Global Myocardial Work in Coronary Artery Disease Patients Without Regional Wall Motion Abnormality: Correlation With Gensini Score

PurposeThis study aimed to investigate global myocardial work (GMW), derived from non-invasive left ventricular (LV) pressure-strain loops (PSLs) in coronary artery disease (CAD) patients without regional wall motion abnormality (RWMA), and explored the relationship between GMW and severity of CAD using Gensini score (GS) . Methods120 patients prepared for coronary angiography (CAG) who had left ventricular ejection fraction≥55%, no resting RWMA in two-dimensional echocardiography were enrolled. Global longitudinal strain (GLS), GMW parameters (including global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW) and global myocardial work efficiency (GWE)) were quantified. The severity of coronary lesions was evaluated by GS system based on CAG findings. We divided CAG-confirmed CAD patients into three subgroups according to the tertiles of GS: low 0<GS 16, mid 16<GS 38, and high GS>38. ResultsCAD patients showed a significantly reduced GLS and GWE, but an increased GWW. GLS, GWE, GWI and GCW were significantly decreased in the high-GS group while GWW was increased. GLS, GWE, GWI and GCW was negatively correlated with the GS, GWW was positively correlated with GS. Multivariate regression analysis showed that GWE was the independent factor of predicting coronary stenosis. ROC analysis demonstrated that GWE was the most powerful predictor of high-GS and was superior to GLS. GWE under 91% had the optimal sensitivity and specificity for identifying high-GS. ConclusionThe proposed GWE, which outperformed the GLS, showed the optimal performance and could be considered as a potential predictive indicator to detect severe coronary disease in non-RWMA CAD patients.

Echocardiographic Findings and Associated Factors in HIV Infected Patients at a Tertiary Hospital in Ethiopia

Background: Non-communicable diseases including cardiovascular diseases are becoming an important part of Human Immunodeficiency Virus (HIV) care. Echocardiography is a useful non-invasive tool to assess for cardiac disease and different echocardiographic abnormalities have been seen previously. Available evidence on the echocardiographic abnormalities in Ethiopia is scarce. The aim of this study was to investigate the echocardiographic abnormalities in HIV infected patients and factors associated with the findings.Methods: A cross-sectional study was conducted on 285 patients with HIV infection including collection of clinical and echocardiographic data. Logistic regression was used to examine the association between echocardiographic abnormalities and associated factors with variables with a p-value of < 0.05 in the multivariate model considered statistically significant.Results: Diastolic dysfunction was the most common abnormality seen in 30.1% of the participants followed by regional wall motion abnormality (22.2%), left ventricular hypertrophy (10.3%), enlarged left atrium (8.1%), pulmonary hypertension (3.5%) and pericardial effusion (2.1%). Almost all patients had normal left ventricle systolic function. Diastolic dysfunction was independently associated with increasing age, elevated blood pressure and left ventricular hypertrophy while regional wall motion abnormality was associated with male gender, increasing age and abnormal fasting blood glucose. Left ventricular hypertrophy was associated with increasing age and blood pressure and the later was associated with left atrial enlargement. The level of immunosuppression did not affect echocardiography findings. Conclusions: A high prevalence of echocardiographic abnormalities was found and included diastolic dysfunction, regional wall motion abnormality, left ventricular hypertrophy and left atrial enlargement. Male gender, age above 50 years, elevated blood pressure and elevated fasting blood glucose were associated with echocardiographic abnormalities. Appropriate screening and treatment of echocardiographic abnormalities is needed.

Flecainide toxicity with high pacemaker capture thresholds and associated takotsubo syndrome

We describe a case of a woman in her 80s with persistent atrial fibrillation (AF) despite being on flecainide who was admitted for AF with rapid ventricular response. Attempts with direct-current cardioversions were unsuccessful despite increased doses of the antiarrhythmic therapy. At atrioventricular (AV) nodal ablation, very high right ventricular capture thresholds resulted in abortion of the procedure as back-up ventricular pacing could not be assured with adequate margin for safety. Shortly following the electrophysiology (EP) study, the patient developed cardiogenic shock with new apical left ventricular regional wall motion abnormality suggestive of apical ballooning and a toxic-appearing wide QRS complex electrocardiogram (EKG). The patient was successfully treated with sodium bicarbonate infusion for presumed flecainide toxicity. The regional wall motion abnormality and EKG changes resolved along with normalisation of capture thresholds after 2 days of treatment. The patient underwent an uncomplicated successful AV nodal ablation several weeks later.

Risk Factors for Left Ventricular Dysfunction Following Surgical Management of Cardiac Fibroma

Background: Surgical resection of cardiac fibromas in children reduces hemodynamic and arrhythmia burden; however, little is known about postoperative left ventricular (LV) function. We aimed to evaluate factors associated with postoperative LV dysfunction. Methods: In this retrospective observational cohort study, imaging data were reviewed from 41 patients who had undergone surgical resection of a cardiac fibroma. Tumor volume was indexed to body surface area (tumor volume index). Right ventricular tumors were excluded from analysis of postoperative ventricular function. Postoperative regional wall motion abnormality score was defined as number of wall segments with regional wall motion abnormality, and LV dysfunction was defined as LV ejection fraction <50%. Cardiovascular magnetic resonance-derived strain was low if <5%ile by previously published normative data. Results: Of 41 patients who underwent resection at a median age of 2.1 years (range, 0.5–19), 37 fibromas were in the LV, (29 free wall and 8 septal), and 4 in the right ventricle. Preoperative median tumor volume index was 66 mL/m 2 (range, 11–376). Of 37 patients with LV tumors, younger patients had larger tumor volume index and higher grades of preoperative mitral regurgitation ( P <0.001). Larger tumor volume index correlated with higher postoperative regional wall motion abnormality score ( P <0.001). By paired pre- and post-operative cardiovascular magnetic resonance (n=14), LV end-diastolic volume increased (mean 76 versus 101 mL/m 2 , P =0.011), with decreased LV ejection fraction (mean 60% versus 55%, P =0.014), a higher prevalence of low global circumferential strain (36% versus 64%, P =0.045), and decreased cardiac index (mean 4.8 versus 3.9 L/[min·m 2 ], P =0.039). More than mild preoperative mitral regurgitation was the only independent predictor of predischarge LV dysfunction (odds ratio, 22 [95% CI, 2.8–179], P =0.008). Conclusions: Surgical resection of LV fibroma is associated with regional wall motion abnormality, increased LV volume, and reduced systolic function. Children with significant preoperative mitral regurgitation are at highest risk for LV dysfunction and warrant ongoing close surveillance.

Abstract 311: Machine Learning of the Electrocardiogram to Detect Regional Structural Abnormalities of the Heart

Introduction: Regional dysfunction of cardiac myocardium can result from diverse underlying conditions and cause adverse events even in patients without clinically apparent cardiovascular disease over ejection fraction. Assessment of regional wall motion abnormalities (WMA) currently requires sophisticated imaging that is not feasible for population screening or frequent disease monitoring. Hypothesis: We hypothesized that an AI-enabled ECG model trained on a dataset of qualitative labels could identify and localize wall motion abnormalities with higher accuracy than traditional ECG analysis Methods: In a large academic center, a deep convolutional network was developed with raw 12-lead ECGs and associated reports from 82,424 transthoracic echocardiograms (N = 50,960 patients, age 64 ± 17 years, 54.5% male). 80% of the data was used in model development and the remaining 20% was used for testing. ECGs with ventricular pacing and non-finalized echocardiography reports were excluded. Pre-processing included Kors transformation and beat extraction for input size of 3x300 samples (Figure 1A) and output labels were established by NLP of semi-structured echocardiography reports. Results: ML ECG based models predicted inferior/posterior regional wall motion abnormality with C-statistic of 0.772 (Figure 1B). Physician interpretation of Q-wave ECG pattern was inferior (C-statistic of 0.505). Other segments had similar AUC (apex 0.81, anterior 0.80, lateral 0.75, septal 0.75). Patients with positive ECG screen had +LR 2.70 of having a wall motion abnormality on echocardiography and patients with WMA by echocardiography had decreased survival (LR 0.41, CI: 0.34-0.47, p<0.005) mortality over follow-up of >1500 days (Figure 1C). Conclusion: This study is the first to evaluate the presence and location of regional wall motion abnormalities from inexpensive and noninvasive 12-lead ECG. This approach could be applied for widespread ambulatory screening.

A case of recurrent takotsubo-like cardiomyopathy associated with pheochromocytoma exhibiting different patterns of left ventricular wall motion abnormality and coronary vasospasm: a case report

Background Takotsubo-like cardiomyopathy associated with pheochromocytoma (Pheo-TTS) is a recognized but uncommon disorder. While Pheo-TTS might more often recur and the pattern of left ventricular (LV) wall motion abnormality is more diverse compared with primary TTS, it remains to be elucidated whether coronary functional abnormalities are also involved. Case summary A 50-year-old woman was referred with a chief complaint of transient chest pain, dyspnoea, and paroxysmal thyroid swelling that usually developed after meals. In the past, she had been admitted to emergency rooms three times due to pulmonary oedema following the above attacks. Serial cardiac catheterizations showed normal coronary arteries and morphologically different types of LV dysfunction each time; apical LV ballooning at the first, basal LV ballooning at the second, and diffuse LV hypokinesis at the last admission. Acetylcholine (ACh) provocation testing for coronary vasospasm was negative at the second admission. During hospitalization in our department, abdominal ultrasonography for screening detected a right adrenal mass and the urinary normetanephrine level was increased. The adrenal tumour was urgently removed surgically and finally she was diagnosed as having norepinephrine-secreting pheochromocytoma. Acetylcholine testing was again performed just after the operation, showing both epicardial and microvascular coronary spasms. Since the operation, she has been free of symptoms. Importantly, ACh testing at 1-year follow-up showed that epicardial spasm was no longer noted, whereas coronary microvascular spasm persisted. Discussion Adrenal pheochromocytoma could cause recurrent attacks of catecholamine surges with different patterns of LV dysfunction, where coronary vasospasm may also be involved along the coronary arteries.