762 Myocardial bridge evaluation towards personalized medicine (the rialto registry): preliminary findings

Aims Myocardial bridge (MB) is the most common inborn coronary artery variant in which a segment of an epicardial coronary artery takes a tunneled course under a bridge of myocardium. MB has been documented from 1.5% to 16% of invasive angiographic series thus the true prevalence of MB is uncertain. The clinical relevance of MB is heterogeneous, being usually an asymptomatic bystander. However, a growing body of evidence suggests its association with myocardial ischaemia. In the present work, by setting up a database of patients affected by MB, we sought to assess their clinical characteristics and risk of major adverse cardiac events (MACE). Methods and results This is a prospective/retrospective study and observational study in which we included 17 681 patients referred to undergo invasive coronary angiography (ICA) for suspected coronary artery disease. During the screening phase, we found that 338 cases (26 non-recruitable) were reported to have MB (1.9%). In-hospital clinical-instrumental data was acquired after ICA. The data obtained in the follow-up (FUP) visit is also included in the study. In particular, we recorded MACE and Seattle Angina Questionnaire (SAQ). The most frequent location of MB was the LAD coronary artery (96.8%). Other locations were the circumflex artery (1.3%), the right coronary artery (1%), the posterior interventricular artery (0.6%), and the first diagonal artery (0.3%). Chronic coronary syndrome (CCS) was the most frequent clinical presentation (47.5%). A big proportion (34.6%) of our patients were found to have MB during the occurrence of an acute coronary syndrome (ACS). In acute setting, unstable angina was the most frequent clinical presentation (17.6%). 47 patients (15%) underwent coronary angiography with provocative test (intracoronary acetylcholine) in order to search vasomotor disorders: according to COVADIS criteria, 17 procedures (5.5%) resulted positive for vasospastic angina (VSA). Invasive functional assessment with FFR/iFR was accomplished to assess the haemodynamic significance both of MBs and atherosclerotic plaques proximal to the MB segment in 35 patients (11.2%): in nine procedures (2.9%), functional tests resulted positive. β-Blockers (BBs) are suggested as first-line drugs as they increase diastolic filling time, by decreasing heart rate. Calcium channel blockers (CCBs) are useful, in VSA setting, to reduce epicardial spasm. In our court, 40% of patients toke BBs and 20% of patients toke CCBs at admission. The primary endpoint of the study is the incidence of MACE, defined as the composite of cardiac death, myocardial infarction and cardiac hospitalization. Considering patients who have already undergone FUP (114; 36.5%), we recorded 19 MACE (16.7% of patients with FUP). The secondary endpoint is the rate of patients with SAQ Angina Summary Score < 70: the rate of patients with SAQ < 70 is 23.7% at 6 months, 23.8% at 12 months and 23.2% at 24 months. Conclusions MB has been typically considered benign and asymptomatic, but its clinical relevance is still matter of debate. A remarkable proportion of our patients were found to have a MB during the occurrence of ACS or CCS, highlighting that different mechanisms of ischaemia may coexist. Furthermore, invasive functional assessment shows a plausible correlation between MB and vasomotor disorders. Our study is still ongoing, and we hope to maximize the data in order to have a solid comprehension of MB and to propose the assessment that may indicate a tailored therapy.

Reference values for fetal Doppler-based cardiocirculatory indices in monochorionic-diamniotic twin pregnancy

Background Placental anastomoses in monochorionic diamniotic (MCDA) twin pregnancy have a major impact on fetal circulation. This study was designed to define reference ranges of cardiac and vascular Doppler indices in MCDA twin pregnancies. Methods This cross-sectional study included 442 uncomplicated MCDA twin fetuses undergoing Doppler ultrasonography at 18–35 weeks of gestation. Left and right myocardial performance index (LV-MPI, RV-MPI), E/A ratio of atrioventricular valves, pulsatility indices of umbilical artery, middle cerebral artery (MCA), and ductus venosus (DV), cerebroplacental ratio, peak systolic velocity of MCA, S/a ratio of DV, and early diastolic filling time of ductus venosus (DV-E) were evaluated under standardized settings. The equation models between Doppler indices and gestational age (GA) were fitted. After adjustment for GA, the correlations between MPI and fetal heart rate (FHR), and between MPI and DV indices were analyzed. Results Estimated centiles of Doppler indices were derived as a function of GA, being distinct in values from those of singletons. There was no correlation between GA-adjusted MPI and FHR. DV-E was inversely related to LV-MPI. Conclusions MCDA twins showed significant changes in some Doppler indices throughout gestation with quantitative differences from singletons, emphasizing the importance of MC twin-specific reference values for clinical application. Further adjustment of MPI for FHR was unnecessary. DV-E is a vascular index indirectly representing fetal diastolic function.

Indicators of ambulatory blood pressure monitoring in patients with essential hypertension of the 2-nd stage depending on the type of 24-hours blood pressure profile, the state of the left ventricular diastolic filling and endothelial function of vessels

Annotation. Arterial hypertension (AH) is one of the most important risk factors for the development of cardiovascular complications and mortality in the world and it has become a medical and social problem. The prevalence of hypertension will increase to 1.56 billion by 2025, making the disease a very serious problem. The severity of clinical manifestations and prognosis in patients with hypertension are determined not only by the degree of increase in blood pressure (BP) but also the damage to target organs. The load on the cardiovascular system caused by elevated BP leads to structural remodelling of the heart and vessels. The aim – to evaluate peculiarities of indicators of ambulatory blood pressure monitoring in patients with essential hypertension of the 2nd stage depending on the type of 24-hours blood pressure profile, the state of the left ventricular diastolic filling and endothelial function of the vessels and determine independent clinical and instrumental criteria of the 24-hours profile “dipper” and “non-dipper”. The study involved 110 patients (40 men and 70 women) with hypertension of the II-nd stage, hypertensive heart, chronic heart failure of the 0-I stage (average age was 54.19±0.89 years). The patients underwent 24-hour blood pressure monitoring, echocardiography and determination the thickness of the intima-media complex (IMCT) of the brachial artery, endothelium-dependent (EDVD) and endothelium-independent (EIVD) vasodilatation. For statistical analysis, arithmetic means (M), errors of mean values (m), t - Student's t test for paired measurements were calculated. Correlation ratios were evaluated by the method of linear correlation for parametric data and the method of Spearman’s rank correlation for nonparametric data. Paired group comparisons were performed by the nonparametric Mann-Whitney method. Wilcoxon test was used in the analysis of dependent samples. Step-by-step multifactor regression was used to identify independent criteria for daily blood pressure profiles. Two types of 24-hours profile of blood pressure – “dipper” and “non-dipper” were detected. The left ventricle diastolic dysfunction (LVDD) by type of relaxation disorder was observed in all “non-dipper” patients and most “dipper” patients. Patients with DD had higher levels of BP per 24-hours, day, night, corresponding the time indexes, the magnitude of the morning increase of systolic and diastolic blood pressure, more pronounced structural changes of the heart and vessels compared with patients with preserved diastolic filling of the LV(р<0,01). The duration of the hypertensive anamnesis (p=0.0002), the thickness of the posterior wall of the LV (p=0.002), the maximum speed of early diastolic filling of the LV (E) (p<0.0001), the LV ejection fraction (p=0.001), the index of the left atrium (p=0.008), the thickness of the intima-media complex of the brachial artery (p=0.013), increase of the diameter of the brachial artery in 90 s after compression (EDVD) (p<0.0001) and in 5 min after taking of nitroglycerin (EIVD) (p=0.009) were determined as independent clinical and instrumental criteria of the “dipper” and “non-dipper” profile. Insufficient the degree of the nightly decrease of the BP, higher magnitude of the morning increase of systolic and diastolic BP cause more hemodynamic pressure on target organs and lead to more significant pathological remodeling of the LV and vessels, disorders of the LV relaxation processes and endothelial dysfunction.

Clinical significance of the determination of natriuretic peptides in diastolic dysfunction of the left ventricle in patients with type 2 diabetes mellitus

Objective: of article was to study the level of cerebral natriuretic peptide in patients with type 2 diabetes mellitus with diastolic dysfunction and with various types of left ventricular remodeling. Materials and methods: 256 patients with type 2 diabetes mellitus (DM) who had moderate arterial hypertension (AH) and no clinical signs of chronic heart failure were examined. The control group consisted of 30 practically healthy persons, comparable in age and sex with the examined patients. All patients were determined the concentration of brain natriuretic peptide (BNP) in blood plasma. The structural and functional parameters of the heart were determined by echocardiography in B- and M-modes according to the standard technique. Results: in patients with type 2 diabetes and diastolic dysfunction, the BNP concentration was 156 (84; 228) pg / ml, in patients without diastolic filling disorders — 24 (12; 38) pg / ml. The highest BNP values were found in the subgroup of patients with a restrictive type of transmitral flow. Also, BNP values were higher in the group of patients with concentric and eccentric left ventricular (LV) hypertrophy. Conclusion: in all patients with type 2 diabetes and concomitant moderate hypertension, even in the absence of clinical signs of CHF, there is an increase in the BNP level compared to the control group. The highest BNP values were observed in patients with severe diastolic dysfunction and unfavorable variants of LV remodeling.

Significance of mitral L wave to predict late recurrence of atrial fibrillation after radiofrequency catheter ablation

Background Mitral L wave, prominent mid-diastolic filling wave in echocardiographic examinations, is associated with severe left ventricular diastolic dysfunction, and that has been reported to predict recurrent atrial fibrillation (AF) after cardioversion. However, association between mitral L wave and the outcome of AF after radiofrequency catheter ablation (RFCA) has not been established. Objective The aim of this study is to evaluate the predictive value of mitral L wave on AF recurrence after RFCA. Methods 250 patients including 164 paroxysmal AF (65.6%) and 86 non-paroxysmal AF (34.4%) who received RFCA in single center from January 2015 to December 2016 were enrolled consecutively. Echocardiographic examinations before RFCA were recorded, and the mitral L wave was defined as a distinct mid-diastolic flow velocity with a peak velocity ≥20 cm/s following the E wave. Systematic follow-up was conducted after RFCA. Univariate and multivariate analyses were carried out to determine the factors predicting late recurrence of AF (LRAF) which means AF recurrence after 3 months. Enrolled patients were divided into groups with the L wave (L-group; n=57) or without the L wave (NL-group; n=193) based on the findings of echocardiographic examinations. Results During a follow-up of 35.0±17.6 months, the ratio of LRAF in the L-group was significantly higher than that in the NL-group (32 (56.1%) vs. 41 (21.2%), Hazard ratio [HR]: 3.55, 95% confidence interval [CI]: 2.33 - 5.42, p&lt;0.001). Among the clinical factors, presence of mitral L wave, BNP value, non-paroxysmal AF and moderate-severe mitral regurgitation were related to LRAF. A multivariate analysis using a Cox proportional hazard model found that presence of mitral L wave (HR: 2.67, 95% CI: 1.30 - 5.48, p=0.007) was significantly associated with LRAF. Conclusion This study revealed that mitral L wave predicts late recurrence of AF after RFCA. FUNDunding Acknowledgement Type of funding sources: None.

High frame rate speckle tracking echocardiography to assess diastolic function

Background Left ventricular (LV) strain rate (SR) during isovolumic relaxation (SRIVR) and early diastolic filling (SRe) has previously been shown to correlate with the invasive gold standard for LV diastolic function (i.e. the time constant of LV pressure decay tau). However, the translation of these biomarkers to the clinic has been hampered by technical limitations. Indeed, conventional speckle tracking (STE) is limited by its temporal resolution, whereas tissue Doppler imaging (TDI) is angle-dependent, labor-intensive and thus rarely used clinically nowadays. Purpose The aim of this study was to show that these limitations could be overcome by using a recently proposed STE algorithm operating on high frame rate (HFR) imaging data. Methods 37 subjects (age: 64±12, 81% male) were included in the study; 16 had cardiac amyloidosis, 12 were undergoing clinically indicated left and/or right heart cardiac catheterization and 9 were healthy volunteers. Since the sequence of left ventricular activation and thus the repolarization process (i.e. relaxation) starts at mid septum, we measured SRIVR and SRe in the mid septal segment in an apical 4 chamber view using a commercially available clinical system with: (1) TDI (frame rate (FR) ∼142 Hz); (2) STE (FR ∼65 Hz). Moreover, subjects were scanned with HD-PULSE, an experimental high frame ultrasound scanner (FR ∼915 Hz) and then a manually placed contour was tracked during the cardiac cycle by a custom-made 2D HFR STE algorithm, to compute and extract SRIVR and SRe from the mid septum. Since TDI is considered the reference method to assess SR, conventional as well as HFR STE values were correlated against the TDI SR values. Results In 3 subjects, SRIVR could not be reliably assessed with the clinical STE approach, which we attributed to the relatively low temporal resolution of the images; all other measurements could be made in all subjects. For both biomarkers, HFR STE values correlated better with the TDI reference measurements than the clinical STE estimates (Fig.1). The latter estimates showed a systematic underestimation (bias −0.19 1/s (p&lt;0.01) and −0.46 1/s (p&lt;0.01) for SRIVR and SRe respectively) while no significant bias was observed for the HFR STE values. Similarly, the limits of agreement of the HFR STE values were narrower (−0.45 to +0.54 1/s and −0.94 to +0.86 1/s) than those of the clinical STE measurements (−0.85 to +0.48 1/s and −1.32 to +0.41 1/s). Conclusions These results show that HFR STE offers a reliable way to assess novel biomarkers of diastolic function in a user-friendly manner and can therefore facilitate their incorporation to the clinical practice. FUNDunding Acknowledgement Type of funding sources: None.

Echocardiographic features of acute-phase microscopic polyangiitis in Japanese patients: A single-centre retrospective study

ABSTRACT Objectives Microscopic polyangiitis (MPA) affects various organs. However, echocardiographic findings of MPA are unclear. We aimed to evaluate the echocardiographic features of acute-phase MPA in Japanese patients. Methods This single-centre retrospective study included 15 patients with MPA who underwent echocardiography within 2 weeks of commencing steroid therapy for induction or reinduction. The echocardiography parameters of thetients were compared with those of 30 age- and sex-matched controls. Results No significant differences in left ventricular (LV) diameter, LV ejection fraction, or e’ were observed between the two groups. However, the MPA group showed a significantly higher left atrial (LA) diameter and LA volume index, as well as higher early diastolic filling velocity, diastolic pulmonary venous flow velocity, and trans-tricuspid pressure gradient, and a shorter deceleration time (DCT). Serum C-reactive protein levels were positively correlated with E wave, E/A, and DCT. These results may indicate that increased LV stiffness, rather than impairment of LV relaxation, contributed to LV diastolic function, resulting in LA enlargement. Conclusions Patients with acute-phase MPA had LA dilatation associated with LV diastolic dysfunction. This finding indicates the importance of cardiac assessment in patients with MPA, especially in patients with a strong inflammatory reaction.

Subclinical cardiac impairment relates to traditional pulmonary function test parameters and lung volume as derived from whole-body MRI in a population-based cohort study

To evaluate the relationship of cardiac function, including time-volume-curves, with lung volumes derived from pulmonary function tests (PFT) and MRI in subjects without cardiovascular diseases. 216 subjects underwent whole-body MRI and spirometry as part of the KORA-FF4 cohort study. Lung volumes derived semi-automatically using an in-house algorithm. Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and residual volume were measured. Cardiac parameters derived from Cine-SSFP-sequence using cvi42, while left ventricle (LV) time-volume-curves were evaluated using pyHeart. Linear regression analyses assessed the relationships of cardiac parameters with PFT and MRI-based lung volumes. Mean age was 56.3 ± 9.2 years (57% males). LV and right ventricular (RV) end-diastolic-, end-systolic-, stroke volume, LV peak ejection- and early/late diastolic filling rate were associated with FEV1, FVC, and residual volume (excluding late diastolic filling rate with FEV1, LV end-systolic/stroke volume and RV end-diastolic/end-systolic volumes with residual volume). In contrast, LV end-diastolic volume (ß = − 0.14, p = 0.01), early diastolic filling rate (ß = − 0.11, p = 0.04), and LV/RV stroke volume (ß = − 0.14, p = 0.01; ß = − 0.11, p = 0.01) were inversely associated with MRI-based lung volume. Subclinical cardiac impairment was associated with reduced FEV1, FVC, and residual volume. Cardiac parameters decreased with increasing MRI-based lung volume contrasting the results of PFT.

Need for Speed: The Importance of Physiological Strain Rates in Determining Myocardial Stiffness

The heart is viscoelastic, meaning its compliance is inversely proportional to the speed at which it stretches. During diastolic filling, the left ventricle rapidly expands at rates where viscoelastic forces impact ventricular compliance. In heart disease, myocardial viscoelasticity is often increased and can directly impede diastolic filling to reduce cardiac output. Thus, treatments that reduce myocardial viscoelasticity may provide benefit in heart failure, particularly for patients with diastolic heart failure. Yet, many experimental techniques either cannot or do not characterize myocardial viscoelasticity, and our understanding of the molecular regulators of viscoelasticity and its impact on cardiac performance is lacking. Much of this may stem from a reliance on techniques that either do not interrogate viscoelasticity (i.e., use non-physiological rates of strain) or techniques that compromise elements that contribute to viscoelasticity (i.e., skinned or permeabilized muscle preparations that compromise cytoskeletal integrity). Clinically, cardiac viscoelastic characterization is challenging, requiring the addition of strain-rate modulation during invasive hemodynamics. Despite these challenges, data continues to emerge demonstrating a meaningful contribution of viscoelasticity to cardiac physiology and pathology, and thus innovative approaches to characterize viscoelasticity stand to illuminate fundamental properties of myocardial mechanics and facilitate the development of novel therapeutic strategies.

Reproducibility of left ventricular blood flow kinetic energy measured by four-dimensional flow CMR

Objectives Four-dimensional flow CMR allows for a comprehensive assessment of the blood flow kinetic energy of the ventricles of the heart. In comparison to standard two-dimensional image acquisition, 4D flow CMR is felt to offer superior reproducibility, which is important when repeated examinations may be required. The objective was to evaluate the inter-observer and intra-observer reproducibility of blood flow kinetic energy assessment using 4D flow of the left ventricle in 20 healthy volunteers across two centres in the United Kingdom and the Netherlands. Data description This dataset contains 4D flow CMR blood flow kinetic energy data for 20 healthy volunteers with no known cardiovascular disease. Presented is kinetic energy data for the entire cardiac cycle (global), the systolic and diastolic components, in addition to blood flow kinetic energy for both early and late diastolic filling. This data is available for reuse and would be valuable in supporting other research, such as allowing for larger sample sizes with more statistical power for further analysis of these variables.