News
Sep 4, 2018

ESC Congress 2018, Saturday 25th of August


 

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The world’s largest conference in cardiovascular medicine took place late August in Munich, Germany. The annual Congress hosted by the European Society of Cardiology has earned a strong global reputation as a provider of the latest science in the field. New guidelines and their implementation are discussed. Clinically relevant information and advice is presented in numerous sessions, including over 4 500 abstract presentations.

This year the spotlight was on “Valvular Heart Disease” focusing on innovative treatments and techniques.

Oslo University Hospital contributed with an outstanding amount of results from recent studies.

Copyright: John Aalen / OUH

Category: General
Posted by: Piritta

Following contributions were made by Center members on Saturday 25th of August:

 

Copyright: Kari Nytrøen / OUH

 

Bjerring AW, Landgraff HEW, Leirstein S,  Aaeng A,  Ansari HZ, Saberniak J, Murbrach K, Bruun H, Stokke TM, Haugaa KH, Hallen J, Edvardsen T, Sarvari SI
Cardiac remodelling in preadolescent endurance athletes assessed by traditional and three-dimensional echocardiography.

Background: Athlete's heart (AH) is a term used to describe exercise-induced cadiac remodelling in athletes. Recent studies suggest that these changes may occur even in preadolescence, but little is known of the initial morphological changes.

Purpose: This study aims to further describe the early morphological and functional changes in the hearts of endurance athletes by examining the hearts of preadolescent athletes using traditional and three-dimensional (3D) echocardiography.

Methods: Seventy-six cross-country skiers aged 12.1±0.2 years were compared to a control group of 25 non-competing individuals aged 12.1±0.3 years. Echocardiography was performed in all subjects, including 3D acquisitions of the left ventricle (LV). Relative wall thickness (RWT) was calculated by multiplying the LV posterior wall by two and dividing it by the LV internal diameter.

Results: The cross-country skiers had a significantly greater indexed VO2 max, septal thickness, posterior wall thickness and LV mass (Table). Athletes also had greater indexed LV diameters and higher RWT. Ejection fraction did not differ between the two groups.

Conclusion: Athletes had greater LV mass and LV chamber volumes, and also higher RWT compared to the controls. This supports the notion that there is early physiological, adaptive remodelling in preadolescent athlete's heart. Furthermore, remodelling in preadolescent athletes seems to be primarily concentric in nature.

 

Table 1


Athletes (n=76)

Controls (n=25)

P-value

VO2 max indexed, mL/kg/min

62±7

44±5

<0.001

IVSd, mm

8±1

7±2

<0.05

LVIDd/BSA, mm/m2

21±3

18±2

<0.001

LVPWd, mm

7±1

6±1

<0.05

2D LV Mass/BSA, g/ m2

69±12

57±13

<0.001

3D LV EDV/BSA, mL

75±7

70±6

<0.01

3D LV ESV/BSA, mL

33±4

30±4

<0.01

3D LV Mass/BSA, g/m2

69±6

64±7

<0.01

Relative wall thickness

0.35±0.05

0.29±0.07

<0.001

LV ejection fraction, %

58±3

58±3

1.00

Data expressed as mean ± SD. Right column shows P-values for Student's t-test. BSA, body surface area; EDV, end-diastolic volume; ESV, end-systolic volume; IVSd, interventricular septum in diastole; LV, left ventricular; LVIDd, left ventricular internal diameter in diastole; LVPWd, left ventricular posterior wall in diastole; RWT, relative wall thickness.

 


Bjerring AW, Landgraff HEW, Leirstein S,  Aaeng A,  Ansari HZ, Saberniak J, Murbrach K, Bruun H, Stokke TM, Haugaa KH, Hallen J, Edvardsen T, Sarvari SI
Left and right ventricular deformation in preadolescent athletes assessed by speckle-tracking strain echocardiography.

Background: Studies in adult athletes have found irreversible reduction in right ventricular (RV) deformation with signs of fibrosis in a subset of the athletes. Reduced RV function in athletes has been found to be a pro-arrhythmic substrate.

Purpose: This study aims to improve our understanding of how endurance exercise in preadolescent athletes impacts the LV and RV function.

Methods: Seventy-six cross-country skiers aged 12.1±0.2 years were compared to a control group of 25 non-competing individuals aged 12.1±0.3 years. Echocardiography was performed in all subjects including 2D speckle-tracking strain echocardiography of both ventricles. Left ventricular (LV) global longitudinal strain (GLS) and RV GLS were calculated by averaging 16 LV and 3 RV free wall segments, respectively. All participants underwent cardiopulmonary exercise testing to assess oxygen-uptake and exercise capacity.

Results: While there was no difference in LV GLS, the controls had higher RV GLS than the athletes (Table). There was no difference with regards to LV ejection fraction and RV fractional area change. Athletes had greater indexed RV basal and mid-ventricular diameter, as well as greater RV end-diastolic and end-systolic area (Table). Athletes had greater VO2 max.

Conclusion: Increasing attention is being paid to the potential consequences of the remodeling seen in the heart of endurance athletes. This study supports the notion that cardiac changes are occurring as early as in preadolescent athletes, and that RV function might be key in evaluating and monitoring this growing population.

Table 1


Athletes (n=76)

Controls (n=25)

P-value

VO2 max indexed, mL/kg/min

62±7

44±5

<0.001

RV basal diameter/BSA, mm/m2

28±3

25±4

<0.001

RV mid-cavity diameter/BSA, mm/m2

24±3

22±3

<0.01

RV end-diastolic area/BSA, cm2/m2

14.7±2.9

13.1±1.3

<0.01

RV end-systolic area/BSA, cm2/m2

8.5±1.8

7.5±0.9

<0.01

RV global longitudinal strain, %

28±4

31±3

<0.01

RV fractional area change, %

42±6

43±4

0.52

LV global longitudinal strain, %

23±2

23±2

0.36

LV ejection fraction, %

58±3

58±3

1.00

Data expressed as mean ± SD. Right column shows P-values for Student's t-test. BSA, body surface area; LV, left ventricular; RV, right ventricular.

 

Svensson A, Haugaa KH, Zareba W, Jensen HK, Bundgaard H, Gilljam T, Madsen T,
Hansen J, Karlsson L, Green A, Polonsky B, Edvardsen T, Svendsen JH, Gunnarsson C, Platonov PG
Genetic variant score predicts cardiac events in arrhythmogenic right ventricular cardiomyopathy.

Background: Whether genetic information may contribute to risk stratification of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) remains uncertain. The Combined Annotation Dependent Depletion (CADD) score, a bioinformatic tool that measures the pathogenicity of genetic variants, has not been tested for its association with clinical manifestations of ARVC.

Objective: We aimed to assess whether CADD score is associated with cardiac events in individuals carrying pathogenic variants of plakophilin-2 (PKP-2) gene.

Methods: In this retrospective study, all individuals enrolled in the Nordic ARVC Registry and the North American Multidisciplinary ARVC Study carrying PKP-2 variants that according to the American College of Medical Genetics and Genomics (ACMG) were classified as pathogenic or likely pathogenic were included. In total, 36 unique genetic variants were reported in 187 patients (93 males, 75 probands, 101 with definite ARVC diagnosis by Task Force 2010 and median age of 38 [IQR 24–52] years). No individuals had a pathogenic genetic variant in any other ARVC-related gene. CADD scores were calculated and their association with age at (1) first ventricular tachycardia/ventricular fibrillation (VT/VF) defined as ventricular tachycardia, appropriate ICD therapy or aborted cardiac arrest or (2) cardiac event (VT/VF or syncope) evaluated. Kaplan–Meier analysis and Cox regression analysis adjusted for gender were used to assess relationship between CADD score and the risk of cardiac events before the age of 60 years.

Results: Cardiac events were reported in 81 patients (43%) and VT/VF in 63 (34%). CADD score was higher in patients with cardiac events than in those without (30.9 vs. 28.7, p=0.023) and Kaplan-Meier analysis indicated higher frequency of cardiac events in those with CADD score >30 (log rank p=0.011, Figure). In the Cox regression analysis, CADD >30 (upper tertile) was significantly associated with the risk of cardiac events (HR=1.80, 95% CI 1.12–2.88, p=0.014). No association between cardiac event rates and the most common genetic variant types (splice site, deletion, nonsense) was observed.

Conclusions: We are the first to report a significant correlation between PKP-2 mutation characteristics assessed using CADD-score and the age at first clinical manifestations of ARVC, thus indicating the potential of genetic information for risk stratification.

CADD score and risk of cardiac events


Aalen J, Izci H, Duchenne J, Larsen CK, Storsten P, Sirnes PA, Skulstad H, Remme EW, Voigt JU, Smiseth OA
Septal work is a more sensitive marker of myocardial dysfunction in dyssynchrony than strain.

Introduction: Regional myocardial work by echocardiography was recently introduced as a clinical method. Since work incorporates load it may be superior to strain imaging to identify myocardial dysfunction. We hypothesized that myocardial work identifies preclinical myocardial dysfunction in patients with left bundle branch block (LBBB).

Purpose: To compare the echocardiographic modalities myocardial work and strain in the evaluation of systolic function in patients with LBBB.

Methods: 28 non-ischaemic LBBB patients were divided into three groups based on left ventricular (LV) ejection fraction (EF): Group EFnormal (n=8) with EF>50%, group EFmid (n=10) with EF 36–50% and group EFlow (n=10) with EF≤35%. Furthermore, we included a group of 10 healthy control subjects. All subjects were examined by speckle-tracking echocardiography to calculate peak longitudinal strain in the septum and LV lateral wall. Using a previously validated method for non-invasive estimation of LV pressure, segmental work was calculated by pressure-strain analysis.

Results: There were no significant differences in LVEF between controls and EFnormal LBBB patients (60±4 vs. 58±5%, NS) suggesting normal systolic function. This was also true for septal shortening (21.8±2.8 in controls vs. 21.5±2.2% in EFnormal, NS). Septal work, however, was substantially reduced (2346±280 in EFnormal vs. 4565±1233 mmHg·% in controls, p<0.001). This indicates markedly reduced septal function in LBBB patients despite normal EF (figure). There were further reductions in septal work in the EFmid and EFlow groups consistent with gradually increasing dysfunction. LV lateral wall shortening and work did not change between controls, EFnormal and EFmid, which indicates preserved LV lateral wall function in LBBB patients despite reduced global systolic function.

Conclusions: Myocardial work was more sensitive than strain to identify myocardial dysfunction in patients with LBBB and normal LVEF. This probably reflects that work incorporates loading conditions which are often abnormal in the septum of LBBB patients. These results suggest a role for myocardial work to identify preclinical LV dysfunction. Future studies should investigate whether reduced myocardial work has prognostic value on top of strain.

Galli E, Hubert A, Le Rolle V, Hernandez A, Smiseth OA, Leclercq C, Donal E
Myocardial constructive work is additive to left ventricular dyssynchrony and volumetric response to CRT in the prediction of overall mortality after CRT implantation.

Background: Myocardial constructive work (CW) assessed by pressure strain loops (PSLs) is an independent predictor of cardiac resynchronization therapy response (CRT+).

Purpose of the study: To assess the role of CW in the prediction of long-term outcome in patients undergoing CRT.

Methods: 2D- and speckle-tracking echocardiography were performed in 166 CRT candidates (mean age: 66±10 years, males: 69%) before CRT implantation and at 6-month follow-up. Left-ventricular (LV) end-systolic volume reduction >15% at 6-month follow-up defined CRT+ and occurred in 48 (29%) patients.

Results: After a median 4-year FU (range: 1.3–5 years), all-cause death occurred in 28 patients (17%), cardiac death in 14 (8%). At Cox-regression analysis, CW emerged as an independent predictor of outcome (Table 1). A CW cut-off of 888 mmHg% (AUC 0.71, p=0.007 and AUC 0.67, p=0.004 for cardiac and all-cause mortality) was associated with an increased mortality risk (Figures 1, 2).

Conclusions: The estimation of LV-CW is a relatively novel tool, which allows the prediction of long-term outcome in CRT candidates.

 


Univariable analysis

Multivariable analysis

Cardiac death

HR

95% CI

p-value

HR

95% CI

p-value

Age, per year

1.08

(1.01–1.15)

0.02

1.07

(1.00–1.15)

0.04

Ischaemic disease

3.99

(1.34–11.94)

0.01

2.33

(0.71–1.15)

0.16

NYHA >2

1.39

(0.46–4.24)

0.56




LBBB

0.87

(0.27–2.77)

0.81




LVEF, per %

0.99

(0.92–1.08)

0.89




Septal flash

0.19

(0.06–0.62)

0.006

0.48

(0.12–1.95)

0.30

CW, per mmHg%

0.99

(0.99–1.00)

0.04

0.99

(0.99–1.00)

0.04

CRT-response

0.26

(0.09–0.78)

0.02

0.68

(0.18–2.57)

0.58

All-cause death

Age, per year

1.05

(1.01–1.09)

0.01

1.06

(1.01–1.10)

0.01

Ischaemic disease

2.69

(1.27–5.66)

0.009

1.94

(0.86–4.39)

0.11

NYHA>2

1.86

(0.80–4.30)

0.15




LBBB

0.85

(0.34–2.12)

0.72




LVEF, per %

0.98

(0.93–1.04)

0.50




Septal flash

0.39

(0.19–0.83)

0.02

0.87

(0.34–2.22)

0.77

CW, per mmHg%

0.99

(0.99–1.00)

0.03

0.99

(0.99–1.00)

0.03

CRT-response

0.36

(0.17–0.76)

0.007

0.24

(0.24–1.43)

0.59

 

 

 

Copyright: John Aalen / OUH

Remme EW: Circumferential strain is the main contributor to left ventricular function


 

 


Heart SFI