Elie Dan Schouver

Cardiac biomarkers in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) has recently been identified [1,2].TTC prevalence is up to 7% of all suspected acute coronary syndromes(ACS) in women, and 1% when both sexes are considered [3,4]. Re-hospitalizations are frequent and TTC mortality rate is higher than inthe general population [5]. Early phases of TTC mimic ACS anddistinguishing one from the other could betricky [6]. Cardiac biomarkersusewouldthereforebeinteresting.However,onlyfewbiologicaldataareavailable [7,8].WeaimedtoanalyzeB-typenatriureticpeptide(BNP)andtroponin I (TnI) in TTC patients.We conducted a multicentric prospective study between May 2009and October 2012. We recruited consecutive patients hospitalized forTTC and anterior ACS (age and gender matched) in 3 centers. ACS wasdiagnosed and treated in accordance with the European Society ofCardiology and American College of Cardiology Foundation/AmericanHeart Association criteria [9–11]. TTC was diagnosed using the MayoClinic criteria [6,12]. We conducted this study in compliance with theethical principles of the Declaration of Helsinki. Approval by the localethicscommittee wasobtained. Each patientgavehis written informedconsent.BNPlevelsweremeasuredonadmission.TnIdosagewasrealizedonadmission, then every 6 h for 24 h. Three patterns of TnI kinetic wereidentified: 1) peak (when TnI reaches a maximum before decreasing),2) decreasing (when TnI decreases continuously after the first assay)and 3) plateau (in the absence of clear peak). BNP/TnI ratio was calcu-lated using the TnI peak value. TnI measurements were performedwith the Beckman Access method, with a lowest detection limit of0.01ng/mlandapositivitythresholdof0.06ng/ml.BNPmeasurementswereperformedusinganimmunoassayBeckmanTriagemethod,withapositivity threshold of 100 pg/L. Glomerular filtration rate was evaluated(Modification of Diet in Renal Disease formula). Patients with severerenal failure were excluded ( b30 ml/mn).Ahighriskofbleedingwasde finedwithatleastoneofthefollowingcriteria: symptomatic bleeding, organic lesions likely to bleed,hemostatic abnormalities (platelet count b100,000/mm3, aPTT ratioN2,prothrombin time b40%),or thepresence of severe anemia (hemo-globin b8 g/dl) due to bleeding or unexplained.In this study, 62 TTC and 90 ACS patients (47 anterior ST-segmentelevation myocardial infarctions (STEMI) and 43 anterior non-ST-segment elevation myocardial infarctions (NSTEMI)) were recruitedover a 41-month period. The main features of our population are

Ischaemic Colitis Associated with Adrenergic Acute Cardiomyopathy: A discovery mode of pheochromocytoma

Pheochromocytoma is usually diagnosed in patients with resistant high blood pressure or the classical triad of symptoms including palpitations, sweats and headache. To our knowledge, we describe here the first case of concomitant bifocal complications of pheochromocytoma with a concomitant ischaemic colitis and Takotsubo-like cardiomyopathy. A 65-year-old man with a history of thyroid surgery 20 years ago, dyslipidaemia and smoking was admitted for syncope. Troponine Ic level rose to 3.72 ng/ mL and transthoracic echocardiography revealed severe left ventricular (LV) systolic dysfunction with large akinesia involving midventricular segments. Coronary angiogram was normal and cardiac magnetic resonance (CMR) confirmed the decreased LV ejection fraction (20%) with no evidence of late-gadolinium enhancement (Figure 1), compatible with a median form of Takotsubo. Surprisingly, on the second day of hospitalisation, he presented diarrhoea, abdominal pain and fever (40 8C). An abdominal CT scan suspected sigmoid colitis and revealed a voluminous left adrenal mass. Rectosigmoidoscopy confirmed sigmoid bleeding colitis and all bacteriologic samples remained sterile. Evolution was marked with resolution of digestive symptoms in four days with fasting and symptomatic treatment and recovery of LV systolic function in five days. Given this adrenal mass, pheochromocytoma screening was undertaken and plasmatic catecholamine and chromogranine A showed abnormally high levels. Once adequate aand b-adrenergic receptor blockages were obtained, the patient underwent resection of this left adrenal mass (30 day). Anatomical pathology (histology and immunology) confirmed the suspected diagnosis of pheochromocytoma.

Quantitative assessment of primary mitral regurgitation using left ventricular volumes obtained with new automated three-dimensional transthoracic echocardiographic software: A comparison with 3-Tesla cardiac magnetic resonance

BACKGROUND Quantitative assessment of primary mitral regurgitation (MR) using left ventricular (LV) volumes obtained with three-dimensional transthoracic echocardiography (3D TTE) recently showed encouraging results. Nevertheless, 3D TTE is not incorporated into everyday practice, as current LV chamber quantification software products are time consuming. AIMS To investigate the accuracy and reproducibility of new automated fast 3D TTE software (HeartModelA.I.; Philips Healthcare, Andover, MA, USA) for the quantification of LV volumes and MR severity in patients with isolated degenerative primary MR; and to compare regurgitant volume (RV) obtained with 3D TTE with a cardiac magnetic resonance (CMR) reference. METHODS Fifty-three patients (37 men; mean age 64±12 years) with at least mild primary isolated MR, and having comprehensive 3D TTE and CMR studies within 24h, were eligible for inclusion. MR RV was calculated using the proximal isovelocity surface area (PISA) method and the volumetric method (total LV stroke volume minus aortic stroke volume) with either CMR or 3D TTE. RESULTS Inter- and intraobserver reproducibility of 3D TTE was excellent (coefficient of variation≤10%) for LV volumes. MR RV was similar using CMR and 3D TTE (57±23mL vs 56±28mL; P=0.22), but was significantly higher using the PISA method (69±30mL; P<0.05 compared with CMR and 3D TTE). The PISA method consistently overestimated MR RV compared with CMR (bias 12±21mL), while no significant bias was found between 3D TTE and CMR (bias 2±14mL). Concordance between echocardiography and CMR was higher using 3D TTE MR grading (intraclass correlation coefficient [ICC]=0.89) than with PISA MR grading (ICC=0.78). Complete agreement with CMR grading was more frequent with 3D TTE than with the PISA method (76% vs 63%). CONCLUSION 3D TTE RV assessment using the new generation of automated software correlates well with CMR in patients with isolated degenerative primary MR.

DIURETICS VERSUS FLUID LOADING IN ACUTE SUBMASSIVE PULMONARY EMBOLISM

Background: The benefit of volume expansion (VE) in submassive pulmonary embolism (PE) with right ventricular dysfunction (RVD) is unclear. We sought to compare the effects of a diuretic treatment versus fluid expansion in patients hospitalized for PE with RVD. Methods: We prospectively included 46

Three-Dimensional speckle tracking of the right ventricle: implications on survival

Background: Survival in pulmonary hypertension (PH) relates to right ventricular (RV) function. However, the singular anatomy and structure of the right ventricle (RV) limit 2D analysis, and its regional 3D function has not been studied yet. Purpose: We examined the implications of regional 3D RV deformation on clinical condition and survival in adults with PH and healthy. Methods: We performed a prospective longitudinal cohort study recruiting 104 consecutive adult PH patients (58 female, 63±18 years)) and 34 healthy controls (43±14 years) between September 2014 and December 2015. Sixty-four patients (63.4%) were in NYHA functional class ≥III at baseline and 87 (83.7%) were on PH-targeted advanced therapies. 3D transthoracic RV echocardiographic sequences were acquired. Myocardial tracking was performed by a semi-automatic software. Output RV meshes included spatial correspondences. They were post-processed to extract local motion and deformation (area strain) and align the data temporally. Global and local statistics provided representative shape and deformation patterns for each subgroup of subjects. Results: The highest deformation was found in the RV lateral and inferior regions. In PH patients, RV global and regional motion as well as deformation (both area strain, circumferential and longitudinal strain) and global volume patterns were affected in all segments, as compared to healthy controls (p -18% was the most powerful RV function parameter, identifying patients with a 48%-increased risk of death (AUC 0.83 [0.74-0.90], p<0.001). Conclusion: RV shape and strain patterns are gradually deteriorated in PH patients and provide independent prognostic information in this population. Global RV area strain >-18% identifies high-risk PH patients.

0358: Diuretic treatment versus fluid expansion in acute normotensive pulmonary embolism

Background In submassive pulmonary embolism (PE), when a right ventricular (RV) dysfunction (RVD) is present, the benefit of fluid expansion (FE) is questionable. The Franck-Starling law suggests that the reduction of the RV overload may enhances the RV systolic function. Purpose The aim of our study was to compare the effects of a diuretic treatment (DT) versus FE in patients hospitalized for normotensive PE with RVD. Methods We performed a prospective study. Consecutive patients hospitalized for normotensive PE were treated with diuretic (40mg IV furosemide at admission) or FE (500cc of sodium chloride infusion during four hours at admission). The primary endpoint was the timing for normalization of BNP and troponin Ic values. The secondary endpoints were variations of clinical and RV echographic parameters. Results Forty five patients were included. Timing for Troponin and BNP normalization was 60,7±28 hours in the DT versus 93,2±42 hours in the FE group (figure 1, p=0.02). Normalization of RV dilatation took 91,7±14,2 hours in the DT group versus 108,4±17,5 hours in the FE group (p=0.01). Normalization of the RVD took 81,2±18 hours in the DT group versus 94,9±13,1 hours in the FE group (p=0.03). Conclusion In the early management of normotensive PE with RVD, DT may be superior to FE in order to improve the time to normalization of biological and echocardiographic markers. Download : Download high-res image (49KB) Download : Download full-size image Abstract 0358 – Figure 1

0333: Variability of right ventricular strain derived from speckle-tracking analysis using two different software solutions

Introduction Speckle tracking imaging is a recent technique that can be achieved using either vendor dependent or vendor-independent software. Right ventricular (RV) strain is increasingly used as a prognostic tool in both left and right ventricular diseases. Only little is known regarding the variability of vendor-dependent and - independent speckle-tracking imaging software in the assessment of RV free wall longitudinal strain (RLS). The aim of our study was to compare a vendor-dependent (Qlab 9.0, Philips Medical System, Andover, MA, USA) and - independent (Cardiac Performance Analysis, Tomtec Imaging Systems, Germany) software for RLS analysis. Methods and results We prospectively enrolled 90 consecutive patients with pulmonary hypertension (mean age 55,8±19years) and 26 control patients (mean age 33,9±13years) who underwent a comprehensive echocardiogram including a RV focused 4-chamber view optimised for speckle-tracking analysis. DICOM data sets were stored and analysed by 2 different cardiologists using Qlab and TomTec, blindly to the context and each other. In the whole population, mean RLS was -17,3%±9 and -8,6% ±7,2 respectively using Qlab and Tomtec. Qlab and Tomtec intra-observer coefficients of variation (CV) were -13,19% and -9,56% and interobserver CVs were -22% and -15% respectively. The concordance correlation coefficient was 0,55, indicating poor agreement between the two methods. In the control population, Qlab CV was - 3,63%, whereas CV was -17,8% in RV disease patients. Conclusion Despite an acceptable level of variability for both techniques, Tomtec appears less variable. Variability of Qlab is excellent in control patients but is highly influenced by RV morphology. The agreement between the two software products is low and should lead in clinical practice to the follow-up of patients with the same software and advocates for the development of dedicated RV speckle-tracking software products.

0418: Survival advantage of Eisenmenger syndrome patients: the role of right ventricular transverse strain

Background Survival is improved in pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD) patients and is related to right ventricular (RV) function. In this study we aimed to investigate the prognostic role of RV mechanics in Eisenmenger Syndrome (ES) compared with other causes of PAH using speckle-tracking imaging. Methods and results We performed a prospective cohort study. We recruited 80 consecutive adult PAH patients: 39 patients with ES and noncomplex CHD (mean age 41,5±15,6 years) and 41 patients with group 1 PAH (mean age 58,9±17,8). Clinical assessment, BNP and echocardiography were realised at the time of inclusion and then clinical outcomes were collected during the regular follow-up. Normal strain values were obtained from 37 control volunteers. On inclusion, 53 patients (66.3%) were in functional class III or higher. Mean BNP was lower in ES (p Conclusion The increased RV transverse strain and predominant apical function in ES could explain their survival advantage as transverse strain is a strong independent predictor of outcomes in PAH. Download : Download full-size image Abstract 0418 - Figure: RV Transverse strain predicts event-free survival

0325: Early detection of cardiac involvement in sarcoidosis with 2D speckle tracking echocardiography

Background Cardiac sarcoidosis (CS) is associated with high morbidity and sudden death. Currently, cardiac magnetic resonance (CMR) is the most sensitive method for the diagnosis of CS, however as CMR is being positive relatively late, new imaging methods to improve the early diagnosis of CS are lacking. The aim of this study was to assess the role of left ventricular (LV) strain estimated by 2D speckle tracking imaging in patients with newly diagnosed sarcoidosis without cardiac involvement according to the current guidelines. Methods and results We performed a prospective cohort study including 10 patients with newly diagnosed sarcoidosis and normal cardiac function as assessed by classic echocardiography and CMR and 10 healthy age- and gender- matched controls. All patients underwent a comprehensive LV strain echocardiographic study. Speckle tracking analysis was performed by 2 experienced cardiologists blinded to each other and to clinical data. Mean age of patients was 53±14 years old (5 women). All patients presented mediastinal lymphadenopathy, 1 had renal involvement and 4 had pulmonary manifestations. Compared with controls, LV longitudinal strain was reduced: long axis longitudinal (-16.1±2.8% vs -21.7±2.2%, p Conclusion In this pilot study, Speckle-tracking echocardiography revealed impaired LV longitudinal strain in 100% of patients with normal CMR. Decreased longitudinal LV strain could represent an early sign of myocardial involvement in sarcoidosis patients. Therefore further assessment of cardiac deformation imaging in the setting of sarcoidosis is needed to improve the diagnosis of CS (figure above). Download : Download full-size image Abstract 0325 - Figure: Means values of 4 chamber longitudinal strain (LS-4c) and global longitudinal strain (GLS)

Lack of copeptin elevation during induced myocardial infarction

The specific kinetic of copeptin secretion during the course of an acute coronary syndrome (ACS) had poorly been studied, with most studies assessing copeptin levels in the very first hours of chest pain onset and not ACS itself. To overcome this issue, we took advantage of septal embolization technique for hypertrophic obstructive cardiomyopathy (HOCM) treatment, a unique situation during which myocardial infarction (MI) is provoked, to measure plasmatic copeptin levels variation.