Pierre Gibelin

Real time three-dimensional echocardiographic assessment of left ventricular function in heart failure patients: underestimation of left ventricular volume increases with the degree of dilatation.

Background: Accurate quantification of left ventricular (LV) volumes and ejection fraction (EF) is of critical importance. Cardiac magnetic resonance (CMR) is considered as the reference and three‐dimensional echocardiography (3DE) is an accurate method, but only few data are available in heart failure patients. We therefore sought to compare the accuracy of real time three‐dimensional echocardiography (RT3DE) and two‐dimensional echocardiography (2DE) for quantification of LV volumes and EF, relative to CMR imaging in an unselected population of heart failure patients. Methods and Results: We studied 24 patients (17 men, age 58 ± 15 years) with history of heart failure who underwent echocardiographic assessment of LV function (2DE, RT3DE) and CMR within a period of 24 hours. Mean LV end‐diastolic volume (LVEDV) was 208 ± 109 mL (121 ± 64 mL/m2) and mean LVEF was 31 ± 12.8%. 3DE data sets correlate well with CMR, particularly with respect to the EF (r: 0.8, 0.86, and 0.95; P < 0.0001 for LVEDV, LVESV, and EF, respectively) with small biases (–55 mL, –44 mL, 1.1%) and acceptable limits of agreement. RT3DE provides more accurate measurements of LVEF than 2DE (z= 2.1, P = 0.037) and lower variability. However, 3DE‐derived LV volumes are significantly underestimated in patients with severe LV dilatation. In patients with LVEDV below 120 mL/m2, RT3DE is more accurate for volumes and EF evaluation. Conclusion: Compared with CMR, RT3DE is accurate for evaluation of EF and feasible in all our heart failure patients, at the expense of a significant underestimation of LV volumes, particularly when LVEDV is above 120 mL/m2.

Early detection of cardiac involvement in sarcoidosis with 2-dimensional speckle-tracking echocardiography.

BACKGROUND/OBJECTIVES Cardiac sarcoidosis (CS) is associated with high morbidity and sudden death. The absence of specific symptoms and lack of diagnostic gold standard technique is challenging. New imaging methods could improve the diagnosis of CS. The aim of our study was to assess the role of left ventricular (LV) longitudinal and circumferential strain as estimated by 2D speckle-tracking imaging in patients with diagnosed sarcoidosis without cardiac involvement according to the current guidelines. We investigated the prevalence of LV strain impairment in this population and assessed its relationship with clinical outcomes, composite of mortality, heart failure, arrhythmia and/or secondarily development of CS and cardiac device implantation. METHODS AND RESULTS We performed a prospective case-control longitudinal study including 35 patients with diagnosed sarcoidosis and normal cardiac function as assessed by standard transthoracic echocardiography and 35 healthy age- and gender-matched controls. All patients underwent a comprehensive echocardiographic study. Mean age of patients was 47.9±14.8years old (22 women). Compared with controls, global LV longitudinal strain (LV GLS) was reduced in sarcoidosis patients: (-17.2±3.1 vs -21.3±1.5%, p<0.0001). Circumferential LV strain was preserved in patients compared to controls (-19.9±-4.3% vs -21.3±1.5%, p=0.12). Impaired LV GLS was significantly associated with clinical outcomes (HR 1.56; [1.16-2.11], p<0.01) on univariate analysis. CONCLUSION Speckle-tracking echocardiography revealed decreased longitudinal LV strain in sarcoidosis patients that was associated with outcomes. LV GLS may represent an early marker of myocardial involvement in sarcoidosis patients that needs to be studied further.

Insuficiencia cardiaca en el infarto agudo de miocardio: comparación de pacientes con o sin criterios de insuficiencia cardiaca del registro FAST-MI

INTRODUCTION AND OBJECTIVES To compare acute myocardial infarction patients with or without congestive heart failure in the French FAST-MI registry. METHODS The French FAST-MI registry included 374 centers and 3059 patients over a 1-month period at the end of 2005, with 1-year follow-up. Among this population, patients with at least one congestive heart failure criterion constituted group 1 (n=1149; 37.5%) and were compared to patients without congestive heart failure (group 2, n=1910; 62.5%). The congestive heart failure patients were further divided according to presence of both beta-blockers and antagonists of the renin-angiotensin-aldosterone system at hospital discharge (n=511) or not (n=498), in order to assess the real-world clinical importance of recommended medications. RESULTS Overall in-hospital and 1-year mortality rates were 3.4% and 13.2%, respectively. In hospital survivors, presence of congestive heart failure was associated with increased mortality (adjusted hazard ratio: 1.55; 95% confidence interval, 1.10-2.17; P=.01). Survival was higher in patients without congestive heart failure, compared with congestive heart failure patients receiving or not recommended medications (P<.001). Congestive heart failure patients receiving neither renin-angiotensin-aldosterone system blockers nor beta-blockers (adjusted hazard ratio: 1.66; 95% confidence interval, 1.08-2.55; P=.02) had a significantly higher risk of death than patients receiving both classes of medications (adjusted hazard ratio: 1.16; 95% confidence interval, 0.82-1.64; not statistically significant). Patients receiving only one of the recommended classes had an intermediate risk (adjusted hazard ratio: 1.47; 95% confidence interval, 1.04-2.07; P=.03). CONCLUSIONS Patients admitted for acute myocardial infarction with congestive heart failure criteria are still at very high risk of mortality. When receiving major recommended medications, they presented with significantly reduced mortality rates. Additional efforts should therefore be made to encourage the prescription of recommended medications in acute myocardial infarction patients with congestive heart failure.

Cardiac remodelling amongst adults with various aetiologies of pulmonary arterial hypertension including Eisenmenger syndrome—implications on survival and the role of right ventricular transverse strain

Aims Survival in pulmonary arterial hypertension (PAH) and Eisenmenger syndrome (ES) relates to right ventricular (RV) function. Little is known about differences of ventricular function between ES patients and those suffering from other PAH aetiologies. In this study, we compared global ventricular function assessed by speckle-tracking in adult patients with ES, other PAH aetiologies, or healthy controls; and assessed the relationship between ventricular function and survival. Methods and results We performed a prospective cohort study recruiting 83 adult PAH patients (43 ES and 40 other PAH aetiologies patients) and 37 controls between March 2011 and June 2015. Patients with complex congenital heart disease were excluded. Fifty-three patients (63.9%) were in NYHA functional class ≥III at baseline and 60 (72.3%) were on advanced therapies. Mean RV peak longitudinal strain was -16.3 ± 7% in ES, lower compared with healthy controls (P < 0.001) but similar to other PAH aetiologies (P = 0.6). Mean RV peak transverse strain was +26.1 ± 17% in ES, lower than in controls (P < 0.001) but higher than in other PAH aetiologies (P < 0.001). No difference was observed between ES and other PAH in LV circumferential and longitudinal strain. Over a median follow-up of 22.6 months (3.3-32.2), 22 (26.5%) patients died all from cardio-pulmonary causes. ES and RV peak transverse strain were independent predictors of survival. RV peak transverse strain ≤22% identified patients with a 14-fold increased risk of death. Conclusion Right ventricular remodelling differs between adults with ES and other PAH aetiologies. ES and increased RV free wall transverse strain are associated with better survival.

130 Interest of tricuspid annular displacement “TAD” in evaluation of right ventricular ejection fraction

The ultrasound assessment of right ventricular (RV) function is often sub-optimal. The range of excursions of the mitral or tricuspid annulus measured in mm by 2D or TM mode echocardiography has been shown to reflect the systolic function of both ventricles. Methods We studied a new technique based on a tissue tracking algorithm that is ultrasound beam angle independent for automated detection of tricuspid annular displacement (TAD) (QLAB, Philips Medical Imaging). Twenty six patients (pts) with pulmonary arterial hypertension (n= 13), heart failure (n= 9), valvulopathy (n= 3) or myocarditis (n= 1) were reffered for magnetic resonance imaging (MRI) and underwent a complete transthoracic echocardiography (TTE). MRI was performed on a 1.5 T MR scanner. MRI RV ejection fraction (RVEF) was correlated by linear regression with TAD, peak systolic tricuspid annular velocity (Sa) and RV fractional area change (FAC). Sixteen pts (61.5%) exhibited right ventricular systolic dysfunction (RVEF Results In the pts group, MRI RVEF was positively correlated with TAD (R 2 = 0,65; p 2 = 0,56; p 2 = 0,39 p=0,0025). The strongest relation was observed with TAD. A value of TAD 2 =0,36 ; p Limitations The echocardiographic and MRI parameters were not obtained simultaneously but at an interval of 24 hours. Our study is the first to correlate TAD with MRI RVEF. We conclude that TAD provides a simple, rapid, and non-invasive tool for assessing right ventricular systolic function.

Left ventricular non-compaction associated with Wolff-Parkinson-White syndrome: Echo, contrast-echo and cardiovascular magnetic-resonance data.

A 58-year-old man with a history of dyspnoea was admitted for radiofrequency catheter ablation of an accessory pathway. He was diagnosed with Wolff-Parkinson-White syndrome when he presented a ventricular arrhythmia during atrial fibrillation. Transthoracic echocardiography revealed significant left-ventricular dysfunction with an enlarged left ventricle. We noted numerous and prominent trabeculations predominating in the apical and anterior areas and deep intratrabecular recesses, where colour Doppler revealed blood inflow. The non-compacted/compacted myocardium (NC/C) ratio at the end of systole was greater than 2, leading to a diagnosis of left ventricular noncompaction. The echocardiogram (with SonoVue®) revealed contrast in the recesses and reaching the bottom of the left ventricle (Fig. 1, plate 4). The echocardiograms rule out hypertrophic cardiomyopathy and intraventricular thrombus and detect more non-compacted segments. Three-dimensional echocardiography (Fig. 1, plate 3) was helpful in eliminating other differential diagnoses and for determining the location of the trabeculation: the

Speckle-tracking imaging in patients with Eisenmenger syndrome

BACKGROUND Adults with Eisenmenger syndrome have a survival advantage over those with idiopathic pulmonary arterial hypertension. Improved survival may result from preservation of right ventricular (RV) function. AIMS To assess left ventricular (LV) and RV remodelling in patients with Eisenmenger syndrome compared to a control population, using speckle-tracking imaging. METHODS Adults with Eisenmenger syndrome and healthy controls were enrolled into this prospective two-centre study. Patients with Eisenmenger syndrome with low acoustic windows, irregular heart rhythm or complex congenital heart disease were excluded. Clinical assessment, B-type natriuretic peptide (BNP), 6-minute walk test and echocardiography (including dedicated views to perform offline two-dimensional-speckle-tracking analysis) were performed on inclusion. RESULTS Our patient population (n=37; mean age 42.3 ± 17 years) was mostly composed of patients with ventricular septal defect (37.8%) or atrial septal defect (35.1%). Compared with the control population (n=30), patients with Eisenmenger syndrome had reduced global LV longitudinal strain (-17.4 ± 3.5 vs. -22.4 ± 2.3; P<0.001), RV free-wall longitudinal strain (-15.0 ± 4.7 vs. -29.9 ± 6.8; P<0.001) and RV transverse strain (25.8 ± 25.0 vs. 44.5 ± 15.1; P<0.001). Patients with Eisenmenger syndrome also more frequently presented a predominant apical longitudinal and transverse strain profile. Among patients with Eisenmenger syndrome, those with a post-tricuspid shunt presented with reduced global LV longitudinal strain but increased RV transverse strain, compared to patients with pre-tricuspid shunt. CONCLUSION Patients with Eisenmenger syndrome had impaired longitudinal RV and LV strain, but present a relatively important apical deformation. RV and LV remodelling, as assessed by speckle-tracking imaging, differ between patients with pre- and post-tricuspid shunt.

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.

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.