Emer Joyce

Global longitudinal strain and left atrial volume index improve prediction of appropriate implantable cardioverter defibrillator therapy in hypertrophic cardiomyopathy patients

Accurate predictors of appropriate implantable cardioverter defibrillator (ICD) therapy in hypertrophic cardiomyopathy (HCM) patients are lacking. Both left atrial volume index (LAVI) and global longitudinal strain (GLS) have been proposed as prognostic markers in HCM patients. The specific value of LAVI and GLS to predict appropriate ICD therapy in high-risk HCM patients was studied. LAVI and 2-dimensional speckle tracking-derived GLS were assessed in 92 HCM patients undergoing ICD implantation (69xa0% men, mean age 50xa0±xa014xa0years). During long-term follow-up, appropriate ICD therapies, defined as antitachycardia pacing and/or shock for ventricular arrhythmia, were recorded. Appropriate ICD therapy occurred in 21 patients (23xa0%) during a median follow-up of 4.7 (2.2–8.2) years. Multivariate analysis revealed LAVI (pxa0=xa00.03) and GLS (pxa0=xa00.04) to be independent predictors of appropriate ICD therapy. Both LAVI and GLS showed higher accuracy to predict appropriate ICD therapy compared to presence of ≥1 conventional sudden cardiac death (SCD) risk factor(s) [area under the curve 0.76 (95xa0% CI 0.65–0.87) and 0.65 (95xa0% CI 0.54–0.77) versus 0.52 (95xa0% CI 0.43–0.58) respectively, pxa0<xa00.001]. No patient with both LAVI <34xa0mL/m2 and GLS <−14xa0% experienced appropriate ICD therapy. Assessment of both LAVI and GLS on top of conventional SCD risk factors provided incremental clinical predictive value for appropriate ICD therapy, as shown by likelihood ratio test (pxa0<xa00.001) and integrated discrimination improvement index (0.17, pxa0<xa00.001). LAVI and GLS provide high negative predictive value for appropriate ICD therapy in high-risk HCM patients. Additionally to conventional SCD risk factors, both parameters may be useful to optimize criteria and timing for ICD implantation in these patients.

Leaflet remodelling in functional mitral valve regurgitation: characteristics, determinants, and relation to regurgitation severity

BACKGROUNDnRecently, it has been hypothesized that mitral leaflet remodelling may play a role in the pathophysiology of functional mitral regurgitation (FMR). We investigated the characteristics, determinants, and relation of mitral leaflet remodelling to FMR severity.nnnMETHODS AND RESULTSnThree-dimensional transoesophageal echocardiographic data of the mitral valve (MV) were studied in 30 patients with FMR ≥ grade 3 (≥3), 24 patients with FMR < grade 3 (<3), and 22 controls with normal MV. FMR <3 and ≥3 patients showed leaflet remodelling compared with control subjects with larger overall MV leaflet areas (11.47 ± 3.16 and 9.58 ± 1.99 vs. 7.30 ± 1.57 cm(2)/m(2), respectively; all P < 0.01). Tenting volume (r(2) = 0.55), left ventricular (LV) ejection fraction (r(2) = 0.20), annulus area (r(2) = 0.87), and LV sphericity index (r(2) = 0.25) were correlated with overall MV leaflet area (all P < 0.001). Although these correlates were similar between FMR <3 and ≥3 patients (all P > 0.05), the overall MV leaflet area was smaller in FMR ≥3 compared with FMR <3 patients (P = 0.01), indicating less remodelling despite similar tethering degree. Particularly, coaptation/overall MV leaflet area ratio ≤0.24, reflecting insufficient leaflet remodelling, was associated with FMR ≥3 [area under receiver operating characteristic (ROC) curve = 0.93, sensitivity 90%, and specificity 91%]. This ratio was independently associated with FMR ≥3 (odds ratio 70.0, 95% confidence interval 11.7-419.9, P < 0.001) and showed significant correlation with effective regurgitant orifice area (r(2) = 0.38, P < 0.001).nnnCONCLUSIONnMV leaflet remodelling in FMR is common and relates to LV function, LV sphericity, MV tenting volume, and annulus dilatation. Insufficient leaflet remodelling relative to the mitral annular and LV changes is independently associated with FMR severity.

QRS Fragmentation and QTc Duration Relate to Malignant Ventricular Tachyarrhythmias and Sudden Cardiac Death in Patients with Hypertrophic Cardiomyopathy

QRS fragmentation (fQRS) and prolonged QTc interval on surface ECG are prognostic in various cardiomyopathies other than hypertrophic cardiomyopathy (HCM). The association between fQRS and prolonged QTc duration with occurrence of ventricular tachyarrhythmias or sudden cardiac death (VTA/SCD) in patients with HCM was explored.

Insights Into New-Onset Rhythm Conduction Disorders Detected by Multi-Detector Row Computed Tomography After Transcatheter Aortic Valve Implantation

New-onset rhythm conduction disorders are frequent after transcatheter aortic valve implantation (TAVI). Multidetector row computed tomography may shed light on the pathophysiology of rhythm conduction disorders in patients who undergo TAVI with the Edwards SAPIEN valve. A total of 94 patients (mean age 81 ± 7 years, 48% men) treated with TAVI with the Edwards SAPIEN valve who underwent pre- and post-TAVI multidetector row computed tomography were included. Patients with preexisting right bundle branch block or left bundle branch block (LBBB) and permanent pacemakers were excluded. Pacemaker implantation or new-onset LBBB at 1-month follow-up was the combined end point. Overall, 1 pacemaker was implanted, and 14 cases of new-onset LBBB were recorded. Among several clinical and multi-detector row computed tomographic variables, overexpansion of the transcatheter valve >15% of native annular area (odds ratio 5.277, 95% confidence interval 1.398 to 19.919, p = 0.014) and depth of frame into the left ventricular outflow tract (odds ratio 1.401, 95% confidence interval 1.066 to 1.770, p = 0.010) were independently related to the need for a pacemaker or new-onset LBBB. In conclusion, overexpansion of the transcatheter prosthesis by >15% of native aortic annular area and implantation depth of the frame into the left ventricular outflow tract were independently associated with the need for a pacemaker or new-onset LBBB in patients who underwent TAVI with the Edwards SAPIEN valve.

Position of Edwards SAPIEN transcatheter valve in the aortic root in relation with the coronary ostia: implications for percutaneous coronary interventions.

To determine the implications of stable coverage of the coronary ostia by the Edwards SAPIEN valve frame in terms of myocardial ischemia and subsequent percutaneous coronary intervention (PCI), following transcatheter aortic valve implantation (TAVI).

Left Atrial Dysfunction in the Pathogenesis of Cryptogenic Stroke: Novel Insights from Speckle-Tracking Echocardiography

Background: Myocardial strain analysis by speckle‐tracking echocardiography, which can detect subtle abnormalities in left atrial (LA) function, may offer unique insights into LA pathophysiology in patients with cryptogenic stroke (CS). The aim of this study was to investigate whether LA reservoir strain by speckle‐tracking echocardiography, as a measure of LA compliance, is impaired in patients with CS and no history of atrial fibrillation. Methods: A retrospective case‐control study of 742 patients (mean age, 59 ± 13 years; 54% men; 371 with CS and 371 control subjects) was conducted. LA reservoir strain was quantified using speckle‐tracking echocardiography. Results: LA strain was significantly lower among patients with CS than control subjects (30 ± 7.3% vs 34 ± 6.7%, P < .001). Current smoking (odds ratio [OR], 2.6; 95% CI, 1.7–4.0; P < .001), systolic blood pressure (OR, 1.17 per 10 mm Hg increase; 95% CI, 1.06–1.29; P = .001), antihypertensive treatment (OR, 0.45; 95% CI, 0.30–0.66; P < .001), larger indexed left ventricular end‐systolic volume (OR, 1.04; 95% CI, 1.01–1.07; P = .02), higher E/E′ ratio (OR, 1.06; 95% CI, 1.01–1.11; P = .01), mitral regurgitation (OR, 1.8; 95% CI, 1.2–2.7; P = .003), and lower LA reservoir strain (OR, 1.07 per 1% reduction; 95% CI, 1.05–1.10; P < .001) were independently associated with CS. Importantly, LA reservoir strain conferred incremental discriminatory value in the identification of patients with CS (likelihood ratio P < .001). Conclusions: Subtle LA dysfunction, as assessed by LA reservoir strain with speckle‐tracking echocardiography, is associated with CS independent of other cardiovascular risk factors. These findings suggest a potential role for LA strain to risk‐stratify patients in the prevention of stroke.

Young Investigator Award session - Clinical * Clinical applications

# 66 3D speckle-tracking echocardiography in acute myocardial infarction: relationship between contrast-enhanced magnetic resonance imaging and myocardial deformation {#article-title-2}nnSpeckle analysis of 3D echocardiography improves information on left ventricle (LV) segmental and global deformation by avoiding loss of speckles as it is the case in monoplane 2D analysis. Our goal was to evaluate the accuracy of 3D deformation parameters to detect myocardial delayed enhancement (MDE) transmural extent by cardiac magnetic resonance imaging (CMR) in myocardial infarction (MI).nnMethods: We included 72 patients (57.3±12.4yo) with first acute MI who underwent within 3 days following revascularization both CMR (GE 3T) and echocardiography (GE Vivid E9) including a 3D acquisition of full LV volume. Furthermore, 31 normal subjects (56.5±8.2yo) underwent a complete echocardiography. Automated analysis of 3D allowed the calculation of 3D global LV area (3DGAS), longitudinal (3DGLS), circumferential (3DGCS) and radial (3DGRS) strains (S%). Peak systolic 2D and 3D S values from the 17 LV myocardial segments were recorded. For each segment MDE was defined as transmural (MDE>66%), intermediate (33–66%) and subendocardial (<33%). Pearson was used to study correlation between 2D, 3DTTE and CMR measurements. ROC analysis identified strain cutoff value predicting scar extent.nnResults: The 72 MI pts show a slightly decreased CMR-LVEF (47.1±8.8%) with a small infarct size (global scar extent 20±13%). CMR identified 920 non-infarcted segments (75.2%) and 199 segments with transmural (16.2%), 86 with intermediate (7.0%) and 19 with subendocardial MDE (1.6%). A good tracking quality was obtained respectively in 87% and 93% of the segments in control and MI pts with good inter observer reproducibility (ICC 0.824 for 3DGLS and 0.945 for 3DGAS). All S values were significantly higher in control than in MI pts (3DGAS: −36.4±7.1 vs −25.9±5.8; 3DGLS: −21.7±5.6 vs −14.84±3.8; 3DGCS: −20.4±6.2 vs −14.18%±4.3; 3DGRS: 60.9±19.3 vs 39.2±11.8, p<.0001). All 3DGS values were correlated with CMR-LVEF (3DGLAS r=−0.715; 3DGLS r=0.602; 3DGCS r=−0.64; 3DGRS r=0.66; 2DGLS r=−0.652; all p<0.0001). All 3D S values were significantly different between non-infarcted, subendocardial, intermediate and transmurally infarcted segments (p<0.0001) and were significantly lower in non-infarcted segments of MI patients than in segments of control pts except for 3DGRS.The optimal cut-off value for segmental 3DAS to predict a transmural extent was −27.5% with a sensitivity of 89.5% and a specificity of 88.3% (AUC:0.94).nn3D speckle imaging is an interesting tool in the acute phase of MI and 3D area strain seems the most valuable parameter, both as a global marker of LV dysfunction and as a regional marker of transmural scar extent.nn# 67 Left atrial strain for prediction of cardiovascular outcomes {#article-title-3}nnBackground: The incremental value of left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) compared with LA volume or LA ejection fraction as a cardiovascular risk marker has not been evaluated prospectively. We sought to compare LA function by STE to other conventional LA parameters for the prediction of adverse cardiovascular outcomes.nnMethods: This prospective study includedxa0425 adults (mean age 70±6 years, 55% males) in sinus rhythm who were followed for development of first AF, congestive heart failure, stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death. Global peak atrial longitudinal strain (global PALS) by STE was measured in all subjects by averaging all atrial segments. Left atrium was assessed with biplane LA volume, LA ejection fraction, four-chamber LA area, and M-mode dimension.nnResults: Of thexa0425 subjects at baseline,xa054 hadxa071 new events during a mean follow-up of 3.3 ± 1.5 years. All LA parameters, traditional ones and STE derived, were independently predictive of combined outcomes (all p < 0.0001). The overall performance for the prediction of cardiovascular events was greatest for global PALS (area under the receiver operator characteristic curve: global PALS 0.84; indexed LA volume 0.71; LA ejection fraction 0.70; LA area 0.62; LA diameter 0.59). A graded association between the degree of LA enlargement and risk of cardiovascular events was only evident for global PALS and indexed LA volume.nnConclusions: Global PALS is a strong and an independent predictor of cardiovascular events and appears to be superior to conventional parameters of LA analysis.[⇓][1] nn![Figure][2] nn# 68 Left ventricular subepicardial twist represents a novel marker of contractile reserve in patients after acute myocardial infarction: a speckle-tracking dobutamine stress echocardiography study {#article-title-4}nnPurpose: Dobutamine stress echocardiography (DSE) remains the most widely used method of assessing contractile reserve (CR) in patients with left ventricular (LV) dysfunction following myocardial infarction. LV twist, an emerging parameter of global LV function, has not been systematically evaluated on DSE. In particular, the potential value of multiple layer (subepicardial and subendocardial) twist assessment has not been explored despite the knowledge that each are affected differently after STEMI. The aim of the current study was to investigate whether response of subepicardial LV twist – known to be impaired only in transmural infarctions - on full protocol DSE may serve as a marker of CR in STEMI patients.nnMethods: Consecutive STEMI patients undergoing primary percutaneous coronary intervention and standard protocol DSE at 3 months with abnormal wall motion score index (WMSI) at rest were selected. Studies positive for ischemia were excluded. Two-dimensional speckle-tracking was used to calculate subepicardial and subendocardial LV twist – defined as the net difference (in degrees) of the apical and basal rotation for each sub layer – at rest and peak-dose stages. Improvement in WMSI by ≥1 grade in ≥ 1 segment was also determined. Primary endpoint of the study was an absolute increase in LV ejection fraction (LVEF) by ≥ 5% at 6-month follow-up and its predictors were investigated.nnResults: In total 69 patients (mean age 61 ± 13, 87% male, mean LVEF 49 ± 9%, mean WMSI 1.4 ± 0.3) had complete DSE studies feasible for speckle-tracking at each stage. Improved LVEF at follow-up occurred in 41% (n=28). The mean change in both subepicardial (Δsubepi) and subendocardial (Δsubendo) LV twist from rest to peak-stress was significantly higher in LVEF improvers: 2.76 versus 0.91°, p=0.009 and 3.76 versus 1.45°, p=0.04 respectively. On multivariate analysis higher Δsubepi twist (OR 1.4 95% CI 1.1–1.7, p=0.009), and lower baseline LVEF (OR 0.88 95% CI 0.80-0.96) were independently associated with improved LVEF at 6 months while subendo and WMSI improvement were not. Area under the receiver operating characteristics curve for Δsubepi twist to predict LVEF improvement was 0.70.nnConclusions: In post-STEMI patients with persistent wall motion abnormalities, the response of subepicardial LV twist on full-protocol DSE predicts improvement in LVEF at follow-up, supporting previous studies suggesting preserved subepicardial rotation reflects less extensive infarction. This finding suggests a novel, clinical use for LV twist as a marker of contractile reserve in patients following STEMI.nn [1]: #F1n [2]: pending:yes

Young Investigator Award session – ClinicalClinical applications663D speckle-tracking echocardiography in acute myocardial infarction: relationship between contrast-enhanced magnetic resonance imaging and myocardial deformation67Left atrial strain for prediction of cardiovascular outcomes68Left ventricular subepicardial twist represents a novel marker of contractile reserve in patients after acute myocardial infarction: a speckle-tracking dobutamine stress echocardiography study

# 66 3D speckle-tracking echocardiography in acute myocardial infarction: relationship between contrast-enhanced magnetic resonance imaging and myocardial deformation {#article-title-2}nnSpeckle analysis of 3D echocardiography improves information on left ventricle (LV) segmental and global deformation by avoiding loss of speckles as it is the case in monoplane 2D analysis. Our goal was to evaluate the accuracy of 3D deformation parameters to detect myocardial delayed enhancement (MDE) transmural extent by cardiac magnetic resonance imaging (CMR) in myocardial infarction (MI).nnMethods: We included 72 patients (57.3±12.4yo) with first acute MI who underwent within 3 days following revascularization both CMR (GE 3T) and echocardiography (GE Vivid E9) including a 3D acquisition of full LV volume. Furthermore, 31 normal subjects (56.5±8.2yo) underwent a complete echocardiography. Automated analysis of 3D allowed the calculation of 3D global LV area (3DGAS), longitudinal (3DGLS), circumferential (3DGCS) and radial (3DGRS) strains (S%). Peak systolic 2D and 3D S values from the 17 LV myocardial segments were recorded. For each segment MDE was defined as transmural (MDE>66%), intermediate (33–66%) and subendocardial (<33%). Pearson was used to study correlation between 2D, 3DTTE and CMR measurements. ROC analysis identified strain cutoff value predicting scar extent.nnResults: The 72 MI pts show a slightly decreased CMR-LVEF (47.1±8.8%) with a small infarct size (global scar extent 20±13%). CMR identified 920 non-infarcted segments (75.2%) and 199 segments with transmural (16.2%), 86 with intermediate (7.0%) and 19 with subendocardial MDE (1.6%). A good tracking quality was obtained respectively in 87% and 93% of the segments in control and MI pts with good inter observer reproducibility (ICC 0.824 for 3DGLS and 0.945 for 3DGAS). All S values were significantly higher in control than in MI pts (3DGAS: −36.4±7.1 vs −25.9±5.8; 3DGLS: −21.7±5.6 vs −14.84±3.8; 3DGCS: −20.4±6.2 vs −14.18%±4.3; 3DGRS: 60.9±19.3 vs 39.2±11.8, p<.0001). All 3DGS values were correlated with CMR-LVEF (3DGLAS r=−0.715; 3DGLS r=0.602; 3DGCS r=−0.64; 3DGRS r=0.66; 2DGLS r=−0.652; all p<0.0001). All 3D S values were significantly different between non-infarcted, subendocardial, intermediate and transmurally infarcted segments (p<0.0001) and were significantly lower in non-infarcted segments of MI patients than in segments of control pts except for 3DGRS.The optimal cut-off value for segmental 3DAS to predict a transmural extent was −27.5% with a sensitivity of 89.5% and a specificity of 88.3% (AUC:0.94).nn3D speckle imaging is an interesting tool in the acute phase of MI and 3D area strain seems the most valuable parameter, both as a global marker of LV dysfunction and as a regional marker of transmural scar extent.nn# 67 Left atrial strain for prediction of cardiovascular outcomes {#article-title-3}nnBackground: The incremental value of left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) compared with LA volume or LA ejection fraction as a cardiovascular risk marker has not been evaluated prospectively. We sought to compare LA function by STE to other conventional LA parameters for the prediction of adverse cardiovascular outcomes.nnMethods: This prospective study includedxa0425 adults (mean age 70±6 years, 55% males) in sinus rhythm who were followed for development of first AF, congestive heart failure, stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death. Global peak atrial longitudinal strain (global PALS) by STE was measured in all subjects by averaging all atrial segments. Left atrium was assessed with biplane LA volume, LA ejection fraction, four-chamber LA area, and M-mode dimension.nnResults: Of thexa0425 subjects at baseline,xa054 hadxa071 new events during a mean follow-up of 3.3 ± 1.5 years. All LA parameters, traditional ones and STE derived, were independently predictive of combined outcomes (all p < 0.0001). The overall performance for the prediction of cardiovascular events was greatest for global PALS (area under the receiver operator characteristic curve: global PALS 0.84; indexed LA volume 0.71; LA ejection fraction 0.70; LA area 0.62; LA diameter 0.59). A graded association between the degree of LA enlargement and risk of cardiovascular events was only evident for global PALS and indexed LA volume.nnConclusions: Global PALS is a strong and an independent predictor of cardiovascular events and appears to be superior to conventional parameters of LA analysis.[⇓][1] nn![Figure][2] nn# 68 Left ventricular subepicardial twist represents a novel marker of contractile reserve in patients after acute myocardial infarction: a speckle-tracking dobutamine stress echocardiography study {#article-title-4}nnPurpose: Dobutamine stress echocardiography (DSE) remains the most widely used method of assessing contractile reserve (CR) in patients with left ventricular (LV) dysfunction following myocardial infarction. LV twist, an emerging parameter of global LV function, has not been systematically evaluated on DSE. In particular, the potential value of multiple layer (subepicardial and subendocardial) twist assessment has not been explored despite the knowledge that each are affected differently after STEMI. The aim of the current study was to investigate whether response of subepicardial LV twist – known to be impaired only in transmural infarctions - on full protocol DSE may serve as a marker of CR in STEMI patients.nnMethods: Consecutive STEMI patients undergoing primary percutaneous coronary intervention and standard protocol DSE at 3 months with abnormal wall motion score index (WMSI) at rest were selected. Studies positive for ischemia were excluded. Two-dimensional speckle-tracking was used to calculate subepicardial and subendocardial LV twist – defined as the net difference (in degrees) of the apical and basal rotation for each sub layer – at rest and peak-dose stages. Improvement in WMSI by ≥1 grade in ≥ 1 segment was also determined. Primary endpoint of the study was an absolute increase in LV ejection fraction (LVEF) by ≥ 5% at 6-month follow-up and its predictors were investigated.nnResults: In total 69 patients (mean age 61 ± 13, 87% male, mean LVEF 49 ± 9%, mean WMSI 1.4 ± 0.3) had complete DSE studies feasible for speckle-tracking at each stage. Improved LVEF at follow-up occurred in 41% (n=28). The mean change in both subepicardial (Δsubepi) and subendocardial (Δsubendo) LV twist from rest to peak-stress was significantly higher in LVEF improvers: 2.76 versus 0.91°, p=0.009 and 3.76 versus 1.45°, p=0.04 respectively. On multivariate analysis higher Δsubepi twist (OR 1.4 95% CI 1.1–1.7, p=0.009), and lower baseline LVEF (OR 0.88 95% CI 0.80-0.96) were independently associated with improved LVEF at 6 months while subendo and WMSI improvement were not. Area under the receiver operating characteristics curve for Δsubepi twist to predict LVEF improvement was 0.70.nnConclusions: In post-STEMI patients with persistent wall motion abnormalities, the response of subepicardial LV twist on full-protocol DSE predicts improvement in LVEF at follow-up, supporting previous studies suggesting preserved subepicardial rotation reflects less extensive infarction. This finding suggests a novel, clinical use for LV twist as a marker of contractile reserve in patients following STEMI.nn [1]: #F1n [2]: pending:yes