Association Between Patent Foramen Ovale and Overt Ischemic Stroke in Children With Sickle Cell Disease

Ischemic stroke is one of the most devastating complications of sickle cell anemia (SCA). Previous studies have shown that intracardiac shunting including patent foramen ovale (PFO) can be a potential risk factor for stroke in children with SCA. This study investigates the association between PFO and overt ischemic stroke in the DISPLACE (Dissemination and Implementation of Stroke Prevention Looking at the Care Environment) study cohort of 5,247 children with SCA of whom 1,414 had at least one clinical non-contrast transthoracic echocardiogram. Presence of PFO was taken from the clinical report. Further, we assessed the association between PFO and other clinical and hemolytic factors in children with SCA such as history of abnormal sickle stroke screen [elevated Transcranial Doppler ultrasound (TCD) velocity] and patient's baseline hemoglobin. In 642 children for whom all data were available, the adjusted odds ratio (OR) for overt stroke was higher in those with PFO but this was not statistically significant (OR: 1.49, 95% CI: 0.20–11.03, p = 0.6994). With an OR of 0.85, the study suggested less PFOs in those with abnormal TCD, but this was not statistically significant (95% CI: 0.17–4.25, p = 0.8463). Overall, the prevalence of PFO in this large sub study of non-contrast echocardiography amongst children with SCA is much lower than previous smaller studies using bubble contrast echocardiography. Overt stroke was non-statistically more common in children with SCA and PFO, but there was no evidence that PFO was more common in those with abnormal TCD, the most important pediatric sickle stroke screen.

813 The added value of transthoracic three dimensional echocardiography in apical hypertrophic cardiomyopathy

We present the case of a 73-year-old patient with a recent diagnosis of hypertrophic cardiomyopathy (HCM). He was asymptomatic and has no family history of sudden cardiac death (SCD), syncope or ventricular arrhythmias. An echocardiogram performed at the moment of diagnosis (2020), showed left ventricular (LV) asymmetric apical hypertrophy with maximal wall thickness of 21 mm. Cardiac magnetic resonance (CMR) confirmed LV apical hypertrophy with mid-ventricular obliteration, and late gadolinium enhancement in the apical segments, without wall motion abnormalities present at rest. According to 2014 ESC guidelines, his calculated risk score for sudden cardiac death was low (1.23% at 5 years). On 2021, a comprehensive transthoracic echocardiographic examination including advanced techniques (three-dimensional echo-3DE-, and two-dimensional speckle-tracking-2DSTE) was done as part of his routine follow-up in our cardiomyopathy outpatient clinic. The echo study showed an asymmetric pattern of LV hypertrophy with a maximal wall thickness of 21 mm at the level of the anterolateral apical segment, normal LV volumes (end-diastolic volume 55 mL/m2) and ejection fraction (69%) by 3DE. LV longitudinal strain analysis by 2DSTE showed impaired LV myocardial deformation mainly at the apical LV segments (GLS = −13.6%). There was evidence of dynamic intracavitary obstruction (maximal gradient 32 mmHg at rest and raised to 52 mmHg during Valsalva manoeuvre). 3DE views of the LV (both multi-slice display and 3D rendered image) allowed to avoid foreshortening of the LV apical views, and to appreciate the actual wall motion at the real LV apex. They revealed a LV apical aneurysm which was not detected in the conventional LV-focused apical 2D views (Figure 1A and B). Apical hypertrophic cardiomyopathy (ApHCM) is a variant of HCM that is characteristic of focal thickening of the LV apical myocardium and was reported to have a more benign course than other non-apical forms. However, the presence of LV aneurysm in ApHCM patients is associated with an increased risk for ventricular arrhythmias, sudden cardiac death and thromboembolism. Accordingly, the detection of apical LV aneurysms has significant impact on patient management. Guidelines recommend the use of contrast echocardiography or CMR when the apical region of the LV is suboptimally visualized by conventional 2D echocardiography. However, contrast echocardiography may still be affected by apical foreshortening resulting in suboptimal accuracy, as it is a 2D technique. On the other end, CMR may be contraindicated or not widely available for routine yearly follow-up for all HCM patients requiring regular imaging follow-up. Our clinical case emphasizes the added value of 3DE to increase the sensitivity of transthoracic echocardiography in detecting apical LV aneurysms in patients with apical HCM with important clinical implications for the management of the patient. 813 Figure 1(A) 2D 4chamber-view showing maximal wall thickness in the apical segments (21 mm) with apical obliteration. At a first evaluation, apical aneurism is not easily detected. (B) 4D rendering of the apex showing the apical aneurism.

440 Assessing cardiac output by echocardiography: is contrast always better?

Aims Contrast echocardiography is very useful in clinical cardiology. It is mainly performed for the assessment of global left ventricular (LV) function, left ventricular ejection fraction (LVEF), and stroke volume (SV), thanks to improved visualization of endocardial LV borders. Contrast echocardiography, however, is not always easily available, it is more expensive than an ordinary echocardiography and it can be contraindicated in some situations (e.g. in the presence of egg allergy). This study aimed to compare the estimation of cardiac output during traditional transthoracic echocardiography and after the injection of (Sonovue) contrast. Methods and results Patients who underwent an echocardiography with and without injection of (Sonovue) contrast between April 2019 and September 2021 were enrolled in the study. A complete transthoracic echocardiography was performed and Sonovue contrast was then injected. End-diastolic and end-systolic left ventricular volume in apex 4 and 2 chamber views, biplane LVEF with Simpson’s formula, end-diastolic and end-systolic left ventricular diameters in parasternal long axis were measured prior and after injecting contrast. Left ventricular outflow tract diameter (LVOTd) was measured and LV outflow tract velocity time integral was traced in order to calculate LVOT VTI SV, as the product of LVOT cross sectional area (assuming that LVOT is circular) to the LVOT VTI. LVOT VTI SV obtained during traditional echocardiography was compared to LVEF SV, calculated as the difference between end-diastolic and end-systolic volume traced after injecting Sonovue contrast. Seventy-eight patients were enrolled in the study. Forty-two had history of CAD, 22 presented dilatative cardiomyopathy, 2 hypertrophic cardiomyopathy (HMC), 1 arrhythmogenic right ventricular dysplasia; 16 had atrial fibrillation, 66 arterial hypertension, and 20 diabetes. The main indications for contrast echocardiography were measurement of EF (39 cases) and exclusion of thrombi in LV apex (18 cases). Other indications were suspect of HCM, atrial myxoma or LV non-compaction. LVOT VTI stroke volume was calculated in 64 patients (LVOT diameter was not well visualized in 8 patients and LVOT VTI could not be measured in 14 patients due to poor acoustic windows). In the same patients LVEF Stroke Volume was also calculated. A strong correlation (P-value < 0.0001) between LVOT stroke volume and LVEF Stroke Volume was found (Figure 1). Conclusions Contrast echocardiography is very useful in clinical practice, however, requires trained physicians and its use is not widespread. This study demonstrates that estimating cardiac output through LVOT VTI SV, in patients with suboptimal echo images can be equally accurate as measuring LVEF SV with contrast echocardiography. This could be particularly useful in the acute settings when contrast echocardiography isn’t always feasible and knowing cardiac output can be important for therapeutic implications.

Reduced Microvascular Blood Volume as a Driver of Coronary Microvascular Disease in Patients With Non-obstructive Coronary Artery Disease: Rationale and Design of the MICORDIS Study

Background: Ischemia with non-obstructive coronary arteries (INOCA) is part of the ischemic heart disease spectrum, and is particularly observed in women. INOCA has various mechanisms, such as coronary vasospasm and coronary microvascular dysfunction (CMD). A decreased coronary flow reserve (CFR) and-or increased myocardial resistance (MR) are commonly used to diagnose CMD. However, CFR and MR do not describe all pathophysiological mechanisms underlying CMD. Increased myocardial oxygen consumption (MVO2) normally increases myocardial blood volume (MBV), independently from myocardial blood flow (MBF). In addition insulin enhances MBV in healthy skeletal muscle, and this effect is impaired in INOCA-related conditions such as diabetes and obesity. Therefore, we propose that MBV is reduced in INOCA patients.Aim: To assess whether myocardial blood volume (MBV) is decreased in INOCA patients, at baseline, during hyperinsulinemia and during stress.Design: The MICORDIS-study is a single-center observational cross-sectional cohort study (identifier NTR7515). The primary outcome is MBV, compared between INOCA patients and matched healthy controls. The patient group will undergo coronary function testing using a Doppler guidewire, intracoronary adenosine and acetylcholine to measure CFR and coronary vasospasm. Both the patient- and the control group will undergo myocardial contrast echocardiography (MCE) to determine MBV at baseline, during hyperinsulinemia and during stress. Subsequently, cardiac magnetic resonance (CMR) will be evaluated as a new and noninvasive diagnostic tool for CMD in INOCA patients. Microvascular endothelial function is a determinant of MBV and will be evaluated by non-invasive microvascular function testing using EndoPAT and by measuring NO production in circulating endothelial cells (ECFCs).

Percutaneous Closure of Patent Foramen Ovale under TEE Guidance in Cryptogenic Stroke and Migraine

Background. To investigate safety and clinical efficacy of percutaneous closure of PFO under TEE guidance in patients with cryptogenic stroke (CS) and migraine, combined PFO and large right-to-left shunt（RLS）. Methods. From January 2018 to June 2021 in our hospital, 128 patients were treated by percutaneous PFO occlusion under TEE guidance in CS and migraine. Effective occlusion rate, complications, cerebral ischemia events, migraine relief, and hospitalization costs were analyzed. Postoperative follow-up were conducted. Results. All the 128 patients were successful in percutaneous PFO occlusion. The average operation time was 20~32 (25.6±4.2) min, the average hospitalization time was 2~3(2.8±0.4) d. There were 122 patients without RLS and 6 patients with medium residual RLS, with the sealing efficiency of 95.31% by TTE and right heart contrast echocardiography. 30 patients with migraine underwent percutaneous PFO occlusion, 24 patients relief after operation, with a relief rate of 80.0%. Postoperative follow-up was conducted for 1-36（28.8±3.6）months, and no follow-up was lost. 98 cases of CS with PFO underwent percutaneous blockade were followed up without cerebral embolism recurrence, 26 of 30 patients with migraine received significant remission of migraine, with remission rate of 86.66%. There were no serious adverse events. Conclusions. For patients with CS and migraine, combined PFO and large RLS, percutaneous PFO occlusion under the guidance of TEE has fewer complications and is safe and effective. It can prevent the recurrence of CS and treat migraine.