Subclinical Myocardial Dysfunction in Patients with Persistent Dyspnea One Year after COVID-19

Long coronavirus disease 2019 (COVID-19) was described in patients recovering from COVID-19, with dyspnea being a frequent symptom. Data regarding the potential mechanisms of long COVID remain scarce. We investigated the presence of subclinical cardiac dysfunction, assessed by transthoracic echocardiography (TTE), in recovered COVID-19 patients with or without dyspnea, after exclusion of previous cardiopulmonary diseases. A total of 310 consecutive COVID-19 patients were prospectively included. Of those, 66 patients (mean age 51.3 ± 11.1 years, almost 60% males) without known cardiopulmonary diseases underwent one-year follow-up consisting of clinical evaluation, spirometry, chest computed tomography, and TTE. From there, 23 (34.8%) patients reported dyspnea. Left ventricle (LV) ejection fraction was not significantly different between patients with or without dyspnea (55.7 ± 4.6 versus (vs.) 57.6 ± 4.5, p = 0.131). Patients with dyspnea presented lower LV global longitudinal strain, global constructive work (GCW), and global work index (GWI) compared to asymptomatic patients (−19.9 ± 2.1 vs. −21.3 ± 2.3 p = 0.039; 2183.7 ± 487.9 vs. 2483.1 ± 422.4, p = 0.024; 1960.0 ± 396.2 vs. 2221.1 ± 407.9, p = 0.030). GCW and GWI were inversely and independently associated with dyspnea (p = 0.035, OR 0.998, 95% CI 0.997–1.000; p = 0.040, OR 0.998, 95% CI 0.997–1.000). Persistent dyspnea one-year after COVID-19 was present in more than a third of the recovered patients. GCW and GWI were the only echocardiographic parameters independently associated with symptoms, suggesting a decrease in myocardial performance and subclinical cardiac dysfunction.

‘Oscar’

This article applies a persona studies approach to the case study of the Academy Awards. Key literature is used to situate an ‘Oscar’ persona within existing conceptualisations from the discipline. Oscar represents a composite persona that encapsulates an event, its broadcast, an Academy of individuals, and a larger discursive industry. It is a non-human persona that is coloured by distinctly human elements; it is collectively constructed on a massive scale, the process of which inviting constant contestation. Drawing from these theorisations I conduct a textual analysis to reach a persona reading of Oscar. As collective authors of the persona, members of the Academy, associated performers, and discursive contributors employ three distinct and consistent persona strategies: the Functional, the Spiritual, and the Ironic. Oscar’s taste-making function is enabled by extravagant staging and tempered by expressions of philanthropy yet performed with ironic self-effacement. The cumulative effect of these three performances allows Oscar manoeuvrability across the requirements of the different cultural contexts of each year. As well as providing a unique prism for understanding the Oscars as an institution, this work demarcates different levels of collective persona construction, challenging notions of central authority in production and performance, and accounting for the ongoing constructive work of publics.

164 Effect of cardiac contractility modulation therapy on myocardial work in patients with heart failure with reduced ejection fraction

Aims Cardiac contractility modulation therapy (CCMT) has been shown to reduce hospitalizations and to improve quality of life in heart failure patients with reduced ejection fraction (HFrEF) who remain symptomatic despite disease-modifying therapies. Strain imaging derived myocardial work (MW) is an emerging tool for evaluating left ventricular mechanics by incorporating systolic deformation and afterload burden in the analysis. To evaluate prospectively the impact of CCMT in HFrEF patients on MW derived parameters in relation to standard echocardiographic indices. Methods and results We recruited 12 HFrEF patients with indications to CCMT according to current clinical practice. A comprehensive echo-Doppler evaluation, including speckle tracking derived assessment of global longitudinal strain (GLS), was performed before and after three months from the CCM device implantation. Parameters of MW such as global work index (GWI), global constructive work (GCW) global wasted work (GWW), and global work efficiency (GWE) were calculated according to standardized procedures. Median values (interquartile range) were compared for all those parameters from baseline and 3-month follow-up with Wilcoxon Rank Sum test for continuous variables. At three months from CCM implant an improvement of LVEF [from 32% (27–34) to 36% (29–39), P < 0.05], GLS [from 7.4% (6.2–11.2) to 9.9% (7.5–9.4), P < 0.05], GWI [from 461 mmHg (372–613) to 589 mmHg (413–696), P < 0.05], GCW [from 800 mmHg (620–930) to 970 mmHg (644–1009), P = 0.236], and GWE [from 73% (65–78) to 85% (78–87), P < 0.05] was observed, with a consistent reduction of GWW [from 161 mmHg (148–227) to 125 mmHg (101–188), P < 0.05]. We also found a positive correlation between the magnitude of LVEF improvement and the baseline values of GCW (r = 0.727, P = 0.011). Conclusions At 3 months, CCMT significantly improves standard and advanced left ventricular systolic function indices. This improvement is due to the increase of constructive work and a reduction of wasted work. In addition, the increase of left ventricular ejection fraction can be predicted by the global constructive work levels at baseline.

48 Correlation of left ventricular myocardial work indices and invasive measurement of stroke work

Aims A novel echocardiographic method allows to non-invasively assess myocardial work using pressure–strain loops. Even though left ventricular myocardial work has already emerged as a promising prognostic tool for various pathological conditions, its relationship with invasively-derived corresponding indices has not been assessed in humans yet. This study aimed to explore the correlation between left ventricular myocardial work (LVMW) indices and invasively derived left ventricular stroke work index (LVSWI) in a cohort of patients with advanced heart failure (HF) considered for heart transplantation. Methods and results All consecutive patients with advanced heart failure considered for heart transplantation from 2016 to 2021 that had already performed right heart catheterization (RHC) as part of the workup and with an available echocardiographic exam were included (n = 91). Myocardial work analysis was performed in 44 patients, according to exclusion criteria. Conventional LV functional parameters and LVMW indices, including LV global work index (LVGWI), LV global constructive work (LVGCW), LV global wasted work (LVGWW), LV global work efficiency (LVGWE), and other were calculated and compared with invasively measured LV stroke work index (LVSWI). Median age was 60 years [interquartile range (IQR): 54–63]. Median time between RHC and echocardiography was 0 months (IQR: 0–1). For the most part, etiology of HF was non-ischaemic (61.4%) and all patients were either on class NYHA II (61.4%) or III (27.3%). Median left ventricular ejection fraction was 25% (IQR: 22.3–32.3), median NT-proBNP 1377 pg/ml (IQR: 646–2570). Among conventional parameters of LV function, LVEF did not significantly correlate with LVSWI (r = 0.308; P = 0.050) whereas LV global longitudinal strain (LVGLS) did (r = −0.337; P = 0.031). With regard to LVMW indices, some of them demonstrated correlation with LVSWI, particularly LVGWI (r = 0.425; P = 0.006), LVGCW (r = 0.506; P = 0.001), LV global positive work (LVGPW; r = 0.464; P = 0.003), and LV global systolic constructive work (LVGSCW; r = 0.471; P = 0.002). Conclusions Among left ventricular myocardial work indices, LVGCW correlated better with invasively derived stroke work, thus representing a powerful and reliable tool for a more comprehensive evaluation of myocardial function.

New Indicators of Myocardial Work in Healthy Individuals

Aim. To study in healthy individuals the gender and age characteristics of left ventricular (LV) myocardial work indicators, their correlations with global LV deformity indicators and echocardiographic parameters characterizing LV systolic and diastolic functions.Materials and methods. 70 Healthy individuals (n=70; 34 men and 36 women; aged 39.3±8.9 years) were included in the study. The echocardiographic examination determined the standard parameters and indicators of myocardial work: global work efficiency (GWE), global constructive work (GCW), global wasted work (GWW), global myocardial work index (GWI); as well as the myocardium deformation characteristics: global longitudinal deformation (GLS), global radial deformation (GRS) and global circular deformation (GCS). Spearman's correlation coefficient was used to investigate the relationship between parameters. A correlation was considered weak at r≤0.3, moderate at 0.3<r<0.7, and strong at r≥0.7.Results. The average value of global work efficiency (GWE) in men was 97% (96; 98), in women – 98% (97; 98). Global constructive work (GCW) in men was 2343.8±350.4 mm Hg%, in women – 2362.2±343.8 mm Hg%. The average value of global wasted work (GWW) in men was 46 mm Hg% (27; 75), in women – 44 mm Hg% (33; 55.5). The global myocardial work index (GWI) in men was 2069.9±356.4 mm Hg%, in women – 2055.7±339.9 mm Hg%. No significant differences were found in the comparative analysis of performance indicators. The analysis of correlations found that the myocardial work indicators didn't have significant correlations with age. Ejection fraction was moderately correlated with GWI (r=0.45) and GCW (r=0.49). Global longitudinal strain was strongly correlated with GWI (r=0.77) and GCW (r=0.77). Global radial strain correlated moderately directly with GWI (r=0.4) and GCW (r=0.4). Global circular strain was moderately correlated with GCW (r=0.35). A strong negative correlation was found between the GWE indicator and the post systolic contraction index (PSI) (r=-0.85). At the same time, PSI and GWW had a strong positive correlation (r=0.85).Conclusion. Indicators of LV myocardial work in healthy individuals do not have gender differences. The efficiency of the work of the myocardium depends primarily on the deformation of the LV, while the constructive work is determined by the volume characteristics. The wasted work indicator depends on the number of segments that peak in the post-systolic period.

A Critique of Twentieth Century Feminist Criticism

Feminist criticism arose in response to developments in the field of the feminist movement. Many thinkers such as John Stuart Mill, Mary Wollstonecraft raised their voice against the injustice done to women in every sphere of life. As this gained momentum throughout the world, feminist also awakened to the depiction and representation of women in literature which is one of the influential medium of socialization and culture. They argued that woman and womanhood are not biological facts but are given social constructs. One is not born a woman, but becomes one through culture and socialization. At first, feminist criticism was reactionary in the nature in the sense that they exposed stereotypical images of women in the literature. These images of women were promulgated by the male writers. These images of women were what men think of women. Gradually, feminist criticism moved from this phase to more constructive work. They unearthed many women writers that were either suppressed or neglected by the male literary tradition. In this way, they created a separate literary tradition of women writers. Feminist critics divided this tradition in such phases as feminine phase, feminist phase and female phase. They also studied the problems faced by female creative writers. They used theories from post-structuralism, Marxism, psychoanalysis to study the nature of female creativity. They also realized that there is an innate difference between male and female modes of writing. Feminist critics also exposed the sexiest nature of man-made language. They also exposed phallic centrism of much of the western literary theory and criticism. They also started to study the language used by the women writers. Simon De Beauvoir, Virginia Woolf, Elaine Showalter and Juliet Mitchell are some of the feminist critics discussed in this paper.

Global constructive myocardial work predicts left ventricular disfunction onset beyond longitudinal strain in patients with significant primary mitral regurgitation

Accurate surgical timing for significant primary mitral regurgitation (PMR) still remains an issue despite of several ways of left ventricular (LV) hidden disfunction detection, including LV global longitudinal strain (GLS). Since novel modalities such as myocardial work (MW) or area strain (AS) are currently available we assumed that they might predict surgical timing beyond known parameters. Methods 58 patients (31 female) 63±8 years, asymptomatic and with pulmonary systolic pressure (PSP) ≤45 mmHg on exercise echo test (ET), with PMR, in sinus rhythm, with ejection fraction (EF) ≥65% and GLS &lt;−19.5% were enrolled into the study along with 23 healthy subjects matched by age and sex and followed up for 1 year. Comprehensive echocardiography (EchoCG) was performed with offline analysis including MW and AS by one experienced specialist. GW index (GWI) was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure.Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work (GWW) aa energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency (GWE) as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained by the dedicated software. Results 13 (22%) patients with PMR became symptomatic or increase PSP &gt;50 mmHg on ET in 1 year follow up. EF, GLS, AS and GWI did not differ between symptomatic patients and those who remained asymptomatic during follow up, however these patients had significantly lower values of GCW, and higher values of GWW (EF 68.3±6.1% vs 69.2±6.5%, p=NS; GLS –22.4±2.3% vs 23.1±3.2%, p=NS, GWI 2452±161 mmHg% vs 2479±147 mmHg%, p=NS; GCW 1875±119 mmHg% vs 2321±124 mmHg%, p&lt;0.01; GWW 118±9 mmHg% vs 88±7 mmHg%, p&lt;0.03; GWE 93±8% vs 96±9%, p=NS; AS −32.5±5.4% vs −34.3±6.1%, p=NS;). Patients with subsequent symptoms development had significantly lower values of GCW and higher values of GWW. Among all parameters GCW was the predictor of MR clinical course worsening (AUC 0.769). Conclusion MR GCW is able to predict clinical course of patients with PMR beyond known conventional parameters. FUNDunding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): City Hall resources

Normal ranges of global left ventricular myocardial work indices in adults: a meta-analysis

Background Non-invasive global myocardial work recently emerged as new parameter to characterize left ventricle function with potential advantages over both ejection fraction and global longitudinal strain. Purpose We aimed to perform a meta-analysis of normal ranges of non-invasive left ventricular myocardial work (MW) indices including global constructive work (GCW), global work index (GWI), global wasted work (GWW), and global work efficiency (GWE) and to identify confounding factors that may contribute to variance in reported measures. Methods The authors searched four databases, Pubmed, Scopus, Embase, and Cochrane Library through January 2021 using the key terms “myocardial work”,“global constructive work”, “global wasted work”, “global work index”, “global work efficiency”. Studies were included if the articles reported LV myocardial work using 2D transthoracic echocardiography in healthy normal subjects, either in the control group or comprising the entire study cohort. The weighted mean was estimated by using the random effect model with a 95% confidence interval. Heterogeneity across studies was assessed using the I2 test. Publication bias was examined by funnel plot and Egger's regression test. Results The search yielded 476 articles. After abstract and full text screening we included 13 datasets with 1665 patients for meta-analysis. The reported normal mean values of GCW and GWI among the studies were 2278 (95% CI, 2167 to 23878; I2=95%), and 2.010 (95% CI, 1922 to 2098, I2=97%), respectively. The mean GWE was 96.0 (95% CI, 95.6% to 96.5; I2=92%), and the mean GWW was 79.7% (95% CI, 68.8% to 90.7%; I2=90%) (Figure). Furthermore, age and gender did not significantly contribute to variations in normal values. No evidence of significant publication bias was observed in the funnel plots and the Egger test. Conclusion In this meta-analysis, we provide echocardiographic reference ranges for non-invasive indices of MW. These normal values should serve as a template for clinical and research use for this promising technology. FUNDunding Acknowledgement Type of funding sources: None.

Damage compensation for innocent defendants and Convicts in Iran and the Canadian legal system

In the field of innocent defendants and convicts' damage compensation who have endured further losses due to issue criminal supply contracts or orders execution, their innocence has been cleared by issuing acquittance sentences. It counted as one of the most challenging issues in private and criminal law. In these recent years, based on positive changes in the rules of Iran, a lot of works done for innocent defendants and convicts' damage compensation have endured different and unfair punishments. But no integration or constructive work has been done for guiltless convicts' damage compensation who have endured some parts or all their punishments, and their innocence has been proved but not predicted. The reverse of this matter is true in the Canadian law system. Only a guilty convict who has tolerated some or all parts of unfair punishment deserves to receive damage compensation. This study attempted to research the subject's international binding rules, and many practical strategies for guiltless convicts' damage compensation will be considered in both systems by a comparative study.

Abstract P137: Nonspecific ST-T Change In Electrocardiogram Was Associated With A Reduced Constructive Myocardial Work In Hypertensive Patients With Preserved Ejection Fraction

Background: Nonspecific ST-T change in electrocardiogram can be observed in hypertensive heart disease with preserved left ventricular ejection fraction (LVEF); however, the relationship between nonspecific ST-T change and global myocardial work in echocardiography was unclear. Methods: We evaluated global longitudinal strain (GLS), GWI (global work index), GCW (global constructive work), GWW (global wasted work), GWE (global work efficiency), using offline analyzing system (View Pal, GE) in 196 hypertensive patients with preserved LVEF (>50%). Nonspecific ST-T change and major ST-T change (depression of ST in V5 lead >1mV) was also evaluated in electrocardiogram. Results: Mean age was 79.3±8.2 years (men 37.8%). Compared with patients with no ST-T change, those with nonspecific and major ST-change had a smaller absolute value of GLS (-20±3, -18±4, -14±5%, P<0.001) and had smaller constructive work load [GWI (2140±488, 1915±472, 1523±776 mmHg%, P<0.001), GCW (2410±514, 2165±471, 1694±784 mmHg%, P<0.01)]. Additionally, those with nonspecific and major ST-T change had an increased wasted myocardial work [GWW (87±61, 109±58, 138±71 mmHg%, P<0.001)], and this resulted in reduction of myocardial work efficiency [GWE (95±4,93±3,87±12%,P<0.001)]. Even after adjustment for age, sex, diabetes, dyslipidemia, EF, LV mass index, relative wall thickness, parameters of diastolic function (E/A, E/e’, left atrial volume index, tricuspid valve regurgitant flow velocity), and electrocardiogram LVH of Cornell product and Sokolow-Lyon voltage, the patients with nonspecific ST-T change had a significantly smaller LV global constructive work. [GWI (2243±41 vs. 1998±96 mmHg%, P=0.025), GCW (2501±45 vs. 2210±105 mmHg%, P=0.015)]. Conclusion: In hypertensive patients with preserved LVEF, nonspecific ST-T change in electrocardiogram was associated with a reduced constructive work in LV.