Association between Cardiac Auscultation and Echocardiographic Findings in Warmblood Horses

Heart murmurs are detected frequently when auscultating horses and certain murmurs can usually be linked to specific valvular regurgitations. Limited information exists about the accuracy of these broad rules in warmblood horses and the influence of grade of the regurgitation and dimensional changes on murmur intensity. This study aims to clarify the accuracy of cardiac auscultation in warmblood horses and the influence of the grade of regurgitation and dimensional changes on the loudness of the murmur. In this retrospective study, 822 warmblood horses presented for cardiac examination in a large equine referral center in northern Germany underwent a thorough cardiac auscultation. In total, 653 of these revealed one or more heart murmurs. Most common auscultatory findings were left-sided systolic murmurs (68%) or left-sided diastolic murmurs (15%). On 635 of these horses, an echocardiographic examination was performed, revealing regurgitations of the mitral valve as the most common valvular regurgitation (77%) followed by regurgitations of the aortic valve (23%). Thirty-one percent of horses that underwent echocardiographic examination displayed dimensional changes of one or more compartments of the heart, with the left atrium being most affected (21%), followed by the left ventricle (13%). The main goal of this study was to link certain auscultatory findings with results of the echocardiographic examinations, trying to determine whether auscultation and echocardiography agreed on the valve affected, as well as to find out if loudness of the murmur coincided with grade of regurgitation and presence of dimensional changes. Agreement between auscultation and cardiac ultrasound was substantial (Kappa 0.74) if one or more murmurs and regurgitations were present and almost perfect (Kappa 0.94) if only one murmur and one regurgitation were found. Auscultation was particularly well suited for detection of left-sided systolic and diastolic murmurs, with 87% of left-sided systolic murmurs being caused by a mitral valve regurgitation and 81% of left-sided diastolic murmurs originating from an aortic valve regurgitation. We found a fair agreement between the grade of regurgitation and the respective murmur. Association was particularly good between mild regurgitations and low-grade murmurs, while differentiation between moderate to severe regurgitation based upon the loudness of the murmur was less reliable. Dimensional changes were usually linked to more severe regurgitations and higher-grade murmurs. However, a direct correlation between murmur intensity and the presence or severity of dimensional changes, independent of the grade of valvular regurgitation, could not be established in this cohort of horses.

751 Quantitative changes in intracardiac vortices between patients with different ventricular geometry

Aims Over the past decades growing evidence have demonstrated the promising role of intracardiac fluid-dynamics in evaluating cardiac performance. To investigate quantitative changes in vortices parameters in patients with different ventricular geometry. Methods and results We enrolled 50 consecutive patients with one of the following: LV concentric hypertrophy (CH), eccentric hypertrophy (EH), concentric remodelling, and normal LV geometry (CTRL). They underwent a complete echocardiographic examination with intracardiac fluid-dynamic analysis by Color Vector Flow Mapping (Hyperdoppler). The following parameters were obtained: vortex area (VA); vortex length (VL); and vortex depth (VD). Bland Altman Plot has been used to assess intra and inter-observer variability. Mean VD was higher in CR, CH, and EH compared to CTRL (P = 0.013, P = 0.001, and P = 0.022, respectively). Moreover, CH showed higher VL (P = 0.006) and larger VA (P = 0.012) compared to CTRL. A similar trend was noticed in EH patients, despite did not reach statistical significance (P = 0.21 and P = 0.07 for VA and VL, respectively). No significative differences in vortices parameters have been observed between CH and EH. Conclusions This is the first study providing quantitative echocardiographic parameters of vortex location and morphology in different LV geometries. Quantitative fluid-dynamic assessment was feasible and reliable in the whole population.

639 A case of acute transient constrictive pericarditis—an unusual presentation

Aims Transient constrictive pericarditis (TCP) is a rare manifestation which can occur in up to 15% of cases of acute pericarditis and most have resolution after 3 months of anti-inflammatory therapy. Methods and results We present the case of a young guy who showed up at our emergency department complaining of pericarditic chest pain and fever up to 39 °C degrees since the previous 4 days. After physical examination, electrocardiogram, blood tests, chest X-ray, and echocardiography acute pericarditis with severe pericardial effusion (more than 20 mm of thickness) were diagnosed and an empiric anti-inflammatory therapy with ibuprofen and colchicine was started. After 2 weeks of therapy, patient was not clinically improving with a worsened pericardial effusion and only a mild reduction of inflammatory markers. During an echocardiographic examination, features of constrictive physiology were discovered: respirophasic interventricular septal shift, increased respiratory variation of the mitral and tricuspidal inflow, plethoric inferior vena cava, and ‘annulus reversus’ and ‘annulus paradoxus’ on Tissue Doppler Imaging (TDI). Cardiac magnetic resonance (CMR) was also performed to confirm the diagnosis of acute pericardial constriction: it revealed increased T2-weighted imaging signal and increased Delayed Gadolinium Enhanced (DGE) signal, respectively consistent with oedema and with neovascularization, both suggestive of acute pericardial inflammation. Therefore, oral low doses corticosteroid was started After 2 weeks course of ‘triple therapy’ the patient was clinically improved and the echocardiographic features of constrictive physiology were no longer present thus allowing his discharge and the continuation of therapy at home. Conclusions This case was remarkable because it showed that constrictive pericarditis may present in a reversible form with medical therapy, this meaning it is due to pericardial oedema, inflammation and fibrin deposition similar to acute pericarditis rather than the pericardial fibrosis and calcification more commonly seen in chronic pericardial constriction.

445 The long-term natural course of moderate tricuspid regurgitation

Aims The epidemiological and clinical burden of tricuspid regurgitation (TR) has lately gained much attention from the scientific community. In fact, recent epidemiological studies report a prevalence of moderate and severe TR in population over the age of 65 screened for valve disease ranging from 2.7% to 4%, with an independent prognostic role clearly worsening long-term survival along with the increasing severity of TR grade. Particularly, as TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up and management. Nonetheless, data focusing on the clinical and echocardiographic course of a cohort of patients suffering from moderate TR, although eagerly awaited, are lacking. To evaluate and clarify the evolution and the long-term independent clinical outcome of a cohort of patients suffering from moderate functional or organic TR. Methods We electronically searched for ambulatory and in-patients who underwent transthoracic and/or transesophageal echocardiography with a diagnosis of moderate TR, along with a complete clinical evaluation, in our centre between January 2014 and December 2019. Patients were considered eligible if a second echocardiographic examination including a careful evaluation of the severity of TR and clinical information were available for a minimum follow-up of 6 months. The primary endpoint was all-cause mortality; secondary endpoints were hospitalization for HF and TV intervention, either surgical or percutaneous. Results We enrolled 130 patients, predominantly female with multiple comorbidities, cardiovascular risk factors and history of atrial fibrillation; TR aetiology was functional in most cases (93 patients, 72%). Over a mean follow-up of 5 years, TR grade progressed to at least severe in 55 patients (42%): at multivariate analyses, diabetes mellitus (P=0.003), anaemia (P=0.03) and at least moderate mitral regurgitation or aortic stenosis (P=0.039) were all predictors of TR severity progression. The primary endpoint occurred in 41(32%) of patients and was significantly more frequent (P<0.0001) in patients with severe TR at follow-up compared to those without TR severity progression. HF hospitalization and TV intervention occurred in 47 (36%) and 20 (14%) of patients: again, both were significantly more frequent in patients with severe TR (P=0.0008 and P=0.02, respectively) in comparison to those without worsened TR severity at follow-up. Conclusions Our results show that moderate TR, over a long-term follow-up period, worsens to at least severe grade in a relevant proportion of patients, conveying a significant independent risk of hard events such as all-cause death, HF hospitalization and TV intervention. Therefore, this cohort of patients should be appropriately managed and closely followed-up in order to avoid adverse clinical events related to the natural course of this valvulopathy.

Progression of Carcinoid Heart Disease in the Modern Management Era

Background The development of carcinoid heart disease (CaHD) is still relatively unclear. It is difficult to define an optimal follow‐up for patients without any cardiac involvement at baseline. The aim of this study was to assess the prevalence and natural history of CaHD by annual echocardiographic examinations. Methods and Results We studied 137 consecutive patients (61±12 years, 53% men) with proven digestive endocrine tumor and carcinoid syndrome between 1997 and 2017. All patients underwent serial conventional transthoracic echocardiographic studies. Right‐sided and left‐sided CaHD were systematically assessed. We used a previous validated echocardiographic scoring system of severity for the assessment of CaHD. An increase of 25% of the score was considered to be significant. Mean follow‐up was 54±45 months. Prevalence of CaHD was 27% at baseline and 32% at 5‐year follow‐up. Disease progression was reported in 28% of patients with initial CaHD followed up for >2 years (n=25). In patients without any cardiac involvement at baseline, occurrence of disease was 21%. CaHD occurred >5 years from the initial echocardiographic examination in 42% of our cases, especially in patients presenting with new recurrence of a digestive endocrine tumor. An increase of urinary 5‐hydroxyindoleacetic acid by 25% during follow‐up was identified as an independent predictor of CaHD occurrence during follow‐up (hazard ratio [HR], 5.81; 95% CI, 1.19–28.38; P =0.03), as well as a maximum value of urinary 5‐hydroxyindoleacetic acid >205 mg/24 h during follow‐up (HR, 8.41; 95% CI, 1.64–43.07; P =0.01). Conclusions Our study demonstrates that in patients without initial CaHD, cardiac involvement may occur late and is related to serotonin. Our data emphasize the need for cardiologic follow‐up in patients with recurrence of the tumor process.

Efficiency of the Left Atrial Appendage Thrombus Dissolution in Patients with Persistent Nonvalvular Atrial Fibrillation with Warfarin or Direct Oral Anticoagulants Therapy

Aim. Compare the incidence of the left atrial appendage (LAA) thrombus dissolution in patients with persistent nonvalvular atrial fibrillation receiving warfarin and direct oral anticoagulants (DOAC).Materials and methods. 68 patients with persistent nonvalvular atrial fibrillation were included in a retrospective study (age was 59.7±9.8 years, 60.3% men), in whom at least one repeated transesophageal echocardiographic examination was performed after detecting a thrombus. After detecting a thrombus in the LAA, 37 (54.4%) patients started or continued taking warfarin in doses that ensure the INR maintenance at the level of 2-3, 14 (20.6%) started or continued taking dabigatran at a dose of 150 mg 2 times/day, 14 (20.6%) started or continued taking rivaroxaban 20 mg 1 time/day and 3 (4.4%) started or continued taking apixaban 5 mg 2 times/day. Repeated transesophageal echocardiographic examination was performed on average 33.3±14.2 days after the first one.Results. Dissolution of a previously identified thrombus was found in 26 (83.9%) of 31 patients receiving DOAC and in 19 (51.4%) of 37 patients receiving warfarin (p=0.011). The logistic regression analysis showed that the chances of a thrombus dissolution in LAA while taking DOAC are 14.8 times (95% confidence interval [CI] was 2.469-88.72) higher than while taking warfarin. The size and the rate at which blood is expelled from the LAA also have an independent influence on the chances of thrombus dissolution. An increase in the size of a thrombus by 1 mm reduces the chances of a thrombus dissolution by 1.136 (95% CI was 1.040-1.244) times, and an increase in the rate of blood expulsion from the LAA by 1 cm/sec increases these chances by 1.105 (95% CI was 1.003-1.219) times.Conclusion. In the present study, the incidence of the LAA thrombus dissolution in patients with persistent nonvalvular atrial fibrillation while receiving DOAC was higher than while receiving warfarin.

The influence of region of interest width in fetal 2D-speckle tracking echocardiography late in pregnancy

Speckle tracking echocardiography is a promising method for assessment of myocardial function in fetal and neonatal hearts, but further studies are necessary to validate and optimize the settings for use in fetal cardiology. Previous studies have shown that the definition of the region of interest (ROI) affects strain values in adults. The aim of this study was to investigate how different widths of ROI influences measurements of four-chamber longitudinal systolic strain in fetuses late in pregnancy. Thirty-one singleton, healthy fetuses born to healthy mothers underwent an echocardiographic examination during gestational week 37. Speckle tracking was performed with two different settings for ROI width; the narrowest and second most narrow, provided both widths were assessed as suitable for the myocardial wall thickness of the fetus. We found an inverse correlation between the ROI width and the strain values. Four-chamber longitudinal strain changed from − 20.7 ± 3.6% to − 18.0 ± 4.4% (p < 0.001) with increasing ROI width. Further, strain decreased from the endocardium to the epicardium with multilayer measurements. Different widths of ROI influenced the strain measurements significantly in the fetal heart, comparable to what has been reported in adults. A standardization of the ROI setting could improve the interpretation, and reduce variability in fetal strain measurements.

Effect of adrenalectomy on remission of subclinical left ventricular dysfunction in patients with pheochromocytoma: a speckle-tracking echocardiography study

Background: Pheochromocytomas (PHEO) are tumours with the ability to produce, metabolize and secrete catecholamines. Catecholamines overproduction leads to the decrease of longitudinal function of the left ventricle (LV) measured by speckle tracking echocardiography. Patients with PHEO have lower magnitude of global longitudinal strain (GLS) than patients with essential hypertension. GLS normalization is expected after resolution of catecholamine overproduction. Methods: Twenty-four patients (14 females and 10 males) with recent diagnosis of PHEO have been examined before and one year after adrenalectomy. An echocardiographic examination including speckle tracking analysis with the evaluation of GLS and regional longitudinal strain (LS) in defined groups of LV segments (basal, mid-ventricular and apical) was performed. Results: One year after adrenalectomy magnitude of GLS increased (−14.3 ± 1.8 to −17.7 ± 1.6 %; p < 0.001). When evaluating the regional LS, the most significant increase in the differences was evident in apical segment compared to mid-ventricular and basal segments of LV (-5.4 ± 5.0 vs. -1.9 ± 2.7 vs.-1.6 ± 3.8; p < 0.01). Conclusions: In patients with PHEO, adrenalectomy leads to an improvement of subclinical LV dysfunction represented by increasing magnitude of GLS, which is the most noticeable in apical segments of LV.

Dynamic Aortic Aneurism Risk Factors

According to different systematic reviews incidence of thoracic aortic aneurysms (TAA) in the general population is increasing in frequency ranging from 5 to 10.4 per 100000 patients. However, only few studies have illustrated the role of different risk factors in the onset and progression of ascending aortic dilatation. Currently, noninvasive imaging techniques are used to assess the progression rate of aortic and aortic valve disease. Transthoracic (TT) Echocardiographic examination routinely includes evaluation of the aorta It is the most available screening method for diagnosis of proximal aortic dilatation. Since the predominant area of dilation is the proximal aorta, TT-echo is often sufficient for screening. We retrospectively analyzed the ECHO database with 78499 echocardiographic records in the Almazov National Medical Research Centre to identify patients with aneurysm. Detailed information including demographic characteristics, ECHO results and comorbidities were extracted from outpatient clinic and from hospital charts related to hospitalizations occurring within a year before index echocardiography was performed. Comorbid diseases were similarly extracted from outpatient clinic and/or hospital admissions. The classifier showed an AUC-ROC for predicting of aneurism detection after a repeated ECHO at 82%.