P5595Non-invasive atrial work in the differential diagnosis of pre-capillary and post-capillary pulmonary hypertension

Abstract Background Right heart catheterization (RHC) is the gold standard for the diagnosis of pulmonary hypertension (PH) and for the discrimination of pre-capillary from post-capillary PH, but it is an invasive method with high costs and limited availability. While echocardiography is widely used in the evaluation of patients with PH, no algorithm has been validated to discriminate between the various forms of PH. Purpose We aimed to assess the differences in echocardiographically-derived atrial work between patients with different forms of PH. Methods We included 80 patients in our study, which were divided in two groups. The pre-capillary group consisted of 28 patients with pulmonary arterial hypertension confirmed at RHC. The post-capillary group consisted of 52 patients with PH and severe left heart disease. All patients underwent transthoracic echocardiography. Atrial work is defined as the product between atrial volume and atrial pressure; for the right atrium, we estimated atrial pressure from the inferior vena cava diameter and change with respiration; for the left atrium, we used thetransmitral E-wave/ septal mitral annular Doppler Tissue Imaging e'-wave ratio (E/e') as a surrogate for atrial pressure and we defined left atrial work as E/e' × left atrial volume. Results The mean age was 54±14 years in the pre-capillary group and 71±13 years in the post-capillary group (p&lt;0.001). Among the patients in the post-capillary group, 36 (69%) had severe left ventricular systolic dysfunction (mean ejection fraction=23±8%) and 16 (31%) had severe aortic stenosis. The right atrial work was significantly higher in the pre-capillary group: 1089±1105 vs. 382±508 in the post-capillary group (p=0.004). Using receiver operating characteristic (ROC) analysis, a cut-off value of 289.5 provided fair discrimination (area under the curve [AUC] = 0.762) between the two groups (sensitivity=67%, specificity=67%). The left atrial work was significantly lower in the pre-capillary group: 392±206 vs. 1907±1072 in the post-capillary group (p&lt;0.001). Using ROC analysis, a cut-off value of 764 provided excellent discrimination (AUC=0.980) between the two groups (sensitivity=95%, specificity=96%). There was a moderate positive correlation correlation between right atrial work and left atrial work in the post-capillary group (r=0.60, p&lt;0.001), but no significant correlation in the pre-capillary group (p=0.84). Conclusion Echocardiographically-derived atrial work, both right and left, differ significantly between pre-capillary and post-capillary PH. These two simple echocardiographic parameters might guide the differential diagnosis of PH and potentially reduce the need for RHC, should they be further validated. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC-A2-0.2.2.1-2013-1 cofinanced by the ERDF </jats:sec

P1385 Mechanical dispersion of the right atrium in dilated cardiomyopathy: does the etiology matter?

Abstract Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Background Mechanical dispersion assessed by myocardial strain reflects a susceptibility for arrhythmia development. While the contractile heterogeneity of both ventricles has been assessed in different clinical settings, the incidence and significance of right atrial (RA) dyssynchrony in dilated cardiomyopathy (DCM) are unknown. Methods 50 consecutive patients with DCM were divided in 2 groups according to the etiology: group I had 26 patients with ischemic DCM (68 ± 10 years, 23 men), group N had 24 patients with non-ischemic DCM (52 ± 12 years, 18 men). We assessed the RA strain by 2D speckle-tracking analysis, and we calculated RA mechanical dispersion as the standard deviation of the time-to-peak contraction strain in 6 RA segments. 20 healthy individuals served as controls. Data were compared between groups with one-way analysis of variance and using a post-hoc Bonferroni correction. Results The RA strain was reduced in DCM patients, both in group I and in group N. All three components of the RA strain were most reduced in group I (p &amp;lt; 0.001 for reservoir and conduit strain, p = 0.001 for contraction strain) (Table). The RA mechanical dispersion was highest in group I (56.8 ± 21.6 ms), followed by group N (39.9 ± 15.3 ms) and controls (23.8 ± 7.7 ms)(p &amp;lt; 0.001). Patients with DCM and documented supraventricular arrhythmias (either atrial fibrillation, atrial flutter or premature atrial contractions) had higher RA mechanical dispersion (57.5 ± 19.7 ms) than DCM patients with no documented atrial rhythm disturbances (44.9 ± 19.9 ms, p = 0.04). Conclusion Mechanical dispersion of the RA is pronounced in patients with DCM and it is higher in patients with documented supraventricular arrhythmias. Patients with ischemic DCM have a more pronounced mechanical dispersion of the RA than patients with non-ischemic DCM, reflecting a more heterogenous RA contraction in ischemic heart disease when compared to other forms of DCM. The prognostic significance of RA dyssynchrony in a disease primarily involving the left heart warrants further studies. Group I Group N Controls P value Reservoir RA strain (%) 12.9 ± 7.4§ 17.6 ± 12.9§ 30.1 ± 9.9 &amp;lt;0.001 Conduit RA strain (%) -6 ± 5.5§ -8 ± 8.9§ -15.2 ± 6.4 &amp;lt;0.001 Contraction RA strain (%) 6.9 ± 6§ 9.6 ± 8.1 14.9 ± 6.1 0.001 RA mechanical dispersion (ms) 56.8 ± 21.6§ 39.±15.3§* 23.8 ± 7.7 &amp;lt;0.001 § significant difference with controls; * significant difference with group I </jats:sec

P907 Ventriculo-vascular interaction in patients with severe aortic stenosis: a comparison of three different clinical settings

Abstract Funding Acknowledgements This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF Ventriculo-arterial coupling (VAC) reflects the interaction between the ventricle and the arterial system and its prognostic role was studied in different clinical settings. VAC can be assessed with echocardiography as the ratio between the arterial elastance (Ea) and the end-systolic left ventricular elastance (EES). Data concerning the role of VAC in severe aortic stenosis (AS) are scarce. We aimed to determine VAC in patients (pts) with severe AS and assess its relationship with symptoms. We included 61 consecutive pts with severe AS (vave area &amp;lt; 1 cm2) and we divided them in 3 groups according to their symptoms: group A consisted of 28 pts (81 ± 10 yrs, 14 men) admitted for acute pulmonary edema, group B consisted of 25 pts (76 ± 12 yrs, 13 men) with either angina, syncope or dyspnea class I-III NYHA and group C consisted of 8 asymptomatic patients (71 ± 19 yrs, 3 men). We determined the VAC non-invasively and we compared the results between the 3 groups using one-way analysis of variance and a post-hoc Tukey test. There were no significant differences in age (p = 0.08) and aortic valve area (p = 0.18) between groups. Variations of Ea and EES between groups were not significant (p = 0.08 and p = 0.94, respectively). However, VAC differed significantly between the 3 groups, being most impaired in group A (1.11 ± 0.69), followed by 0.77 ± 0.23 in group B and 0.73 ± 0.16 in group C (p = 0.03). The left ventricular ejection fraction (EF) also differed significantly between groups: 41 ± 13% in group A, 51 ± 11% in group B and 57 ± 3% in group C (p &amp;lt; 0.001). VAC and the EF had a moderate negative correlation in group A (r=-0.52, p = 0.004) and group B (r=-0.51, p = 0.009), but no correlation in group C (p = 0.37). VAC is impaired in patients with severe AS and acute heart failure and it differs significantly from VAC in severe AS with chronic, stable symptoms and from VAC in asymptomatic severe AS. This suggests that the progression of symptoms in severe AS might be related to the interactions between the left ventricle and the vascular load, making thus VAC a potential therapeutic target and a parameter to be considered in the thorough evaluation of patients with severe AS. Group A Group B Group C Ea 2.69 ± 1.31 2.09 ± 0.94 1.95 ± 0.60 p = 0.08 EES 2.93 ± 1.90 2.87 ± 1.33 2.71 ± 0.73 p = 0.94 VAC 1.11 ± 0.69 0.77 ± 0.23* 0.73 ± 0.16* p = 0.03 EF 41 ± 13% 51 ± 11%* 57 ± 3%* p &amp;lt; 0.001 *significant difference with group A </jats:sec

P2598Left atrial mechanics in patients with acute pulmonary edema and preserved ejection fraction

Abstract Background The left atrium (LA) is a highly dynamic chamber that has 3 mechanical functions (reservoir, conduit, booster pump), as well as additional endocrine and regulatory properties. It is a marker of both the severity and chronicity of diastolic dysfunction and its remodelling has been shown to be a reliable predictor of clinical outcome in patients with heart disease. While LA function has been extensively studied in chronic heart failure, information about LA mechanics in patients with acute heart failure and preserved left ventricular ejection fraction (EF) are scarce. Purpose We sought to assess LA mechanics in a cohort of patients with acute pulmonary edema and preserved EF and compare it with a normal reference group. Methods We included 50 consecutive patients (22 men) with acute pulmonary edema, preserved EF and sinus rhythm in our study. Patients with significant mitral or aortic valve disease were not considered eligible. The control group consisted of 30 subjects (18 men) with no previous cardiovascular disease. We performed conventional transthoracic echocardiography for all patients and we assessed various parameters of LA mechanics. To evaluate the reservoir function, we determined the total ejection volume (EV), the total EF, the LA expansion index (LAEI) and the LA function index (LAFI). To evaluate the conduit function, we determined the passive EV and passive EF. For the booster pump function, we determined the active EV, active EF, the atrial filling fraction, the ejection force and the LA kinetic energy (LAKE). We used T-test to compare the parameters between the two groups. Results The mean age in the study group was 72±14 years, while in the control group the mean age was 56±16 years (p=0.06). The total EV did not differ significantly between groups (p=0.44). The total LA ejection fraction was lower in the study group: 29±10% vs. 51±9% (p&lt;0.001), as well as the LAEI (45.1±24.6 vs. 110.9±32.1, p&lt;0.001) and the LAFI (0.17±0.12 vs. 0.58±0.20, p&lt;0.001). Among parameters assessing LA conduit function, there were no differences in passive EV (p=0.64), but passive LA ejection fraction was significantly lower in the study group: 15±7% vs. 28±11%, p=0.003. The same trend was noted for active LA ejection fraction (16±10% vs. 31±13%, p=0.005). The ejection force was impaired in the study group: 39.1±30.6 kdynes vs. 15.2±12.3 kdynes, p&lt;0.001. Other parameters evaluating LA booster pump function did not differ significantly between groups (p=0.12 for atrial filling fraction, p=0.74 for LAKE). Conclusion All three integrated phases of left atrial mechanics (reservoir, conduit, booster pump) are impaired in patients with acute pulmonary edema and preserved left ventricular EF. These findings highlight the importance of diastolic dysfunction in the pathogenesis of acute heart failure for these patients and they suggest that LA dysfunction might be a potential therapeutic target in this clinical setting. Acknowledgement/Funding This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC-A2-0.2.2.1-2013-1 cofinanced by the ERDF </jats:sec

Non-invasive assessment of right ventriculo-arterial coupling in dilated cardiomyopathy – insights from 3D echocardiography

Abstract Background Right ventricular-pulmonary artery coupling (RVPAC) reflects the mechanical efficiency of the interaction between the right ventricle (RV) and the pulmonary circulation unit. Although it has been traditionally assessed with right heart catheterisation (RHC), modern imaging techniques enable the non-invasive estimation of the RVPAC, which proved to correlate well with measurements derived from RHC. Methods We used three-dimensional (3D) echocardiography to study 88 consecutive patients (60.4±13.4 years, 69 men) with dilated cardiomyopathy (DCM) and left ventricular ejection fraction&amp;lt;40% and we measured the RV volumes and RV ejection fraction (RVEF) using dedicated software. 15 healthy individuals served as controls. RVPAC was estimated non-invasively as the ratio between the RV end-systolic volume and stroke volume. Right-sided heart failure was defined as either elevated jugular venous pressure, pedal oedema or congestive hepatomegaly. Results Patients with DCM showed larger RV end-diastolic volume (163±60.9 ml vs. 91.3±13.2 ml; p&amp;lt;0.0001), as well as larger RV end-systolic volume (97.3±43.2 ml vs. 39.8±7.2 ml; p&amp;lt;0.0001) than healthy controls. The patients in the study group showed lower RVEF: 41.5±8.5% vs. 56.5±3.6% (p&amp;lt;0.0001). Non-invasive RVPAC was 1.53±0.60 in DCM patients vs. 0.78±0.11 in controls (p&amp;lt;0.0001). RVPAC had an excellent negative correlation with RVEF, both in DCM patients (r=−0.96, p&amp;lt;0.0001) and in controls (r=−0.99, p&amp;lt;0.0001). Patients with no signs of right-sided heart failure had lower RVPAC (1.38±0.45) than patients with at least one sign of right heart failure (1.90±0.72, p=0.03). Patients with mild symptoms of heart failure (NYHA classes 1 or 2) showed lower RVPAC (1.37±0.48) than DCM patients with severe heart failure (NYHA classes 3 or 4): 1.79±0.68 (p=0.003). Conclusions 3D echocardiography provides useful insights in the functional assessment of the cardiopulmonary unit. Non-invasive RVPAC is impaired in patients with DCM, and it is more impaired when signs of right-sided heart failure are present. Severe symptoms are associated with more pronounced decoupling of the RV and the pulmonary circulation. The prognostic significance of non-invasive RVPAC in a disease primarily involving the left ventricle remains to be clarified. Funding Acknowledgement Type of funding source: Other. Main funding source(s): This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF </jats:sec