positive blood cultures. Through strict application of the modified Duke criteria, 8 cases (1.3%) were classed as ‘definite’, 14 cases (2.3%) were classed as ’possible’, 567 cases (96.4%) were classed as ‘rejected’.In the current cost-conscious NHS it seems inappropriate to use advanced imaging techniques such as TTE if it adds little additional clinical information in an identifiable patient population. Over 90% of the TTE referrals in our series could have been avoided by the judicious use of appropriate clinical criteria. View this table:Enlarge tableIndependent predictors for IE on TTEClinical criteriaOR (95% CI)p valueCentral venous access7.4 (1.6-33)30 mmHg during Valsalva) and NYHA functional class.Methods. In 75 HCM patients (pts) with preserved LV ejection fraction (EF>50%) and 75 age- and gender-matched controls, LV volumes, LV mass (LVM), sphericity index (SphI) and 3D strain parameters were measured by EchoPac BT13 (GE Vingmed, Horten, N). Pts with more than mild mitral regurgitation were excluded.Results. With respect to controls, HCM pts had smaller LV volumes, larger LVM, LVM/end-diastolic volume and EF, lower 3D strain magnitudes (p83 g/m2 and LVM/EDV>1.8 identified symptomatic patients (AUC=0.66 and 0.65, p30 mmHg during Valsalva) were explored.Results. Both anterior and posterior leaflets were significantly longer in HCM than in controls (total ALL 23±3 vs 19±2 mm; total PLL 20±3 vs 13±2 mm, p<0.001). However, due to the anterior displacement of coaptation in systole, HCM patients had larger closure PLA and smaller closure ALA than controls, even after indexing for MAA (PLA/MAA 0.64±0.12 vs 0.44±0.08; and ALA/MAA 0.53±0.10 vs 0.69±0.09 for HCM vs controls; p<0.0001 for both).By ROC curve analysis, the best ability of discriminating obstructive (n=20) vs nonobstructive HCM pts (n=55) was found for PLA/MAA at MS (AUC=0.88; cutoff of 0.68), better than for ALA/MAA at MS (AUC=0.70; cutoff of 0.48)(p<0.001 for both). Indexation to MAA further improved the ability of leaflet closure areas to separate pts with LVOTO (p<0.01). Total diastolic ALL and PLL by 2DE showed the weakest relationship with LVOTO, even after indexing for LVOT diameter (AUC=0.54-0.58).Conclusions. MV leaflet-to-annulus area ratio measured at MS by transthoracic 3DE showed a significantly stronger relationship with the presence and the severity of LVOTO than total diastolic leaflet lengths measured by 2DE in HCM patients. Quantitative 3DE analysis of MV abnormalities should complement the routine imaging assessment in patients with known or suspected HCM. Background: Obesity and atrial fibrillation (AF) are two major growing epidemics associated with considerable morbidity and mortality. Obesity is a risk factor for AF but there are limited data for structural and functional echocardiographic parameters for predicton of AF occurrence in obese women.Purpose: To identify echocardiographic predictors for AF occurrence in obese women.Methods: Our study enrolled 44 age-matched women with mild obesity ( 30 without AF and 14 with
VIEWING ONLY POSTERS1323Evaluation of right ventricular transverse strain and strain rate in patients with acute ST-segment elevation myocardial infarction: a cardiac magnetic resonance feature tracking study1333Cardiac resynchronization in ischemic heart failure patients: a comparison between therapy guided by cardiac magnetic resonance imaging and 2D-speckle tracking echocardiography1338Cardiac magnetic resonance versus bisphosphonate scintigraphy for diagnosis of cardiac amyloidosis1341Strain relaxation index, a novel tagged MRI-derived diastolic function parameter, is impaired in metabolic syndrome1349Global Longitudinal Strain Predicts Chronic Myocardial Infarction in Patients with Normal Ejection Fraction1352Optimal Dose Of Dobutamine During Low-Dose Dobutamine Stress Echocardiography In Correctly Identify Viable Segments On Cardiovascular Magnetic Resonance1368Absolute wall thickening and left ventricular ejection fraction–a unifying theory of myocardial contraction and heart failure?1376Transient St Elevation in Acs Like Myocarditis1379Patients after Fontan with a “total cavopulmonary connection” Fontan modification develop more collateral flow compared to “old-fashioned” Fontan modifications1387A MRI–derived 3D patient specific model for fibrosis quantification in atrial fibrillation1391Scar burden and survival in patients with ischemic cardiomyopathy and poor LV ejection fraction1392Relation of inflammatory markers with myocardial and microvascular injury in patients with reperfused ST- elevation myocardial infarction1406Equivalence of segmented conventional and fast single-shot late gadolinium enhancement (LGE) techniques for1410Cardiac Mri Appearances of Tuberculosis - A Review of Varied Presentations in India1415Atheroma burden, cardiac remodelling and epicardial fat: A comparison between healthy South Asian and European adults using Whole Body Cardiovascular MR1418Symptomatic Ventricular Arrhythmias: Diagnostic Yield of Cardiac Magnetic Resonance1421CMR assessment of aortic stiffness in asymptomatic low risk patients with type 2 diabetes mellitus1436Shock index as a predictor of myocardial damage and clinical outcome in ST-elevation myocardial infarction1451Combined biomarker testing for the prediction of microvascular obstruction after primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction1452A novel oscillometric technique compared with cardiac magnetic resonance for the assessment of aortic pulse wave velocity in ST-segment elevation myocardial infarction1456Aorto-pulmonary collaterals evaluated by CMR is associated to reduced “effective” cardiac index late after Fontan palliation1458Evaluation of pulmonary transit time and Pulmonary Blood Volume with first-pass perfusion CMR imaging in adult with repaired Congenital Heart disease1459Prognostic value of the cardiac magnetic resonance as a predictor of improvement in ventricular function after TakoTsubo syndrome1462Diagnostic performance of ECG detection of left atrial enlargement in patients with arterial hypertension relative to the cardiac magnetic resonance gold-standard: impact of obesity1463Utility of cardiac magnetic resonance imaging for diagnosis of cardiac sarcoidosis and prediction of therapeutic effects in patients with complete heart block and implanted magnetic resonance-conditional pacemaker: A multicenter study1467Cardiac magnetic resonance late gadolinium enhancement in patients with genetic dilated cardiomyopathy14712.Left ventricular hypertrophy in hypertensive patients–comparison of Cardiac Magnetic Resonance and Echocardiographic analysis of morphological and functional LV-parameters1472Is Angiographic Perfusion Score assessed in patients with acute myocardial infarction correlated with Cardiac Magnetic Resonance infarct size and N-terminal pro-brain natriuretic peptide in 6-month follow-up1476Cardiac Magnetic Resonance Patterns of Left Ventricular Diastolic Function In Hypertrophic Cardiomyopathy1477Impact of platelet volume on thrombus burden and tissue reperfusion in patients with STEMI treated with primary angioplasty: MRI study1479Right ventricle systolic function assessment and its prognostic implications in cardiac amyloidosis1484Cardiac MRI - an important tool in the evaluation of multsystemic inflamatory diseases. An Erdheim-Chester Disease case report1485Predictive value of cardiac magnetic resonance for future adverse cardiac events in patients with ST-segment elevation myocardial infarction1486Time-to-treatment but not thrombectomy influence infarct size and microvascular obstruction in patients with acute ST-segment elevation myocardial infarction treated with primary coronary intervention1489Primary PCI versus Early Routine Post Fibrinolysis PCI for ST Elevation Myocardial Infarction1490Evaluation of ventricular function in Fontan patients undergoing feature tracking magnetic resonance strain1491Impacts of atrialized right ventricle and left ventricular displacement in Ebstein's anomaly on left ventricular function assessed by cardiovascular MRI1494Final diagnosis for patients presenting with chest pain, electrocardiographic changes or troponin rise and normal coronary arteries: insights from Cardiovascular MRI in our population1495Early Predictive Factors of LV Remodeling after STEMI; Assessment by Coronary Angiogram and Cadiovascular Magnetic Resonance1497The Pathobiologic Mechanisms and the Prognostic Meaning of t wave Inversion in Acute Myocarditis. a Study Performed by Cardiac Magnetic Resonance1501The Influence of Left Atrial Function on Exercise Tolerance in Patients with Heart Failure and Preserved Ejection Fraction: A Cardiac Magnetic Resonance Feature Tracking Study1504Microvascular Obstruction in Patients with Anterior ST-Elevation Myocardial Infarction who Underwent Primary Percutaneous Coronary Intervention: Predictors and Impact on the Left Ventricular Function1508Histological Validation of ECV Quantification by Cardiac Magnetic Resonance T1 Mapping in Cardiac Amyloidosis1513Comparative Evaluation of Flow Quantification Across the Atrioventricular Valve in Patients with Functional Univentricular Heart After Fontan's Surgery and Healthy Controls: Measurement by 4D Flow Magnetic Resonance Imaging and Streamline Visualization1515Does arterial switch for d-transposition of the great arteries alter myocardial deformation of the ventricles?1527Accuracy of T1 Mapping by multi-professional CMR operators to predict myocardial infarct1531Detecting hypertensive heart disease: the additive value of cardiovascular magnetic resonance imaging1534Diagnostic Performance of Cardiac Magnetic Resonance Strain Parameters in Assesment of Myocardial Ischemia1535Relationships between left ventricular filling pressures and longitudinal dysfunction with myocardial fibrosis in uncomplicated hypertensive patients1539Predictive Clinical Factors of Tissue Damage Severity in Reperfused Acute Myocardial Infarction as Visualized by Cardiac Magnetic Resonance1541Which CMR derived parameter predicts better the need of invasive treatment in aortic coarctation?1543Contrast-enhanced magnetic resonance tomography in patients with supraventricular tachyarrhythmias1546Prognostic Value of CMR Imaging Biomarkers on Outcome in Peripheral Arterial Disease: a 6-year Follow-up Pilot Study1549Dobutamine-Stress-CMR in Young Adults after Arterial Switch Operation as Neonates1553Impact of posteromedial papillary muscle infarction on mitral regurgitation after ST-segment elevation myocardial infarction1556Role of cardiac magnetic resonance imaging in assessment of left ventricular hypertrophy1569Using intrinsic Cardiac Shear Waves to measure Myocardial Stiffness: Preliminary results from Patients with Heart failure with preserved Ejection Fraction1571Relationship of cerebrovascular reactivity and MRI pattern of carotid atherosclerotic plaque1577Feasibility study of an MR conditional pedal ergometer for cardiac stress MRI–preliminary results in healthy volunteers and patients with suspected coronary artery disease1581Pulmonary valve replacement for severe pulmonary stenosis has a positive effect on left ventricular remodeling1582The RV after cardiac surgery, more resilient than thought: multiparametric quantification shows altered rather than reduced function1584Usefulness of cardiovascular magnetic resonance to differentate coronary artery disease from non ischemic cardiomyoptathy in patients with heart failure1593What does CMR add to the ESC Risk Prediction Model to Assess the Occurrence of Sudden Cardiac Death in Patients with HCM?1597Detecting Progression of Diffuse Interstitial Fibrosis in Alstrom Syndrome1612Diffuse fibrosis in the ventricles of patients with transposition of great arteries late after atrial switch1631Utility of Cardiac Magnetic Resonance in the diagnosis and stratification of arrhythmic risk in patients with confirmed or suspected ventricular arrhythmias1635Size matters: pulmonary veins geometry by cardiac magnetic resonance imaging in atrial fibrillation patients1642How do the differences in Left Ventricular wall measurements from Echocardiography and CMR in patients with Hypertrophic Cardiomyopathy affect current Sudden Cardiac Death Risk Scores?1651Noninvasive assessment of intracardiac viscous energy loss in Fontan patients from 4D Flow CMR1653Behcet and Myocardial Infarction: A Rare Combination1328Impact of New Cerebral Ischemic Lesions On the Occurrence of Delirium after Transcatheter Aortic Valve Implantation1329Heart T2* assessment to measure iron overload using different software tools in patients with Thalassemia Major1332Hypertrabeculated Left Ventricle at Cardiac Magnetic Resonance Imaging: β-Thalassemia Major vs. Left Ventricular Non -Compaction Disease1335Aortic Regurgitation following Transcatheter Aortic Valve Implantation (TAVI): a CMR Study of two prosthesis designs1336Incremental value of semi-quantitative evaluation of myocardium perfusion with 3T stress cardiac MRI1343Left ventricular morphological quantification with single shot and free-breathing SSFP cine imaging compared with standard breath-hold SSFP cine imaging1344Changes of cardiac iron and function during pregnancy in transfusion-dependent thalassemia patients1346Significant improvement of survival by T2* MRI in thalassemia major1350The impact of trans-catheter aortic valve implantation induced left-bundle branch block on cardiac reverse remodelling1351Value of magnetic resonance myocardial perfusion imaging in patients with indeterminate coronary computed tomography angiography results1353Gender differences in response to Transcatheter Aortic Valve implantation in patients with severe aortic stenosis assessed by feature tracking1354A qualitative assessment of first-pass perfusion bolus timings in the assessment of myocardial ischemia: A magnetic resonance study1355MRI prospective survey on cardiac iron and function and on hepatic iron in non transfusion-dependent thalassemia intermedia patients treated with desferrioxamine or non chelated1358Coronary Calcification Compromises Myocardial Perfusion Irrespective of Luminal Stenosis1359Non–contrast three–dimensional magnetic resonance imaging for pre–procedural assessment of aortic annulus dimensions in patients undergoing transcatheter aortic valve implantation1360“Systolic ventricularization” of the left atrium with bileaflet mitral valve prolapse: impact on quantification of mitral regurgitation1361CMR assessment of left ventricular remodeling 6 months after percutaneous edge-to-edge repair using Mitraclip1363Accuracy of Transthoracic Echocardiography (TTE) in comparison with Cardiac Magnetic Resonance (CMR)1374CMR for myocardial iron overload assessment: a new calibration curve from the MIOT project1381Can Speckle Tracking Imaging Reveal Myocardial Iron Overload in Thalassemia Major? A Combined Echocardiography and Cardiac Magnetic Resonance Study1382Native myocardial T1 mapping in patients with pulmonary hypertension and age matched volunteers1384A Insidious Line Between Thalassemia Intermedia And Left Ventricular Non-Compaction Disease: The Role Of Cardiac Magnetic Resonance1388Pulmonary Artery : Ascending Aorta Diameter - An Important and Easily Measureable Prognostic Parameter1394Novel carotid artery ultrasound index–Extra-media thickness and a well-established cardiac magnetic resonance fat quantification method1403Validation of CMR-derived LVOT diameters against direct in-vivo measurements1409Early myocardial perfusion measured by CMR in acute myocardial infarction treated by primary PCI–a postconditioning study1420Assessment of paravalvular aortic regurgitation after transcatheter aortic valve implantation using cardiac magnetic resonance imaging: a comparative study with echocardiography and angiography1422Left atrial strain measured by feature tracking predicts left ventricular end diastolic filling pressure1426Validation of extracellular volume equation by serial cardiac magnetic resonance imaging measurements in patients with varying hematocrit1427Assessing diastolic function applying Cardiovascular Magnetic Resonance - comparison with the gold standard1475Role of Adenosine Stress Cardiac Mri in the Setting of Chronic Total Occlusion of Coronary Arteries1520Aortic Elasticity Indexes by Magnetic Resonance Predict Progression of Ascending Aorta Dilation1522Combined atrioventricular assessment of diastolic function by cardiac magnetic resonance1537Safety, image quality and clinical utility of cardiac magnetic resonance in patients with antiarrhythmic devices1538Usefulness of cardiac magnetic resonance to predict the need for surgical procedures in patients with mitral regurgitation1550Normal T1, T2, T2* and extracellular volume reference values in healthy volunteers at 3 Tesla cardiac magnetic resonance1551Comprehensive intra-ventricular myocardial deformation strain analysis in healthy volunteers: implications for regional myocardial disease processes1557Elastic properties changes of aorta in patients with dilatation of the ascending aorta evaluated by Magnetic Resonance1558The prevalence of active myocarditis assessed by cardiovascular magnetic resonance in patients with clinically suspected myocarditis1563Quantitative assessment of myocardial scar heterogeneity using texture analysis to risk stratify post–MI patients for ICD insertion1564Gender differences in exercise capacity and LV remodeling in response to pressure overload in aortic stenosis1572Myocardial wall stress as a novel CMR measure to assess cardiac function1573Feature tracking cardiac magnetic resonance to assess LV mechanics in pressure and volume overload1574Safety, feasibility and clinical impact of Cardiovascular Magnetic Resonance in patients with MR-conditional devices1576T1 Mapping at 1-Year Following Aortic Valve Replacement: Baseline Geometry Defines Magnitude of Fibrosis Regression1583Normal values of LV global myocardial mechanics using two and three-dimensional cardiovascular magnetic resonance1585Prediction of infarct transmurality in acute myocardial infarction based on cardiac magnetic resonance deformation analysis1595Measuring invasive blood pressure by catheters guided solely by Cardiovascular Magnetic Resonance by using a new guidewire without the need of a hybrid CMR-fluoroscopy suite1599Influence of active and passive cardiac implants on CMR image quality: results from a consecutive patient series1600Reproducibility of aortic 4D flow measurements in healthy volunteers1601An automatic approach to extract 4D flow hemodynamic markers: application in BAV-affected patients1602Global myocardial mechanics with 2 and 3-Dimensional cardiovascular magnetic resonance feature tracking in patients with myocarditis1603A CMR-based clinician-friendly assessment of in vivo left ventricle hemodynamics1604Reproducibility of left atrial strain using cardiovascular magnetic resonance myocardial feature tracking1605The severity of myocardial infarction in STEMI, determined by transmurality of infarct and infarct characteristics, impacts on myocardial T2 values1606MicroRNA as potential biomarkers of acute myocardial damage following STEMI1607Myocardial blush grade is associated with microvascular obstruction on CMR following STEMI16084D Flow CMR imaging: Comparison of conventional parallel imaging and variable density k-t acceleration1609In-vitro comparison of segmented-gradient-echo versus non-segmented echo planar imaging 4D Flow CMR: validation of flow volume and 3D vortex ring assessment1614Not just 2D but also 4D flow measurements in pulsatile phantom are accurate and reproducible1615Diffusion Tensor Imaging: Comparison of Hypertrophic Cardiomyopathy, Hypertension and Healthy Cohorts1624Impact of myocardial fibrosis measured by cardiac magnetic resonance imaging on reverse left ventricular remodelling after transcatheter aortic valve implantation1625Prosthetic valve regurgitation after transcatheter aortic valve implantation with new-generation devices compared to surgical aortic valve replacement–a cardiac magnetic resonance imaging flow measurement analysis1637Assessment of Aortic and Pulmonary Artery stiffness in Patients with COPD using Cardiac Magnetic Resonance1638Myocardial Mechanics implications using 2D Cardiovascular Magnetic Resonance in Aortic Regurgitation1639Delineation of myocardial infarction & viability by 12 lead ECG vs cardiac magnetic resonance1641Regional variation in native T1 values in normal healthy volunteers?1645Feasibility of myocardial strain assessment using tissue tracking at 3.0T CMR following ST-segment elevation myocardial infarction1648Diagnostic Impact of Cardiac Magnetic Resonance in patients with acute chest pain, troponin elevation and no significant angiographic coronary artery disease
Tomas Lapinskas, Chiodi Elisabetta, Chrysanthos Grigoratos, Ricardo Ladeiras-Lopes, Gj. Fent, E. Abdul Rahman, Jonathan Rodrigues, Giuseppe Gibelli, Naira Mkrtchyan, Maddalena Valinoti, et al.
European Heart Journal - Cardiovascular Imaging, Volume 17; doi:10.1093/ehjci/jew183

Background: Impaired right ventricular (RV) systolic function after acute ST-segment elevation myocardial infarction (STEMI) is associated with poor clinical outcomes. CMR feature tracking technique enables quantification of myocardial deformation and becomes promising method. The aim of this study was to evaluate longitudinal and transverse strain and strain rate of RV free wall in patients with acute isolated left ventricular STEMI using CMR feature tracking.
Poster session 5The imaging examinationP1097Correlation between visual and quantitative assessment of left ventricle: intra- and inter-observer agreementP1099Incremental prognostic value of late gadolinium-enhanced by cardiac magnetic resonance in patients with heart failureAnatomy and physiology of the heart and great vesselsP1100Left ventricular geometry and diastolic performance in erectile dysfunction patients; a topic of differential arterial stiffness influenceAssessment of diameters, volumes and massP1101Impact of the percutaneous closure of atrial septal defect on the right heart "remodeling"P1102Left Ventricular Mass Indexation in Infants, Children and Adolescents: a Simplified Approach for the Identification of Left Ventricular Hypertrophy in Clinical PracticeP1103Impact of trabecules while quantifying cardiac magnetic resonance exams in patients with systemic right ventricleP1104Detection of subclinical atherosclerosis by carotid intima-media thickness: correlation with leukocytes telomere shorteningAssessments of haemodynamicsP1105Flow redirection towards the left ventricular outflow tract: vortex formation is not affected by variations in atrio-ventricular delayAssessment of systolic functionP1106Reproducibility and feasibility of cardiac MRI feature tracking in Fabry diseaseP1107Normal left ventricular strain values by two-dimensional strain echocardiography; result of normal (normal echocardiographic dimensions and functions in korean people) studyP1108Test-retest repeatability of global strain following st-elevation myocardial infarction - a comparison of tagging and feature trackingP1109Cardiotoxicity induced by tyrosine kinase inhibitors in patients with gastrointestinal stromal tumors (GIST)P1110Finite strain ellipses for the analysis of left ventricular principal strain directions using 3d speckle tracking echocardiographyP1111Antihypertensive therapy reduces time to peak longitudinal strainP1112Right ventricular systolic function as a marker of prognosis after inferior myocardial infarction - 5-year follow-upP1113Is artery pulmonary dilatation related with right but also early left ventricle dysfunction in pulmonary artery hypertension?P1114Right ventricular mechanics changes according to pressure overload increasing, a 2D-speckle tracking echocardiographic evaluationAssessment of diastolic functionP1115Paired comparison of left atrial strain from P-wave to P-wave and R-wave to R-waveP1116Diagnostic role of Tissue Doppler Imaging echocardiographic criteria in obese heart failure with preserved ejection fraction patientsP1117Evaluation of diastolic function of right ventricle in idiopathic pulmonary arterial hypertensionP1118Severity and predictors of diastolic dysfunction in a non-hypertensive non-ischemic cohort of Egyptian patients with documented systemic autoimmune disease; pilot reportP1119correlation between ST segment shift and cardiac diastolic function in patients with acute myocardial infarctionIschemic heart...
S Colunga Blanco, C Gonzalez Matos, A Angelis, P G Dinis, M Chinali, A Toth, M G Andreassi, D Rodriguez Munoz, A B Reid, Jh Park, et al.
European Heart Journal - Cardiovascular Imaging, Volume 16; doi:10.1093/ehjci/jev275

Background: Handheld ultrasound devices allow for a bedside screening although quantitative parameters are not easily obtained. We aim to assess the reliability of visual qualitative evaluation of left ventricle (LV) compared with standard quantitative evaluation with 2D transthoracic echocardiography (TTE).
Helle Gervig Carstensen, Linnea Hornbech Larsen, , , Morten Dalsgaard, Charlotte Burup Kristensen, Jan Skov Jensen, Rasmus Mogelvang
Journal of the American Society of Echocardiography, Volume 28, pp 969-980; doi:10.1016/j.echo.2015.03.013

Assessment of myocardial longitudinal function has proved to be a sensitive marker of deteriorating myocardial function in aortic stenosis, demonstrated by both color Doppler tissue imaging and recently by two-dimensional speckle-tracking echocardiography. The aim of this study was to compare velocity (color Doppler tissue imaging) and deformation (two-dimensional speckle-tracking echocardiography) in relation to global and regional longitudinal function in asymptomatic and severe symptomatic aortic stenosis. In a cross-sectional design, 231 patients with aortic stenosis were divided into four groups: asymptomatic moderate aortic stenosis (aortic valve area, 1.0-1.5 cm(2); n = 38), asymptomatic severe aortic stenosis (aortic valve area < 1.0 cm(2); n = 66), and symptomatic severe aortic stenosis with preserved (n = 68) and reduced (<50%) left ventricular ejection fraction (n = 59). Among all global (peak systolic s', diastolic e' and a', longitudinal displacement, and global longitudinal strain and strain rate) and regional longitudinal (basal, middle, and apical longitudinal strain and strain rate) parameters, only diastolic e', longitudinal displacement, and basal longitudinal strain (BLS) remained significantly associated with symptomatic status, independent of age, gender, heart rate, aortic valve area, stroke volume index, left ventricular mass index, left atrial volume index, and tricuspid annular systolic plane excursion. Furthermore, in a model with the aforementioned parameters, including e', longitudinal displacement, and BLS, only BLS remained significantly associated with symptomatic status in the entire study population (BLS per one-unit decrease: odds ratio, 1.23; 95% CI, 1.04-1.46; P = .017). Furthermore, patients with BLS < 13% were more likely to be symptomatic (odds ratio, 4.97; 95% CI, 2.6-9.4; P < .001), and no patients with asymptomatic severe aortic stenosis with BLS ≥ 13% were admitted with myocardial infarction or heart failure during follow-up of 1,462 days. Among the many echocardiographic measures of longitudinal velocity and deformation, BLS has the strongest association with symptomatic status in aortic stenosis, and BLS < 13% is related to adverse outcomes in severe asymptomatic aortic stenosis.
Junichi Imanishi, , Takuma Sawa, , Tatsuya Miyoshi, , Yuko Fukuda, Kazuhiro Tatsumi, , , et al.
Published: 18 September 2014
Echocardiography, Volume 32, pp 758-767; doi:10.1111/echo.12733

Identification of heart failure (HF) symptoms in patients with severe aortic stenosis (AS) and preserved left ventricular (LV) ejection fraction (EF) is clinically important, but assessment of HF symptoms is challenging. It was recently reported that resting left atrium (LA) functions are related to exercise performance and are also important prognostic markers for patients with HF. The aim of this study was to assess the association of the HF symptoms with LA function in patients with severe AS and preserved LVEF.
Angela B. S. Santos, Elisabeth Kraigher-Krainer, Deepak K. Gupta, Brian Claggett, , Burkert Pieske, Adriaan A. Voors, Marty Lefkowitz, Toni Bransford, Victor Shi, et al.
European Journal of Heart Failure, Volume 16, pp 1096-103; doi:10.1002/ejhf.147

Left atrial (LA) enlargement is present in the majority of heart failure with preserved ejection fraction (HFpEF) patients and is a marker of risk. However, the importance of LA function in HFpEF is less well understood. The PARAMOUNT trial enrolled HFpEF patients (LVEF ≥45%, NT-proBNP >400 pg/mL). We assessed LA reservoir, conduit, and pump function using two-dimensional volume indices and speckle tracking echocardiography in 135 HFpEF patients in sinus rhythm at the time of echocardiography and 40 healthy controls of similar age and gender. Systolic LA strain was related to clinical characteristics and measures of cardiac structure and function. Compared with controls, HFpEF patients had worse LA reservoir, conduit, and pump function. The differences in systolic LA strain (controls 39.2 ± 6.6% vs. HFpEF 24.6 ± 7.3%) between groups remained significant after adjustments and even in the subsets of HFpEF patients with normal LA size or without a history of AF. Among HFpEF patients, lower systolic LA strain was associated with higher prevalence of prior HF hospitalization and history of AF, as well as worse LV systolic function, and higher LV mass and LA volume. However, NT-proBNP and E/E' were similar across the quartiles of LA function. In this HFpEF cohort, we observed impairment in all phases of LA function, and systolic LA strain was decreased independent of LA size or history of AF. LA dysfunction may be a marker of severity and play a pathophysiological role in HFpEF. NCT00887588.
Yau-Huei Lai, Chuan-Chuan Liu, Jen-Yuan Kuo, Ta-Chuan Hung, Yih-Jer Wu, Hung-I Yeh, Bernard E. Bulwer, Chung-Lieh Hung
Published: 7 January 2014
Clinical Cardiology, Volume 37, pp 172-177; doi:10.1002/clc.22242

The effect of body fat distribution on left ventricular (LV) mass and geometry has been recently recognized. However, data regarding circulating inflammatory markers in relation to regional visceral fat deposits, which are metabolically active tissues that can impact cardiac structural remodeling, remain sparse. We hypothesized that obesity has adverse effects on cardiac function and structure. We consecutively studied 1071 asymptomatic subjects (age 49.5 ± 10.5 years, 39.4% female) free from significant valvular disorders, chronic lung disease, or renal disease. Echocardiography‐defined cardiac structures and LV geometries including LV mass, mass‐to‐volume ratio, and fractional shortening were all determined. Body fat composition (Tanita‐305 Body‐Fat Analyzer; Tanita Corp., Tokyo, Japan) was obtained and calculated. Multivariate regression models from various models were used to represent the independent association between body fat and echo‐derived ventricular mass and geometries. In multivariable analysis, increasing body fat was significantly related to increase in left atrial (LA) and LV diameter, posterior wall thickness, relative wall thickness (RWT), LV mass, mass‐to‐volume ratio, and decreased midwall fractional shortening with or without stress correction (all P < 0.001). When LV mass and severity of mitral regurgitation was further added, the independent association between increased body fat composition and larger LA diameter remained significant (β coefficient = 0.37, P < 0.001). Elevated high‐sensitivity C‐reactive protein (Hs‐CRP) level was associated with larger LA diameter, increased RWT, and worsened midwall mechanics in the female gender (all interaction P < 0.05). Accumulated body fat seemed to be related to worse ventricular midwall contractility and atrial remodeling, particularly in the female gender, with high systemic inflammation. These gender and Hs‐CRP–specific modification effects may potentiate the pathological mechanisms involved in heart failure with preserved ejection fraction.
The American Journal of Cardiology, Volume 111, pp 996-1001; doi:10.1016/j.amjcard.2012.12.005

Excessive atrial fibrosis is involved in the pathogenesis of atrial fibrillation (AF), but little is known of left ventricular (LV) fibrotic status in patients with AF. In the present study, we investigated the presence of abnormal LV fibrosis in AF, its effect on cardiac function, a possible association with arterial stiffness (i.e., systemic cardiovascular fibrosis), and the parameters of endothelial activation, dysfunction, and damage. We also studied whether LV fibrosis could be linked to the future risk of AF onset. In a cross-sectional study, the severity of LV fibrosis was assessed by echocardiographic acoustic densitometry in patients with permanent AF (n = 49), patients with paroxysmal AF (n = 44), AF-free “disease controls” (n = 42) and “healthy controls” (n = 48). Arterial stiffness (pulse wave velocity), plasma markers of endothelial activation (E-selectin), endothelial damage/dysfunction (von Willebrand factors), and microvascular endothelial function (laser Doppler flowmetry) were quantified. In a longitudinal study, 93 patients with pacemakers (22 with AF) were followed up for ≥1 year to assess the predictive value of LV fibrosis for the development of new-onset AF. More severe LV fibrosis was present in both paroxysmal and permanent AF than in the AF-free controls (p <0.001), with more LV fibrosis in permanent than in paroxysmal AF (p = 0.002). The severity of LV fibrosis in AF wais independently associated with diastolic dysfunction (p = 0.03), but not with LV contractility, arterial stiffness, or endothelial damage/dysfunction. In conclusion, LV fibrosis might contribute to LV diastolic dysfunction and the high prevalence of heart failure with preserved ejection fraction in subjects with AF.
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