Olivier Chiche

Imaging in pulmonary hypertension: Focus on the role of echocardiography

Patients with pulmonary hypertension must be evaluated using a multimodality approach to ensure a correct diagnosis and basal evaluation as well as a prognostic assessment. Beyond the assessment of pulmonary pressures, the echocardiographical examination allows the evaluation of right ventricular adaptation to elevated afterload. Numbers of variables are commonly used in the assessment of the pulmonary hypertension patient in order to detect changes in right heart geometry, right-to-left interaction and right ventricular dysfunction. Whereas an isolated change in one echocardiographical variable is not meaningful, multiple echocardiographical variable modifications together provide accurate information. In this review, we will link pulmonary hypertension pathophysiological changes with echocardiographical indices and describe the clinical implications of echocardiographical findings.

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

B blood group: A strong risk factor for venous thromboembolism recurrence

BACKGROUND Non-O blood group patients are at higher risk of first episode of venous thromboembolism (VTE). However, only little is known about the risk of recurrence according to the blood group. In this study, we aimed to determine the impact of ABO blood group on VTE recurrence. METHODS We prospectively recruited 106 consecutive patients with a first documented episode of pulmonary embolism (PE). Patients were followed at least 12months after anticoagulation discontinuation. The main endpoint was recurrence of symptomatic VTE. RESULTS Data from 100 patients were analyzed. Median follow-up was 28months [24-34.8]. PE was unprovoked in 48 patients. Mean anticoagulation duration was 5.3±2.2months. The rate of VTE recurrence was 12.7 per 100 patient-years (30 recurrences). B blood group patients had a 2.7-fold increased risk of VTE recurrence (95%CI 1.1-6.2, p=0.03). On multivariate analysis, B blood group was the strongest independent predictor of VTE recurrence (Hazard Ratio (HR) 2.6, 95%CI 1.1-6.1, p=0.04). In contrast, A and AB blood groups were not associated with VTE recurrence. VTE recurrences were less frequent in O blood group compared to non-O patients (HR 0.5, 95%CI 0.2-1.1, p=0.09). O blood group women had a 5-fold decreased risk of VTE recurrence (HR 0.2, 95%CI 0.1-0.8, p=0.01). CONCLUSIONS Non-O blood groups, beyond being involved in the occurrence of a first VTE event, also contribute to VTE recurrence. B blood group is strongly associated with VTE recurrence, thus high-risk B blood group patients could benefit from long-term anticoagulation therapy after a first VTE event.

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.

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.

0337: Prognostic value of reflux of contrast into the inferior vena cava or hepatic veins in pulmonary embolism

Background Computed tomography pulmonary angiography (CTPA) is routinely used to diagnose pulmonary embolism (PE). Reflux of contrast medium into the inferior vena cava or hepatic veins (IVC) on CTPA is a simple sign that could help for PE risk stratification. The purpose of this study was therefore to investigate prognosis significance of contrast reflux into IVC in acute PE. Methods and results 141 consecutive patients with acute PE confirmed by CTPA were prospectively included between March 2010 and February 2013. Degree of reflux into the IVC and the hepatic veins was graded from 1 (none) to 6 (severe) by 2 independent observers, blinded to each other. The presence of reflux in IVC was compared with clinical parameters used in the ESC guidelines for PE risk stratification: electrocardiographic signs, Troponine I, BNP and right ventricular dilatation (RV/ LV>0,9) or dysfunction (TAPSE 110 bpm (OR 5.6, 1.03-30), atrial fibrillation (OR 6.3, 1.05-37.7), negative anterior T waves (OR 6.1, 1.3-29.1), elevated Troponin Ic (OR 5.4, 1.1-25.8), elevated BNP (OR 11.5, 1.3-98.2), right ventricular dysfunction (OR 5.3, 1.1-25.1) were predictors of death or clinical deterioration. Contrast reflux into IVC from grade 4 to 6 was observed in 17% of patients. Interobserver agreement was excellent (Concordance correlation coefficient 0.91). Grade 4 reflux or greater was a strong predictor of events (OR 15.1, 2.8-83.7) and had a 86% specificity and 71% sensitivity to predict adverse outcomes (AUC 0.88). Conclusion A grade 4 or higher contrast reflux into the IVC is a simple and frequent CTPA sign, highly predictive of adverse outcomes in PE patients.

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.

087: Kinetics of copeptin during dobutamine echocardiography in patients with previous Tako Tsubo cardiomyopathy

Purpose To demonstrate the abnormal kinetics of copeptin during stress in patients with Tako-Tsubo cardiomyopathy (TTC). Methods We analyzed prospectively copeptin kinetics before and after dobutamine echocardiography in 12 TTC compared to 10 controls, matched for age and gender. The level of the other main stress hormones (adrenaline, noradrenaline, dopamine, insulin, cortisol) were also collected. Results All dobutamine echocardiographies were normal. Before and after echocardiography, there were no differences in hormones values between TTC and controls. Surprisingly, after echocardiography in TTC, copeptin decreased, as did cortisol, noradrenaline, and insulin. In the control group, no variation was found. Conclusions Surprisingly, in TTC after dobutamine echocardiography, most hormones, including copeptin, decreased.