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Sep 6, 2018

ESC Congress 2018, Tuesday 28th of August


 


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The abstract "Myocardial constructive work is additive to volumetric response to cardiac resynchronization therapy in the prediction of mortality after CRT implantation" was selected for the Rapid Fire session on Tuesday. Recent studies have shown that myocardial constructive work (CW) is an independent predictor of the volumetric response to cardiac resynchronization therapy (CRT) and this study concludes that left ventricular CW allows the prediction of cardiac death in CRT candidates.

Center PhD fellow Lars Dejgaard, MD, is the first author of "Mitral annulus disjunction is associated with severe ventricular arrhythmias independently of mitral valve prolapse".

Copyright: Kristina Haugaa / OUH...

The purpose of this study was to describe the clinical presentation and prevalence of severe ventricular arrhythmias in patients with mitral annulus disjunction (MAD) with and without mitral valve prolapse (MVP). MVP was found in only half of the patients with MAD and was not associated with arrhythmic events, indicating mitral annulus disjunction itself as an arrhythmogenic entity.

Center PhD fellow Esther Scheirlynck presented the results of the study "Mechanical dispersion by speckle tracking imaging in Brugada syndrome patients". Brugada syndrome (BrS) is associated with an increased risk for severe ventricular arrhythmias and sudden cardiac death. Although labeled as a disease occurring in structurally normal hearts, functional alterations in some patients, mostly affecting the right ventricle (RV) and less often the left ventricle (LV), have been identified using new imaging techniques. Mechanical dispersion (MD) by speckle tracking imaging has been previously used to predict arrhythmic events in various cardiomyopathies. This study concluded that mechanical dispersion by speckle tracking might be a potential marker for the risk stratification of arrhythmic events in BrS.

Category: General
Posted by: Piritta

Tuesday 28th of August

Contributions

Rapid Fire Abstract

Galli E, Hubert A, Le Rolle V, Hernandez A, Smiseth OA, Mabo P, Leclercq C, Donal E
Myocardial constructive work is additive to volumetric response to cardiac resynchronization therapy in the prediction of mortality after CRT implantation.

Background: Recent studies have shown that myocardial constructive work (CW) is an independent predictor of the volumetric response to cardiac resynchronization therapy (CRT).

Purpose of the study: To assess if CW is additive to volumetric CRT-response in the prediction of cardiac mortality in CRT-candidates.

Methods: 2D-standard 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) CW was assessed by pressure-strain loops (PSLs). A reduction in LV end-systolic volume >15% at 6-month follow-up defined CRT-volumetric response and was observed in 48 (29%) patients.

Results: After a median 4-year FU (range: 1.3–5 years), cardiac death occurred in 14 patients (8%). CW and age were the only prognostic predictors of cardiac death (Table 1), independently from septal flash and CRT-volumetric response. At ROC curve analysis, CW≤888 mmHg% was the best cut-off to predict cardiac mortality (AUC 0.71, p=0.007). Among CRT responders, the presence of CW≤888 mmHg was associated with a dismal prognosis (log-rank test p=0.04). The concomitance of CW≤888 mmHg and absence of volumetric response to CRT identified patients with the worst prognosis (log-rank test p=0.001) (Figure 1)

Conclusions: Left ventricular CW allows the prediction of cardiac death in CRT candidates. A CW≤888 mmHg is associated with a increased cardiac mortality in both CRT responders and non-responders.

Table 1

Predictors of cardiac death

Univariable analysis

Multivariable analysis


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

Male sex

1.75

(0.49–6.27)

0.39




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




QRS duration, per ms

0.99

(0.97–1.03)

0.81




LBBB

0.87

(0.27–2.77)

0.81




LVEF, per %

0.99

(0.92–1.08)

0.89




LVEDV, per ml

1.02

(0.99–1.01)

0.49




LVESV, per ml

1.00

(0.99–1.01)

0.53




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

 

..

 

 

...

Copyright: Kristina Haugaa / OUH


Dejgaard LA, Skjolsvik ET, Lie OH, Ribe M, Stokke MK, Hegbom F, Scheirlynck ES, Gjertsen E, Andresen K, Helle-Valle TM, Hopp E, Edvardsen T, Haugaa KH
Mitral annulus disjunction is associated with severe ventricular arrhythmias independently of mitral valve prolapse.

Background: Mitral valve prolapse (MVP) has been associated with sudden cardiac death. Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point, and has been proposed as a marker for sudden cardiac death in MVP patients. However, risk of ventricular arrhythmias in MAD itself, and in the absence of MVP, is poorly described.

Purpose: To describe the clinical presentation and prevalence of severe ventricular arrhythmias in patients with MAD with and without MVP.

Methods: We included consecutive patients from two hospitals with MAD defined as disjunction of >1 mm by study echocardiogram. We performed clinical examination and evaluated medical records for previous history of severe arrhythmic events, defined as aborted cardiac arrest or sustained ventricular tachycardia. Patients were excluded if they had non-mitral valvular disease, cardiomyopathies, channelopathies or obstructive coronary artery disease. We recorded the presence of MVP, measured MAD in the posterolateral wall (figure) in parasternal long-axis view, and measured left ventricular ejection fraction (EF).

Results: We included 115 patients (49±15 years, 60% female) with confirmed MAD. Severe arrhythmic events had occurred in 14 (12%) patients (n=10 aborted cardiac arrest, n=4 sustained ventricular tachycardia). Reported symptoms were palpitations (71%), presyncope (41%), chest pain (28%) and syncope (13%), with no difference between patients with or without severe arrhythmic events. Patients with severe arrhythmic events were younger (37±13 years vs. 51±14 years, p=0.001) and had lower EF (51±5% vs. 57±7%, p=0.002) compared to patients without events. MVP was evident in 63 (54%) patients and was less frequent in patients with severe arrhythmic events (4 (29%) vs. 59 (58%), p=0.04). In a multivariable logistic regression model including EF, age and MVP, lower EF (Adjusted OR 0.86 (95% CI, 0.77–0.97, p=0.01)) and lower age (Adjusted OR 0.94 (95% CI, 0.89–0.98, p=0.006) remained independent markers for severe arrhythmic events.

Conclusions: Patients with MAD frequently presented with arrhythmic symptoms, and 12% had experienced severe arrhythmic events. MVP was found in only half of the patients with MAD and was not associated with arrhythmic events, indicating MAD itself as an arrhythmogenic entity. In patients with MAD, lower age and EF were markers of severe arrhythmic events.

MVP in MAD with severe arrhythmic events

 

 

Rodriguez Zanella H, Balderas-Munoz K, Jordan-Rios A, Arias Godinez JA, Ruiz Esparza ME, Badano LP, Edvardsen T, Muraru D, Surkova E, Gaxiola-Macias BA, Bucio-Reta E, Baranda-Tovar F, Fritche-Salazar JF
Right ventricular free wall strain predicts low cardiac output syndrome in patients left ventricular ejection fraction >35% undergoing open aortic valve replacement.

Background: Low cardiac output syndrome (LCOS) after surgical aortic valve replacement (SAVR) leads to increased mortality and health care related costs. Right ventricular free wall longitudinal strain (RVFWS) may be a risk factor in patients without severely reduced left ventricular ejection fraction (LVEF). All had LVEF >35%.

Purpose: To evaluate the role of RVFWS to predict the occurrence LCOS after surgical aortic valve replacement in patients without severely reduced LVEF.

Methods: We prospectively recruited patients with severe aortic stenosis, with class I indication for SAVR. Clinical, hemodynamic and echocardiographic data was collected. Conventional right ventricular function parameters and RVFWS were measured using speckle tracking echocardiography. Univariate and multivariate linear regression analysis was used to analyze variables related with the occurrence of LCOS.

Results: Eighty-one patients (63 years ±8 were included and LCOS occurred in 19 (23%). Patients with LCOS had more frequently diabetes (35.5 vs 10.5%, p=0.037), underwent more mitral valve replacement (3% vs 16%, p=0.046), had longer aortic clamping time (72 (85–116 min) vs 96 (79–136 min), p<0.0008), cardiopulmonary bypass time (99 (85–116 min) vs 120 (102–184 min) p<0.001), lower LV global longitudinal strain (GLS) (-17±4% vs 14±5%, p=0.001) and RVFWS (-14±4 vs -18±4%, p=0.0001). Interestingly LVEF (p=0.065), tricuspid annular plane systolic motion (p=0.28) right ventricular fractional area change (p=0.57) and right ventricular systolic pressure (p=0.062) did not differ. In the multivariate analysis, RVFWS was the only independent predictor of LCOS (Table). On ROC curve analysis a RVFWS with an absolute value lower than 15.1% had a sensitivity of 72% and a specificity of 79% (AUC=0.78) for LCOS occurrence.

Conclusions: RVFWS is a strong independent predictor of LCOS after aortic valve replacement in patients without severely reduced LVEF. RVFWS can improve risk stratification for LCOS in this patient subset. Future studies to confirm our findings are needed.

Multivariate linear logistic regression analysis for LCOS

Variable

Odds Ratio (CI 95%)

p value

Diabetes

0.37 (0.05–2.69)

0.32

Mitral valve replacement

1.4 (0.09–20.5)

0.80

CPB

1.029 (0.95–1.07)

0.44

Aortic clamping time

1.12 (0.92–1.08

0.78

LV GLS

1.046 (0.84–1.29)

0.68

RVFWS

1.49 (1.13–1.78)

0.002

 

 

..

Copyright: Kristina Haugaa / OUH


Aalen J, Remme EW, Larsen CK, Hopp E, Andersen OS, Krogh M, Ross S, Odland HH,  Kongsgaard E, Skulstad H, Smiseth OA
Reduced left ventricular lateral wall contractility leads to recovery of septal function in left bundle branch block.

Introduction: Reduced septal work is a main feature of left bundle branch block (LBBB) and considered as a target for cardiac resynchronization therapy (CRT). We hypothesized that septal contractile function in LBBB is modified by crosstalk with the left ventricular (LV) lateral wall.

Purpose: To test the hypothesis that reduced LV lateral wall contractility leads to recovery of septal work in LBBB.

Methods: In 10 anaesthetized dogs we induced LBBB by radiofrequency ablation and occluded the circumflex coronary (CX) artery to reduce LV lateral wall contractility. Septal and LV lateral wall segment lengths were measured by sonomicrometry and regional work calculated as the area of the pressure-segment length loop. Work performed during counterclockwise rotation of the loop was defined as positive, whereas work performed during clockwise rotation of the loop was defined as negative (figure).

Furthermore, we used speckle-tracking echocardiography to study 24 LBBB patients referred for CRT implantation; 8 patients with LV lateral wall scar and 16 patients with non-ischaemic cardiomyopathy. There was no difference in LV ejection fraction between the two groups. Using a previously validated method for non-invasive estimation of LV pressure, regional work was calculated by pressure-strain analysis.

Results: Induction of LBBB caused characteristic regional work distribution with high values of LV lateral wall work and low values of septal work in all animals. CX occlusion, however, resulted in a major loss of LV lateral wall work, which declined from 417±84 (mean±SD) to 74±65 mmHg·mm (p<0.001). This was followed by a marked increase in septal work from 5±62 to 108±47 mmHg·mm (p<0.001) (figure).

Results from the clinical study resembled findings from the experimental study. In patients with non-ischaemic cardiomyopathy LV lateral wall work was 3144±1425 as compared to 1146±836 mmHg·% in patients with LV lateral wall scar (p<0.01). On the other hand, septal work was only 272±922 in non-ischaemic cardiomyopathy patients as compared to 1722±851 mmHg·% in LV lateral wall scar patients (p<0.01) (figure).

Conclusions: In LBBB, septal function is markedly improved or normalized in hearts with LV lateral wall dysfunction. Since recovery of septal function is one of the main mechanisms of improved LV function with CRT, hearts with lateral wall infarcts may have limited potential for response.

 

OH Lie, Rootwelt C, Dejgaard LA, Leren IS, Stokke MK, Edvardsen T, Haugaa KH
Multimodality prediction of life-threatening ventricular arrhythmia in patients with arrhythmogenic cardiomyopathy; a prospective cohort study.

Background: Electrocardiogram (ECG) and cardiac imaging play key roles in the diagnostic criteria for arrhythmogenic cardiomyopathy (AC), but their roles in risk stratification of patients presenting without life-threatening ventricular arrhythmia are unclear.

Purpose: To identify predictors of first-time life-threatening ventricular arrhythmia by assessing clinical characteristics, ECG and cardiac imaging in a prospective cohort study of patients with AC.

Methods: We included consecutive AC probands and mutation positive family members with no previous life-threatening arrhythmic events, and followed them prospectively from time of diagnosis. The endpoint was the first life-threatening ventricular arrhythmia, defined as aborted cardiac arrest, appropriate ICD-shock or sustained ventricular tachycardia. At baseline, we assessed possible risk predictors from three categories; (1) clinical parameters, (2) ECG and (3) cardiac imaging (echocardiography and cardiac magnetic resonance imaging) according to the Task Force Criteria of 2010. In addition to traditional imaging criteria, we assessed left ventricular (LV) and echocardiographic strain parameters. LV mechanical dispersion was defined as the standard deviation of time from onset Q/R on ECG to peak negative strain in 16 LV segments. We recorded exercise habits, and defined high intensity exercise as >6 metabolic equivalents.

Results: We included 117 patients (29% probands, 50% female, age 40±17 years). During 4.2 (IQR 2.4 to 7.4) years of follow-up, 18 (15%) patients experienced life-threatening ventricular arrhythmia. The 1, 2 and 5 year incidence was 6%, 9% and 22%, respectively. History of high intensity exercise was the strongest clinical predictor, T-wave inversions ≥V3 was the strongest ECG predictor and greater LV mechanical dispersion by echocardiography was the strongest predictor from cardiac imaging (adjusted HR; 4.9 [95% CI 1.3–18.3], p=0.02, 5.8 [95% CI 2.1–16.1], p=0.001, and 1.4 [95% CI 1.2–1.6] by 10 ms increments, p<0.001, respectively). These parameters had incremental risk predicting value (Figure, left panel). Arrhythmia free survival in patients with all three risk factors was only 1.2 (95% CI 0.4–1.9) years, compared to 17.4 (95% CI 16.6–18.2) years in patients without any risk factors (Figure, right panel).

Conclusions: History of high intensity exercise, T-wave inversions ≥V3 on ECG and greater echocardiographic LV mechanical dispersion were strong and independent predictors of life-threatening ventricular arrhythmias. AC patients without any of these risk factors had minimal arrhythmic risk, while having more than one risk factor increased the risk dramatically. This may guide decisions on primary preventive ICD implantation in these patients.

Risk prediction model

 

 

....

Copyright: Kristina Haugaa / OUH

 

Klaeboe LG, Brekke PH, Lie OH, Aaberge L, Haugaa KH, Edvardsen T
Classic mechanical dyssynchrony is rare in TAVR-induced left bundle branch block.

Background: Conduction abnormalities, especially left bundle branch block (LBBB), frequently complicate transcatheter aortic valve replacement (TAVR). Acute effects of altered conduction on ventricular mechanics after TAVR have not previously been described.

Purpose: We aimed to investigate how TAVR procedure related conduction abnormalities influence ventricular mechanics with particular focus on new-onset persistent LBBB.

Methods: Patients with severe aortic stenosis undergoing transfemoral TAVR were included in a repeated measures cross-sectional study. ECG and echocardiography with speckle tracking strain analysis were performed before and after the procedure. LBBB was defined by strict ECG criteria. Mechanical contraction patterns were assessed by longitudinal strain in apical 4-chamber view and classified as classical, dyssynchronous LBBB contraction pattern (Figure, left panel) or non-classical patterns.

Results: We included 140 consecutive patients undergoing TAVR (83±8 years old, 49% women) with severe AS (valve area 0.7±0.2 cm2, mean pressure gradient 54±18 mmHg, peak velocity 4.5±0.7 m/s) and relatively preserved LVEF (52±11%). Compared to baseline, GLS improved after TAVR in all patients (-15.1±4.3 vs -16.1±3.9%, p<0.01, n=140), and all subgroups, regardless of, pre-existing (n=27) or procedure-acquired conduction abnormalities (n=32), including in the 28 patients with new-onset LBBB fulfilling strict ECG criteria (-14.5±3.9% vs -15.6±3.0%, p=0.03). Despite significant conduction delay in ECG, the vast majority of new-onset LBBB patients (n=26, 93%) had a non-classical homogenous contraction pattern with segmental synchronous peak shortening timed at aortic valve closure (AVC) and relatively sparse lateral wall pre-stretch (Figure, right panel). Classical dyssynchronous LBBB contraction pattern was only observed in 2 patients (7%) with new-onset LBBB.

Conclusions: Longitudinal function improved in all patients after TAVR, irrespective of conduction abnormalities. Classical dyssynchronous LBBB contraction pattern was absent in the majority of patients with new-onset post-TAVR LBBB, even when applying strict ECG criteria for LBBB. These findings raise a question of whether TAVR-induced LBBB may be functionally and prognostically different from traditional LBBB.

 

 

Galli E, Hubert A, Le Rolle V, Hernandez A, Smiseth OA, Mabo P, Leclercq C, Donal E
Myocardial constructive work is a predictor of long-term outcomes in patients with heart failure undergoing cardiac resynchronization therapy.

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: Margareth Ribe / OUH

 

Scheirlynck E, Van Malderen S, Motoc A, Sieira J, De Asmundis C, Chierchia GB, Brugada P,
Droogmans S, Cosyns B
Mechanical dispersion by speckle tracking imaging in Brugada syndrome patients

Background: Brugada syndrome (BrS) is associated with an increased risk for severe ventricular arrhythmias and sudden cardiac death. Although labeled as a disease occurring in structurally normal hearts, functional alterations in some patients, mostly affecting the right ventricle (RV) and less often the left ventricle (LV), have been identified using new imaging techniques. Mechanical dispersion (MD) by speckle tracking imaging has been previously used to predict arrhythmic events in various cardiomyopathies.

Purpose: To evaluate if LV and RV global longitudinal strain (GLS) and MD by speckle tracking analysis differ between BrS patients and healthy matched controls.

Methods: We included 148 patients with BrS and 67 healthy controls. Patients with coronary heart disease were excluded. For each patient, speckle tracking analysis was performed in 16 LV and 6 RV segments. The time to peak myocardial strain in each segment was measured as the time from onset of the QRS complex on the ECG to maximum myocardial shortening. GLS was defined as the mean of the peak strain in the 16 LV segments and the 3 RV free wall segments. MD was defined as the standard deviation of the time to peak in respectively the 16 LV segments, the 6 RV segments and the 3 RV free wall segments.

Results: LV, RV and RV free wall MD were significantly higher in patients with BrS than in healthy controls [38 (±11) vs. 33 (±8) ms, P<0.001; 29 (±17) vs. 24 (±14) ms, P<0.05; 20 (±17) vs. 15 (±11) ms, P=0.004]. LV and RV GLS did not differ significantly between BrS patients and healthy controls [-18.7 (±2.3) vs. -19.0 (±1.9) %, P=0.39 and -25.9 (±5.2) vs. -25.8 (±3.5) %, P=0.90].

Conclusion: BrS patients had a higher MD than healthy controls, both in the LV and RV. Both LV and RV GLS were not significantly altered in BrS compared to healthy controls. Therefore, MD by speckle tracking might be a potential marker for the risk stratification of arrhythmic events in BrS.

Demographics and Speckle tracking data


All (215)

BrS (148)

Controls (67)

p-value

Age (y)

45±14

45±14

45±13

0.724

Female n (%)

108 (50)

73 (49)

35 (51)

0.884

GLS LV (%)

-18.8±2.2

-18.7±2.3

-19.0±1.9

0.392

MD LV (ms)

36±11

38±11

33±8

<0.001

GLS RV (%)

-25.8±4.7

-25.9±5.2

-25.8±3.5

0.896

MD RV (ms)

27±16

29±17

24±14

0.046

MD RV free wall (ms)

19±16

20±17

15±11

0.004

BrS = Brugada syndrome, GLS = global longitudinal strain, LV = left ventricle, MD = mechanical dispersion, RV = right ventricle.

LV mechanical dispersion


Heart SFI