LV Mechanics in Mitral and Aortic Valve Diseases: Value of Functional Assessment Beyond Ejection Fraction.

The assessment of myocardial function in the context of valvular heart disease remains highly challenging. The myocardium deforms simultaneously in 3 dimensions, and global left ventricular (LV) function parameters such as volume and ejection fraction may remain compensated despite the changes in myocardial deformation properties. Current guidelines recommend valve replacement/repair in the presence of symptoms or reduced LV ejection fraction, but the resolution of symptoms or recovery of LV function post-surgery may not be reliably predicted. A wealth of evidence currently suggests that LV dysfunction is frequently subclinical despite normal ejection fraction. It may precede the onset of symptoms and portend a poor outcome due to progressive myocardial remodeling and dysfunction during the post-operative period. The advent of novel tissue-tracking echocardiography techniques has unleashed new opportunities for the clinical identification of early abnormalities in LV function. This review gathers and summarizes current evidence regarding the use of these techniques to assess myocardial deformation in patients with valvular heart disease

A Hybrid Tissue-Level Model of the Left Ventricle: Application to the Analysis of the Regional Cardiac Function in Heart Failure

International audienceThis work contributes to the systemic interpretation of clinical data for the analysis of the regional cardiac function in the context of heart failure. A two-step patient-specific approach, combining a realistic geometry and a hybrid, tissue-level electromechanical model of the left ventricle is proposed. For the first step, a fast framework to extract a realistic geometry of the left ventricle from MSCT data is proposed. This geometry is then applied to a tissue-level model of the left ventricle, coupling a discrete electrical model, a mechanical model integrating a visco-elastic law, solved by a finite element method and a hydraulic model. A set of simulations carried out with the model are shown and preliminary results of the parameter identification approach, based on real patient data, are presented and discussed

A tissue-level model of the left ventricle for the analysis of regional myocardial function.

International audienceThis paper presents a model-based method for the analysis of regional myocardial strain, based on echocardiography and Tissue Doppler Imaging (TDI). A multi-formalism, tissue-level electromechanical model of the left ventricle is proposed. The parameters of the model are identified in order to reproduce regional strain signal morphologies obtained from a healthy subject and a patient presenting a dilated cardiomyopathy. The parameters identified for the DCM patient allow the localization of the failing myocardial segments and may be useful for a better design of cardiac resynchronization therapy on heart failure patients

0081: Prevalence and determinants or right ventricular dysfunction in severe aortic stenosis

Introductionsystolic pulmonary artery pressure (sPAP) is a well known predictor of outcome in patients with valvular heart disease. In spite of this fact, limited data are available regarding the assessment of RV function in patients with aortic stenosis (AS).Aimof this study is therefore to evaluate the prevalence and the determinants of RV dysfunction in severe AS patientsMethods201 patients (mean age:79.7±8.7, male sex 55.5%) with severe AS underwent 2D echocardiography and speckle tracking echocardiography (STE) for the evaluation of left ventricular and RV function, aortic valve gradients and sPAP. A tricuspid annular plane systolic excursion (TAPSE) ≤17mm was used to define reduced RV ventricular function.ResultsRV function was impaired in 48 patients (24%). Patients with reduced TAPSE had an impaired LV ejection fraction (LVEF) (49.2±15.4 vs 57.9±10.9%, p<0.0001), significantly altered STE parameters (GLS: –10.3 ±3.9 vs –13.2±3.5%, GCS: –7.0±3. vs –10.4±4.9%, GRS: 18.7±11.6 vs 28.4±15.6, all p<0.001) and a higher sPAP (48.4±15.8 vs 40.9±12.7mmHg, p=0.002) with respecto to patients with a normal RV function. Correlates of a reduced TAPSE were: LVEF (β=0.35, p<0.0001), LV global longitudinal, circumferential and radial strain (β=–0.40, β=–0.40, β=0.37 respectively, all p<0.0001), LV indexed stroke volume (β=0.44, s<0.0001), lnNT-proBNP (β=–0.51, p<0.0001) and sPAP (β=–0.27, p<0.0001). At Kaplan-Meier survival curve, a TAPSE ≤17mm was associated with a reduced survival in patients with AS (Log Rank test, p=0.034).ConclusionsIn patients with severe AS, RV function impairment is frequent and is associated with a poor prognosis. The correlations of TAPSE highlight the RV-LV interdependence in AS patients. Further studies will clarify the real and independent prognostic value of RV function in severe AS patients and test for the RV reverse remodelling after treatment of the AS

070: Heterogeneity in regional peaks of left ventricular deformation is correlated with exercise capacity in primitive hypertrophic cardiomyopathy

ObjectivePrevious studies have described a left ventricular (LV) heterogeneity in regional peaks of deformation in patients with primitive hypertrophic cardiomyopathy (HCM). We studied this heterogeneity in HCM patients with echocardiography both at rest and during exercise in order to evaluate its correlation with exercise capacity.MethodsThirty consecutive HCM patients were evaluated with echocardiography at rest and during exercise on a dedicated table. 2D speckle tracking echocardiography (STE) was used to assess LV deformation heterogeneity according to the standard deviation between systolic peaks of regional longitudinal strains.ResultsAge was 55.1±12.7 yrs, maximal wall thickness was 20.3±.4mm. Maximal load during exercise was 94±41 Watts. LV ejection fraction was preserved both at rest and during exercise (67±8% at rest and 69±8% during exercise). Global longitudinal strain (GLS) was altered (-15.5±4.1% at rest and -15.2±5.9% during exercise). Heterogeneity in regional peaks of deformation was 54.6±27.8ms at rest and 41.3±23.9ms during exercise. We noted correlations between maximal load achieved (r=-0.48, p=0.007), exercise GLS (r=0.47, p=0.009) and maximal LV thickness (r=0.48, p=0.007) with the level of LV deformation heterogeneity recorded during exercise. These correlations were lower if we considered LV deformation heterogeneity at rest. The population was then divided in 2 groups according to the level of exercise heterogeneity in regional peaks of deformation (cut-off value of 41ms, i.e. mean value of the global population). The group with the more marked heterogeneity of LV deformation showed the thicker wall, the lower GLS at exercise and the weaker exercise capacity. This result was independent of the age.ConclusionIn CMH patients exercise echocardiography add information. Indeed heterogeneity in regional peaks of deformation in longitudinal LV is correlated with exercise capacity and importance of myocardial hypertrophy

085: Heart failure with preserved ejection fraction: changes in clinical parameters between acute presentation and subsequent follow-up

PurposeIn the prospective KaRen registry of heart failure with preserved ejection fraction (HFPEF), changes in clinical and biological parameters and medications were assessed between acute presentation and out-patient follow-up in stable state.MethodsThe KaRen study included patients presenting with acute heart failure (HF) according to inclusion criteria: Framingham criteria for HF, left ventricular ejection fraction > or=45% and brain natriuretic peptide (BNP)>100pg/mL or NT-proBNP>300pg/mL. Once stabilized, 4-8 weeks after the index presentation, patients returned as out-patients for repeat assessment. Changes in clinical and biological parameters and medications between inclusion and follow-up were assessed with Students t-test and Chi-square testsResults577 patients were recruited and 458 returned for the 4-8 weeks visit. 56% were women. The median [25-75pctl] age was 79 [72-84] years. Medical history included 78% hypertension, 58% atrial arrhythmia, 26% type II diabetes and 27% serum creatinin >100 micromol/l. The table provides inclusion and follow-up dataConclusionsPatients presenting with HFPEF are elderly and a majority are women, with a high rate of hypertension and atrial arrhythmias. Blood pressure is incompletely controlled. At follow-up, blood pressure and NT-proBNP were reduced, but patients remain symptomatic. Still, efforts are needed to improve symptoms in HFPEF.Table (abstract 85) – Inclusion and follow-up data.Variable Mean (IQR)NYHA I / II / III / IVSBPCreatinineNT-proBNPACEI /ARBB-blockerANTICOAGInclusion0.8 / 9.4 / 40 / 49.8%148 [130-170]93 [74-128]2433 [1272-4790]60%65%41%Follow-up13 / 62.5 / 22.2 / 2.3140 [120-150]95 [75-129]1409 [514-2641]68%67.5%51.3%p<0.00010.003<0.000

073: Very long-term effects of pacing therapy in Hypertrophic Obstructive Cardiomyopathy (HOCM)

The clinical value of DDD pacing as primary treatment of HOCM remains controversial. Very long-term data are lacking.Aimssingle-centre observational study aimed at describing the very long term effects on symptoms, clinical and echocardiographic outcomesPatients54 patients (59±14 years) with symptomatic (NYHA Class >2) drug-refractory HOCM implanted with a DDD pacemaker with or without defibrillator between 1991 and 2007 and followed up to 20 years (mean 11.5; range 0,4-21,8).Main resultsare summarised in table. No patient had myomectomy or septal ablation during follow-up (f/u). NYHA functional class and other symptoms were significantly improved at 1-2 years and at the end of f/u. Left ventricular outflow tract (LVOT) gradient decreased by a mean of 78% at 1-2 years and 89% at end f/u consistent with SAM resolution. LV ejection fraction decreased over time with a mean value of 56% at end f/u without evidence of cavity dilatation. The actuarial survival rate was 90% at 5-yrs and 65% at 10-yrs. 24 patients died, 19 from non cardiac cause and 5 cardiovascular. 2 patients had heart transplant after 8 and 13yrs.ConclusionThe clinical and echocardiographic outcome of HOCM patients treated by DDD pacing seems favourable, inviting to re-evaluate the exact value of the therapy in further controlled studiesTable – Main results.Baseline3 months1-2 yearsEnd f/uP valueNYHA functional class, (%)<0,0001Grade 10313536Grade 243535957Grade 3521667Grade 45000Syncope/nearsyncope (%)76/482/22/22/2<0,0001Angina (%)57444<0,0001LVOT gradient (mmHg)79±3620±2411±158±21<0,0001SAM (%)96383016<0,0001LVEF (%)63,5±7,561±759±756±90,05LVEDD (%)47±5NANA43±120,3

Electrocardiographic correlates of mechanical dyssynchrony in recipients of cardiac resynchronization therapy devices

SummaryBackgroundThe relationship between electrical and mechanical indices of cardiac dyssynchronization in systolic heart failure (HF) remains poorly understood.ObjectivesWe examined retrospectively this relationship by using the daily practice tools in cardiology in recipients of cardiac resynchronization therapy (CRT) systems.MethodsWe studied 119 consecutive patients in sinus rhythm and QRS≥120ms (mean: 160±17ms) undergoing CRT device implantation. P wave duration, PR, ePR (end of P wave to QRS onset), QT, RR–QT, JT and QRS axis and morphology were putative predictors of atrioventricular (diastolic filling time [DFT]/RR), interventricular mechanical dyssynchrony (IVMD) and left intraventricular mechanical dyssynchrony (left ventricular pre-ejection interval [PEI] and other measures) assessed by transthoracic echocardiography (TTE). Correlations between TTE and electrocardiographic measurements were examined by linear regression.ResultsStatistically significant but relatively weak correlations were found between heart rate (r=−0.5), JT (r=0.3), QT (r=0.3), RR–QT intervals (r=0.5) and DFT/RR, though not with PR and QRS intervals. Weak correlations were found between: (a) QRS (r=0.3) and QT interval (r=0.3) and (b) IVMD>40ms; and between (a) ePR (r=−0.2), QRS (r=0.4), QT interval (r=0.3) and (b) LVPEI, though not with other indices of intraventricular dyssynchrony.ConclusionsThe correlations between electrical and the evaluated mechanical indices of cardiac dyssynchrony were generally weak in heart failure candidates for CRT. These data may help to explain the discordance between electrocardiographic and echocardiographic criteria of ventricular dyssynchrony in predicting the effect of CRT