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Eur J Echocardiography Abstracts Supplement, December 2009 doi:10.

1093/ejechocard/jep129

POSTER SESSION I

Thursday 10 December 2009, 08:3012:30 Location: Poster area

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ATRIAL FUNCTION AND CONTRACT


159
Volume versus diameter measurements: Practical impact on reporting left atrial size
H. Vyas1; K. Jackson1; A. Chenzbraun1 1 The Royal Liverpool University Hospital, Liverpool, United Kingdom Background: Left atrial (LA) size has been shown to correlate with the degree of diastolic dysfunction and to have signicant prognostic value in cardiac patients. LA volume measurement (LAV) is supported lately as being more sensitive in detecting left atrial enlargement (LAE) and having a better prognostic power than diameter measurements (LAD). However, most echocardiography services still rely on the standard measurement of the LA antero-posterior diameter only. Purpose: Prospective study to assess the potential impact of switching to LA volumetric measurement on the reported prevalence of LA enlargement, and thus, on the diagnosis of diastolic dysfunction and the risk stratication of cardiac patients. Methods: LA antero-posterior diameter in the parasternal long axis view, and LA volume by Simpsons method in apical views were measured in 72 consecutive patients (age68+10 yrs, males30) referred for routine echo studies. LAE by diameter and by volume measurements was dened using accepted guidelines. Wall thickness was used to calculate LV mass and ow and tissue Doppler were used to characterize diastolic function. LAE by both methods was correlated with clinical variables, presence of LVH and degree of diastolic dysfunction. Results: LAE by LAD measurement was found in 28 patients (39%) and by LAV measurement in 46 (64%), p,0.01. There was agreement between the two methods in 52 patients (72%). 19 of the 46 patients (41%) with LAE by LAV were missed by LAD measurements. Only one patient was diagnosed with LAE by LAD and not by LAV. Using body surface area indexed values did not improve the percentage of patients missed by LAD measurements: 26/46 (56%). Patients with LAE by LAV but not by LAD measurements were older (72+11 vs. 67+9, p0.05), had smaller LAD (3.5+0.3 cm vs. 3.9+0.8 cm, p0.01) and more severe diastolic dysfunction by both E velocity (5.7+1.9 cm/s vs. 7.2+2 cm/s, p0.02) and E/E ratio (16.6+7.9 vs. 12.1+4.5, p0.05). Conclusion: 1) Left atrial linear measurements miss a signicant proportion of patients with LAE by volume measurements. Indexing for body surface area does not improve the accuracy of the method. 2) Under-diagnosis of LAE by LAD is associated with more severe (type 2) diastolic dysfunction. This underscores the importance of identifying these patients. 3) Wide scale implementation of the volume standard for LAE may result in an expected 40% increase in the number of patients reported as having left atrial enlargement, with implications in terms of risk stratication and proportion of reported abnormal studies.

no clear indication in the guideline what kind of angulations should we take into consideration while assessing LA size apical four chamber view. Aim: to analyze the implications of shape denition and size assessment using current recommendations vs a new methodology. Methods: 186 consecutive hospitalized patients (pts) aged 53+27 years, were included. LA volume (LAV) was assessed using 2 methodologies: M1: current guidelines recommendations and M2: LA tracing and automatic volume calculation after visualization of maximum number of PV and ostia denition. A new measurement was introduced, the basal LA dimension (LAb) as the maximal transverse distance at the base-roof of LA apical four chamber view. LA measurements were calculated at end-systole (maximal). Trapezoidal LA shape was dened if transverse dimension , basal dimension. Results: 52 pts had paroxysmal/persistent AF, 106 pts had arterial hypertension and 91 had evidence of diastolic heart failure. LAV ranged 33.5203.5 ml; LA assessed M1 was ellipsoidal in 90% of pts. Trapezoid LA was found in 65% of pts using M2. Mean number of PV (M2) was 2.3+0.5. LAV (M2) was 85.2+27.6 ml, signicantly higher than LAV (M1) 69.5+19 ml (p,0.0001) The difference between these values was due mainly to the pulmonary veins antrum which is increased in LA with moderate and severe dilatation. Trapezoid LA is more common in AF pts (85%), pts with diastolic heart failure (74%) and hypertension (68%). Increased left ventricular lling pressure may induce subclinical earlier LA remodeling undetected using M1. The difference between LAV measurements using M1 and M2 increase in moderate (9.5+3.6 ml) to severe LA dilatation (15.9+6.5 ml, p,0.0001), suggesting that progressive LA dilatation evolve to trapezoid shape. Trapezoid LA with atrialization of the pulmonary veins and predominant dilatation of basal atrium than annular side may explain underestimation of LAV using ellipse model. Conclusion: Complete characterization of LA remodeling should include shape denition and LAb. LAV is a reliable parameter to estimate LA dilatation, but the real LAV is still debatable with high inter and intraobservator variability due to lack of precise guidelines denitions.

161
Effect of aging on left atrial pump function in healthy subjects
L. Zhong1; CJ. Finn1; LK. Tan1; LH. Chua1; FQ. Huang1; RS. Tan1; ZP Ding1 . 1 National Heart Centre, Singapore, Singapore Purpose: Left atrial (LA) function contributes to left ventricular (LV) lling. However, the impact of age and gender on LA function has not been extensively studied. Methods: We performed echo studies (IE33, Philips) on normal healthy volunteers. The transmitral ow, pulmonary venous ow (PMF) and tissue Doppler imaging (TDI) were recorded using standard echo. LA volumes were calculated using the biplane modied Simpsons method. LA empting fraction (EF) was calculated as (LAmax-LAmin)/ LAmax100%. Early and late diastolic mitral annular velocity Ea/Aa ratio by pulsed TDI was measured. E/Ea was obtained as a marker of LV lling pressure. LA ejection force was calculated as 1/3mitral annular area(peak velocity of A wave)^2 according to Newtons law of motion and hydrodynamics. Results: There were 108 healthy volunteers (mean age 43+13 years, range 22 to 72 years). ANOVA analysis revealed that there was no signicant difference for LA volume indices, emptying fraction (see Table). No age-related differences in pulmonary vein S velocity and AR velocity. However, the Ea/Aa ratio declined signicantly with age. The E/Ea, pulmonary venous velocity S/D ratio and LA ejection force increased signicantly with age. When the group was stratied by gender, there were no signicant differences on LA ejection force. Conclusions: The increased LA ejection force appears to be the compensatory process for age-related LV diastolic dysfunction. Hence, LA dysfunction may be used as a measure for the increased risk of heart failure.

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Should we (re)consider pulmonary vein antrum in the assessment of left atrium volume and shape remodeling?
DC. Cozma1; C. Mornos1; A. Ionac1; L. Petrescu1; C. Blaj1; SI. Dragulescu1 1 Institute of Cardiovascular Medicine, Timisoara, Romania Background: The border between left atrium (LA) and pulmonary vein (PV) and PV antrum implication/importance in the geometry of LA dilatation has not been completely investigated. Current guidelines clearly specify that while assessing LA size care should be taken to exclude PV from the LA tracing. In the other hand there is

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Abstracts

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Table 1 Age

LA size and function with age ,31 (n23) 24+5 8+2 65+12 1.6+0.5 7.6+1.6 48+10 52+11 25+4 0.9+0.3 4.2+2.3 3140 (n25) 24+3 8+2 65+7 1.4+0.4 7.6+1.4 53+11 53+11 28+15 1.0+0.2 5.1+2.2 4150 (n20) 22+5 8+3 66+10 1.0+0.3 9.0+1.8 55+11 47+11 29+15 1.2+0.3 7.8+4.0 5160 (n29) 25+5 9+4 63+10 0.9+0.2 9.6+1.9 58+13 44+11 28+5 1.3+0.3 8.0+3.9 .60 (n11) 25+3 9+3 63+10 0.7+0.2 10.3+1.2 53+10 38+6 29+4 1.4+0.3 13.7+6.2 ANOVA P value 0.34 0.29 0.86 ,0.0001 ,0.0001 0.64 ,0.001 0.64 ,0.0001 ,0.0001

Maximal LA volume index (ml/m2) Minimal LA volume index (ml/m2) LA emptying fraction (%) Septal Ea/Aa E/Ea ratio Pulmonary venous S (cm/s) Pulmonary venous D (cm/s) Pulmoanry venous AR (cm/s) S/D ratio LA ejection force (kdynes)

162
Left atrium volume decreases after successful balloon mitral valvuloplasty: an echographic and hemodynamic study
S. Adavane1; S. Santhosh2; S. Karthikeyan2; S. Ederhy1; S. Rajagopal2; N. Haddour1; J. Balachander2; A. Cohen1 1 AP-HP - Hopital St Antoine, Paris, France; 2Jawaharlal institute of post graduate medical education and research, Pondicherry, India Background: Left atrium (LA) remodelling is known to have a crucial impact on adverse outcome and prognosis in mitral stenosis (MS). Limitations regarding LA evaluation using LA diameters or areas have been reported. To our knowledge there is no study about LA volume variation immediately after balloon mitral valvuloplasty (BMV). The aim of the study is to assess the evolution of LA volume immediately and 1 month after successful BMV in patients in sinus rhythm. Methods: Thirty three consecutive patients (70% female, age 31 +8 years old; range 19 to 45) with moderate to severe MS (i.e. mitral valve area (MVA) 1.5 cm2) who underwent successful BMV (i.e. a 50% increase in MVA and/or a decrease in LA pressure ,18 mmHg in the absence of mechanical complications) were prospectively included. Using 2D echocardiography, and according to the prolate ellipse method, LA volume and LA volume indexed to body surface area were measured before BMV, 24h after BMV and 1 month after BMV. Cardiac catheterization was systematically performed during procedure. Results: MVA increased from 0.88 +0.15 to 1.55 +0.26 cm2 (p,0.0001) and mitral valve mean gradient (MVG) decreased from 16 +9 to 6 +2 mmHg (p,0.0001) immediately after BMV. Indexed LA volume fell immediately from 56 +14 to 48 +12 (p0.0003) then 45 +13 ml/m2 at 1 month (p,0.001). Though, only patients with LA volume !55ml/m2 (median value) prior to BMV had a signicant reduction of LA volume (p0.0001). LA volume decrease was correlated to the immediate decrease in PA-RV peak diastolic gradient and MVG decrease at 1 month. Conclusion: In patients with MS in sinus rhythm, successful BMV results in an immediate decrease in LA volume. This reduction is correlated to the variation of MVG, PA-RV peak diastolic gradient and is signicant when LA volume prior to BMV is very enlarged i.e. !55 ml/m2.

Objective: To evaluate the value of pulmonary vein, mitral and aortic ows by pulsedwave Doppler echocardiography as a noninvasive tool for differential diagnosis of narrow QRS complex tachycardia. Methods: In 30 patients referred for electrophysiological study (EPS) and ablation for a narrow QRS tachycardia, transthoracic echocardiography was performed during tachycardia and in sinus rhythm. Pulsed-wave Doppler was recorded with sample volume placed into the pulmonary vein, at the tips of mitral valve and in aortic ejection tract, measuring duration and peak velocity at the retrograde pulmonary venous ow (AR), left ventricular lling time and stroke volume. According to EPS, typical AVNRT was diagnosed in 17 patients and AVRT in 13 patients. Results: Retrograde peak velocity of the AR at the patients with AVNRT was signicantly lower than in AVRT patients (30,5+4,89cm/s vs 36,20+1,03cm/s, p,0,002). However, dening a cut-off value was not possible due to low sample size. LV lling time was not signicantly different (126+19,8ms in AVNRT group and 113,2ms+13,7 in AVRT group, pNS). Stroke volume was reduced to a similar extent in both groups during tachycardia (from 71+6,4ml to 33,5+3,26ml in AVNRT and from 70+9ml to 34,8+3,48ml in AVRT, pNS). Conclusions: Recorded peak velocity pulmonary retrograde ow could be an important tool for differential diagnosis between AVRT and AVNRT. In spite of atrial contraction occuring always in AVNRT against closed atrioventricular valves, the peak velocity of the AR is signicantly lower in AVNRT group than in AVRT group suggesting that the mechanism remains unclear. Larges studies should be performed to evaluate a cut-off value of peak velocity pulmonary retrograde ow for differential diagnosis.

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Two-dimensional atrial systolic strain imaging may predict the onset of atrial brillation and supraventricular tachycardia at 4-year follow-up in patients with asymptomatic mitral stenosis
R. Ancona1; S. Comenale Pinto1; P Caso1; G. Di Salvo1; R. Lo Piccolo1; G. Petrone1; . F. Pisacane1; R. Calabro1 1 Ospedale Vincenzo Monaldi, Naples, Italy Purpose: Mitral stenosis (MS) is a progressive disease in which, after a long period free of symptoms, often the initial manifestation is the onset of atrial brillation (AF) and supraventricular parossistic tachycardia (SVPT), that occur in about 3040%. The assessment of systolic left atrial (LA) reservoir function in asymptomatic MS was studied by two-dimensional (2D) strain (S) and strain rate (SR) imaging. Its power to predict the onset of AF or SVPT was evaluated at 4-year follow-up. Methods: Sixty-three asymptomatic patients (pts) with pure rheumatic MS and 60 healthy controls were evaluated by standard echo-Doppler study (mitral valve area, mean gradient, systolic pulmonary pressure, left atrial (LA) width, LA volumes, LA ejection fraction) and by 2D Speckle Tracking S and SR. The end-point at 4-year follow-up was the onset of AF or SVPT. Results: LA width, volumes and systolic pulmonary pressure were signicantly increased (p,0.001) and LA 2D S and SR were signicantly compromised in MS pts (p,0.0001). Peak systolic LA myocardial 2D S and SR were signicantly correlated with LA volumes (S: p: 0.01; R:-0.43; SR: p: 0.04; R:-0.34), with LA width (S: p:0.08; R:-0.31), with LA EF (S: p0.0006, R:0.55; SR: p:0.09; R: 0.29), systolic pulmonary pressure (S: p: 0.06; R:-0.35; SR: p: 0.03; R:-0.39). At 4-year follow-up 14 (22%) pts showed AF or SVPT at standard ECG or 24-h Holter ECG. In multivariate analysis, including age, PHT mitral area, LA volume, systolic pulmonary pressure, LA ejection fraction, the best predictor of AF and SVPT was LA peak systolic S (P0.02; coefcient, 0.22; SE, 0.098), with a sensitivity of 89%, specicity of 81%. Conclusions: LA myocardial deformation properties, assessed by 2D S imaging, are abnormal in asymptomatic pts with rheumatic MS. The degree of this impairment is predictor of AF and SVPT a 4-year follow-up. 2D S Imaging could be helpful to recognize pts who will develop AF and SVPT, that is well-known to be associated with worse prognosis.

Table 1

LA volume variation after BMV Before BMV After BMV 1 month after p value p value (before-after) (before-1month) ,0.0001 ,0.0001 ,0.0001 ,0.0001 ,0.0001

0.88+0.15 1.55 +0.26 1.59 +0.28 ,0.0001 MVA (cm2) MVG (mmHg) 16.25 +5.99 6.39 +2.63 7.13 +2.29 ,0.0001 LA volume (ml) 76.67 +22.28 66.00 +18.15 62.54 +18.45 0.0003 Indexed LA 55.79 +14.81 48.06 +12.12 45.63 +13.65 0.0002 volume (ml/m2) PVR (Wood 2.52 +0.92 1.86 +0.43 1.85 +0.39 ,0.0001 unit)

165
Left atrial appendage velocities are affected by mitral annular motion
Z. Ashour1; MHS. Shalaby1; AA. El Amragy1 1 Dept of Cardiology, Faculty of Medicine, Cairo University, Cairo, Egypt, Cairo, Egypt, Egypt Background: In patients with Mitral stenosis, due to stagnation of blood in the left atrium, the risk of thrombus formation is high. As the left atrial appendage (LAA) is a famous site for thrombus formation, a lot of attention has been paid lately to LAA lling and emptying velocities as markers for LAA function. Recording of these velocities usually requires transesophageal echocardiography, as by a conventional transthoracic study the LAA may not be well visualized. In this study we tried to determine whether the LAA velocities correlated to Tissue Doppler measurements in an attempt to replace a semi-invasive technique by a non invasive one Patients and Methods: Twenty nine patients with Mitral stenosis, 16 females and 13 males with a mean age of 34.2 15.2 years were examined by both transthoracic and transesophageal echocardiography. 20 were in sinus rhythm and 9 had atrial brillation . Tissue Doppler measurements of the lateral Mitral annulus velocities were obtained by transthoracic echocardiography and included Em, Am, And Sm. By transesophageal echo the LAA emptying and lling velocites were obtained. Results: The LAA emptying velocity correlated with both the Peak E ( r= 0.605, p, 0.001) and S velocities ( r= 0.705, p, 0.000) and in sinus rhythm patients (n=20) in

MVA mitral valve area; MVG mitral valve mean gradient; LA left atrium; PVR pulmonary vascular resistance.

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Retrograde pulmonary vein ow can differentiate between atrioventricular orthodromic tachycardia and atrioventricular nodal reentrant tachycardia.
A. Alexandrescu1; R. Vatasescu1; N. Dumitrescu1; D. Constantinescu1; C. Caldararu1; L. Platica1; A. Scafa-Udriste1; M. Dorobantu1 1 Emergency Hospital Bucharest, Bucharest, Romania Background: Differential diagnosis between atrioventricular orthodromic tachycardia (AVRT) and typical atrioventricular nodal reentrant tachycardia (AVNRT) is sometimes difcult without invasive electrophysiology testing. However sequential V-A activation during AVRT vs almost concomitant V-A activation during ANRT might have different haemodynamic consequences.

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Abstracts
analysis, the best predictor of AF recurrence was LA anteroposterior diameter ( RR 1.08, 95% IC 1.009 1.147, p 0.02) and LA volume measured by 3D TTE (RR 1.03, 95% IC 1.005 1.062, p 0.02). Conclusions: A simple and widely available parameter, the LA anteroposterior diameter, is as accurate as LA volume determined by 3D echo for predicting AF recurrence after PVA.

correlated with the A wave r= 0.897 p, 0.001)The LAA lling velocity correlated with both the Peak E velocity only ( r= 0.665, p, 0.001) Five patients had an LAA thrombus an ten patients had spontaneous contrast echoes, however due to the small number , no relationship could be found between these and the other parameters measured. Conclusion: Left atrial appendage emptying and lling velocities are affected by Mitral annular motion, denoting that lling and emptying of the atrial appendage is to a large extent a passive process. No relationship was found between these velocities and the presence or absence of thrombi or spontaneous contrast echoes.

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Prognostic implication of the left atrial appendage mechanical function in patients with lone atrial brillation after successful electrical cardioversion
E. Suchon1; M. Kostkiewicz1; A. Lesniak-Sobelga1; M. Krochin1; W. Tracz1; P Podolec1 . 1 John Paul II Hospital, Krakow, Poland Aim: The study aimed to assess whether mechanical function of the left atrial appendage (LAA) enables prediction of atrial brillation (AF) recurrence after successful electrical cardioversion (CR) in patients with persistent lone AF after successful electrical cardioversion (CR). Methods: Fifty patients (mean age of 54 +13; range 23-73 years) with successfully cardioverted persistent lone AF lasting less than 3 months were enrolled. All patients underwent transthoracic and transesophageal (TEE) echocardiography before CR. In TEE we measured: left atrial appendage peak emptying ow velocity - LAAempvel, LAA fractional area change - LAAFAC % (calculated from maximal and minimal LAA area) and LAA lateral wall peak systolic velocity measured by tissue pulsed Doppler with the sample volume placed 1cm from the orice of LAA. Results: At one-year follow-up 33 (66%) patients remained in SR, whereas AF recurred in 17 (34%). There were no difference in age, gender, AF duration, LVEF, LA diameter between patients in SR and AF, but LAA empvel, LAA peak lateral systolic wall velocity and LAA fractional area change - LAAFAC (%) were signicantly lower in patients who recurred to AF (Table 1.) On multivariate logistic regression analysis only LAA empvel (p,0.001, chi(2)6.9, OR 2.6, CI95% 0.20.36) predicted recurrence of AF. Conclusion: Our data indicate that in patients with persistent lone AF the mechanical dysfunction of the LAA may predict recurrence of AF after successful CR.
Table 1. SR (n33). Age (years) Male LA diameter (mm) LVEF (%) LAAempvel (cm/s) LAAFAC (%) LAA lat. wall syst. vel. (cm/s) 51.9 + 9.9 20 (64%) 45 + 2.3 53.8 + 3.8 29.8 + 3.6 0.33 + 0.12 7.4 + 1.2 AF (n17). 52.3 + 10.5 11 (65%) 46 + 2.1 54.1 + 4.2 22.1 + 4.3 0.21 + 0.13 6.3 + 1.4 P NS NS NS NS ,0.001 ,0.01 ,0.05

Dilated left atrium at presentation signicantly decreases the chances for successful rhythm control during 5-year-follow-up
T. Potpara1; B. Vujisic-Tesic1; M. Petrovic1; M. Polovina1; M. Ostojic1 1 Institute for Cardiovascular Diseases, Clinical Center of Serbia, Belgrade, Serbia Purpose: successful rhythm control in patients with atrial brillation (AF) depends on numerous factors. The aim of present study is to examine the relationship between left atrial (LA) anteroposterior diameter at presentation and progression to permanent AF during 5-year follow-up of patients with initially persistent AF. Methods: patients with persistent nonvalvular AF eligible for pharmacological or DC cardioversion were included. Baseline clinical and routine transthoracic echocardiographic parameters were recorded. During 5-year-follow-up cardioversion was repeated when needed and long-term antiarrhythmic therapy was applied, in concordance with current international guidelines for AF. The relationship between progression to permanent AF and independent variables listed below was examined using multivariate logistic regression analysis. Results: out of 335 patients [mean age 53.9+11.7 years, 234 males (69.9%), hypertension 140 patients (41.8%), coronary artery disease 25 (7.5%), cardiomyopathies 39 (11.6%), mild valvular regurgitation 34 (10.2%), heart failure at presentation 33 patients (9.9%), diabetes mellitus 19 (5.7%), obesity 34 (10.1%), AF.48h before initial cardioversion 278 (83.0%), LA anteroposterior diameter , 4cm 198 (59.1%) and reduced left ventricular ejection fraction 68 patients (20.3%)], at the end of 5-year-follow-up 197 patients (58.8%) had permanent AF, i.e. rhythm control was successful in ,50% of study population. Multivariate logistic regression model identied dilated LA, AF.48h before cardioversion and heart failure at presentation as independent predictors of progression to permanent AF (RR 2.3, 95%CI 1.8-4.9, p0.002, RR 4.1, 95%CI 2.1-5.5, p,0.0001 and RR 5.0, 95%CI 4.0-6.6, p0.006, respectively). Conclusion: dilated left atrium at presentation signicantly decreases the chances for successful rhythm control (i.e. restoration and maintenance of sinus rhythm) during 5-year-follow-up, despite active treatment.

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Left atrial ejection fraction as a predictor of cardiovascular events in patients with left ventricular hypertrophy
MG. Trabulo Corte-Real1; P Carmo1; N. Cardim1; P Goncalves1; D. Ferreira1; . . V. Carmelo1; F. Pereira Machado1; J. Roquette1 1 Hospital da Luz, Lisbon, Portugal Introduction: Left atrial (LA) volume and E/E0 ratio are recognized predictors of cardiovascular events in various populations. LA ejection fraction has been less studied in this context. The objective of this study was to assess whether LA ejection fraction (LAEF) had additional prognostic value in a population of high cardiovascular risk. Methods: We studied 58 consecutive patients (pts), 29 women, with more than 60 years (70 + 7 years) with hypertension and moderate or severe left ventricular hypertrophy (LVH) in echocardiography (dened as LV mass index exceeding 109 g/m2 in women and 132 g/m2 in men). We excluded pts with LV ejection fraction below 50%, signicant valvular disease and atrial brillation. We assessed LA maximum and minimum volumes to obtain LAEF (Maximum volume-Mininum volume/ Maximum volume and E/E0 ratio by analysis of pulsed wave mitral ow and tissue Doppler pattern in lateral mitral anullus. We evaluated the occurrence of cardiovascular events - death, myocardla infarction, stroke, CABG, PCI, and onset of atrial brillation (AF) in a median follow-up of 539 (509; 553) days. Results: During follow-up 7 CV events occurred (3 AF, 1 myocardial infarction, 2 PCI and one stroke). Mean E/E0 ratio in pts with events was 14.4 + 1.3 versus 11.0 + 2.7 in pts without events (P 0.002). The median value of LAEF in patients with events was 24% (22, 30) versus 46% (43, 50) in pts without events (P ,0.001). Both LAEF and E/E ratio had high accuracy for predicting events (area under the curve: 0.86, 95% CI: 0.747 to 0.939) and 0.975, 95% CI: 0.895 to 0.997, respectively). The best cut-off for E/E0 ratio was .12 and for LAEF was 33%. In multivariable logistic regression analysis LAEF was an independent predictor of events (Hazard Ratio 0.79, 95% CI: 0.69 to 0.91, P 0.001). Conclusion: This study suggests that LA contractile function in a population with signicant LVH is a potent predictor of cardiovascular events, with additional prognostic value in relation to other factors most commonly assessed. This parameter could be included in the echocardiographic assessment of these patients.

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LA size quantication and recurrence after pulmonary vein ablation: which is the best option?
N. Calvo Galiano1; M. Sitges1; B. Vidal1; S. Montserrat1; D. Tamborero1; A. Garcia-Alvarez1; L. Mont1; J. Brugada1 1 Hospital Clinico Universidad de Barcelona, Barcelona, Spain Introduction: Left atrial (LA) size has been shown to be associated with the success of the pulmonary vein ablation (PVA) in patients with atrial brillation (AF). However, the denition of the best parameter to measure LA size in this setting and to predict AF recurrence after PVA remains controversial. Methods: Patients with symptomatic and drug refractory AF undergoing PVE between October 2004 and October 2008 were included. Within 48 hours prior to the PVA a 2D and 3D transthoracic echocardiography (TTE) were performed in order to asses left atrial (LA) maximum, minimum and preA volumes and LA anteroposterior, longitudinal and transversal diameters. The left ventricular and LA ejection fraction (EF), and LA function (passive, active and reservoir), the late peak diastolic transmitral ow velocity (A) and the velocity-time integral (VTI) of the A wave were also measured. PVE was dened as successful if patients remained asymptomatic and in sinus rhythm (SR) in a 24 hours ECG Holter registry at 6-month follow-up. Results: A series of 176 patients were included. Patients without AF recurrence had smaller LA volumes and anteroposterior diameter and better LA function before the procedure and more often were in sinus rhythm during the study (Table). In the multivariate

No recurrence LA maximum volume 3D (ml) LA minimum volume 3D (ml LA anteroposterior diameter 2D (mm) LA Volume preA (ml) LA total emptying fraction (%) LA passive emptying fraction (%) LA active emptying fraction (%) LAEF (%) Sinus rhythm during TTE 52 + 14 29 + 13 40 + 6 38 +17 23 + 9 14,7 + 8 11 + 8,4 44 + 19 58 (74.4%)

AF recurrence 64 + 22 41 + 18 44 + 6 45 + 16 23,5 + 14 17 + 13 9+9 36 + 16 35 (46.7%)

p p,0.05 p,0.05 p,0.05 ns ns ns ns p,0.05 p,0.05

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Biatrial longitudinal deformation assessment in a clinically diverse series of outpatients using two dimensional speckle tracking
A. Kiotsekoglou1; SC. Govind2; A. Younis1; JC. Moggridge1; SS. Ramesh2; AS. Gopal3; AH. Child1; SK. Saha4

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
1 St. Georges University of London, London, United Kingdom; 2VIVUS-BMJ Heart Center, Bangalore, India; 3Saint Francis Hospital, New York, United States of America; 4 Sundsvalls Hospital, Sundsvall, Sweden

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Left atrial strain and strain rate in patients with severe aortic stenosis
K. O Connor1; J. Magne1; M. Moonen1; LA. Pierard1; P Lancellotti1 . 1 CHU de Liege - Domaine du Sart Tilman, Liege, Belgium Introduction: Global longitudinal left atrial (LA) function may be assessed by the measurement of strain (SI) and strain rate (SR) using tissue Doppler imaging (TDI). The objective of this study was to evaluate the feasibility of SI and SR quantication in patients with severe aortic stenosis (AS). Method and results: TDI, Doppler and 2D transthoracic echocardiography including measurements of left atrium (LA) function and AS assessment were performed in 11 healthy control subjects and in 48 patients with severe AS (71+14 years, 66% of male, aortic valve area (AVA), 0.68+0.2 cm2, mean gradient, 45+14mmHg). Systolic (S), early (E) and late diastolic (A) SI and SR, corresponding respectively to reservoir, conduit and contractile periods of the LA, were measured in lateral, septal, anterior and inferior LA wall and then averaged to obtain global longitudinal SI and SR. Control group was signicantly younger than AS group (47+14 vs. 71+14 years, p,0.01). There was no other difference between control and AS groups with regard to demographic data. The E SI (i.e. conduit phase) was similar between groups. Conversely, S-SI, A-SI, and S-SR, E-SR and A-SR were signicantly impaired in AS group as opposed to control group: S SI= 21+9% vs. 31.9+11%, p=0.0011, A-SI= 14.9+6% vs. 19.7+5.5%, p=0.02, S SR= 1.7+0.5/s vs. 2.6+0.75/s, p,0.0001, E-SR was 21.5+0.6/s vs. 22.7+1.1/s and A SR= 22.3+0.86/s vs. 23.2+0.65/s. Aortic valve area was correlated with LA contractile function (A SI: r=0.39, p=0.01; A SR: r=0.44, p=0.005) but not with SI and SR of the LA reservoir and conduit function. Conclusion: By using SI and SR, reservoir, conduit and contractile functions of the LA are reduced in patients with severe AS. Moreover, the impairment of contractile function of the LA is related to the severity of AS.

Purpose: Recent advances in echocardiography have led to the development of twodimensional speckle tracking (2DST) as a useful tool in left ventricular (LV) myocardial function assessment. This technique has also been used in the evaluation of left atrial longitudinal deformation. The purpose of this study was to investigate whether 2DST can be implemented for biatrial deformation assessment in an outpatient setting. Methods and Results: 2D echocardiographic studies from 62 outpatients (mean age of 53+12 years, 36 men) with different clinical diagnoses were retrospectively analysed. From 4- and 2-chamber apical images of left and right atria (LA and RA) the following measurements were obtained using the Simpson method: a) pre-atrial contraction LA and RA volumes, (LAVpreA and RAVpreA) measured at the start of P wave on the ECG; b) minimal LA and RA volumes (LAVmin and RAVmin) measured at the mitral and tricuspid valve closure, respectively; & c) maximal LA and RA volumes (LAVmax and RAVmax), measured just before the mitral and tricuspid valve opening. From these measurements 3 indices were calculated: 1) LA and RA active emptying fraction (LA AEF)(LAVpreA2LAVmin)/LAVpreA100 and (RA AEF)(RAVpreA2 RAVmin)/RAVpreA100, respectively; 2) LA and RA expansion index (LAEI)(LAVmax 2 LAVmin)/LAVmin 100 and (RAEI)(RAVmax 2RAVmin)/RAVmin 100, respectively; & 3) LA and RA passive emptying fraction (LAPEF)(LAVmax 2LAVpreA)/LAVmax 100 and (RAPEF)(RAVmax 2RAVpreA)/RAVmax 100, respectively. 2DST was also used to measure biventricular systolic parameters and strain/strain rate in contractile and reservoir periods and strain rate in conduit phase for both atria. Statistical analysis showed that LA and RA reservoir strain were signicantly correlated with LV and right ventricular global longitudinal systolic strain (r0.70, p,0.001 and r0.50, p,0.001, respectively). LA and RA EI were signicantly correlated with LA and RA reservoir strain (r0.57, p,0.001 and r0.43, p,0.001, respectively). LA and RA EI were also correlated with LA and RA reservoir strain rate (r0.50, p,0.001 and r0.47, p,0.001, respectively). Multiple regression analysis including age, sex, body surface area, heart rate and global longitudinal ventricular strain showed that age, sex and LV systolic strain had an effect on LA deformation (p 0.003) whilst only age had an impact on RA deformation (p0.018). Conclusions: These ndings suggest that 2DST may be providing accurate atrial deformation analysis and could be used interchangeably with the conventional atrial indices in the clinical setting.

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Relationship of left atrial myocardial deformation with left ventricular lling pressures in patients with severe aortic stenosis
A. Calin1; BA. Popescu1; C. Beladan1; M. Rosca1; D. Muraru2; F. Antonini-Canterin3; GL. Nicolosi3; C. Ginghina1 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 2Institute of Cardiovascular Diseases, Bucharest, Romania; 3Cardiology, ARC, Santa Maria degli Angeli Hospital, Pordenone, Italy Background. Previous studies have emphasized the important role of the left atrium (LA) in cardiovascular performance in patients (pts) with left ventricular (LV) hypertrophy. LA myocardial deformation properties were not studied yet in pts with aortic stenosis (AS). Purpose. We aimed to assess LA strain (e) and strain-rate (Sr) and their relationship with conventional indices of LV diastolic function and lling pressures in patients with severe AS and preserved LV ejection fraction. Methods. We prospectively enrolled 35 consecutive pts (63+6 years, 28 men) with severe AS (indexed aortic valve area, AVAi,0.6 cm2/m2), preserved LVEF (61+6%), and no signicant coronary artery disease, and 19 age-matched normal subjects (58+11 years, 7 men). A comprehensive echocardiogram was performed in all, including TDI-derived parameters of LV diastolic function (E was measured at both septal and lateral sites from the apical 4-chamber view). LV lling pressures were assessed using the E/E ratio. Longitudinal LA strain parameters were assessed from the apical 4-chamber view using a commercially available software (2D Strain). Left atrial reservoir function was assessed by peak systolic values of average segmental e and Sr (LAe and SSr), LA conduit function by early diastolic Sr (ESr) and LA pump function by late diastolic Sr (ASr). Results. In pts, NYHA class was 1.7+0.9, AVAi was 0.39+0.10 cm2/m2 and mean transvalvular gradient was 55+19 mm Hg. LV volumes and LVEF were similar in pts and in normals (p.0.50 for all). There were no signicant differences between groups regarding E/A ratio (p=0.30), E/Vp ratio (p=0.10), and indexed LA volumes (p=0.10). Pts with AS had higher E/E ratios both at the septal and lateral sites (p,0.001). In pts with AS peak LA e was signicantly lower (19+7 vs 30 +7%, p,0.001) and LA strain rate parameters were signicantly reduced (SSr, 0.9+0.2 vs 1.2 +0.2 s-1; ESr, 20.6+0.3 vs 21.4+0.5 s-1; ASr, 21,2+0.5 vs 21.6+0.4 s-1, p,=0.002 for all). In pts with AS there was a signicant correlation between LAe, ESr and ASr with indexed LA volume (p,0.05 for all), and both LA e and ESr correlated to septal E (r=0.48, p=0.004 and r=20.70, p,0.001 respectively). A signicant correlation was found between LAe, SSr, ESr, ASr and septal E/E ratio (r=20.49, p=0.003; r=20.42, p=0.013; r=0.51, p=0.002; r=0.51, p=0.002). Conclusions. In patients with severe AS and preserved LVEF, LA reservoir, conduit and booster pump function are signicantly reduced and are related to LV lling pressures. These ndings support the important role of the LA in LV lling in pts with severe AS and normal LVEF.

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2D atrial longitudinal strain correlates well with left ventricular lling pressure: a study in patients with hypertension and diabetes mellitus
M. M. M. E. R. P . M. S. Mondillo1 1 University of Siena, Department of Cardiovascular Diseases, Siena, Italy; 2Cardiology Operative Unit, S. Andrea Hospital, La Spezia, Italy; 3Cardioangiology Unit with CCU, Department of Clinical and Experimental Medicine, Federico II Univers, Naples, Italy Purpose: Speckle tracking imaging is a new echocardiographic technique and strain (S) imaging for the quantication of longitudinal myocardial left atrial (LA) deformation properties have made it feasible to look at atrial myocardial dynamics in several pathophysiological conditions. However, the role of the LA longitudinal strain as a quantitative measure of left ventricular (LV) diastolic dysfunction in patients with hypertension and/or diabetes mellitus and left ventricular hypertrophy is not established. The aim of this study was to evaluate whether, in patients with hypertension and/or diabetes, LA longitudinal strain correlates with the Tissue Doppler E/Em ratio, assumed as an index of LV lling pressure. Methods: In 94 consecutive patients with hypertension and/or diabetes mellitus, free from other signicant cardiovascular diseases, Peak atrial longitudinal strain (PALS) was measured from apical views using a 12-segment model for the left atrium. Values were obtained by averaging all segments (global PALS) and by separately averaging segments measured in the 4-chamber and 2-chamber views. Results: A close negative correlation between global PALS and the E/Em ratio was found (R=20.74, p,0.0001). The strength of the relationship was similar for the average 4-chamber PALS (R0.73, p,0.0001) and the average 2-chamber PALS (R0.71, p,0.0001). In multivariate analysis, global PALS emerged as a determinant of the E/Em ratio, independent on other confounding factors. Conclusions: Global PALS, an index of LA function expressing LA longitudinal deformation dynamics, is independently related to LV lling pressures in patients with hypertension and/or diabetes. Caputo1; Cameli1; Lisi1; Palmerini1; Urselli1; Ballo2; Galderisi3;

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The improvement of left atrial function in patients with interatrial defects undergoing atrial septal closure
S. Aggio1; C. Piergentili1; L. Conte1; G. Rigatelli1; N. Schenal1; F. Zanon1; A. Marcolongo2; L. Roncon2 1 SOC Cardiologia, Rovigo, Italy; 2General Hospital, Rovigo, Italy

Global PALS - E/E0 correlation.

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Conclusions: atrial function seems to differ, in presence of PFO, ASD or ASA, from that of healthy controls, with lower left atrial ejection fraction due to reduced passive atrial emptying values. Left atrial conduit function was not impaired .The implications of this different physiology has not yet been evaluated.

Background: The atrial function in pts. with ASD is not usually evaluated even if undergoing procedures leading to atrial septal correction. Methods: 39 consecutive pts. affected by different interatrial septal anathomy (patent foramen ovale [PFO], atrial septal defect [ASD], atrial septal aneurysm [ASA]) underwent atrial septal defect closure. Median age was 52,7 + 14(SD), 41 % men. All pts. underwent 2 standard TTE examination (using VIVID5 GE provided with ECHOPAC or Philips iE33, both using a broadband frequency transthoracic 2nd harmonic probe), the rst in the 3 weeks before the procedure and the second the day after. Left atrial (LA) volumes (Vol.) during the cardiac cycle were obtained as average of fourchamber and two-chamber view values. Maximal Vol. of LA was indexed to BSA and the (R-R)2 (VMAXi). Minimal Vol. (VMINi) and remaining measures were indexed in the same way. Passive emptying indexed Vol. (PEVi) was measured one frame after the opening of mitral valve. Percentage (%) of passive emptying (%PE) was calculated: (VMAXi-PEVi)/VMAXi. % of active emptying (%AE) was calculated: (PEVi-VMINi)/VMAXi. LA indexed conduit function (LACi) was the difference between ventricular and left atrial stroke Vol. Results: We used the paired samples T-test to compare results of echo-data before and after the procedure. We could observe signicant differences of %PE, (with increase of this parameter after the haemodynamic procedure (22,9 + 6,4 [SD] vs 33,3 + 8,8 [SD], p ,0,001) and of atrial EF (with increase of this parameter after the haemodynamic procedure (55,1 + 7,4 [SD] vs 61,3 + 6,3 [SD], p ,0,001). Conclusions: differences in atrial function can be evidenced in pts with ASD, PFO, ASA, apparently ameliorating after haemodynamic procedure, with an increase of percentage of passive emptying.

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Left atrial function in the elderly subjects with normal transmitral inow velocity pattern elucidated by an automatic left atrial volume tracking technique
D. Mukaide1; T. Tabata1; H. Yokoi1; G. Ukai1; T. Kamata1; M. Yoshinaga1; H. Izawa1; M. Nomura1 Fujita Health University Second Hospital, Nagoya, Japan Background: Newly developed automatic left atrial volume tracking (LAVT) method can create LA volume loop using two-dimensional tissue tracking technique. The transmitral inow (TMF) velocity usually shows relaxation failure (RF) pattern in the elderly subjects. However, there sometimes appear subjects with normal TMF pattern even in the elderly more than 60 years old without signicant cardiac diseases. Purpose: To elucidate the mechanisms of the normal TMF pattern in the elderly normal subjects using LAV loop obtained by LAVT method. Methods: Subjects consisted of 21 normal volunteers with their ratio of early to late diastolic TMF velocity E/A .1 (N: , 60yrs), 40 elderly normal subjects with their E/A .1 (EN: . 60yrs), 30 elderly normal subjects with their E/A,1 (RF . 60yrs) and 13 pseudonormal patients (PN: E/A .1) with congestive heart failure regardless of age. Image clops of the apical four chamber view were stored into the commercially available EUB-6500 (Hitachi Medico, Japan). The LAV loop was created automatically using a specically customized program (E-tool Viewer) off-line. LAV index (LAVI) at a given cardiac phase was calculated dividing LAV by body surface area. The early (dV/dtE) and late (dV/dtA) diastolic LA emptying rates were calculated from the rst derivative of LAV loop. The early (E) and late (A) diastolic mitral annular tissue velocities were also measured. Results: 1) In the EN, the E was signicantly lower than in the N (9.7+1.9 vs 14.5+2.2cm/sec, p,0.0001) similarly to the RF (8.1 +2.1cm/sec), and A was signicantly lower than in the RF (9.6+2.9 vs 11.4+1.9cm/sec, p,0.05). The ratio of E/E signicantly increased in the order of N RF EN PN. 2) The maximal LAVI was signicantly greater in the EN (30.3+14.1ml) than in the N (22.3+9.6ml, p,0.05) and RF (27.4+11.0ml, p,0.05), while it was signicantly lower than that in the PN (43.6+16.8ml, p,0.01). 3) The passive emptying LAVI (9.5+5.8 vs 6.9+3.5ml) and dV/dtE (139+78 vs 106+61ml/sec) were insignicantly greater in the EN than in the RF. The active emptying LAVI (6.9+3.7 vs 8.5+3.4ml, p,0.05) and dV/dtA (123 + 49 vs 163 + 63ml/sec, p,0.001) were signicantly smaller in the EN than in the RF. Conclusions: The left ventricular diastolic function in the EN was deteriorated as much as in the RF with greater LA volume. The decreased active LA emptying with compensatory increased passive LA emptying were resulting in E/A .1 TMF pattern in subjects with EN. We conclude that the E/A . 1 in the elderly subjects were representing the deteriorated LA functions.

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VMAXi and PEVi pre- and after procedure.

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Left atrial function in patients with pathologic atrial septum anatomy differs from healthy controls.
S. Aggio1; L. Conte1; C. Piergentili1; G. Pastore1; N. Schenal1; G. Rigatelli1; L. Roncon1 1 General Hospital, Rovigo, Italy Purpose: To evaluate the left atrial function in patients (pts.) affected by pathologic interatrial septal anatomy compared to healthy controls. Methods: We analized data of two groups of subjects that underwent a transthoracic echocardiography (TTE). 108 pts. (Gr. A, median age 48,3+16 yrs (SD), 31 % men) affected by pathologic interatrial septal anathomy (patent foramen ovale [PFO], atrial septal defect [ASD], atrial septal aneurysm [ASA]) and 101 healthy controls (Gr. B, median age 45 + 17 (SD), 37% men) were studied with complete TTE. Maximal (VMAXi) and minimal (VMINi) left atrial (LA) volumes (Vol.) were obtained as average of four-chamber and two-chamber view values and indexed to BSA and the (R-R) interval square root. LA passive emptying indexed Vol. (PEVi) was measured one frame after the opening of mitral valve and indexed in the same way. Atrial ejection fraction (AEF) was dened: VMAXi-VMINi/VMAXi. LA passive emptying fraction (%PE) was calculated: (VMAXi-PEVi)/VMAXi. LA active emptying fraction (%AE) was: (PEVi-MINi)/ VMAXi. LA indexed conduit function (LACi) was the difference between ventricular and left atrial indexed stroke Vol. We used the independent samples T-test to compare mean results of echographic and demographic data between groups after a Levenes test for equality of variances. Results: We found no demographic difference between groups nor difference about left ventricular volumes and mass. However Gr. A showed a lower AEF, lower %PE and but higher %AE (Table, data expressed as means + SD). We found no difference between groups in LA indexed conduit function (LACi).

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Echocardiographic predictors of cardiovascular mortality in hemodialyzed patients
H. Ribeiro1; R. Margato1; S. Carvalho1; C. Ferreira1; A. Ferreira1; P Mateus1; JI. Moreira1 . 1 Centro Hospitalar de Traos Montes e Alto Douro, Cardiology Department, Vila Real, Portugal Purpose: The prevalence of cardiovascular disease in end stage renal disease (ESRD) patients is high, being the most common cause of death in this group. Echocardiography has been widely used in prediction of cardiovascular risk in HD patients focusing mainly on the importance of hypertrophy and left ventricular dysfunction. The aim of this study was to evaluate the prognostic value of different echocardiography parameters in the clinical course of hemodialyzed (HD) patients. Methods: We studied 59 patients with ESRD on hemodialysis (HD) for 53-7 months (68% male, mean age of 61 years old). All had an echocardiogram immediately after HD. Cardiac chambers dimensions (left ventricular end diastolic diameter - LVEDD, left ventricular end systolic diameter - LVESD, left atrial antero-posterior diameter LAD), left ventricule mass index -LVMI, relative wall thickness - RWT and left ventricular ejection fraction LVEF were determined. We also recorded myocardial contractility abnormalities, valvular calcications and the presence of pericardial effusion. Patients were followed for 24 months and study endpoint was cardiovascular mortality. Results: On univariate analysis increased LAD and LVEDD, decreased LVEF, presence of pericardial effusion, myocardial contractility abnormalities and older age were predictive of cardiovascular mortality. LVMI, RWT, LVESD and clinical features such as gender, co-morbidities (hypertension, diabetes, dyslipidemia) and nephropathy etiology were not predictive of worst prognosis. Multivariate analyses showed that LAD (OR= 2.2; 95% CI 1.8 - 4.4; p 0.034) and LVEF (OR 1.9, 95% CI 1.4 to 6.9; p 0.046) were independent predictors of cardiovascular mortality. Conclusions: This study conrmed that a traditional echocardiographic predictor of cardiovascular risk in HD patients such as decreased LVEF but not hypertrophy is an independent predictor of mortality. We also showed that a nontraditional predictor of cardiovascular mortalityincreased LAD was a strong predictor of worst prognosis so that we speculate that LAD should be incorporated in cardiovascular risk stratication of HD patients.

AEF Group A Group B p 54 + 10 % 61 + 11 % ,0,0001

%PE 23 + 7% 37 + 12% ,0,0001

LACi (ml/m2) 30,9+ 11,6 30,2 + 10,9 0,68

%AE 32 + 11 % 24 + 11 ,0,001

AEF: left atrial ejection fraction %PE: left atrial passive emptying fraction LACi: left atrial indexed conduit function %AE: left atrial active emptying fraction.

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Is atrial dyssynchrony important in sinus node disease with or without atrial brillation?
M. Wang1; CP Lau1; K. Lee1; XH. Zhang1; D. Siu1; GH. Yan1; WS. Yue1; HF. Tse1 . 1 The University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Purpose: Atrial electromechanical dysfunction might contribute to the development of atrial brillation (AF) in patients with sinus node disease (SND). The aim of this study was to investigate the prevalence and impact of atrial mechanical dyssynchrony on atrial function in SND patients with or without paroxysmal AF. Methods: We performed echocardiographic examination with Tissue Doppler imaging in 30 SND patients with (n11) or without (n19) paroxysmal AF who received dual chamber pacemakers. Tissue Doppler indexes included atrial contraction velocities (Va) and timing events (Ta) were measured at mid left atrial (LA) and right atrial (RA) wall. Intra-atrial synchronicity was dened by the standard deviation and maximum time delay of Ta among six segments of LA (septal/lateral/inferior/anterior/posterior/ anterospetal). Inter-atrial synchronicity was dened by time delay between Ta from RA and LA free wall. Results: There were no differences in age, P-wave duration, left ventricular ejection fraction and LA volume and ejection fraction between with or without AF. Patients with paroxysmal AF had lower mitral inow A velocity (70+19vs.91+17cm/s, P0.005), LA active empting fraction(24+14vs.36+13%,P0.027), mean Va of LA (2.6+0.9vs.3.4+0.9cm/s,P0.028), and greater inter-atrial synchronicity (33+25vs.12+19ms,P0.022) than those without AF. Furthermore, a lower mitral inow A velocity (Odd ratio[OR]1.12, 95% Condence interval[CI] 1.011.24, P0.025) and prolonged inter-atrial dyssynchrony (OR 1.08, 95% CI 1.011.16, P0.020) were independent predictors for the presence of AF in SND patients. Conclusion: SND patients with paroxysmal AF had reduced regional and global active LA mechanical contraction and increased inter-atrial dyssychrony as compared with those without AF. These ndings suggest that abnormal atrial electromechanical properties are associated with AF in SND patients.

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presentation including: age, sex, presence of chronic obstructive pulmonary disease, and BMI Methods: 80 consecutive patients underwent simultaneous dobutamine and RTP-CE using Denityw (Lantheus Imaging, USA) [one vial (1.3 mL) in 30 ml 0.9% normal saline], initially infused (150 ml/hr), then amplied with multi-bolus technique during rest and peak stress perfusion imaging. Repetitive 4 ml boluses were administered according to discretion of sonographer for optimization of image quality. Qualitative RTP-CE analysis (Syngo, Siemens) was done by segments (n=16) and by major coronary territories. Results: The study included 44 (55 %) males [age 70 + 12 years, BMI 30 + 5 Kg/m2, range(18 to 44)]. Qualitative analysis was feasible in 1233/1280 (96%) segments at rest and 1174/1280 (92%) segments at stress. At rest, there was no signicant correlation between the contrast amount and any of the presenting characteristics. At peak stress, there was a signicant correlation between the amount of contrast administered and BMI (p=0.007, r =0.32). When rest and stress were combined, the correlation with BMI remained signicant (p =0.041, r =0.243). Using multivariate linear regression for adjustment of possible confounding effects of age, sex, chronic obstructive pulmonary disease and the variability in initial rate of infusion, the contrast amount remained correlated to BMI [p=0.076]. A dose increase of 0.58 ml per unit (kg/m2) BMI was required for BMI .30, vs. 0.12 ml for BMI , 30. The mean number of vials used was 1 + 0.2 (BMI ,30) vs.1.2 + 0.4 (BMI.=30) [p=0.054]. Conclusions: BMI is an independent predictor of the amount of contrast used during RTP-CE. Patients with higher BMI (.30 Kg/m2) required more contrast compared to those with lower BMI. This nding impacts importantly on the use of contrast for optimization of RTP-CE.

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Real-time perfusion echocardiography accuracy for detecting viability in chronic left ventricular dysfunction undergoing myocardial revascularization
DR. Aleixo1; JM. Tsutsui1; LAM. Cesar1; JA. Ramires1; W. Mathias-Jr1 1 Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil Background: Real-time perfusion echocardiography (RTPE) is an emerging modality for assessing myocardial perfusion and allows noninvasive quantication of regional myocardial blood ow. The aim of this study was to evaluate the accuracy of RTPE for predicting myocardial viability and improvement in quality of life after coronary revascularization. Methods: Twenty four patients with coronary artery disease and ventricular dysfunction (ejection fraction ,40%) underwent RTPE and answered Minnesota Quality of Life Questionnaire before and after coronary artery bypass grafting (CABG). RTPE was performed using continuous PESDA or Denity intravenous infusion with power modulation image. Viability was dened as presence of homogeneous opacication in at least one myocardial segment in the resting on revascularized territory, according coronary distribution. All revascularized territories were analyzed. Results: Hibernating myocardium (regional recovery after CABG) was observed in 77% of RTPE viable territories and in 44% of non-viable (p=0.03). Sensitivity, specicity, predictive positive and negative values of RTPE for detecting viability were 74%, 60%, 77% and 56%, respectively. Quality of life score improved from 36.4 (29.143.6) to 18.1 (12.823.4; p=0.001). However, there was no statistical correlation with RTPE. Conclusion: RTPE provides good accuracy for detecting hibernating myocardium in patients with coronary artery disease and ventricular dysfunction. Nevertheless, it couldnt predict the quality of life improvement after CABG.

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Effect of exercise based rehabilitation on myocardial blood ow reserve as measured by real-time contrast echocardiography in patients with nonischemic dilated cardiomyopathy
JM. Theotonio_Dos_Santos1; I. Kowatsch1; JM. Tsutsui1; NMV. Canavesi1; CE. Negrao1; C. Mady1; JAF. Ramires1; W. Mathias Junior1 1 Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil Background: Exercise training has been shown to be effective in improving functional class of the New York Heart Association and exercise capacity in patients with heart failure. There is no a conclusive study demonstrating the cardiac contribution in this clinical response to exercise. Real-time myocardial contrast echocardiography (RTMCE) is a new technique that allows quantitative analysis of myocardial blood ow (MBF). Objective: We sought to determine the effects of exercise based rehabilitation on MBF reserve measured by RTMCE in patients with primary dilated cardiomyopathy (DCM). Methods: We prospectively studied 23 patients with DCM and left ventricular ejection fraction ,45% who underwent RTMCE and cardiopulmonary exercise test before and after 16 weeks of optimized medical treatment (control group; n=10) or optimized medical treatment associated with exercise training program consisted of three 60-min exercise sessions/week with corresponding intensity between the anaerobic threshold and 10% below the point of respiratory compensation (trained group; n=13). The replenishment velocity (b) and an index of MBF (An x b) reserves were derived from quantitative RTMCE. Results: The exercise training did not change left ventricular diameters, volumes or ejection fraction in patients with DCM. At baseline, b reserve was lower in trained group than control group [1.51 (1.10-1.85) versus 1.72 (1.451.88); p=0.02] while no difference was observed in MBF reserve [1.81 (1.282.38) versus 1.89 (1.671.98); p=0.39]. A 16-week of optimized medical treatment associated with exercise training program resulted in signicant increase in the b reserve from 1.51 (1.101.85) to 2.20 (1.692.77); p,0.0001, and increase in MBF reserve from 1.81 (1.282.38) to 3.05 (2.073.93); p,0.001. On the other hand, after 16 weeks of optimized medical treatment, the b reserve decreased from 1.72 (1.451.88) to 1.46 (1.142.33); p= 0.03 and the MBF reserve decreased from 1.89 (1.671.98) to 1.55 (1.112.27); p,0.01. Peak oxygen consumption increased by 13.8% at 16 weeks of exercise training and decreased by 1.9% in the control group. Conclusions: Exercise training resulted in signicant improvement of MBF reserve obtained by RTMCE in patients with DCM and heart failure.

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Impact of spontaneous reperfusion on infarct size and microvascular damage after primary PCI
S. Funaro1; E. Canali2; A. Mattatelli2; D. Berardi2; M. Madonna2; A. Pordia3; L. Galiuto3; L. Agati2 1 Catholic University of the Sacred Heart, Campobasso, Italy; 2Sapienza University of Rome, Rome, Italy; 3Catholic University of the Sacred Heart, Rome, Italy Purpose: Previous studies demonstrated that patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous intervention (PCI) take advantage of a spontaneous reperfusion of infarct-related artery (IRA) on initial angiography in terms of angiographic and clinical results. So, we evaluated in a group of STEMI patients undergoing primary PCI the weight of spontaneous IRA reperfusion before angiography on infarct size (IS) and microvascular damage (MD) extension. Methods: 103 out of 110 STEMI patients enrolled in AMICI (acute myocardial infarction contrast imaging) multicenter study represented our study population. Clinical characteristics were collected and CK peak, early % ST-segment reduction, Blush and TIMI grade were evaluated before and after PCI. IS was measured by using conventional echocardiography as a percent of dysfunctional LV segments (WMA%), MD was assessed by using contrast echocardiography as a percent of myocardial contrast defect length (CDL%). Ejection fraction (LVEF%) was also assessed. According to TIMI ow grade before PCI, patients were divided in two groups: Group A : TIMI ow 23 (spontaneous reow), Group B: TIMI ow: 01. Results: 35 patients entered in group A, and 68 in group B. There were no signicant differences between groups as for time to reperfusion and risk factors except for family history of coronary diseases and hypercholesterolemia which were higher in group B (37% vs 9% p0.002 and 45% vs 28% p0.046 respectively). The percentage of female gender was higher in group A (26% vs 10% p 0.042). Furthermore, clinical indexes of reperfusion as % ST segment reduction, and peak CK

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Predictors of optimal contrast dosing during dobutamine stress real time perfusion contrast echocardiography
SS. Abdel Moneim1; M. Bernier1; SS. Abdelkader2; S. Moir1; PA. Pellikka1; SV. Mankad1; SL. Mulvagh1 1 Mayo Clinic, Rochester, United States of America; 2Assiut University, Assiut, Egypt Purpose: While contrast dosing methods for left ventricular opacication are wellestablished, optimal dosing for real-time perfusion contrast echocardiography (RTP-CE) is unclear. We sought to determine potential predictors for contrast dosing in RTP-CE during dobutamine stress based upon the available information at time of

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Echo Particular velocity imaging (ECHOPIV) is a promising tool detectingow patterns in cardiovascular structures. Optical ow method implemented forcontrast movement detection usually gave semi-quantitative information. Wethought to improve pre treatment and image processing in order to obtain morereliably results. Validation of our image processing approach was done usingtwo pulsatiles in vitro modelssimulating vascular laminar ow and intra ventricular complex ow and usingoptical PIV as reference. Method: In order to determine the particle displacement we have to applydifferent treatment on the image sequences to recover suitable images formovement detection. First: we remove the noise through soft wavelet thresholding method. Thesequence is decomposed in approximation and details coefcient for a givingscale, thus very small details (mostly representative of noise) are avoiding,and then the image is reconstructed. Second: we decompose images into two components, rst one holdinggeometry, the structure of images and second one representative of texture, theparticles in our case. This is very convenient to estimate the movement sinceour sequence isnt disturbed by quite chaotic particle mixture movement andproblem induced by plane transfer of particles between two consecutive frames.Since we got the regularized component, the optical ow could be estimatethrough partial derivative equation method. We use a multi-scale implementation, the movement is rst estimate onlow-resolution version of the sequence to catch the global motion, then themovement is estimate at the upper resolution rene by previous results. Thismethod is iteratively applied till to reach the original resolution. Image 1 show the velocity eld and the shear stress prole obtained inthe vascular model

did not differ between groups (56+35 vs 46 + 51 p 0.564 and 2345 + 2000 vs 2400 + 1900 p 0.895 respectively). Finally TIMI grade after PCI was good in both groups (2.7+0.41 vs 2.7 + 0.46 p 0.83). On day 1 after PCI, CDL% and WMA% were signicantly lower and LVEF% slightly higher in patients with spontaneous reow (11+ 15 vs 21+16% p0.018, 28+21 vs 42+17% p0.006 and 49+7 vs 46+9% p0.178 respectively). On multivariable analysis for prediction of spontaneous reow, family history and female gender were independently associated with spontaneous reow before PCI (OR7.3; 95%IC 1.928 p0.04 and OR3.9 96%IC113 p 0.28 respectively). Conclusion: In STEMI patients spontaneous reestablishment of ow pre primary PCI is more frequent in female gender and in patients without family history of CAD and with lower incidence of hypercholesterolemia. Such spontaneous reow is associated with smaller microvascular damage and infarct size and better LV systolic function.

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Improvement of microvascular ow and myocardial function after reopening of chronic coronary occlusion. Early results of recanalization of chronic coronary occlusion and recovery of dysfunction
S. Barchetta1; AM. Leone1; E. Fedele1; A. Pordia1; AR. De Caterina1; AG. Rebuzzi1; F. Crea1; L. Galiuto1 1 Catholic University of the Sacred Heart, Rome, Italy Purpose: the utility of reopening a chronic coronary occlusion (CCO) is under debate. We postulate that recanalization of CCO is associated with improved microvascular ow and myocardial function. Methods: we analyzed the rst 13 patients that completed the follow up out of the 26 patients initially enrolled in the trial. Patients were included in the trial if they had coronary occlusion that dated between 3 days and 12 months. All patients underwent myocardial contrast echocardiography (MCE) before reopening of CCO and after 9 3 months of follow-up. The length of perfusion defect was measured in 3 apical views averaged and expressed as % left ventricle (LV). Wall motion score index (WMSI) , contrast score index (CSI), LV volumes and ejection fraction were calculated. Results: at follow-up, a signicant reduction of perfusion defect (9.5 + 12 % vs 1.4 + 4.7 %, p 0.005), improvement of CSI (1.4 + 0.3 vs 1.1 + 0.2, p 0.001), improvement of WMSI (1.5 + 0.4 vs 1.2 + 0.2, p 0.0004) and increase of ejection fraction (50.8 + 7.9% vs 58.2 + 6.2%, p 0.0001) were observed in the absence of LV dilatation (end diastolic volume 111.1 + 20.7 ml vs 100.6 + 17.6 ml, p 0.005 ; endsystolic volume 55.6 + 20 ml vs 42.8 + 13.2 ml, p 0.001). Conclusions: preliminary results of the study demonstrate that reopening of chronic coronary occlusion is associated with improved microvascular ow, regional and global myocardial function and with preserved LV volumes.

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echopiv for euroecho.

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Detection of restenosis using Dobutamine stress myocardial contrast echocardiography after coronary angioplasty
M. Olszowska1; M. Kostkiewicz1; P Podolec1; W. Tracz1 . 1 Jagiellonian University, Krakow, Poland Background: Dobutamine stress echocardiography (DSE) detects coronary stenosis by inducing ischaemia and subsequently wall motion abnormalities. Myocardial perfusion can be assessed at real time, when using a low mechanical index and harmonic imaging, following intravenous injection of contrast agent. The study aimed to determine whether myocardial contrast echocardiography (MCE) may be used in detecting restenosis during DSE after coronary angioplasty. Methods: The study group consisted of 71 patients (pts), (41 M; 30 F) who underwent coronary angioplasty (PCI) due to coronary artery disease (CAD). All pts underwent DSE. Dobutamine was infused in incremental doses of 5 to 40mg/kg/min. Bolus injection of intravenous Optison was administered at rest and during peak dobutamine stress test. Wall motion score index (WMSI) and segmental perfusion were estimated at real time before and 10-14 days after PCI using low MI (0.3) after 0.3 ml bolus injection of intravenous Optison. MCE was scored semiquantitatively as: 1 - homogenous contrast enhancement, 0.5 - patchy contrast enhancement, 0 - no contrast. The follow-up period was 6.05+0.45 months. DSE with contrast agent and coronary angiography was repeated in pts with suspected restenosis. Results: The analysis of the mean WMSI was 1.27+0.19 at rest and 1.4+0.18 at peak and decreased to 1.2+0.16 at rest and 1.29+0.4 at peak (p,0.001) after PCI. 68 pts after PCI had no segments with induced perfusion defect at peak dose of dobutamine, 3 pts had segments with induced perfusion defect but it was smaller. In the follow-up period 20 pts were suspected to perform restenosis. The sensitivity, the specicity, and the accuracy of DSM with MCE in detecting perfusion defect due to restenosis after coronary angioplasty (conrmed angiographically) was 88%, 77% and 85%, respectively. Conclusions: MCE during DSE revealed substantial potential for identifying angiographically restenosis after coronary angioplasty.

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Bioeffects of the ultrasound contraste in normal and abnormal situations of the microcirculation: an experimental study
A. Camarozano1; F. Cyrino2; E. Bouskela2; AG. Siqueira-Filho1; K. Camarozano3; R. Noe1 1 Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil; 2Universidade Estadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil; 3Fundaca ABC, SaoPaulo, Brazil Purpose: Adhesion of microspheres to leukocytes in inammatory tissues has been discussed and the effect of ultrasound in this context as well. However, little is known about the behavior of microspheres in capillaries under disease conditions. The evaluation of circulatory effects of these agents may explain their effect on the myocardium. Aim: To investigate microvascular and hemodynamic behavior of microspheres (contrast for ultrasound-US) in the following groups of hamsters: control, ischemia-reperfusion, type-2 diabetes, diabetes with ischemia and sepse. Method: An experimental study of the microcirculation, using the cheek pouch preparation, in 90 male hamsters was performed. Animals were divided into groups according to disease induction: GI=ischemia/reperfusion; GD=diabetes; GDI=diabetes with ischemia/reperfusion and GS=sepse, in relation to GC (control group). We analyzed the inammatory response in the microcirculation (AL=adhered leukocytes, RL=rolling leukocytes), VD=vein diameter and DA=arteriolar diameter and the hemodynamic pattern such as arterial blood pressure (BP), heart rate (HR) and rheology according blood ow (BF), at the baseline and after 15, 30, 45 and 60min after microsphere administration. During the procedure we administered Denity (a lipid coated microsphere containing peruoropropane gas) or placebo (saline solution). ANOVA and Mann-Whitney tests were used for comparisons, with a signicance level set at 5%. Results: There was no difference in AL, RL, VD and AD with or without microspheres in different groups. There was also no difference in BP and HR before and after Denity (NS) and BF was subjectively worse in GS. Number of AL and RL was higher in GDI and GS in relation GC (p,0,05). Conclusion: Inammatory and hemodynamic responses in the microcirculation showed no alteration with this contrast agent. The inammatory response seemed to be pronounced in GDI and GS, independent of microsphere use. These ndings help us to establish the safety level when using contrast for ultrasound.

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Description of new image processing tools improving echo contrast detection for ECHOPIV method
M. Lugiez1; D. Coisne2; M. Menard1; S. Dubois1; C. Cuvier3; V. Deplano3; L. Christiaens2 1 L3I University, La Rochelle, France; 2CHU de Poitiers - Hopital de la Miletrie, Poitiers, France; 3Irphee CNRS, Marseille, France

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Myocardial contrast echocardiography is superior to single photon emission computed tomography for the detection of hibernating myocardium
RK. Chelliah1; M. Hickman1; L. Burden1; R. Senior1 1 Northwick Park Hospital, Harrow, United Kingdom Background: Single photon Emission Computed Tomography (SPECT) is widely used for the assessment of hibernating myocardium (HM) in patients with ischemic cardiomyopathy. Myocardial Contrast Echcardiography (MCE) is a relatively new technique which can assess myocardial perfusion at the bedside. We hypothesised that MCE, due to its better spatial and temporal resolution compared to SPECT, will be superior to SPECT for the detection of HM. Method: Accordingly 32 patients with symptomatic ischemic cardiomyopathy (mean left ventricular ejection fraction= 30% /- 9%) underwent simultaneous rest and vasodilator SPECT and MCE. Of these, 23 patients underwent coronary revascularisation. These patients were then assessed 3 months after revascularisation, for recovery of left ventricular function, which is the denition of hibernating myocardium. Results: Of the 214 dysfunctional LV segments, 156 (73%) segments demonstrated HM in 23 patients of which 16 (70%) showed signicant improvement of LV function (dened as 30% improvement of wall motion score index at follow up). Logistic regression analysis using both qualitative and quantitative MCE and SPECT showed that qualitative and quantitative MCE were the independent predictors for the detection of HM( p value=0.03 for qualitative MCE and p=0.000 for quantitative MCE ). Furthermore, using clinical LV function data, SPECT and MCE for predicting recovery of LV function, MCE was the only independent predictor(p value=0.02). Of the 32 patients, signicantly more reversible defects (p,0.0001) were identied by MCE(267 segments) compared to SPECT( 98 segments) and signicantly more reversible defects ( p, 0.0001) by MCE (54%) predicted recovery of function compared to SPECT (20%). Conclusion: MCE was superior to SPECT for the assessment of HM in ischemic cardiomopathy.

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Inuence of gender on the extent of myocardial viability after primary coronary angioplasty
E. Canali1; A. Mattatelli1; D. Berardi1; S. Funaro2; M. Madonna3; L. Galiuto2; L. Agati1 1 Sapienza University of Rome, Rome, Italy; 2Catholic University of the Sacred Heart, Campobasso, Italy; 3IRCCS San Raffaele Hospital, Rome, Italy Purpose: Few studies have been addressed about sex distinctions in the amount of jeopardized myocardium that is salvaged by mechanical reperfusion in patients with acute myocardial infarction (AMI). The aim of our study was to evaluate possible gender-related differences in tissue viability after ST elevation myocardial infarction (STEMI). Myocardial contrast echocardiography (MCE) was used to assess residual tissue perfusion within the infarct area after successful coronary reperfusion. Methods: We studied 110 consecutive patients who underwent successful primary coronary angioplasty within 6 h of onset of STEMI. Two-dimensional echocardiography was performed within 24 hours of coronary recanalization and microvascular perfusion was assessed by real-time MCE on 7+2 days after AMI by using a quantitative analysis software. Contrast defect length (CDL%) was measured to assess microvascular integrity on endocardial border. Myocardial viability index was obtained by summing perfused but dysfunctioning segments divided by all dysfunctional segments and expressed as percentage. Results: Of the 110 patients received primary PCI, 28 patients were females (26%) and 82 (74%) were males. Women were signicantly older (62 10 years vs. men age 58 10, p=0.101) and had a longer time to reperfusion (8.6 7.1 hours vs 4.5 4.2 hours in men, p=0.011). Contrast defect length was larger in men than women (20 7.2 % vs 11 7.0 %, respectively, p=0.009) suggesting the presence of a bigger microvascular damage. Myocardial viability index was higher in women than in men (56 37 % vs 33 22 %, respectively, p= 0.016). Multiple linear regression analysis was used to assess the independent impact of gender on myocardial viability. After adjustment for other variables, female gender (p=0.006), younger age (p=0.019), anterior infarction (p=0.003), shorter time to reperfusion (p=0.018), small contrast defect length (p=0.002) and the use of glycoprotein IIb/IIIa inhibitors (p=0.004) were identied as independent factors associated with a higher myocardial viability. Conclusions: In successfully reperfused STEMI population, myocardial viability as detected by MCE is gender-dependent also after adjusting for other baseline and risk factors. A different response to antiaggregating drugs, a higher tolerance to hypoxic setting and the activation of estrogen receptors against intracellular calcium loading could probably be involved in this favorable women behavior. Despite a longer time to reperfusion and a lower respect of recent STEMI guidelines, tissue viability after coronary reperfusion was higher in women.

Background: The course of right ventricular function abnormalities in patients with rheumatic mitral stenosis (MS) treated with balloon mitral valvuloplasty (BMV) is not clearly dened. Purpose: The study aimed to assess the evolution of systolic, diastolic and global function of the right ventricle (RV) immediately and one month after BMV using a standard Doppler echocardiographic approach combined with tissue Doppler imaging (TDI). Methods: Thirty three consecutive patients (70% female, age 31+ 8 years old; range 19 to 45) with moderate to severe MS (mitral valve area MVA 1.5cm2) in sinus rhythm who underwent successful BMV (i.e. a 50% increase in MVA and/or a decrease in left atrial pressure to less than 18 mmHg without mechanical complications) were prospectively included. Echocardiographic parameters of RV function were performed before BMV, 24 to 48 hours after BMV and one month after BMV and included pulsed wave TDI (S velocity, E/Ea, Ea/Aa, E/A, isovolumic relaxation time (IVRT), Tei index, tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), and pulmonary vascular resistance (PVR). The control group included 14 healthy subjects (64% female, 32+ 5 years old; range 23 to 45). Results: MVA by planimetry increased from 0.88+0.15 to 1.55+0.26 then 1.66 +0.28cm2 at one month (p,0.0001) and mitral valve mean gradient (MVG) fell from 16+6 to 6+2 then 7+2 mmHg (p,0.0001) after BMV. The right atrium (RA)-RV pressure gradient decreased from 57+25 to 42+13 then 40+12 mmHg (p,0.0001) and PVR fell from 2.53+0.92 to 1.86+0.43 then 1.85+0.37 Wood units (p,0.0001). There was no signicant change with regard to TDI S velocity, RVFAC and Tei index, the last one remaining signicantly higher than controls. There was a signicant increase of TAPSE (p0.01 immediately after BMV; p,0.001 at one month) which was signicantly correlated to the decrease in PVR, RV-RA pressure gradient, the immediate decrease in MVG, and the increase in MVA at one month. There was a signicant improvement in E, Ea, E/A, Ea/Aa immediately and one month after BMV which was correlated to the decrease in right heart pressures but IVRT remained prolonged compared to controls. This improvement occurred only in patients with MVA.1.5 cm2 after BMV. Conclusion: In patients with MVA.1.5 cm2 after BMV, successful BMV results in a signicant improvement of RV systolic function assessed by TAPSE, of diastolic function assessed by E, Ea, E/A, Ea/Aa while Tei index and IVRT remained signicantly higher than controls immediately and one month after BMV.

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Isovolumic myocardial acceleration, new index of right ventricular function after percutaneous mitral valvuloplasty
E. Khalifa1 1 Dar Al Fouad Hospital, Giza, Egypt Objectives: In mitral stenosis, Right ventricular (RV) function may be affected either by rheumatic process or due to pulmonary vascular alterations. The aim of this study was to determin if isovolumic myocardial acceleration (IVA) measured by tissue Doppler imaging (DTI) of tricuspid annulus could be used in detection of RV function immediately after percutaneous mitral valvuloplasty (PMV) Patients and methods: The current study enrolled 80 patients with chronic rheumatic mitral stenosis in sinus rhythm. Conventional echocardiographic parameters, mitral valve area (MVA), transmitral diastolic gradient, pulmonary artery pressure (PAP), RV fractional shortening (RVFS%), tricuspid annular plane systolic excursion (TAPSE). TDIderived systolic velocities of tricuspid annulus, isovolumic myocardial acceleration (IVA), peak myocardial velocity during isovolumic contraction (IVV), peak systolic velocity during ejection period (Sm) and RV Tei index were calculated to all patients befor and after (one day ) PMV Results: TAPSE, RVFS% and Sm were relatively higher following PMV but did not attain statistical signicance. TDI-derived IVA, IVV index were found to be signicantly increased after PMV from 1.710.54 m/s2 to 3.270.22 m/s2 , and from 0.110.04 cm/s to 0.140.06 cm/s respectivly with (P,0.001) for all. RV Tei index signicantlly deceased from 0.490.025 to 0.310.21 (P, 0.01). Signicant negative correlation could be established between IVA and PAP (before and after PMV) (r = 20.61, r=20.58 respectively), Tei index (r = 20.72) and mean transmitral diastolic gradient (r = 20.74), whereas signicant positive correlation was established between IVA and MVA (r = 0.68) with p,0.0001 for all correlations. Conclusion :TDI- derived IVA can be used as reliable, non invasive parameter to detect early improvement of RV function following PMV

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The role of interventricular interaction for the functional recovery of the RV after pulmonary endarterectomy
S. Giusca1; V. Dambrauskaite1; J. Dhooge1; P Claus1; L. Herbots1; F. Rademakers1; . M. Delcroix1; JU. Voigt1 1 Catholic University of Leuven (KULeuven), Leuven, Belgium Aims: The impact of LV on RV function is not fully understood. In this study, we investigated the changes of regional RV free wall and septal function compared to changes in invasive and non-invasive measures of RV and LV performance in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who undergo pulmonary endarterectomy (PEA). Methods: 16 pts(60+15) with CTEPH underwent echocardiography before (PREOP), 1week (1W) and 1, 3 and 6months (1M, 3M, 6M) after PEA. We determined RV and LV end diastolic area (EDA) and volume (EDV) and ratio of

ECHOCARDIOGRAPHIC EVALUATION OF THE RIGHT HEART


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Right heart function evolution immediately and one month after successful balloon mitral valvuloplasty: a tissue Doppler imaging study
S. Adavane1; S. Santhosh2; S. Karthikeyan2; S. Ederhy1; S. Rajagopal2; N. Haddour1; J. Balachander2; A. Cohen1 1 AP-HP - Hopital St Antoine, Paris, France; 2Jawaharlal institute of post graduate medical education and research, Pondicherry, India

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children are lacking. Our aim was to implement normal TAPSE values regarding the size of the body from birth to childhood. Methods: We prospectively included 248 normal neonates, infants and children (51.2% male). The patients were referred to ofce mainly for asymptomatic murmur. Subjects with any other condition were excluded. Complete echocardiographic studies were performed and reported as normal in all cases. The weight and height of each patient were recorded at the same time. Results: The mean age was 4.11 years (range 0.01-18), the mean height 95.9 cm (range 46171) and the mean weight was 18.1kg (range 2.376.5). Mean TAPSE was 17.3+4.1cm. There was no signicant difference in TAPSE values between gender. Regression curvilinear adjustment models were tested for TAPSE, showing incremental values regarding age, height, weight, body mass index and body surface. Figure 1 depicts a scatterplot including TAPSE measures related to body surface (logarithmic regression model). Body surface displayed the closest positive correlation with TAPSE values (r-coefcient0.82) while cardiac frequency a negative relationship (r=-0.72). Conclusions: Normal TAPSE values depends on age, being most closely correlated with body surface area. We provide these adjusted data. This information can be presented as Z-score nomograms, and be useful in the real-life practice.

diameters (RV/LVEDD) as markers of ventricular shape. Longitudinal strain in the RV free wall (Srfw) and the interventricular septum (Sivs) was measured using speckle tracking. LV ejection fraction (LVEF) and RV fractional area change (RVFAC) indicated LV and RV function. Invasive hemodynamic were obtained PREOP and 1W after PEA. Results: After PEA, systolic pulmonary artery pressure decreased and remained low (87+12 mmHg PREOP vs. 49+13mmHg 1W, 49+20mmHg 6M, all p,0.001 vs. PREOP). Likewise, cardiac index improved immediately (1.6+0.5 vs. 3.2+0.6 l/min/m2, p,0.001). RV volume decreased and LV volume increased, with the septum shifting from a left-convex to a regular shape (RV/LVEDD, see table). LV function was normal throughout the study, while the impaired RV function (RVFAC) improved after PEA and continued to increase during follow up. This initial increase was only due to a Sivs improvement, while Srfw recovered only after 1M. Conclusions: Initial RV function improvement after PEA is due to a better septal function, which may be explained by its more favorable postoperative shape. RV free wall recovers slowly, independent from the acute unloading. We conclude that marked ventricular interaction occurs during recovery after PEA.

Preop RVEDA (cm2) LVEDV (ml) LV/RVEDD LVEF (%) RVFAC (%) Sfws(%) Sivs(%) *p,0.05. 27.5+6 51+11 0.65+0.1 64+6 29.5+6 213+6 217.5+4

1week 22.2+4* 69+11* 1.1+0.2* 65+7* 36.5+7* 214.8+4 221.1+5*

1month 21.1+4* 74+13* 1.1+0.2* 65+5* 42.5+5* 218.8+4* 221.4+3*

3months 20.5+4* 70+16* 1.1+0.2* 65+6* 44.8+9* 223.9+5* 221.8+3*

6months 17.8+3* 72+17* 1.2+0.1* 64+4* 43.2+7* 227+4* 221.9+3*

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How does the reference system of echocardiographic measurements inuence the assessment of acute changes in RV Function? A study in patients who underwent pulmonary endarterectomy
S. Giusca1; V. Dambrauskaite1; J. Dhooge1; P Claus1; L. Herbots1; F. Rademakers1; . M. Delcroix1; JU. Voigt1 1 Catholic University of Leuven (KULeuven), Leuven, Belgium Aims: In the clinical routine, a variety of echocardiographic parameters are used to assess right ventricular (RV) function. We sought to compare the ability of different conventional and tissue Doppler derived echocardiographic parameters to reect acute RV function changes in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who underwent pulmonary endarterectomy (PEA). Methods: 16 patients with CTEPH (60+15) underwent echocardiography and right heart catheterization before and within 1 week after PEA. Tricuspid annular plane systolic excursion (TAPSE) and longitudinal systolic velocity of the tricuspid ring (Vt) were measured as parameters dependent on the transducer as reference. RV fractional area change (RVFAC), RV Tei index, and Strain in the interventricular septum (Sivs) and RV free wall (Srfw) were measured as independent parameters. Results were compared to pulmonary vascular resistance (PVR), mean pulmonary artery pressure (mPAP) and cardiac index (CI) as obtained from right heart catheterization. Results: Hemodynamics improved signicantly after PEA (PVR: 976+432 vs. 276+143 dyne*sec/cm5, mPAP 44+9 vs 32+12 mmHg and CI 1.6+0.5 vs. 3.2+0.6 l/min, all p,0.001. This was mirrord by Sivs (217.5+3.5% vs. 221+5%, p0.04), Tei index (0.59+0.16 vs. 0.39+0.13, p,0.001) and RVFAC (29.4+6% vs. 36.5+7%, p0.02). Srfw did not change. In contrast, TAPSE (14.5+4.5mm vs. 8.5+2.7mm , p,0.001) and Vt (9.3+3cm/s vs. 6.9+2.3 cm/s, p0.04) decreased, indicating a worsening of function. Changes in mPAP correlated well with changes in Sivr (r 20.81, p0.001) and RVFAC (r 20.7, p0.02); changes in PVR and CI correlated with the changes in Tei index (r0.65, p0.01, and r 20.6, p0.03). In contrast, TAPSE and Vt did not correlate to hemodynamic data. Conclusions: Parameters which are measured vs. the transducer (TAPSE, Vt) do not accurately reect postoperative changes in RV function due to operation induced changes in overall heart motion. Parameters without external reference system (S, Tei, RVFAC) are superior and should be preferred for pre-/post-operative comparisons.
Figure 1.

194
Bosentan reduces right-to-left ventricular diastolic delay in patients with chronic thromboembolic pulmonary hypertension
HACM. Bruin De-Bon1; M. Hardziyenka2; S. Surie1; P Bresser1; RBA. Van Den Brink1; . HL. Tan1; BJ. Bouma1 1 Academic medical center, Amsterdam, Netherlands; 2Interuniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, Netherlands Aim: To assess effects of bosentan treatment on diastolic interventricular synchronicity in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods and Results: Eighteen patients with CTEPH (mean age 56+17 years, 7 women) treated for 16 weeks with bosentan underwent transthoracic echocardiography and 6-minute walking test (6MWT) at baseline and after treatment. Tricuspid annulus plane systolic excursion (TAPSE), right ventricular (RV) peak systolic velocity of tricuspid annulus (RV Sm), systolic pulmonary artery pressure were estimated using tricuspid regurgitation jet velocity (sPAP), and RV and left ventricular (LV) myocardial contraction duration (MCD) (time interval between onset of QRS and onset of early diastolic lling velocity E0 of each ventricle) of basal segments were obtained and analyzed off-line. RV-to-LV diastolic delay was calculated by subtraction of LV MCD from RV MCD. Paired Student0 s t-test was applied for comparisons. After 16 weeks of bosentan treatment, RV-to-LV diastolic delay and sPAP decreased, while 6MWT increased signicantly compared to baseline (Table). Conclusion: Bosentan treatment reduces RV-to-LV diastolic delay in CTEPH patients.

Table 1

Effects of bosentan treatment Baseline After bosentan 494+121 81+11 36+19 423+43 387+36 71+23 1.9+0.5 10.9+2.5 P value 0.001 0.82 ,0.001 0.075 0.33 0.043 0.30 0.43

6MWT, m heart rate, bpm RV-to-LV diastolic delay, ms RV MCD, ms LV MCD, ms sPAP mmHg , TAPSE, cm RV Sm, cm/s

456+121 82+14 63+24 439+52 376+47 76+21 1.8+0.4 11.1+2.4

193
TAPSE values and body size: an echocardiographic study in normal infants and children
I. Nunez-Gil1; MD. Rubio2; L. Deiros2; C. Blanco2; L. Garcia-Guereta2; C. Labrandero2; A. Barrios2; F. Gutierrez-Larraya2 1 Hospital Clinico San Carlos, Madrid, Spain; 2Hospital Universitario La Paz, Madrid, Spain Purpose: Detailed data on normal echocardiographic values are vital since important decisions concerning management often rely on these ndings. TAPSE (Tricuspid annular plane systolic excursion) measurements correlate nicely with right ventricular function and its values are well established in adults. However, normalized data in

195
How much precise is tricuspidal annular plane systolic excursion in assessing right ventricle systolic function? A comparison with the gold-standard cardiac magnetic resonance.
O. Catalano1; G. Moro1; M. Mussida1; S. Antonaci1; M. Frascaroli1; M. Baldi1; F. Cobelli1 1 Foundation Salvatore Maugeri, I.R.C.C.S., Pavia, Italy Right ventricle (RV) contractility predicts prognosis and is a functional determinant in many congenital and acquired heart diseases. Thanks to an inherent simplicity, tricuspidal annular plane systolic excursion (TAPSE) is the most frequently used parameter

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
in clinical practice. Aim of the study was to compare TAPSE with the gold-standard RV ejection fraction (EF) at cardiac magnetic resonance (CMR). Methods and results. We performed a retrospective study by retrieving, from our hospital data-base, all consecutive patients (pts) who underwent, from 1st September 2005 to 31 August 2007, a CMR study with RVEF and TAPSE calculation and (within 1 week) an Echo evaluation including TAPSE assessment. We selected 190 pts: 153/37 m/f, 61+15 years, BSA 1.81+0.18 m2, RR interval 928+175 msec and SBP/DBP 128+23/76+12 mmHg. At linear regression analysis Echo TAPSE and CMR TAPSE were signicantly but weakly correlated with CMR RVEF (r0.35, R2 0.12, p,0.000, and r0.42, R2 0.18, p,0.000, respectively). We used a CMR RVEF cut-off value of 40%, the 95th percentile inferior limit of a normal population tested in our laboratory, to dene a reduced or normal RV contractility. Receiver operator characteristic (ROC) curves showed that Echo TAPSE values , 15 mm are sufciently specic (specicity 81%) to assess a reduced RVEF, and values ! 19 mm (specicity 79%) to identify a preserved RVEF. TAPSE performance was overall modest in predicting RVEF (area under the curve 71%). Conclusions. TAPSE is a simple and useful echocardiographic method for a rst step assessment of RV contractility. However, uncertainty about RV funcion remains in case of intermediate values of TAPSE. Moreover, TAPSE can not be considered the method of choice whenever a precise assessment of RV contractility is required.

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TAPSE as a predictor of the right heart failure in patients with pulmonary hypertension
OA. Polikina1; VV. Vikentyev1 1 Moscow State University of Medicine and Dentistry, Moscow, Russian Federation Recently tricuspid annular plane systolic excursion (TAPSE) has become a well-known sensitive indicator describing functional state of the right ventricle in patients with cardiovascular and pulmonary diseases. Aim of the study was to assess the predicting value of TAPSE in patients with chronic obstructive pulmonary disease (COPD) and pulmonary hypertension (PH) presenting no clinical signs of right heart failure. Methods: 89 patients of 4677 years with COPD and PH were examined (64% males) and underwent 1 year follow-up. Baseline and follow-up echocardiography was performed including M- and B-mode right ventricle (RV) measurements, Doppler Echocardiography with RV systolic pressure calculation. TAPSE was assessed using M-mode. Results: in patients who within the follow-up period developed clinical manifestations of the right heart failure (RHF), the mean TAPSE at baseline was 9.5 /2 0.17 mm. In subset of subjects whose TAPSE at baseline was less then 15 mm, 66.7% (40 people) developed clinical RHF. In group with TAPSE less then 10 mm, 90% presented clinically signicant RHF. We found that TAPSE was signicantly negatively related to systolic RV pressure and subjects age. Conclusion: TAPSE can be regarded as simple and reliable indicator showing the possibility of RHF development in patients with COPD and PH.

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Mid-term echocardiographic follow-up of the patients with chronic thromboembolic pulmonary hypertension after pulmonary thromboendarterectomy
T. Palecek1; D. Ambroz1; P Jansa1; J. Lindner1; K. Taborska1; M. Vitovec1; P Polacek1; . . A. Linhart1 1 Charles University in Prague, 1st Faculty of Med., Prague, Czech Republic Background and aim of the study: Pulmonary thromboendarterctomy (PEA) is a method of choice for treatment of symptomatic patients with chronic thromboembolic pulmonary hypertension (CTEPH). Short-term studies have repeatedly demonstrated signicant improvement in morphological and functional parameters of right (RV) and left (LV) ventricle. The aim of our study was to evaluate the mid-term changes in echocardiographic parameters obtained from patients with CTEPH who underwent PEA. Methods: The study group consisted of 50 patients (53+13 years) with CTEPH, in whom echocardiography was performed before, 1 month and 12 months after PEA. The investigated parameters comprised pulmonary artery systolic pressure (PASP), right ventricular end-diastolic diameter (RV EDD), area (RV EDA) and fractional area change (RV FAC)); left ventricular end-diastolic diameter (LV EDD), end-diastolic volume (LV EDV), eccentricity index (LV EI) and ejection fraction (LV EF). Results: The results are summarized in Table 1. Conclusions: The profound decline in pulmonary artery pressure occurs early after PEA and is accompanied by signicant decrease in RV size and improvement of its systolic function. Corresponding increase in LV size and normalization of its shape may be also detected early after PEA. These favorable hemodynamic, morphological and functional changes of pulmonary circulation and both ventricles persist or even improve in mid-term one-year follow-up after PEA.

ROC curves: RV function by TAPSE.

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Pulmonary transit of agitated contrast during exercise is associated with reduced pulmonary vascular resistance and augmentation of right ventricular function
A. La Gerche1; AT. Burns2; DJ. Mooney2; H. Heidbuchel3; AI. Macisaac2; DL. Prior2 1 The University of Melbourne, Melbourne, Australia; 2St. Vincents Health, Melbourne, Australia; 3Catholic University of Leuven (KULeuven), Leuven, Belgium Background: Factors modulating exercise induced increases in pulmonary artery pressure are incompletely understood. It has been hypothesized that the pulmonary transit of agitated contrast (PTAC) on echocardiography indicates recruitment of larger vessels and possible RV afterload reduction. Methods: 54 subjects (40 athletes, 14 untrained) performed maximal exercise on a semi-supine bicycle. Repeated 12ml agitated colloid boluses were administered intravenously. Arterial blood gases and B-type natriuretic peptide (BNP) were obtained at baseline and peak exercise. Continuous echocardiographic measures of pulmonary artery pressures (PASP), resistance (PVR), cardiac output (CO), RV and LV myocardial velocities in systole (RVSm, LVSm), isovolumic contraction (RV IVA), LV preload (E/e0 ) and invasive mean arterial blood pressure (BPmean) were obtained. PTAC was semiquantitatively graded by the presence of ,20 or .20 bubbles in the left ventricle (LV) at maximal exercise. Results: The presence of .20 bubbles divided the cohort into 2 equal groups low (n27) and high (n27) PTAC. High PTAC was associated with lower peak PASP and PVR compared with low PTAC. This resulted in improved measures of systolic RV function and a smaller increase in BNP - see Table. There were no differences in measures of LV preload (E/e0 7.5+1.6 vs 7.3+1.0, p0.6 for high vs low), BPmean (121+10 vs 122+10mmHg, p0.5) or LV Sm (13.4+3.2 vs 12.3+2.5cm/sec, p0.2) suggesting that the BNP increase was due to the RV loading differences. There was no difference in pO2 decrease (8.2+14 vs 9.0+14,p0.8) suggesting that if large vessel recruitment explains this phenomenon, it does not cause signicant shunting. Conclusion: Greater degrees of PTAC are associated with a reduction in exercise induced PASP and PVR which results in improved RV function and lower BNP This . physiological variant may be an important modulating factor in pulmonary vascular pathology.
Table 1 Pulmonary and RV measures with exercise Low PTAC (n 27) 62.4+ 13.5 0.018+ .003 18.9+ 2.9 5.1+ 1.9 16.0+ 13.6 High PTAC (n 27) 52.3+ 9.8 0.014+ .003 21.5+ 4.5 6.9+ 2.7 9.4+ 10.5 p value 0.003 ,0.001 ,0.001 0.002 0.048

Table 1.

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Right ventricle performance assessed by TDI in olympic-level athletes
W. Krol1; W. Braksator1; M. Kuch1; B. Chybowska1; A. Mamacarz1; H. Krysztoak2; M. Dluzniewski2 1 Warsaw Medical University, Warsaw, Poland; 2Centre of Sport Medicine, Warsaw, Poland The inuence of exercise on heart is widely discussed topic especially when left ventricle is considered, however much less attention is given to right ventricle (RV). It is known that enlargement of right ventricle with tricuspid valve regurgitation (TVR) and moderately increased TVR gradient (TVRG), which are known signs of RV overload in general population are sometimes observed in athletes, especially in those

Measures at peak exercise PASP (mmHg) PVR PASP/(HR RVOT VTI) RVSm (cm/s) RV IVA (cm/s2) Increase in BNP (pg/ml)

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Abstracts
hypertension (PH) was present in 30 subjects (68%) by both methods. In 8 subjects (18%), exercise and immediate-recovery PASP values were bellow the cut-off limits. In 6 patients (14%), there was a discrepancy between both methods in relation to the diagnosis of stress-induced PH. Conclusions: Although the values of PASP measured at peak exercise and within rst minute of recovery phase signicantly differ, the estimation of PASP at the early beginning of recovery phase allows the detection of stress-induced PH in the majority of subjects.

participating in sports requiring intensive mixed (dynamic and static) exertion such as cycling or rowing (group IIIC according to 36th Bethesda Conference). Available date concerning right ventricle assessment was based on varied or endurance (IIIA) athletes. Methods: We examined 36 members (30 men, 6 women) of Polish Olympic Team -25 rowers, 5 mountain cyclist, 6 ice skaters aged 25,5yrs in average. A single TTE was performed. Beside standard measurements systolic (S0 ), early (E0 ) and atrial (A0 ) diastolic velocities of tricuspid annulus were assessed using TDI. To decrease the bias of preload dependent parameters and increase quality of image measurements were performed during deep expiration. Values were taken as a average of 3 consequent measurements. Student test T was used to assess statistic differences in subgroups with or without RV dilation (above 3cm) or elevated TVRG (above 30mmHg). Results: All measured in TDI velocities were within normal values for young, healthy individuals (see tab.), no abnormal patterns or inverted E/A ratio were observed. There were no statistically signicant differences in annular velocities between athletes with or without RV enlargement. However, one with elevated TVRG( which was present in 11% of examined) was related to lower S0 annular velocities- 11cm/s vs. 15,4cm/s (p0,002). Conclusion: 1. In athletes with extreme mixed exercise load right heart annular velocities are normal- even in individuals with enlarged right ventricle and elevated TVRG. 2. Enlargement of RV and moderately increased TVRG seems to be another sign of athletes heart syndrome. 3. Elevated (.30mmHg) TVRG is related to lower TV annulus systolic velocities.

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The inuence of mitral balloon valvuloplasty on short and long term right ventricular function: evaluation by tissue Doppler imaging
H. Karapinar1; Z. Kaya2; H. Kaya2; OB. Esen3; M. Akcakoyun2; G. Acar2; AM. Esen2; C. Kirma2 1 Van High Speciality Education and Research Hospital, Van, Turkey; 2Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey; 3Istanbul Memorial Hospital, Istanbul, Turkey Introduction: We aimed to evaluate the effect of mitral balloon valvuloplasty (MBV) on right ventricular systolic and diastolic functions at early (24 hours) and long term (6 months) period. Methods: Twenty-seven consecutive patients who were successfully treated with MBV were included in the study. All of the patients underwent transthoracic echocardiographic (TTE) examination that also included right ventricular tissue Doppler evaluation (TDI) 24 hours before the planned MBV. TDI evaluation included measurement of systolic (S, indicate right ventricular systolic function), early (E) and late diastolic (A, indicate right atrial systolic function) wave velocities from the lateral tricuspid annulus. E wave velocity and E/A ratio were chosen to be markers of right ventricular diastolic function. The same TTE evaluation was performed at 24 hours and 6 months after the procedure. MBV was done by the Inoue technique under TTE guidance. The results are expressed as mean+standard deviation, and compared by paired sample t-test. Results: In the early phase, all of the patients displayed signicant increase in right ventricular S and A wave velocities (9.52+1.85 vs 10.92+1.2 cm/s, p0.012; 210.44+2.64 vs 211.73+2.05 cm/s, p0.029; respectively). And, there was no signicant change in E wave velocity and E/A ratio (pNS). In the late phase, S wave velocity was similar to the one obtained at 24 hours and was signicantly higher than the preprocedural velocity (10.69+1.72 vs 9.52+1.85 cm/s, p0.023). However, A wave velocity decreased and did not sustain the signicance of increase it showed 24 hours after the procedure (210.74+2.63 vs 210.44+2.64 cm/s, pNS). Finally, E wave velocity increase just reach signicant level in the late phase (29.21+1.81 vs 27.85+1.54 cm/s, p0.046). Conclusion: The systolic right ventricular function started to improve early after MBV and this improvement was sustained in the late phase. Although the improvement in the diastolic right ventricular function in the early phase was not signicant, the improvement reached statistical signicance in the late phase.

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Table 1. TV annulus velocities. Examined group (n36) E0 (cm/s) A0 (cm/s) S0 (cm/s) 15,8 10,6 14,9 SD 2,6 3,4 3 Healthy, young controls n55 (Erol et al.) 16,6 10,9 14,5 SD 4,7 2,2 2

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Early detection of subclinical right ventricular changes in elite rowers using automated functional imaging and measurement of isovolumic acceleration
G. King1; EMM. Ho1; K. Bennett1; I. Almuntaser1; RT. Murphy1; AS. Brown1 1 St. Jamess Hospital, Dublin, Ireland Introduction: Participationin high-intensity training for endurance sports may predispose the athlete to mild subclinical changes of right ventricular (RV) injury. Aim: To assess changes to the right ventricle as a consequence of high-intensity training by measuring global longitudinal strain and isovolumic acceleration(IVA). Methods: 18 male elite rowers were compared with an age- and gender-matched group of 17 controls. Two-dimensional speckle tracking-based automated functional imaging was used to measure RV longitudinal strain and pulsed-wave tissue Doppler at the lateral tricuspid annulus was used to measure IVA. RV diameter, RV wall thickness, and pulmonary arterial pressure (PAP) were also measured. Independent t-tests were used to compare RV longitudinal strain, RV diameter, RV thickness, and PAP The Mann-Whitney Utest was used to compare IVA between the two groups. . Results: In rowers, the mean RV diameter was signicantly increased compared with controls (34.0+ 6.77 vs 22.5+ 6.92; p,0.0001). The mean RV longitudinal strain was lower in rowers compared with controls (20.11+ 2.81 vs 25.38+ 2.57;p,0.001). The mean IVA was signicantly greater in rowers compared to controls (2.02+ 0.60 vs 1.48+ 0.30; p=0.002). The mean RV wall thickness was no different between rowers and controls (0.422+ 0.10 vs 0.359+0.11, p=0.063). The mean PAP was also similar in both groups (23.29 mmHg+ 6.04vs 21.12 mmHg+ 4.4, p=0.8). Conclusions: Our study demonstrates that subclinical changes in the right ventricle as a consequence of high-intensity training, manifest as an increase in RV size, and a reduction in peak global longitudinal strain and an increase in isovolumic acceleration.

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Evaluation of right ventricular hemodynamic by two-dimensional strain in patients with chronic pulmonary thrombus embolism
K. Takada1; K. Sugimoto2; A. Yamada1; H. Inuzuka2; M. Kato2; S. Ito2; M. Iwase1; Y. Ozaki1 1 Fujita Health University School of Medicine, Toyoake, Japan; 2Fujita Health University Hospital, Toyoake, Japan Background: Assessment of right ventricular (RV) function is important as RV dysfunction is associated with worse clinical outcomes. However, this could be problematic because standard methods of evaluating RV function are limited due to its poorly dened geometry. Recent studies demonstrated that RV myocardial strain could accurately quantify RV function in patients with pulmonary hypertension (PH). Purpose: The purpose of this study was to examine the correlation of RV strain with invasive pulmonary hemodynamic and RV function in patients with chronic pulmonary thrombus embolism (CTPE). Subjects: Forty ve patients with CPTE (mean age: 57.114.2 years) underwent twodimenional (2D) echocardiography and 2D speckle-tracking strain evaluation of RV regional contractility. Patients additionally underwent right-heart cardiac catheterization. PH was dened as mean pulmonary artery pressure (mPAP) .25mmHg at rest. Study subjects were divided into 2 groups based on mPAP as below: Group 1 (n=25): mPAP .25mmHg (mean age: 58.812.0 years) Group 2 (n=20): mPAP,25mmHg (mean age: 56.316.0 years) Methods: All patients underwent transthoracic echocardiography to obtain longitudinal strain with placement of two regions of interest in the basal and middle ventricular segments of RV free wall. Right atrial pressure, pulmonary artery pressure, mPAP pulmon, ary wedge pressure, cardiac index were measured by right-heart catheterization. Results: RV peak strain (RV-PS) was signicantly higher in Group 1 than in Group 2 (-16.1+ 4.7% versus -29.7+ 6.9%, p , 0.01, respectively). RV-PS showed a signicant correlation with mPAP (r=0.804, p,0.001). Receiver operating characteristic analysis revealed that a cut-off value of RV-PS at -18% could detect mPAP.25mmHg with sensitivity 91%and the specicity 86% (area of under the curve 0.953, p,0.001) Conclusion: RV strain could assess not only RV regional and global function but also RV hemodynamics in patients with CPTE.

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Stress Doppler echocardiography: the estimation of pulmonary artery systolic pressure at peak and within early recovery phase
M. Vitovec1; T. Palecek1; P Jansa1; D. Ambroz1; A. Linhart1 . 1 General University Hospital, Prague 2, Czech Republic Background: Stress Doppler echocardiography represents a promising tool for the evaluation of exercise-induced increase of pulmonary artery systolic pressure (PASP) in subjects with borderline PASP values at rest. However, the estimation of PASP at peak exercise might be technically difcult. Aim of our study: To compare the values of PASP obtained at peak exercise with those measured within the rst minute of recovery phase. Methods: 44 subjects (55+11 years, 24 females) with borderline Doppler-estimated values of PASP at rest and without inferior vena cava dilatation underwent stress echocardiography on a variable-load supine bicycle-ergometer. PASP was estimated from peak tricuspid regurgitant jet velocity (5mmHg) as an estimate of right atrial pressure). PASP was measured at peak exercise and at the end of rst minute of recovery phase. Results: In the whole study group, PASP at rest was 33+6 mmHg, at peak exercise 58+10 mmHg and 47+9 mmHg at the rst minute of recovery phase (all p .0.05). Using current recommended cut-off values for exercise-induced PASP (50mmHg for peak exercise and 40mmHg for immediate recovery phase), stress-induced pulmonary

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Right ventricular dysfunction evaluate by echocardiography in spontaneously hypertensive rats after sinoartic denervation
RA. Sirvente1; LE. Souza1; RN. Fuente1; B. Rodrigues1; ICM. Silva1; C. Mady1; MC. Irigoyen1; VMC. Salemi1 1 Instituto de Cardiologia da Faculdade de Medicina da Universidade de SaPaulo, Sao Paulo, Brazil Purpose: Assessment of right heart hemodynamics in patients with heart failure is of great clinical importance for both diagnostic purpose and prognostication. During the development of hypertension, sympathetic hyperactivity commonly seems to be related to left ventricular dysfunction and baro and chemo reexes impairment. However, right ventricle (RV) function has not been evaluated specially regarding the association of hypertension and baroreex dysfunction. In this issue, the aim of this study was to evaluate the role of chemo and baroreex dysfunction induced by sinoaortic denervation (SAD) on RV performance of spontaneously hypertensive rats (SHR), as well as the impact of this alteration on cardiac function. Methods: The animals were divided into 4 groups: normotensive rats (CTR, n5); SHR (n5); SAD (n7); and SADSHR (n7). SAD was induced in 2 months old SHR and Wistar rats (normotensive). After 10 weeks of SAD induction the animals were submitted to echocardiographic examination for assessment of RV function, that included ow velocity pattern in the right ventricular outow tract to evaluate the acceleration time (AT) and right ventricular ejection time (RVET). RV end-diastolic pressure (RVEDP) was invasively measured by right heart catheterization. Results: The groups SAD, SHR and SADSHR showed a decrease AT (32+1.35, 32+1.22 and 26+1.48msec, respectively) when compared with control (41+2.16 msec., p 0.05). Either AT or AT/RVET were decreased while RVEDP was increased in SAD, SHR and SADSHR group when compared to CTR group (5.9+0.59, 6.7+0.15 and 8.1+1.02 vs 3+0.39 mmHg, respectively). SADSHR group presented the greater RVEDP and the shorter AT compared to all groups (p, 0.05). A very strong correlation was found between AT and APT/RVET with RVEDP (r 20.8723; p 0.05; r20.7373, p 0.05, respectively). Conclusions: These data suggest that the reex dysfunction induced by SAD in SHR may lead to an additional impairment on RV function, and also the development of pulmonary hypertension.

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Purpose: Cardiac brosis is an important complication of carcinoid disease leading typically to right-sided valvular dysfunction and heart failure. Current echocardiographic evaluation of right ventricular (RV) function in patients with carcinoid heart disease (CaHD) is limited and may be difcult due to its poorly dened geometry. CaHD is dened as the presence of at least mild right-sided valvular regurgitation or stenosis most often in the form of tricuspid regurgitation (TR). We hypothesized that assessment of myocardial strain by echocardiography may be useful for evaluation of early RV dysfunction in patients with CaHD. Methods: We studied 89 patients with carcinoids (mean age 61+12; 47 females) and 20 healthy individuals (mean age 55+15; 7 females). Peak systolic strains were averaged from 3 myocardial segments in the RV free wall. We compared RV free wall strains in the patient group to the corresponding strains in the control group. Patients were divided into two groups according to the presence or absence of TR. Results: Average RV strain was reduced in the patient group compared to the control group ( 20.6+5.0% vs 28.6+5.3%,p,0.001). Of the patients, 38 had mild or greater TR. There was no difference in RV function between the patients with and without TR (221.2+4.5% vs 219.9+5.4%,ns), indicating early subclinical RV dysfunction even in carcinoid patients currently not fullling the criteria for CaHD. Conclusions: RV function assessed by myocardial strain was lower in patients with intestinal carcinoid disease irrespective of valvular involvement compared to controls. These ndings may indicate early RV involvement even in patients without right-sided valvular dysfunction. Myocardial strain may therefore disclose RV dysfunction in patients with intestinal carcinoid disease.

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2D-echocardiography of the right ventricle in athletes heart and hearts of normal size compared to magnetic resonance imaging: which measurements should be applied in athletes?
J. Scharhag1; T. Thuenenkoetter2; A. Urhausen2; G. Schneider3; W. Kindermann4 1 University Outpatient Clinic, Centre for Sports Medicine, Potsdam, Germany; 2Centre of Sports Medicine, Luxembourg, Luxembourg; 3University Clinic of Radiology, Homburg, Germany; 4Institute for Sports and Preventive Medicine, University of Saarland, Saarbruecken, Germany Purpose: Pathologic hypertrophy and cardiomyopathy of the right ventricle (RV) have been shown to be related to ventricular arrhythmias and sudden cardiac death in athletes. However, it is unclear which 2 dimensional (2D) echocardiographic measurements reect RV dimensions in athletes heart (AH) correctly. Therefore, the study aimed to compare 2D-echocardiography of the RV in AH and hearts of normal size to magnetic resonance imaging (MRI), and, thereby, derive recommendations for RV echocardiography in athletes. Methods: 23 healthy male endurance athletes with AH (A; age: 28+ 4yrs; heart volume: 14.1+ 1.0 ml/kg; VO2max: 68+ 6 ml/min/kg) and 26 healthy untrained males (C; age: 26+ 4yrs; heart volume: 11.0+ 0.9 ml/kg; VO2max: 43+ 6 ml/min/kg) matched for body dimensions were examined by transthoracic 2D-echocardiography. Enddiastolic RV free wall thicknesses (T1,T5,T9) and diameters (m-mode enddiastolic diameter [RV-EDD]; longitudinal [RV-LAX], sagittal, outow-tract and tricuspid valve anulus diameters) were determined in recommended parasternal and 4-chamber views. RV enddiastolic volume (RV-EDV) and mass (RVM) were determined by MRI. Results: Signicant correlations between echocardiographic and MRI measurements were found for RV-EDV and RV-EDD (r0.49; p=0.001) as well as RV-LAX (r0.38; p0.01), and RVM and T5 (r0.52; p0.01). For RV echocardiography, mild signicant differences between A and C were documented for RV-EDD (medians [quartiles]: A:26mm [24/29mm]; C:22mm [21/27mm]; p0.04; measurable in 49/49 subjects), and in the parasternal short axis view for T5 (A:6.0mm [5.4/7.8mm]; C:5.0mm [4.5/5.2mm]; p0.04; measurable in 22/49). Conclusion: 2-dimensional RV echocardiographic measurements offer only a limited potential to reect true RV dimensions. Only RV-EDD may differentiate between normal hearts and exercise related RV adaptations in AH, and is the only recommendable parameter to be measured in athletes routinely. In unclear cases additional methods should be used to examine the RV in athletes.
reduced RV strain in a patient

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Tricuspid annular displacement predicts brain natriuretic peptide levels in chronic pulmonary hypertension
T. Hugues1; S. Bun1; G. Latcu1; F. Lemoigne2; JP Rinaldi1; N. Saoudi1; P Gibelin2 . . 1 The Princess Grace Hospital Centre, Monaco, Monaco; 2CHU de Nice - Hopital Pasteur, Nice, France TAD based on a tissue tracking algorithm is a new sample technique that is ultrasound beam angle-independend for automated detection of tricuspid annular displacement. Purpose: We evaluated right atrial (RA) contractility and right ventricular (RV) systolic function (as assessed by TAD) in adults with pulmonary arterial hypertension (PAH) and correlated it with serum brain natriuretic peptide levels (BNP). Methods: Seventeen patients (pts) with PAH underwent a standard and pulsed Doppler tissue transthoracic echocardiography. TAD Late diastolic myocardial velocity Aa of RV (RV Aa) was regarded as the parameter of RA contractility and RV E/Ea as an index of RA pressure. BNP levels were measured within 24 hours of echocardiographic examination. Results: Among the 17 PAH pts, 9 were male with mean age of 63,5 /- 13, mean BNP level 590,4 /- 515,3 pg/mL, mean RV Aa was 13,2 /- 3,9 cm/s and mean Sa 9,7 /2,2 cm/s. BNP level was negatively correlated with TAD (r2= 0,57; p= 0,0005) and positively with RA pressure (r2= 0,39; p= 0,007), RA area (r2= 0,39; p= 0,007) and heart rate (r2= 0,65; p= 0,0005). A value of TAD . 14 mm predicted BNP level , 90 pg/mL (Se= 100%, Sp= 66,7 %, PPV= 93,3% , NPV= 100%) and TAD , 10 mm predicted BNP level . 150 pg/mL (PPV= 100%; NPV = 40%). In pts with BNP, 90 pg/mL, TR E/A and DT was respectively 0,6 /- 0,1 cm/s and 220 /- 28,3 ms. So there was impaired diastolic function. When BNP was . 90 pg/mL, RV E/Ea was 7,5 /2,9 in favour of an increase of RA pressure. Conclusion: We have demonstrated that BNP level was good correlated to TAD. So we believe that TAD represents a interesting tool for evaluating RV function

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assessment of myocardial strain may disclose right ventricular dysfunction in patients with intestinal carcinoid disease
LG. Sahakyan1; KH. Haugaa2; DS. Bergestuen3; E. Thiis-Evensen3; T. Edvardsen2 1 Yerevan State Medical University, Armenia/ Dept. of Cardiology, Rikshospitalet University Hospital, Oslo, Norway; 2Dept. of Cardiology, Rikshospitalet University Hospital and University of Oslo, Oslo, Norway; 3Dept. of Medicine, Rikshospitalet University Hospital, Oslo, Norway

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right ventricular (RV) physiology that is challenging given the complex geometry of the RV designed for synchronized mechanical and volumetric functions, as in LV. Subjects and Methods: 59 normal subjects (60+12 years, 30 men) underwent standard Doppler (St2D), 3D, 4D echocardiography (SONOS 5500), and CMR (1.5 T Siemens) for estimation of RV ejection fraction (EF). 2D images of 42 subjects were feasible for further analyses using the 2D cardiac performance imaging, CPA, (TomTec Image Arena 4.0) for estimation of RV EF (2DEF), longitudinal and radial velocity, displacement, and strain (S%). Pearsons correlation coefcients with two-tailed t tests were performed to study the relationship between mechanical and volumetric properties of the RV. Results: CPA data revealed signicant difference of 2DEF (%) between individuals ,70 and . 70 years of age (58+ 7 vs. 52+ 9; p,0.05). The mean values of longitudinal and radial data did not differ (10+3 vs. 9+2 and 7+2 vs. 6+2 respectively for longitudinal and radial velocities, cm/s; 37+ 12 vs. 33+13 and 47+20 vs. 35+25 respectively for longitudinal and radial strain%, all p. 0.05). Correlations test revealed strongest association between CMR EF and 3DEF (r= 0, 8; p = 0.000) and modest but signicant associations between 2DEF vs. 3D and CMR EF (all r = 0,4; p= 0.007) as well as between CMR EF vs. longitudinal strain (r= 0,4; p= 0.007). Signicant interrelationship also existed among all the CPA variables while St2D had a signicant relationship with radial strain (r = 0,4; p= 0.007). 4D EF did not have any correlation with any other variables. CMR EF (%) was lower in females (48+8 vs. 58+7; p,0.001). Conclusions: CPA in combination with 3D and/or MR may provide better insight into RV physiology. Though any single modality may not be suitable to study complex RV functions, CPA with its simultaneous generation of mechanical and volumetric data maybe suitable for routine use in a busy practice. Further evaluation of the soft ware with far greater number of subjects is however needed. Age and gender considerations are also required for proper assessment of RV functional status.

Incidence of pulmonary hypertension in patients with Sarcoidosis in Greece


E. Gialafos1; K. Aggeli1; G. Rousakis1; A. Kalianos1; G. Siasos1; G. Marinos1; A. Rapti1; C. Stefanadis1 1 University of Athens, Athens, Greece Introduction: Pulmonary hypertension (PH) is a life threatening complication of Sarcoidosis and the presence of PH adversely affects the survival of these patients. Aim of this study was the investigation of the frequency of PH and the possible association of PH with clinical parameters of the disease in greek patients. Methods: A retrospective analysis was performed on 113 patients with biopsy proven Sarcoidosis. The patients were evaluated for PH by detailed cardiac ultrasound including Doppler echocardiography. All patients underwent lung function test and high resolution computed tomography (HRCT) was used to evaluate the stage of the disease. PH was dened as estimated systolic pulmonary artery pressure (PASP) ! 40 mmHg. The frequency of PH was evaluated, and clinical parameters were compared between patients with PH and those without. Results: Among 113 patients, 11 patients (9,7%) had PH. These patients had reduced values of PFT indices (FVC78+24 %, TLC69+14, DLCO61+15) implying more advanced staging than the patients without PH. Also, the PH-patients showed diastolic dysfunction of right and left ventricle assessed by E/A wave ,1 detected in tricuspid and mitral valve. Multivariate analysis showed that stage of the disease and the presence of reduced DLCO reduction(,60% of the predicted ) were independent predictors for the presence of PH. Conclussion: The incidence Pulmonary Hypertension in greek patients with Sarcoidosis was 9,7% estimated echocardiographically. The stage of the disease and the DLCO reduction were independent predictors for the presence of PH in this setting of patients.

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Predictive echocardiographic parameters of pulmonary hypertension in sickle cell disease : results from Etendard study ( French prospective multicenter study )
S. Lahmam Bennani1; J. Inamo2; F. Parent3; L. Hajji4; O. De Sauniere1; MS. Slama1; G. Simonneau3 1 ` Service de Cardiologie, Hopital Antoine Beclere, Clamart, France; 2Service de cardiologie, Hopital de Fort de France, Martinique, Fort de France, France; 3Service de ` Pneumologie, Hopital Antoine Beclere, clamart, France; 4Service de Cardiologie, Hopital Henri Mondor, Creteil, France Pulmonary hypertension (PH) is dened at right-heart catheterisation (RHC) by a mPAP ! 25 mmHg. PH recognized complication of chronic hemolytic anemias and particularly of sickle cell disease (SCD). Different studies showed a high prevalence of PH in SCD, if estimated by a tricuspid regurgitation jet velocity (TRV) ! 2.5m/s on Doppler echocardiography (around 30%). The aim of this prospective multicenter study was to evaluate the prevalence of PH, and to determinate predictive echocardiographic parameters of PH in 385 consecutive adult patients with stable SCD, recruited from 4 SCD referral centers. All patients had echocardiography and RHC when TRV was ! 2.5m/s. Of the 385 patients, 96 had a TRV ! 2.5m/s on echocardiography (25%). RHC was performed and showed no PH in 72/96 patients (false positive of echocardiography75%). Post-capillary PH (dened by a mPAP ! 25 mmHg and PCWP .15 mmHg) was seen in 13/96 patients, a hyperkinetic state with mPAP ! 25 mmHg and high cardiac output but normal pulmonary vascular resistance (PVR ,160 dyn.sec.cm25) in 5/96, and precapillary pulmonary arterial hypertension (PAH) (dened by mPAP ! 25 mmHg, PCWP 15 mmHg and PVR ! 160 dyn.sec.cm25) in only 6/96 patients (mean mPAP 29+5 mmHg). In these patients, at univariate analysis, the following echocardiographic variables were signicantly associated with PH : Left auricular diameter in M-mode (p,0,0001), longitudinal right auricular diameter in 4 chambers view (p0,004), mitral peak early diastolic velocity at TDI (Ea) (p0,0002), and mitral E/Ea ratio (p0,02). PH conrmed by RHC is rare among SCD patients, with a prevalence of 24/385 (6%). PAH was present in only 6 patients (1.6%). In this population, using a TRV ! 2.5m/s on Doppler echocardiography, alone, is inapropriate to diagnose PH. The association with others echocardiographic parameters seems to be interesting to identify patients who must have a RHC to conrm and classify PH in SCD patients.

Dyssynchrony can be a reason for false positive myocardial SPECT results in stable angina patients
JS. Cho1; HJ. Youn1; EJ. Cho1; HD. Kim1; HJ. Yoon1; SW. Jin1; HO. Jung1; HK. Jeon1 1 The Catholic University of Korea College of Medicine, Seoul, Korea, Republic of Purpose: Thallium single photon emission computed tomography (SPECT) has been known as its high incidence of false positive result, even though quantitative perfusion SPECT scans have advantage in differentiating attenuation artifacts from true perfusion defects. Dyssynchrony is one of the causes of false positive result of SPECT and by normal QRS duration, dyssynchrony cannot be excluded. The incidence of dyssynchrony in normal left ventricular (LV) function is reported upto 30%. We aimed this study to evaluate the dyssynchrony might be a reason for false positive results of myocardial SPECT in stable angina patients. Methods: 30 patients with clinically diagnosed stable angina and positive myocardial SPECT results who underwent coronary angiogram were included. These patients were divided into two groups (group I, patients with positive SPECT results and normal coronary angiography (n16, mean age69.4+5.8 years, 8 males), group II patients with positive SEPCT results and signicant coronary lesion in coronary angiography (n14, mean age71.1+4.3 years, 7 males). We examined conventional echocardiographic parameters and dyssynchrony index including septal to posterior wall motion delay on parasternal long axis view, both inter-ventricular and intraventricular electromechanical delay, septal to lateral delay on apical 4 chambes view , and maximal difference in time to peak velocities between any two of twelve LV segments (Ts-12) on apical 4 chambes view, 2 chambes view and long axis view. Results: There were no signicant differences in conventional echocardiograpic parameters (LV dimension, volume, ejection fraction and E/E0 ) between two groups. The inter-ventricular (15.4+12.6 vs. 17.3+12. msec, P0.784) and intra-ventricular (115.1+20.7 vs. 106.5+27.1msec, P0.409) electromechanical delay was not signicantly different. (Time delay between anterior and inferior wall was no signicantly different (basal segment : 60.0+50.8 vs. 66.9+49.5, P0.827, mid segment ; 77.0+58.9 vs. 73.3+51.1msec, P0.911). But the basal segment time delay between lateral and septal wall peak systolic velocity were signicantly delayed in group I (76.9+43.3 vs. 28.8+27.1 P0.013). Conclusions: In patients with stable angina, dyssynchrony of left ventricle might be the reason for false positive SPECT results in patients with stable angina. Myocardial SPECT examination with dyssynchrony index measurement might be good tool for screen possible normal coronary angiographic results.

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Relationship between mechanical and volumetric properties of right ventricle: A study on healthy subjects using modern echocardiography and cardiac magnetic resonance imaging SK. Saha1; A. Patel2; A. Kiotsekoglou3; SC. Govind4; J. Nowak5; LA. Brodin6; A. Younis3;
AS. Gopal2 1 Sundsvall Hospital, Sundsvall, Sweden; 2Saint Francis Hospital, New York, United States of America; 3St Georges University of London, London, United Kingdom; 4 VIVUS-BMJ Heart Center, Bangalore, India; 5Karolinska University Hospital, Stockholm, Sweden; 6Royal Technical University, Stockholm, Sweden Purpose: Newer markers of mechanical functions (velocity, displacement, and strain: all being age and gender dependent), that have been well studied and validated to assess left ventricular (LV) pathophysiology, have not been tested in the right ventricle (RV). We propose that advanced echocardiographic modalities in combination with cardiac magnetic resonance imaging (CMR) may provide a better understanding of

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Mid-term evolution of patients with severe pulmonary hypertension receiving vasodilating therapy. Study of clinical, biological and echocardiography parameters
C. Ginghina1; RO. Jurcut1; IM. Coman1; I. Ghiorghiu1; D. Iorgoveanu1; O. Andrei1; S. Vasile1; OR. Savu1 1 Institute of Cardiovascular Diseases "Prof. Dr. CC Iliescu", Bucharest, Romania Purpose: Pulmonary hypertension (PHT) is a severe disease with poor prognosis. The aim of the study was to assess the evolution of clinical, biological, and echocardiography parameters during modern vasodilating therapy. Methods: Eighteen pts with PHT (30.8+10.8y, 4 men) receiving specic vasodilating therapy (sildenal and/or bosentan) were enrolled: grA, 8 pts with arterial idiopathic PHT; grB, 10 pts with Eisenmenger syndrome. All pts underwent evaluation of clinical (6-minute walk distance, 6MWD), biological (BNP) and echocardiography parameters (conventional and 2-dimensional strain imaging, 2DSI) at baseline, after 3 and 6

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
months of therapy. Right ventricular (RV) function was assessed by 2DSI from a modied apical 4-chamber view, centered on the RV. Peak systolic velocity (VEL) and strain (S), postsystolic S index were calculated. Results: Systolic pulmonary pressure was 94+21 mmHg (similar in the 2 groups). All pts survived the 6 months follow-up. An improvement was noted in the 6MWD (pANOVA,0.001), and there was a trend towards lower BNP levels. Echocardiography ndings are presented in the table, similar in both groups. Conclusions: Clinical improvement of severe PHT pts under vasodilating therapy began at 3 months of therapy, but was not paralleled by evidence of signicant changes in pulmonary artery pressure, RV geometry and function as assessed by conventional or modern echocardiographic techniques

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pressure (PAP) ! 49 mmHg (relative risk (RR) of death 3.94 [95% CI 1.3411.5, p 0.012]); diastolic PAP ! 29 mmHg (RR 4.97 [95% CI 1.5815.6, p 0.006]); abnormal end-diastolic septal curvature (RR 5.33 [95% CI 1.2123.5, p 0.027]); inferior vena cava diameter ! 20 mm with respiratory variation of diameter , 50% (RR 3.39 [95% CI 1.239.35, p 0.018]). The 3 other echocardiographic parameters found in our study and already described in the literature were the Tei index, presence of pericardial effusion and tricuspid annular plane systolic excursion (TAPSE). After adjustment for NYHA class IV, these parameters remained signicant. Conclusion: Transthoracic echocardiography, because of the prognostic factors of mortality it reveals at the initial investigation, must have its place in therapeutic decision making and so its role should not be restricted to screening for PAH.

Baseline 6MWD (m) BNP (ng/ml) Systolic pulmonary pressure (mmHg) Mean pulmonary pressure (mmHg) RV end-diastolic diameter (mm) RV fractional area change (%) TAPSE (mm) Global RV performance index Cardiac output (l/min) RV basal systolic VEL (cm/s) RV basal peak systolic S (%) RV basal postsystolic S index (%) 304+141 462.2+479.1 94+21 51+7 45+11 25+9 16.0+4.5 0.79+0.25 4.4+1.4 7.5+2.2 216.6+8.0 25.0+21.1

3 months 405+131* 306.7+327.4 100+16 53+7 48+10 27+9 16.2+3.6 0.80+0.29 4.6+2.1 7.6+4.2 217.2+9.3 20.7+16.2

6 months 600+170 232.4+174.2 109+21 52+4 44+9 25+9 17.0+4.1 0.71+0.15 4.0+2.1 7.6+2.9 219.7+12.4 25.5+20.5
#

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Impact of right ventricle dysfunction assessed with tissue Doppler echocardiography on exercise capacity in patients after inferior myocardial infarction treated invasively
K. Smarz1; B. Zaborska1; T. Jaxa-Chamiec1; P Maciejewski1; A. Budaj1 . 1 Postgraduate Medical School, Warsaw, Poland Background: Right ventricular (RV) involvement in patients (pts) with inferior myocardial infarction (MI) occurs in 30-50% of cases. In pts with chronic heart failure RV dysfunction causes worsening of exercise capacity (EC). RV systolic myocardial velocity (SmRV) was shown to be an indicator of RV systolic function. Data on inuence of RV function on EC in pts with MI are scarce. Aim: To assess EC in the group with RV dysfunction complicating inferior MI in comparison to the group without RV dysfunction. Methods: Pts with rst inferior STEMI treated by primary percutaneous coronary intervention (pPCI) were prospectively assessed. ECHO was performed post pPCI within 48 hours from the onset of symptoms (early) and on the day of cardiopulmonary exercise test (CPET) (late). RV dysfunction was dened as SmRV ,12 cm/s in pulse wave tissue Doppler echocardiography (TDE). CPET was done on day 14/210. VO2 peak (ml/kg/ min) and percent of predicted VO2max values (%) were assessed as EC parameters. None of the pts had exercise limiting factors other than dyspnoe and/or fatigue. Results: Pts with inferior MI (n=61, 75% male, mean age 60/210) were enrolled. Patients were divided into three groups: the group without RV dysfunction (n=34, 76% male, mean age 59/212), the group with RV dysfunction in the rst 48 hrs (n=27, 74% male, mean age 61/28) and the group with RV dysfunction on the day of CPET (n=17, 71% male, mean age 62/29). Comparison of EC parameters is shown in the table. Conclusion: In patients after acute inferior MI early and late RV dysfunction has a signicant impact on exercise capacity estimated with cardiopulmonary stress test.
Table 1 Comparison of EC parameters SmRV!12cm/ s VO2 peak (ml/kg/min) VO2 peak /VO2 max predicted (%) 21+ 6.2*# 72+ 21 SmRV,12cm/s rst 48 hrs 18.5+ 5.2* 63+ 12.8 SmRV,12 cm/s day of CPET 17.5+ 5.6# 61+ 13.3

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Posthoc analysis: *p0.04 vs baseline; #p,0.01 vs baseline and vs 3 months.

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Right ventricular function before and after conversion of atrial brillation to sinus rhythm
L. Lenartowska1; M. Stopyra-Poczatek1; J. Kowal1; A. Kaczmarzyk-Radka1; J. Lewczuk1 1 Wojewodzki Szpital Specjalistyczny, Dpt. of Cardiology, Wroclaw, Poland Left ventricular (LV) function were widely studied during atrial brillation (AF). The aim of this study was to determinate right ventricle (RV) function before and after conversion of AF to sinus rhythm (SR). Materials and method: We studied 68 patients (32 women, 56,5+11,2 years) with AF (duration of AF 4,2+1,6 weeks). Echocardiographic examination with 2D, PW, CW, Color and TDI were performed. We studied RV function parameters as TAPSE (tricuspid annulus systolic excursion), FAC (fractional area changing), TDI of lateral tricuspid annulus (peak systolic velocity St, peak early diastolic velocity Et and peak late diastolic velocity At). All patients were examinated before, 1 day after and 3 months after conversion to SR. Results: Before cardioversion TAPSE was signicantly lower comparing to healthy subjects (18,1+1,9mm), no difference 1 day after conversion to SR, but signicantly improved after 3 months (p.0.05). FAC was normal at baseline and no difference during two next examinations. TDI parameters as St was signicantly lower in AF (10,7+2,4cm/s) and 1 day after cardioversion, but after 3 months signicantly increased (16,3+2,2cm/s, p.0.05). Et was examined 24 hours after conversion to SR and after 3 months, we didnt found difference. At after successful cardioversion signicantly increased after 3 months (17,3+3,2cm/s, p.0.05). Conclusions: 1. Right ventricular function is reduced during atrial brillation. 2. The parameters of right ventricular function improved after successful conversion to sinus rhythm. 3. Recovery of right ventricular function is not immediately after cardioversion.

VO2 peak *# vs * P= NS, *# vs # P = 0.05 VO2 peak /VO2 max predicted P = 0.05.

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Enhanced pressure increase in the pulmonary artery after peak ow assessed using Doppler echocardiography identies patients with elevated pulmonary vascular resistance
F. Lindgren1; B. Rundqvist1; S. Petersson1; N. Selimovic1; O. Bech-Hanssen1 1 Institute of Medicine at Sahlgrenska Academy, Gothenburg, Sweden Purpose: It is important to distinguish patients with pulmonary hypertension (PH) due to increased pulmonary vascular resistance (PVR) from those due to increased pulmonary capillary wedge pressure (PCWP), as it effects both treatment and prognosis. Doppler echocardiography (DE) can estimate the pulmonary artery (PA) systolic and mean pressures (PASP PAMP) as well as the PVR (DE-PVR). Low peripheral resistance and a small , pressure increase (PI) after peak ow in the PA, characterize the normal pulmonary circulation. In the present study we hypothesized that the level of PI after peak velocity identies patients with increased PVR. The aim of the study was to evaluate the diagnostic accuracy of DE-PVR and the PI to identify patients with increased PVR (PVR.3WU). Methods: DE and right heart catheterization (Swan-Ganz catheters, thermodilution for cardiac output, CO) were performed within 24 hours at 106 occasions in 96 patients. The investigations were divided into a testing sample (n53) and a validation sample (n53). The tricuspid regurgitation velocity was used to estimate PASP dias, tolic (PADP) pressures and the pressure at the time of peak velocity (PAVP). The time intervals from QRS to the pulmonary valve opening (PADP) and the peak velocity in the PA using pulsed Doppler were superimposed on the tricuspid velocity envelope. Right atrial pressure and CO were assessed using standard DE methods. The DE-PCWP was estimated as 9, 15 or 20 mmHg by combining mitral and pulmonary venous ow data. The PI was calculated as PASP-PAVP PAMP as PADP0.33 (PASP, PADP) and PVR as PAMP-PCWP/CO. Results: The proportion of patients with catheter PASP.40 mmHg, PVR.3 WU) and PCWP.12 mmHg were 77%, 70% and 46% respectively. The receiver operator characteristic curves in the testing sample for DE-PVR/PI to detect increased PVR had an area under the curve (95% CI) of 0.83 (0.700.96)/0.95 (0.891.0). The Table shows the

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New echocardiographic prognostic factors of mortality in pulmonary arterial hypertension
G. Brierre1; N. Souletie1; B. Degano1; L. Tetu1; V. Bongard1; D. Carrie1 1 CHU de Toulouse - Hopital de Rangueil, Toulouse, France Purpose: Right cardiac function conditions the prognosis of pulmonary artery hypertension (PAH). The clinician needs objective parameters for evaluating right ventricular function in order to assess the gravity of the disease as early as possible and so adapt the treatment. The present role of transthoracic echocardiography is generally limited to screening for PAH. The aim of our study was to seek new echocardiographic prognostic factors of mortality in PAH which would give this investigation an important place in the management of this disease. Methods: We prospectively included, between June 2005 and February 2008, 79 patients of groups 1, 3, 4 and 5 of the Venice classication. At inclusion patients underwent right cardiac catheterization, transthoracic echocardiography and a 6-minute walking test. Results: Distribution according to the NYHA functional classication was class I 1.3%, class II 29%, class III 57% and class IV 12.7%. The 6-minute walking distance was 300 m [210375] (median [interquartile interval]), cardiac index 2.38 L.min21.m22 [2.03 2.87] and pulmonary vascular resistance 8.4 WU [5.611.4]. During follow-up (12 months [521]), 16 patients died of their pulmonary disease. The incidence rate of death was 18 for 100 person-years (one-year survival rate 82%). In univariate analysis, 7 echocardiographic parameters were associated with mortality, of which 4 have never previously been reported in PAH: mean pulmonary arterial

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Abstracts
Purpose: Pulmonary arterial hypertension (PAH) is a rare and serious disease, characterized by increased pulmonary resistance leading to right heart failure and death. Transthoracic echocardiography has its place in screening and surveillance of PAH. The normal interventricular septal curvature (SC) is convex towards the right ventricle in systole and in diastole. It is considered abnormal if it is attened or convex towards the left ventricle in parasternal short-axis views through the base of the heart, in two-dimensional mode. We aimed to study the relation between an abnormal SC and pulmonary pressure measurements, in the absence of systemic arterial hypertension. Methods: Seventy-nine patients with PAH were prospectively included between June 2005 and February 2008. All patients underwent transthoracic echocardiography with direct measurement of systolic and diastolic pulmonary artery pressure, indirect measurement by calculation of mean pulmonary artery pressure and visual assessment of the interventricular septal curvature (normal or abnormal). Results: During the median follow-up of 12 months (interquartile interval:521 months), 16 patients died of their pulmonary disease (mortality rate 18 for 100 person-years). An abnormal end-diastolic septal curvature was signicantly associated with higher mortality (relative risk of death 5.33 [95% CI 1.2123.5; p 0.027]). Conclusions: The appearance of the interventricular SC, normal or abnormal, and its time period (systolic, diastolic, or systolic and diastolic) provides semi-quantitative information on the presence and severity of PAH. Abnormal end-diastolic SC is a factor of poor prognosis of the disease.

sensitivity, specicity, positive (PV) and negative predictive (PV2) values in the validation sample. Conclusion: In the present study we found that the novel DE parameter PI identied patients with increased PVR with a diagnostic accuracy superior to DE-PVR.

Cut-off DE-PVR PI 5 WU 5 mmHg

Sensitivity 92 94

Specicity 62 81

PV 82 88

PV2 80 85

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Prognostic value of right ventricular function in ischemic dilated myocardiopathy
SGC. Gamaza1; P Cabeza1; FJ. Camacho1; E. Diaz1; A. Gutierrez1; J. Gallego1; . M. Sancho1; R. Vazquez1 1 Puerta del Mar Hospital, Cadiz, Spain Purpose: The aim of this study was to determine the prognostic value of the right ventricular function estimated by transthoracic echocardiogram in patients with ischemic dilated cardiomyopathy. Methods: We studied those patients who went to our Echocardiography Laboratory in our center between January and December of 2007, and they were diagnosed as dilated cardiomyopathy with severe left ventricular dysfunction (left ventricular ejection fraction less than 35%), and severe lesions in the coronariography. All of these patients underwent traditional echocardiography, and meditions of the right ventricular function (Tricuspid Annular Plane Systolic Excursion -TAPSE- and S wave of the tricuspid annular by Tissue Doppler). We recorded their demographic, risk factors and echocardiographic values. It was dened as primary objective MACE (combined end-point of death, acute heart failure hospital readmissions or heart transplantation). Results: We studied 38 patients with ischemic dilated myocardiopathy, with 12.86 months of mean follow-up. The MACE was present in 46.4% of the patients (28.6% cardiovascular deaths). These MACE were more frequent in the right ventricular dysfunction group (31.3% vs 66.7%, p,0.05), due to a more frequent hospital readmissions in this group. We found statistical signicant differences in TAPSE value (15.08+4.11 vs 18.8+5.17) between the two groups. There were not signicant differences in cardiovascular risk factors, atrial brillation, functional class, left ventricular ejection fraction. Conclusions: We found a signicant higher proportion of acute heart failure readmissions and cardiovascular events, in ischemic dilated myocardiopathy with right ventricular dysfunction, independent of associated factors.

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Table 1

SC according to pulmonary pressures Normal systolic and diastolic SC N14 Abnormal systolic or diastolic SC N20 52.5 46.8 [41.167.2] 122 126 [117130] 76 80 [6880] 79 73 [6784] 26 22 [2028] 44 41 [3550] Abnormal systolic and diastolic SC N45 60.6 63.4 [48.874.9] 124 124 [110140] 78 80 [6887] 91 86 [77102] 29 28 [2433] 49 48 [4252] P-value*

Age SAP DAP sPAP dPAP mPAP

63.7 (1) 65.9 [54.476.1] (2) 138 135 [122150] 78 81 [7185] 65 64 [5470] 17 18 [1519] 33 33 [2935]

0.050 0.096 0.716 ,0.0001 ,0.0001 ,0.0001

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The prognostic importance of right ventricular dysfunction in patients with moderate ischemic mitral regurgitation and left ventricular dysfunction qualied to cardiosurgery treatment
R. Piatkowski1; J. Kochanowski1; P Scislo1; M. Grabowski1; M. Marchel1; D. Kosior1; . G. Opolski1 1 Medical University of Warsaw, 1st Department of Cardiology, Warsaw, Poland Purpose: Right ventricular (RV) function assessed after myocardial infarction (MI) have been identied as an important prognostic factors for mortality and/or development of heart failure (HF). The purpose of this study was to evaluate the use of RV function as predictor of mortality and hospitalizations due to exacerbation of HF in patients (pts) with ischemic mitral regurgitation (IMR) qualied for cardiosurgical treatment - coronary artery by-pass grafting alone (CABGa) or CABG with mitral reconstruction (CABGmr). Materials and methods: We prospectively analyzed 100 pts (M 56, 64+8 years) with moderate IMR, 3-24 weeks after MI. Effective regurgitation orice (ERO) was used for quantitative IMR assessment (moderate !10-20 mm2). All the pts were qualied for CABG (multiple vessel coronary disease, ejection fraction (EF) 44+9%, wall motion score index (WMSI) 1.57+0.3). The patients were referred for CABGa (gr.1; n=74) or CABGmr (gr.2; n=26) based on clinical assessment, 2D and 3D echo at rest and exercise. Tricuspid annular plane systolic excursion (TAPSE) was acquired to evaluate RV function (measured with M-mode imaging in the 4-chamber view). RV function was related to clinical outcome (median follow-up: 12 months). Results: During the follow-up period of 12 months, 5 deaths (5 %) and 8 hospitalizations (8%) due to exacerbation of HF occurred. With use of the following cut-off points of TAPSE 12 mm (group I), and TAPSE .12 mm (group 2)an association was found between the lower TAPSE and increased mortality. In group 1 (n 52 pts), 5 pts (21%) died and 6 pts was hospitalized due to HF (11.5%); in group 2 (n 48), no patient died and 2 pts was hospitalized (4%). There was a signicant difference (p0.02) in clinical outcomes between group I and II. ROC analysis identied TAPSE 12 mm as predictive cut-off for prediction adverse clinical outcome in all study group: (death: sensitivity 80%, specicity 76%, area under curve [AUC]=0.807; death and HF hospitalizations: sensitivity 69%, specicity 79%; AUC 0.767). Conclusion: TAPSE is simple and useful quantitative measurement of RV systolic performance and have a predictive value in pts with moderate IMR reffered for cardiosurgery treatment.

SC : septal curvature ; (1)mean - (2) median [interquartile interval]; *Wilcoxon non-parametric test ; SAP/DAP: systolic/diastolic arterial pressure; m/d/sPAP: mean/diastolic/systolic pulmonary artery pressure.

HEART FAILURE
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Longitudinal global strain by speckle tracking is an independent predictor of outcome in heart failure patients with impaired left ventricular function
J. Nahum1; C. Dussault1; A. Bensaid1; L. Macron1; P Gueret1; P Lim1 . . 1 AP-HP - Hopital Henri Mondor, Creteil, France Objective: To assess the predictive value of peak global longitudinal strain(1) and 1 rate by speckle tracking to predict outcome in heart failure (HF)patients. Methods: The study included 112 consecutive patients admitted for HF (64+13years, 81% male, 52% ischemia) with reduced left ventricular ejection fraction(LVEF,50%, mean 31+10%, range 10-49]. Longitudinal global-1 and 1 rate by speckletracking were curves computed from apical views and compared to the occurrenceof major cardiac events (death, heart transplantation, and recurrent HF). Results: On the whole, peak systoliclongitudinal global-1 and 1 rate averaged 28+ 3% [range 23 to-18] and 20.34+0.20s-1 [range 21.6 to 20.1], respectively. Duringthe follow up period (208+149 days), major cardiac adverse events occurred in40 (36%) patients (11 death, 23 recurrent HF and 4 heart transplantation).Univariable analysis using Cox model shown that global-1, 1 rate, LVEF, tricuspid annular plane systolic excursion, NYHAclass and BNP level were associated with cardiac adverse event. However, only global-1(OR1.2, p0.025) and BNP level (OR1.3, p0.024) were predictive of outcome bymultivariable analysis. Conclusion: Inpatients admitted for heart failure with impaired LVEF, peak global strain byspeckle tracking appears to be the only echocardiography predictor of adverseoutcome.

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Correlation between longitudinal systolic function and ejection fraction of the left ventricle assesed with bimode and tissue doppler echocardiography in patients with reduced ejection fraction
I. Daskalov1 1 MMA, Soa, Bulgaria Aims: The aim of the study was to asses the relationship between longitudinal systolic function of the left ventricle, quantitative analyzed with tissue Doppler and

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The interventricular septal curvature in echocardiography : a new approach for screening and prognostic assessment in pulmonary arterial hypertension
N. Souletie1; G. Brierre1; B. Degano1; L. Tetu1; V. Bongard1; D. Carrie1 1 CHU de Toulouse - Hopital de Rangueil, Toulouse, France

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
echocardiographycally estimated ejection fraction in patients with reduced left ventricular systolic function. Design: prospective, one-year study. Patients: Forty patients aged from twenty to eighty-nine years were successfully enrolled in the study. All participants were with reduced left ventricular ejection fraction. Methods: The quantitative analysis of the left ventricular longitudinal systolic function was assessed according to the average peak mitral annular descent velocity in two consecutive regimens: PW and colour M-mode tissue Doppler echocardiography. The average peak systolic velocity was calculated for every regimen separately, as a sum of velocities divided to a sum of used positions. The echocardiograms were obtained from six mitral annular sites. Results: The average peak mitral annular descent velocity from color coded M mode tissue Doppler showed strong correlation with left ventricular ejection fraction (r 0,798; p,0.0001). The similar results but with lower coefcient of correlation showed average peak mitral annular descent velocity from PW tissue Doppler and left ventricular ejection fraction (r 0,275; p0,002). Peak mitral annular descent velocity from the septal corner of the mitral ring in apical 4-chamber view correlated most closely with TTE estimated ejection fraction. Conclusion: The data collected from our study provide high diagnostic accuracy especially when ejection fraction is difcult to assess. We recommend using average peak mitral annular descent velocity from color coded M mode as a quantitative index of a global systolic function of the left ventricle. Peak mitral annular descent velocity average ! 2,64 sm/sec from color coded M mode tissue Doppler had a sensitivity of 97 percent for an ejection fraction !25 percent and specicity of 60 percent to reject ejection fraction 25 percent for the same velocity. We recommend using followed equation: EF 7,18 X average Peak mitral annular descent velocity (color Mmode tissue Doppler). These data are valid for patients with reduced ejection fraction.

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sensitivity and 75% specicity). In patients with E/(EaSa) ,1.23 (n=42), cardiac event-free rate was markedly higher than in the rest with E/(EaSa) !1.23 (70% versus 27%, p,0.001, log-rank). Conclusion: E/(EaSa) could be a powerful predictor of cardiac events in patients with LV dysfunction.

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Global and regional myocardial function is depressed during therapeutic hypothermia
V. Kerans1; H. Skulstad1; A. Espinoza1; PS. Halvorsen1; T. Edvardsen1; JF. Bugge1 1 Oslo University Hospital, Oslo, Norway Purpose: Moderate hypothermia is widely used as neuroprotective treatment after cardiac arrest. These patients may have reduced myocardial function due to ischemic damage, but hypothermia itself may also inuence on myocardial performance. The effects of moderate hypothermia on myocardial function were explored in this experimental animal study. Methods: Eight anesthetized pigs were studied in an open chest model. A micromanometer-tipped catheter were positioned in the left ventricle (LV) to measure peak LV pressure (LVP) and LV end-systolic pressure (LVEDP) and calculate the pressure time derivative (dP/dt). Cardiac output (CO) was measured by thermodilution technique from a catheter in the pulmonary artery and systemic vascular resistance (SVR) was estimated. Echocardiography was performed to measure global LV function as ejection fraction (LVEF) by the biplane Simpson method. In addition, regional myocardial function was measured in the LV mid segments of septum and lateral wall (SW, LW) by strain Doppler echocardiography. Negative strain expresses regional systolic shortening. Moderate hypothermia was performed by intravascular cooling. In order to obtain equal conditions during all measurements, right atrial pacing were performed at a xed frequency of 100 beats per minute for ve minutes during normothermia (388C) and hypothermia (338C) prior to hemodynamic measurements and echocardiography . Values are given as mean+SD. Results: Hypothermia reduced spontaneous heart rate in all pigs (87+11 to 75+14 min-1, p,0.05). At a paced frequency of 100 beats/min CO decreased from 5.0+0.7 to 3.7+0.6 l/min (p,0.05). LVP were reduced from 86+5 to 64+7 mmHg (p,0.05) and dP/dt from 1500+504 to 1034+387 (p,0.05). LVEF decreased from 58+6 to 51+4% (p,0.05). Regional myocardial function was reduced in both the septal and lateral wall, as strain changed from -30.9+7.1 to 17.4+5.0% (p,0.05) and from 229.6+8.7 to 218.4+4.5% (p,0.05), respectively. Preload measured as LVEDP and afterload assessed as SVR remained unchanged from normothermia to hypothermia (9+3 vs 8+3 mmHg and 882+144 vs 904+ 123 dyn.s.cm-5 (n.s.)). Conclusion: Moderate hypothermia caused reduced global and regional LV function. As loading parameters were unchanged and dP/dt was reduced, hypothermia seems to have a direct negative effect on myocardial contractility. These ndings should be taken into considerations when LV function is assessed in patients with therapeutic hypothermia following cardiac arrest.

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Prognostic value of E/(EaxSa) ratio in patients with left ventricular dysfunction
C. Mornos1; D. Cozma1; A. Ionac1; L. Petrescu1; SI. Dragulescu1 1 Institute of Cardiovascular Diseases, Timisoara, Romania Background: The E/(EaSa) ratio (where E=peak early diastolic transmitral velocity, Ea=peak early mitral annular diastolic velocity and Sa=peak systolic velocity of mitral annulus) has been shown to reect left ventricular (LV) lling pressure. Purpose: to investigate whether E/(EaSa) could be a predictor of cardiac events in patients with LV dysfunction. Methods: We screened 145 consecutive patients with LV dysfunction in sinus rhythm referred for left heart catheterization at our institution in 2006. Patients with inadequate echocardiographic images, paced rhythm, mitral stenosis, mitral prosthesis, signicant primary or organic mitral regurgitation, severe mitral annular calcication, pericardial disease, acute coronary syndrome or coronary artery by-pass within 72 hours were excluded. Only 110 patients were eligible. In these patients conventional echocardiography and Tissue Doppler Imaging were performed. E/(EaSa) was calculated; the average of the velocities from the septal and lateral site of the mitral annulus was used. Mean age was 62+13 years, 70 patients (63.6%) had coronary artery disease, and LV ejection fraction was 40+14%. The primary study end point was cardiac events such as rehospitalization due to congestive heart failure and mortality. Results: During 32+7 months of follow-up, cardiac events occurred in 86 patients. Mean E/(EaSa) was 2.4+1.3 in those patients, while it was 1.17+0.5 in the rest (p=0.001). The optimal E/(EaSa) cut-off was 1.23 to predict cardiac events (83%

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Left ventricular systolic dysfunction is associated with advanced chronic kidney disease but improved after maintenance hemodialysis
YW. Liu1; CT. Su2; WC. Tsai1; CS. Yang3; MT. Yang3; JH. Chen1 1 National Cheng Kung University Hospital, Tainan, Taiwan; 2National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin, Taiwan; 3Catholic Fu-An Hospital, Yun-Lin, Taiwan Purpose: The aim of the study was to illustrate the heart function of different CKD stages and the inuence of maintenance hemodialysis (HD) on cardiac functions assessed by left ventricular (LV) deformation. Methods: We included 113 chronic renal failure patients and cataloged to 3 subgroups (16 with early-stage CKD, stage 1 or 2; 37 with advanced-stage CKD, stage 3 or 4 or 5; 60 with end-stage renal disease (ESRD) undergoing regular HD, thrice per week, more than 3 months) and 56 patients without renal failure as controls. The conventional parameters, tissure Doppler imaging and 2D strain imaging were acquired. Results: Among all study subjects, no difference in age, and the prevalence of concomitant diseases was revealed. LV ejection fraction (EF), and S0 were similar among the 4 groups. Compared with the controls, radial strain was decreased in all CKD groups (early-stage: 40+ 15%, advanced-stage: 39+ 21%, ESRD: 37+ 21%, controls: 56+ 23%, p,0.001). Importantly, compared with the controls and early-stage CKD group (global longitudinal strain (GSl): 219+ 5 %, circumferential strain (Sc): 222+ 6%), LV systolic function was deteriorated in advanced-stage CKD group (GSl: 215+ 5 %, Sc: 217+ 6%, p,0.001), but improved in ESRD group undergoing regular HD
Table 1 Comparison of echocardiographic results Controls (n56) LVEDVI (mL/m2) LVEF (%) GSl (%) Sc (%) Sr (%) E/E0 66.3+ 15.8 67.8+ 13.9 218.7+ 5.7 222.0+ 5.5 55.7+ 23.3 10.3+ 3.5 Early stage CKD (n16) 78.8+ 15.0 65.4+ 9.9 218.6+ 4.2 220.6+ 6.6 40.1+ 14.5 10.3+ 1.8 Advanced-stage CKD (n37) 77.4+ 33.6 65.4+ 15.1 215.0+ 4.5 217.3+ 6.2 38.9+ 21.4 15.6+ 6.9 ESRD (n60) ANOVA p value 0.231 0.368 0.001 0.007 , 0.001 , 0.001

77.9+ 27.4 63.7+ 9.0 218.7+ 3.9 219.9+ 5.9 36.8+ 20.1 17.5+ 9.6

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Abstracts
and 17.3% and 48%, 19.1% and 43%, in C receiving and in C non-receiving pts, respectively, (p,0.01). Conclusions: 1) Despite higher LV EF and lower levels of BNP pts with CHF and , PEF had a similar mortality to pts with REF. 2) The prognostic importance of BNP was highly signicant, irrespective of LV EF, thresholds or treatment groups. 3) The changes of BNP level !50% identied pts with major cardiac events risk reduction irrespective of LV systolic function. 4) Improvement of prognosis in patients with CHF during long-term C therapy is related to signicant decrease of plasma BNP level.

(GSl: 219+ 4 %, Sc: 220+ 6%). The LV lling pressure (E/E0 ) was signicantly increased in regular HD group (18+ 10 vs. 10+ 2, p,0.001). Conclusion: LVEF and S0 are failed to demonstrate the LV systolic dysfunction in CKD groups. LV contractile dysfunction can be documented by decreased myocardial deformation, including longitudinal, circumferential, and radial strain, in patients with advanced-stage CKD, but actually improve, except radial strain, in ESRD patients on maintenance hemodialyis. However, persistent LV diastolic dysfunction can be detected in the ESRD group even undergoing regular HD.

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clinical characteristic and prognosis of patients with acute congestive heart failure with preserved left ventricular systolic function in Jeju Island of South Korea
S-J. Joo1; S-Y. Hyun1; D-G. Kang1; S-Y. Kim1; K-S. Kim1 1 Jeju National University Hospital, Jeju, Korea, Republic of Objectives: Recent evidences showed that left ventricular (LV) systolic function is preserved in the half of patients with acute congestive heart failure (AHF) in the western countries. They have the different clinical characteristics, but a similar longterm mortality compared with those with decreased LV systolic function. Korean patients with AHF may show a different pattern. We investigated the clinical characteristics and prognosis of AHF with preserved LV systolic function in Jeju Island of South Korea. Methods: From Jan 1st 2005 to Dec 31st 2007, 144 patients with AHF admitted to our hospital. Echocardiographic studies were performed in 138 patients, and LVEF !50% was used to dene AHF with preserved LVSF. Patients with valvular heart diseases, congenital heart diseases or thyroid heart diseases were excluded (n=25). Final 113 patients were grouped as I (LVEF !50%) and II (LVEF ,50%). Results: 37 patients (41%) had LVEF !50%. They were older (79.2+9.7 vs. 72.4+14.1 years, p=0.004) and female-dominant (73% vs. 47%, p=0.004). The underlying causes were signicantly different (p,0.001); hypertensive heart disease (41%), ischemic heart disease (43%), and others (16%) in group I, and hypertensive heart disease (23%), ischemic heart disease (50%), dilated cardiomyopathy (26%) and others (1%) in group II. Atrial brillation at the admission was found in 51% of group I and 42% of group II (p=0.57). Echocardiographic data of group I showed smaller LV end-diastolic dimension (4.63+0.64 vs. 5.69+0.74 cm, p,0.001) and LV end-systolic dimension (2.85+0.61 vs. 4.63+0.75 cm, p,0.001). LVEF was 66.4+9.0% in group I and 34.5+10.2% in group II. Patients with sinus rhythm of group I had lower E/A ratio (0.81+0.36 vs. 1.47+0.87, p,0.001) and E/E ratio (16.6+4.7 vs. 24.3+9.9, p,0.001). Patients of group II had more restrictive LV lling patterns (64% vs. 27%, p=0.017). In-hospital mortality was not signicantly different between group 1 (3%) and group 2 (7%). Kaplan-Meier survival analysis showed the same one-year mortality rate (19.3% in group I vs. 20.4% in group II) Conclusions: LV systolic function was preserved in 41% of Korean patients with AHF. They showed the different clinical characteristics from those with decreased LV systolic function, but one-year mortality rate was not different.

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The prognosis in diastolic heart failure is better than in systolic heart failure in the elderly
M. Denes1; M. Lengyel1 1 Hungarian Institute of Cardiology, Budapest, Hungary In population based studies on heart failure (HF) with normal ejection fraction (HFNEF) diastolic dysfunction (DD) has not been evaluated. The better or similar outcome of HFNEF compared to systolic HF (SHF) is still controversial. In this prospective study we aimed to assess the three-month and the long-term survival rate of patients with true diastolic HF (DHF). Patients: 73 consecutive, hospitalized patients with DHF (24 males, mean age: 72.2+11.2 yrs) were compared with 84 patients with SHF (46 males, mean age: 73.3+11.6 yrs). Methods: NYHA functional class was assessed. E and A velocities, and deceleration time (DT) of the mitral inow pattern, and the systolic (S) and diastolic (D) velocities of the pulmonary venous ow were measured by Doppler-echocardiography. The myocardial Ea velocity was obtained by tissue Doppler imaging (TDI) at the lateral mitral annulus. The E/A, E/Ea and S/D ratios were calculated. Elevated lling pressure (EFP) was dened as DT,150 ms, or E/Ea !7 and/or S/D ,1. DHF was dened as clinical symptoms (NYHA II-IV) or signs of HF, preserved EF (.50%) and EFP SHF . was dened as clinical symptoms (NYHA II-IV) or signs of HF and EF 50%. Threemonth and long-term (median: 352 days) follow-ups was obtained. All-cause mortality, cardiovascular (CV) mortality, and hospitalization for HF were estimated by the KaplanMeier method and compared by the log-rank test. Results: The EF was lower in SHF than in DHF (27.6+7.0% vs 60.1+10.7%; p,0.001). There was no difference between DHF and SHF in age (72.2+11.2 vs 73.3+11.6 yrs, p=0.93), but the female gender was more frequent in DHF (49/73 vs 38/84; chi-square: 7.6, p=0.006). Patients with DHF had less severe NYHA class (2.6+0.8 vs 3.0+0.9 p=0.007). DHF had a better rate of all-cause mortality both in the three-month (9.5% vs 21.4%, p,0.05) and in the long-term follow-up (21.9% vs 42.8%; p,0.005), and also in the long term follow-up of CV mortality (9.5% vs 29.8%; p,0.001), but the difference in the three-month CV mortality was nor signicant (6.8% vs 15.5%; p=0.09). Five patients were readmitted for SHF in contrast to no readmission for DHF (3.5% vs 0%; p,0.05), but the hospitalization rate for HF did not differ during the long-term follow-up (13.7% vs 20.2%). Conclusions: In patients hospitalized for DHF had a better short-and long-term survival rate compared to SHF, which might be associated with lower NYHA functional class in our elderly population.

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Value of brain natriuretic peptide levels for risk stratication and monitoring of beta-blocker therapy in chronic heart failure with preserved or deteriorated systolic function
LR. Tumasyan1; KG. Adamyan1 1 Institute of Cardiology, Yerevan, Armenia The aim of study was to assess the value of BNP level in the risk stratication and association between changes in levels of peptide and modication of prognosis in patients (pts) with III NYHA class chronic heart failure (CHF) in relation to preserved (PEF) or reduced ejection fraction (REF). Methods: 88 pts (age 61.5+1.2) with PEF and 98 pts (age 58.7+0.9) with REF in sinus rhythm were randomly assigned to groups receiving (45 and 51 pts) and nonreceiving (43 and 47 pts) carvedilol (C, up to 50 mg) in addition to ACE inhibitors, aldosterone antagonists and diuretics. Plasma levels of BNP (pg/ml) were assessed at baseline and 12 months of treatment. Results: During mean follow-up of 15+1.2 months from cardiac causes died total 43 (23.1%) pts, 19 (21.6%) pts with PEF and 24 (24.5%) pts with REF. Mean plasma levels of BNP were signicantly higher in pts with REF than in pts with PEF (874+112 vs. 372+55 pg/ml, p,0.001). All pts with adverse outcomes had higher levels of BNP (935+152 vs. 257+80 pg/ml). In addition, the probability of death was predicted by plasma levels of BNP (p,0.001) in groups with REF (986+116 vs. 471+75 pg/ml) or PEF (528+120 vs. 281+75 pg/ml). The distribution of pts with PEF in groups according to baseline BNP levels (BNP,450 and BNP!450) and REF (BNP,600 and BNP!600) allowed to identify patients with low (11.2%) and high risk (38.7%) of one-year mortality from cardiac causes (p,0.01). Plasma baseline levels of BNP were not signicantly differs in pts with PEF and REF receiving and non-receiving C, however, long-term treatment with C has resulted to higher incidence of decreasing of BNP !50% (73% and 81%) compared to pts non-treated by C (28% and 23%, p,0.01). Among patients with a !50% reduction of baseline BNP value, the number of pts with events was signicantly lower compared to pts with a ,30% BNP reduction (relative risk [RR] 0.35, p,0.01). In the groups of pts with REF and PEF, divided according to cut off value of BNP one-year mortality rates were 6.5% and 21%, 6.7% and 25% ,

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Pulmonary sonography in patients with Diastolic Heart Failure
M. Tsverava1; D. Tsverava1 1 Tbilisi Medical Academy, Tbilisi, Georgia, Republic of Background: About 35% of patients with heart failure (HF) have preserved systolic function. Pulmonary congestion and Oedema is useful marker of Diastolic Heart Failure (DHF). The aim of this study was to determine the place of chest sonography in diagnosis of DHF. Methods: We studied 245 patients with II-IV NYHA class HF. 176 Patients have Systolic Heart Failure (SHF) (I gr), 68 patient - DHF (II gr) and 105 patients Left Ventricular Diastolic Dysfunction but without signs of HF (control, III gr). All patients undergone standard EchoCG examination. Sonographic evaluation of a lung was done in horizontal or vertical positions of patient, from 10 points of thoracic wall which corresponded to the projection of lower, middle and upper lobes of a right lung and upper and lower lobes of left lung. Results: In patients with HF we signicantly often found the one of the sorts of reverberation phenomenon - Comet tail Phenomenon (CTPh). CTPh was registered in 97.7% 91.3% and 40.0% of patients in I, II and III gr respectively (the difference between control an HF groups was signicant). The count of points from where the CTPh was registered was 8.8 in SHF group, 6.8 in DHF gr. and 0.7 in control gr. The CTPh was registered from 3 or more points of thoracic wall in 96.02% of patients in I gr, 81.16% - in II gr and only 4,76% in III gr. In HF groups CTPh was prominent, protracted and multiple while in the control group it was single and short lasting, like lightening. There was good correlation between the count of CTPh registration points from the thoracic wall and the heart failure NYHA class (r=0.56), left ventricular systolic (r=0.40) and diastolic (r=0.32) diameters and negative correlation with EF% (r=-0,42). Conclusion: Thoracic US is sensitive and accurate method for evaluation pulmonary congestion in patients Diastolic Heart Failure. The US sign of pulmonary congestion in HF is a Comet tail phenomenon, which is protracted, prominent, multiple and registered from larger area of thoracic wall (3 points or more).

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Resting cardiac function in patients with heart failure and normal ejection fraction
GWK. Yip1; Q. Zhang2; JM. Xie1; YJ. Liang1; YM. Liu1; YY. Lam1; CM. Yu2 1 Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 2Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Purpose: Previous studies suggest presence of normal torsion and circumferential strain in heart failure with normal ejection fraction (HFNEF) but lower longitudinal and radial strain compared with the control subject. We examined the myocardial deformations in a larger cohort with HFNEF. Methods: Two-dimensional speckled echocardiography was performed in 113 (age:74+12) HFNEF patients with ejection fraction .50%, 176 (age:67+13) patients with HF and reduced ejection fraction (HFREF) and 60 (age:53+9) normal control subjects. Results: Torsion (HFREF: 8.2+5.38, HFNEF: 16.2+7.18, control: 21.4+5.18, p,0.001), global circumferential strain (HFREF: 9.5+3.3, HFNEF: 20.7+5.0, control: 26.4+3.6, p,0.001), global longitudinal and radial strains were signicantly lower in both heart failure groups than in controls, and were depressed to a larger extent in HFREF patients than in those with HFNEF (both p,0.001) after age adjustment. (Table 1) Conclusions: There appears to be a continuum of systolic function between normal, HFNEF, and HFREF. Isolated diastolic dysfunction in HFNEF is uncommon.

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IVRT. Groups with biphasic dynamics of CO and IVRT were analyzed. Values of critical HR are presented in the table. Conclusions: Estimation of CO and IVRT can access patients myocardial reserve and severity of heart failure. Minimal myocardial reserve observed in patients with combined dysfunction, restrictive type of diastolic dysfunction, 2-nd functional class of heart failure.

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How to identify latent systolic dysfunction and post operative risk in patients with mitral incompetence and normal ejection fraction?
GEDN. El-Kilany1 1 Chest Diseases Hospital , Cardiology Department, Kuwait, Kuwait Purpose: To study the signicance of impaired positive peak rate of left ventricular (LV) pressure development (MR dp/dt) and global systolic strain (GLPSS) values in patients presented with signicant mitral incompetence (MR) in coronary artery disease (CAD) and early dilated cardiomyopathy (DCM) with normal ejection fraction (EF). Methods: A description of LV contractile behavior requires measurement of the ability of the ventricle to develop force (pressure) and to shorten. Hence, performance of the ventricle as a pump assessed in the present study by measuring the pressure developed by the ventricle (Left ventricular dP/dt is estimated from MR jet as the rate of pressure rise from 1 to 3 m/sec) and shortening assessed by GLPSS (this Doppler technology allowed measurement of LV systolic strain for the entire length of LV myocardium). GLPSS and MR dp/dt were calculated in 30 consecutive patients (mean age was 55+12 years) characterized by echocardiographic evidence of moderate or severe MR (in CAD and DCM patients) and normal EF (mean LV Ejection Fraction of 50.9+ 5.9 %) and compared with those obtained in 35 consecutive controls (age 54.7+11.4 years) with normal echocardiographic study of the heart. Results: The mean values of MR dp/dt and GLPSS averaged from the 3 apical views (Fig.1), differed signicantly in DCM and CAD patients ( characterized by signicant MR with normal EF) compared with control group, ( MR dp/dt 733+ 170 mmhg/s and GLPSS - 13+ 1.3 % ) versus (1420+ 210 mmhg/s and 219 .5+ 3.3 %) for patients versus control, respectively, p,0.001. A depressed values of MRdp/dt were highly correlated with GLPSS values in patients with CAD and DCM ,r 0.78. The combined use of 2D Strain(,213%) and MR dp/dt(, 900mmhg/s) in the presence of MR (grade II or more) had 89% sensitivity and 92% specicity for detection of patients at risk of postoperative major cardiac events after MR and coronary artery bypass surgery (Fig.2). Conclusion: latent LV systolic dysfunction could be dened noninvasively by depressed peak MRdP/dt and GLPSS in the echocardiography laboratories.

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Table 1 Control HFNEF HFREF HFNEF vs HFREF

Age (range) Male (%) SBP (mmHg) DBP (mmHg) LVEF (%) NYHA class(I/II/III/IV) CAD (%) Hypertension (%) Diabetes Mellitus (%) Hyperlipidemia (%) Global circ-S (%)* Global rad-S (%)* Global longitudinal-S (%)* Torsional-S (degree) *

53+9 (3574) 51.7 123+12 75+8 68.4+4.4 26.4+3.6 44.3+10.2 21.0+2.5 21.4+5.1

74+12 (3495) 36.3 158+31 78+19 62.7+7.5 (10/30/44/16) 31.5 63.1 45.0 13.5 20.7+5.0 32.9+10.7 16.0+3.8 16.2+7.1

67+13 (3094) ,0.001 69.3D 130+25 74+16 31.6+8.9 (9/21/46/24) 48.5 54.5 36.4 13.0 9.5+3.3 18.0+9.7 9.6+3.6 8.2+5.3 ,0.001 ,0.001 NS ,0.001 NS ,0.01 NS NS NS ,0.001 ,0.001 ,0.001 ,0.001

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The stroke volume in heart failure with normal ejection fraction is determined by the end-diastolic volume
DH. Maciver1 1 Musgrove Park Hospital, Taunton, United Kingdom Purpose: The function of the left ventricle is to deliver an adequate stroke volume (SV) & cardiac output to the tissues. Heart failure with a normal ejection fraction (HFNEF) is strongly associated with signicant concentric left ventricular hypertrophy (cLVH) and there is robust echocardiographic evidence of important regional contractile dysfunction (reduced long-axis displacement & systolic tissue Doppler velocities and abnormal radial, longitudinal and circumferential strain) in HFNEF. Mathematical modelling has shown that reduced long-axis shortening with cLVH results in augmented myocardial thickening, a normal ejection fraction but a reduced SV. The SV is usually normal in heart failure and so the changes in end-diastolic volume (EDV) necessary to achieve a normal SV were assessed. Methods: Three-dimensional mathematical modelling of left ventricular contraction. Input variables were LVH and long-axis myocardial shortening. Circumferential shortening & SV were constant. Output variables were EDV and ejection fraction. Results: The model demonstrates a reciprocal relationship between EF & EDV so that the end-diastolic volume (EDV) is predicted to be high in heart failure with a reduced ejection fraction but the EDV is normal in presence of the combination of reduced myocardial shortening & left ventricular hypertrophy. This simulates the ndings in HFNEF. Conclusions: The relatively normal EDV in HFNEF can be explained by the combination of reduced myocardial shortening and cLVH. It is suggested that feedback mechanisms normalise SV in both heart failure with reduced ejection fraction & HFNEF and would explain the echocardiographic ndings in heart failure.

* All p values are Age-adjusted. p,0.001, Dp,0.05, p,0.01 vs. control.

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Myocardial reserve estimation in patients with and without heart failure signs
A. Bobrov1; N. Hyshova2 1 Military Medical Academy, Saint Petersburg, Russian Federation; 2Almazov Heart, Blood and Endocrinology Centre, Saint Petersburg, Russian Federation Background: In healthy men the exercise leads to increasing of cardiac output (CO), decreasing isovolumic relaxation time (IVRT) right up to the maximal heart rate (HR). Decreasing of CO and increasing of IVRT during HR growth identies the decompensation (or reserve) of the heart contractility and relaxation. Objective: To evaluate myocardial reserve during the stress test in men with and without systolic and diastolic dysfunction. Methods: We enrolled 398 cardiologist patients (males, age 52.4+1.2 years, without signs of heart failure) referred for the exercise stress-echo. CO and IVRT were calculated on the heart rate 70, 80 . . . 140 bpm. Cardiac frequency at which CO or IVRTc starts its ascending limb called critical HR. Results: 118 patients had normal echo at the rest. 44 (37%) of them had monophasic limb of CO and IVRT dynamics, 74 (63%) had biphasic dynamics of CO and IVRT. 280 patients had systolic or diastolic dysfunction at the rest. 59 (21%) of them had monophasic limb of CO and IVRT dynamics, 221 (79%) had biphasic dynamics of CO and

Critical HR (M+m) Critical HR and type of echo dysfunction Normal Echo, (n74) Mono dysfunction (systolic or diastolic), (n149) Combined dysfunction (systolic and diastolic), (n131) Critical HR and type of dyastolic dysfunction Classic type of dyastolic dysfunction (n123) Pseudonormal type of dyastolic dysfunction (n69) Restrictive type of dyastolic dysfunction (n9) Critical HR and heart failure (NYHA) Without HF (n16) 1-st functional class of HF (n134) 2-nd functional class of HF (n204)

125,0+2,5 111+0,9 107,3+1,2 112,2+1,2 102,3+1,8 96,3+2,5 117,1+1,9 112,4+1,4 107,3+1,1

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The unravelling of reduced left ventricular longitudinal systolic deformation by two-dimensional speckle tracking in outpatients with normal ejection fraction
SC. A. AJ. A. JC. H. SS. Ramesh1; SK. Saha3 1 2 0 VIVUS-BMJ Heart Center, Bangalore, India; St George s University of London, London, United Kingdom; 3Sundsvall Hospital, Sundsvall, Sweden Purpose: In everyday clinical practice, the most commonly used measurement of left ventricular (LV) systolic function is ejection fraction (EF). However, LV performance may not be accurately assessed by conventional measurements. Therefore, our aim was to investigate LV systolic function in an outpatient setting using two-dimensional speckle tracking (2DST) which constitutes a modern, validated and accurate method of assessing myocardial function. Methods and Results: Echocardiographic studies from 57 outpatients (mean age of 53+12 years, 20 women) with a variety of clinical diagnoses such as coronary heart disease, hypertension, diabetes mellitus, stroke and thyroid and kidney abnormalities were retrospectively analysed using 2DST. The images were acquired from parasternal long- and short axis views as well as from apical 4-, 3-, and 2-chamber acoustic windows. LV EF was calculated using the Simpson0 s biplane method. LV images sampled at appropriate frame rates were post-processed using the 2DST software. Longitudinal parameters such as global peak systolic strain rate and end-systolic strain along with regional peak systolic velocities and displacements were obtained from the apical images. In addition to that, global circumferential strain rate at systole were also calculated taking the average of six short-axis LV segments. Patients were divided into 2 groups according to their EF values (EF ,54% and EF!55%). 2DST systolic parameters were signicantly reduced in patients with abnormal EF (p 0.003) as it was expected. In order to identify any possible LV systolic functional abnormalities within the patient group with normal EF, a longitudinal strain value of 16% was selected as a cut-off point. 2DST systolic longitudinal parameters were found to be signicantly decreased in 13 out of 27 outpatients (p 0.008) whilst the circumferential strain values showed no differences. Interclass correlation co-efcient demonstrated that age has a negative association with LV longitudinal systolic function (p 0.03). However, gender showed no effect. Statistical analysis showed that the sensitivity and specicity of 2DST is 81% and 68%, respectively. Conclusions: Our ndings suggest the 2DST can provide more accurate, sensitive and specic assessment of myocardial systolic function in patients with normal LV EF evaluated by conventional echocardiography. As experience improves, this technique should be increasingly incorporated in the monitoring of myocardial function in an outpatient setting. Govind1; Kiotsekoglou2; Camm2; Younis2; Moggridge2; Basappa1;

Table 1

Multiple logistic regression analysis b 0.027 275.46 Wald 4.2 6.2 P value 0.04 0.01 R2 value 0.65

Independent determinants LV end-diastolic volume S

Multivariate logistic regression analysis for determining independent determinants of the presence of LVdys.

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Differences of left ventricular dyssynchrony between high septal pacing and apical pacing in patient with normal left ventricular systolic function
H. Yoshikawa1; M. Suzuki1; T. Otsuka1; T. Tsuchida1; T. Osaki1; N. Tezuka1; M. Noro1; K. Sugi1 1 Toho Univesity ohashi Medical Center, Tokyo, Japan Background: Permanent right ventricular apical pacing results in development of heart failure due to ventricular mechanical dyssynchrony. The purpose of this study was to dene the differences of left ventricular dyssynchrony between high septal pacing and apical pacing by tissue Doppler imaging (TDI) and 2-dimensionnal (2D) speckletracking echocardiography (STE). Methods: Sixty patients undergoing newly implantation of permanent pacemaker with normal left ventricular systolic function were enrolled in this study. Patients were divided into two groups of high septal pacing group (n36), and conventional right apical pacing group (n24). Patients characteristics in high septal pacing group was as follows; mean age was 72.9+13.9, left ventricular diastolic diameter: 47.4+5.6 mm, ejection fraction: 68.2+6.7%. Patients characteristics in apical pacing group was as follows; mean age was 75.4+11.3, left ventricular diastolic diameter: 45.2+5.3 mm, ejection fraction: 72.2+5.2%. Patients with left ventricular systolic dysfunction, myocardial infarction or valvular disorders were excluded in the study. Left ventricular dyssynchrony was measured using TDI and 2D-STE. Systolic velocity curves by TDI obtained at basal -septal, basal-lateral, mid-septal and mid-lateral of left ventricle at 4-chamber view. The time difference (TD) between the earliestand latest-activated segments obtained from each systolic velocity curve by TDI were dened as TD-TDI. The traced endocardium by 2D-STE is automatically divided into 6 standard segments: septal, anteroseptal, anterior, lateral, posterior, and inferior. Time difference obtained by systolic strain curves by 2D-STE were dened as follows; TD-RS: radial strain, TD-CS: circumferential strain, TD-LS: longitudinal strain. Results: TD-TDI in high septal pacing group was signicantly shorter than apical pacing group (20.0+24.3 msec vs 59.7+43.0 msec , p ,0.0001). TD-RS in high septal pacing group was also signicantly shorter than apical pacing group (13.5+19.9 msec vs 45.8+24.6 msec, p ,0.0001). TD-LS by 3 and 4-chamber view were signicantly shorter in septal pacing group (3-chamber view : 34.3+17.9 msec vs 68.4+32.7 msec, p0.031; 4-chamber view: 42.7+22.0 msec vs 66.6+26.8 msec, p0.001). No signicant difference was observed in TD-CS between two groups. Conclusion: Left ventricular dyssynchrony was smaller in patient with high septal pacing. Measurement of time difference by radial and longitudinal strain using 2D-STE is useful to detect the differences of left ventricular mechanical dyssynchrony in patients with permanent pacemaker implantation as well as TDI.

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PACING AND DYSSYNCHRONY


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Differences in left ventricular contraction synchronicity between left bundle branch block and right ventricular pacing
Ji-Hyun JH. Kim1; MK. Seo1; HK. Kim1; YJ. Kim1; GY. Cho1; DW. Sohn1 1 Seoul National University, Seoul, Korea, Republic of Background: Tissue velocity imaging has been used to calculate left ventricular dyssynchrony index(LVdys) in most previous works; however, recent PROSPECT trial revealed its disadvantages. We aimed to evaluate differences in LVdys between acute RV pacing and LBBB pts using 2D speckle tracking-derived radial strain. Methods and Results: Total 34 subjects were enrolled with good echoCG images (normal for GrI, LBBB pts for GrII, and pts with acute RV pacing for GrIII). On top of measure of conventional parameters, LVdys and max difference of time to peak strain were obtained. Results were shown in Tables and Figures in detail. On multivariate logistic regression analysis with 130msec as a cutoff value for LVdys, LV enddiastolic volume(LVEDV) and S0 emerged as independent determinants for LVdys (Figure A and B). Conclusions: Despite similar degree of QRS duration and ECG morphology, a higher proportion of LBBB patients had LVdys. LV preload and contractility were independent determinants for LVdys presence.

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Impact of interventricular septal pacing in ventricular stimulation and interventricular mechanical asyncrony
A. Charalampopoulos1; A. Marinakos1; S. Marinakos1; A. Katranis1; D. Syrseloudis2; N. Raikos1; A. Katsaros1; D. Chrissos1 1 Cardiology Department, General Panarkadian Hospital, Tripoli, Greece; 2Hippokration General Hospital of Athens, Athens, Greece Purpose: Pacing through the right ventricular (RV) apex, even when atrioventricular sequential activation is maintained, affects left ventricular(LV) contractility resulting in paradoxical septal motion and interventricular mechanical asynchrony. The aim of our study is to determine whether septal pacing affects to a lesser extend the electromechanical performance of the left ventricle. Methods: Fifty one patients with a permanent pacemaker were examined and divided into two groups (I and II). Group I consisted of 27 patients (mean age 78+ 7 years) having the pacemaker wire implanted at the apex of the RV, while group II consisted of 24 patients (mean age 77+ 7 years) being paced through the interventricular septum (IVS). Using Doppler echocardiography we measured the time interval (in milliseconds) from the beginning of the QRS complex till the onset of left ventricular outow tract ow velocity (Q-LVOTFV) , from the apical four-chambers view and the time interval from the beginning of the QRS complex till the onset of right ventricular outow tract ow velocity (Q- RVOTFV) from the parasternal short-axis view. The difference between these two intervals [(Q-RVOTFV) - (Q-LVOTFV)] (interventricular asynchrony timing, IAT) was measured in all patients of both groups. The statistical analysis was made by Mann-Whitney test. Results: In all group I patients (27/27, 100%) stimulation of the RV preceded the one of the LV, IAT was 42,19+ 15,4 msec and a paradoxical septal motion was observed in 2D echocardiography. On the contrary, in 16/ 24 patients of group II (66,6%) the RV was stimulated earlier than the LV , in 3/ 24 patients (12,5 %) the stimulation of both ventricles was simultaneous and in 5/24 patients (20,8%) LV preceded RV. IAT in this group

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Abstracts
was 16,26+ 26 msec. The difference in IAT between the two groups was statistically signicant (p , 0,0001). In 11/24 patients of group II (46%) , paradoxical septal motion was not obvious in 2D echocardiography. Conclusions: Nearly one third of the patients with pacing from the IVS , have a mode of heart stimulation closer to the normal one. RV septal pacing showed lesser interventricular mechanical asynchrony. This may contribute to an improvement of some haemodynamic parameters, particularly in patients with a compromised heart function.

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Left ventricular dyssynchrony induced by right ventricular apical pacing correlates with the decrease in left ventricular ejection fraction and both improve by pacing from RV septal sites
H. Alhous1; G. Small1; A. Hannah1; G. Hillis2; P Broadhurst1 . 1 Aberdeen Royal Inrmary, Aberdeen, United Kingdom; 2The George Institute for International Health, Sydney, Australia Introduction Right ventricular apical (RVA) pacing may induce Left Ventricular (LV) mechanical dyssynchrony with deleterious effects on LV function. Lead placement in the RV mid inter ventricular septum (RV mIVS) or RV outow tract (RVOT) may reduce LV dyssynchrony and improve LV performance. There are, however, few data on assessing the effects of alternate RV pacing sites on LV function and LV synchrony. Methods: Twenty two patients [16 (73%) male, mean age 73 years] with standard indications for PPM underwent temporary dual chamber pacing. The RV lead was placed sequentially at the RVA, RV mIVS and RVOT in random order. Detailed echocardiographic studies were performed at baseline (AAI pacing) and at each RV lead position. LV Ejection Fraction (LVEF) was calculated using Biplane Simpsons rule. Intraventricular dyssynchrony was assessed by the calculation of the standard deviation of the time-to-peak systolic velocity in the 12- (6-basal and 6-mid) LV walls segments (the dyssynchrony index: Ts-SD). Continuous data are expressed as median values and compared using the Wilcoxon signed ranks test. Correlation coefcient between Ts-SD and LVEF was calculated using Spearmans rho linear correlation and its signicance level Results: RVA pacing signicantly decreased LVEF compared to baseline (Table 1). RV septal pacing at either RVOT or RV mIVS resulted in signicant improvement in LVEF compared to RVA pacing (Table-1). Ts-SD was signicantly increased by RVA pacing compared to baseline but this was signicantly improved by RV septal pacing compared to RVA pacing (Table-1). There was a signicant negative correlation (r0.36, p0.006), between Ts-SD and LVEF at all RV pacing sites combined. Table-1 Conclusions: RVA pacing results in an acute reduction in LV systolic function which is unaffected by RV septal and outow tract pacing. The mechanism for this may be due to a greater degree of pacing-induced LV dyssynchrony

dysfunction (EF= 52+ 8%). RV peak systolic tissue velocity was 12+ 2.6 cm/s; RV fractional area change 56+ 11%, and RV index of myocardial performance 0.34+ 0.14. Echocardiographic parameters of RV function were similar between patients and controls (strain: 22.8+ 5.8% vs 22.1+ 5.6%; strain rate: 1.47+0.91 s-1 vs 1.42+ 0.39 s-1). Mean interventricular delay was 41.7+ 19 ms, indicating interventricular dyssynchrony. Signicant LV dyssynchrony (septal-to-lateral delay ! 65ms) was found in 31 patients (36%). Intraobserver variability for strain and strain rate was 2.4% and 18.3%, respectively. Conclusion: RV apical pacing does not seem to affect RV systolic function, even in the presence of electromechanical dyssynchrony. Although cardiac resynchronization therapy had benecial effects on RV function, RV response to pacing-induced dyssynchrony remains unclear.

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Evaluation of left ventricular dyssynchrony by velocity vector imaging in subjects with normal QRS duration. Comparison with color coded tissue Doppler imaging
B. Purushottam1; AC. Parameswaran1; A. Amanullah1 1 Albert Einstein Medical Center, Philadelpha, United States of America Purpose: Data on echo criteria for dyssynchrony in patients with left ventricular dysfunction are abundant; data on the normal variations in healthy subjects are scarce. Knowledge of the normal variations will serve as a reference when studying the diseased heart. Unlike color-coded tissue doppler imaging (TDI), velocity vector imaging (VVI) is angle independent and can assess longitudinal, circumferential and radial velocities and strain. Methods: We studied two groups of patients. One group consisted of 135 subjects with normal left ventricular ejection fraction (EF), no clinical evidence of heart failure, QRS duration ,120ms and no history of myocardial infarction. Using the VVI technique, time to peak longitudinal, radial and circumferential velocities and strain were calculated. The second group consisted of 35 patients in whom we compared the time to peak longitudinal velocities by TDI and VVI. Results: 1) Dyssynchrony among healthy subjects: The nal cohort consisted of 100 patients. 52% were male, mean age 60+17 years, mean QRS duration 86+12 ms and EF was 61+5%. Among normal subjects, 17% had septal to lateral (S-L) wall longitudinal delay .75 ms, 63% of subjects had S-L wall radial delay .75 ms and 25% had a circumferential opposing wall delay .100 ms. Those with circumferential opposing wall delay of .100ms had an EF lower than those with ,100 ms delay (57+5 % vs. 62+5 %, p ,0.05). 2) Comparison of VVI with TDI: The second cohort consisted of a nal 33 patients. 62% were male, mean age 63+16 years, mean QRS duration 76+40 ms and 22% had an EF,55%. Among those patients whose TDI could be analyzed, everyone with S-L wall delay .65 ms also had a delay .75 ms by VVI. Conclusions: There is signicant variation in time to peak velocities among healthy subjects. Using published criteria for dyssynchrony, a signicant number of healthy subjects will be labeled as having dyssynchrony. Those with circumferential dyssynchrony have lower EFs, which highlights the contribution of left ventricular twist towards LV function. VVI is an attractive alternative to TDI for assessing mechanical dyssynchrony and can be used when adequate TDI tracings cannot be obtained.

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Table 1 AAI median LVEF (%) Ts-SD (ms) 54 18 RVA median (p values*) 46 (p0.005*) 39 (p0.001*)

RV mIVS median (p values) 51 (0.007) 18 (p0.01)

RVOT median (p values) 54 (0.01) 15 (p0.001)

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Triplane tissue Doppler echocardiography and radionuclide angiocardiography in the assessment of ventricular asynchrony in patients with heart failure
A. Vitarelli1; P Franciosa1; R. Massa1; D. Battaglia1; F. Caranci1; L. Capotosto1; . M. Cortes Morichetti2; S. Rosanio3 1 Sapienza University, Rome, Italy; 2Kremlin-Bicetre Universite Paris-Sud, Paris, France; 3 University of Texas, Galveston, United States of America Purpose: Several parameters have recently been proposed to assess mechanical dyssynchrony both by tissue Doppler / strain Doppler imaging (TDI/SRI) and radionuclide angioscintigraphy (RNA). It is unknown whether large differences exist between TDI and RNA to evaluate inter- and intra-ventricular dyssynchrony and whether the results are interchangeable. Methods: Thirty-four patients with dilated cardiomyopathy (NYHA class II or greater), left bundle branch block (QRS !120ms), and LV ejection fraction 35% were studied with triplane TDI echocardiography (Vivid 9 ultrasound system, GE, Horten, Norway) and RNA before and after biventricular pacing (BP). Intraventricular dyssynchrony was determined as the difference between the longest and shortest electromechanical coupling times in the basal septal, lateral, and posterior LV segments. Interventricular dyssynchrony was determined as the difference between electromechanical coupling times in the basal lateral RV segment and the most delayed LV segment. On line continuous LV volume changings were recorded using RNA and interventricular delay and basal-apical contraction were obtained. Results: At six months follow-up after BV implantation, patients functional status improved by one NYHA class or more and LVEF improved overall from 20.4+6.5% to 29.5+11.1%. Interventricular dyssynchrony by triplane TDI was reduced from 75.7+29 ms to 32.6+20.9 ms (p,0.005) and intraventricular dyssynchrony from 79+24.7 ms to 28.3+12.8 ms (p,0.001). Interventricular dyssynchrony by RNA was reduced from 77+28 ms to 13.7+25.3 ms (p,0.001) and apicobasal intraventricular dyssynchrony from 68.6+26.4 ms to 17.1+19.2 ms (p,0.001). Triplane TDI and RNA parameters had optimal predictive accuracy of the effects of BP on LV function

*p values vs. AAI pacing, p values vs. RVA pacing Table-1: Changes in median & p values for LVEF and Ts-SD at different pacing sites pacing.

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Pacing-induced electromechanical ventricular dyssynchrony does not inuence right ventricular function
MC. Pereira Nunes1; CDG. Abreu1; ALP Ribeiro1; CMV. Freire2; MOC. Rocha1; . RCP Reis3; MM. Barbosa2 . 1 Postgraduate Course of Tropical Medicine, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; 2ECOCENTER, Hospital Socor, Belo Horizonte, MG, Brazil, Belo Horizonte, Brazil; 3Federal University of Minas Gerais, Belo Horizonte, Brazil Background: Asynchronous electrical activation induced by right ventricular (RV) apical pacing can cause various abnormalities in left ventricular (LV) function. However, the effect of ventricular pacing on RV function has not been well described, This study evaluated RV systolic function in patients undergoing long-term RV apical pacing. Methods: An echocardiogram was performed at follow-up (mean intervals from pacemaker implantation, 89.7+ 80.5 months, range 1 to 371 days) in 85 patients. Twenty- four healthy controls (mean age: 42+ 12 years, 12 males) were also studied. Conventional echocardiography and tissue Doppler imaging (TDI) were used to analyze RV function. Strain imaging measurements included peak systolic strain and strain rate at the basal RV free wall. LV function and ventricular dyssynchrony by TDI were assessed. All recordings were performed by one investigator and intraobserver variability was assessed. Results: Percentage of ventricular pacing was 96+ 4% and QRS duration was 139+ 14 ms. All patients were in NYHA functional class I or II and no patient had signicant LV

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prevalent in wide QRS group (Table). However, most of the Doppler methods resulted in a signicantly lower prevalence of dyssynchrony in the narrow QRS group. Overall, Doppler parameters gave rise a lower prevalence of dyssynchrony than TDI and speckle tracking method. Conclusions: Multi-segmental approach by TDI and speckle tracking appears to detect mechanical dyssynchrony more readily than Doppler methods which reect global hemodynamics or only compare one segment, in particular in patients with narrow QRS.

and a larger area under the receiver operating characteristic curve than the QRS duration. Overall agreement between TDI and RNA was 89% (k= 0.67). Conclusions: Triplane TDI and RNA dyssynchrony measurements have an acceptable observer variability and values are largely comparable in pts with poor LV function and broad QRS.

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Comparison Of dyssynchrony between patients with depressed left ventricular ejection fraction and those with normal left ventricular ejection fraction using velocity vector imaging
B. Purushottam1; AC. Parameswaran1; A. Amanullah1 1 Albert Einstein Medical Center, Philadelpha, United States of America Purpose: Identifying the type of intra left ventricular dyssynchrony which is more prevalent among heart failure patients when compared to patients with normal left ventricular (LV) ejection fraction (EF) can potentially serve as a warning sign of systolic dysfunction. The aim of the study was to compare time to peak longitudinal, circumferential, radial velocities and strain and their opposing wall delays in patients with depressed LVEF (,55%) with those patients with a normal LVEF (!55%) in a group of patients with QRS duration ,120ms using Velocity Vector Imaging (VVI). Methods: 110 consecutive patients with a QRS duration ,120ms and with no history of myocardial infarction who had their echocardiograms analyzed with the VVI technique were included in the study. Peak longitudinal, circumferential and radial velocities and strain and the time taken to achieve their peak velocities (TTP) and strain were assessed by VVI from the basal septal, basal lateral, basal inferior and basal anterior walls in the apical view and all the walls in the short axis view at the level of the papillary muscles. Opposing wall TTP delay and time to peak strain delay along with maximum delay were also calculated. Results: The nal cohort consisted of 100 patients. 51% were males, mean age 60+ 18 years and mean EF 58+ 11%. We found that patients with a depressed LVEF had an increased opposing wall TTP circumferential delay (95.58+ 67.08 ms, p0.03) between the anterolateral and inferoseptal walls when compared to those with a normal LVEF (46.55+ 58.04 ms). There were also lower circumferential velocities in all the basal walls of the left ventricle in the group of patients with a depressed LVEF. Conclusion: Using the VVI technique we found that there was no signicant differences in the longitudinal and radial dyssynchrony between patients with depressed LVEF and those with a normal LVEF who have a QRS duration ,120ms. However, there was signicantly increased circumferential dyssynchrony between the anterolateral and inferoseptal walls and lower circumferential peak velocities in patients with a depressed LVEF. This may lead to impaired circumferential twist contributing to left ventricular systolic dysfunction.

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Dening left ventricle synchrony by 2D speckle tracking imaging in heart transplant recipients
H. Saleh1; HR. Villarraga1; Y. Yu1; S. Kushwaha1; F. Miller1; P Pellikka1 . 1 Mayo Clinic, Rochester, Minnesota, United States of America Objective: Noninvasive imaging has an important role in the evaluation of myocardial function in heart transplant recipients. Measurement of strain and strain rate has emerged as a sensitive modality to evaluate cardiac function. We sought to assess left ventricular longitudinal and circumferential synchrony by 2D speckle tracking echocardiography (STE) expressed as the time to peak systolic strain(TTPS) and time to peak systolic strain rate ( TTPSR) in the transplanted heart. Methods: We studied retrospectively 40 heart recipients, including 29 males, 12+3 months after transplantation. Subjects with abnormal ejection fraction (LVEF ,55%), severe rejection, severe valvular disease, or coronary artery disease were excluded. A control group was comprised of 82 healthy individuals; 31 males, with a low pretest probability of CAD and a negative stress echocardiogram. At the time of the assessment, all subjects were in sinus rhythm without cardiac pacing. Echocardiography Imaging was performed using a standardized protocol. Three beat cineloop clips from the parasternal short axis and apical 4, 3 and 2 chamber views were exported and analyzed ofine with dedicated software (Syngo Velocity Vector Imaging, Siemens Medical Solutions, Malvern, PA). Results: characteristics of patients vs. controls included age 52+12 vs 59+14, p =.013, HR 90+16 vs72+13, p,.0001, PR Interval 157+21 vs. 163+27, p=.34, QRS duration 107+20 vs. 90+11, p,.0001, BMI 26+5 vs. 27+5, p= .33, LVEF 65+4vs 63+4, p =.014, LVMI 95+21 vs. 89+21p=.13, respectively. Synchrony ndings for patients and controls are:circumferential TTPS 329+43 vs. 371+46 p, 0.0001, circumferential TTPSR 177+37 vs.196+45 p=0.0446,longitudinal TTPS 344+34 vs.401+36 p,0.0001, longitudinal TTPSR 171+28 207+29 p,0.0001. After adjusting for LVEF, HR and global TTP longitudinal TTPS and SR , were better differentiators between groups. AUC were 0.87 and 0.81, respectively. Conclusion: LV synchrony in cardiac allograft recipients is lower when compared to that of controls and was a good differentiator between the 2 groups after adjusting for other variables. Differences between groups were greatest for longitudinal TTPS and SR. LV synchrony response in other subsets of patients with HTX requires further research.

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Multi-segmental assessment of left ventricular mechanical dyssynchrony reveals better sensitivity than global doppler hemodynamics in congestive heart failure
Q. Zhang1; RJ. Van Bommel2; JYS. Chan3; V. Delgado2; YJ. Liang3; MJ. Schalij2; JJ. Bax 2; CM. Yu4 1 Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China; 2Department of Cardiology, Leiden University Medical Centre, Leiden, Netherlands; 3Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 4Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Background: Eletromechanical dyssynchrony exists in congestive heart failure (HF) where a number of echocardiographic parameters have been suggested for assessment and hence prediction of responses after cardiac resynchronization therapy. However, there is no large study that provides side-by-side comparison of multiple dyssynchrony parameters in the same HF population. Methods: 445 HF patients with NYHA class II-IV and ejection fraction 35% were recruited from 2 cardiac centers, in whom 236 had wide (.120ms) and 209 patients had narrow ( 120ms) QRS complexes. Doppler methods included left ventricular preejection interval (LPEI), ratio of lling time to R-R interval (FT-RR), late lateral wall contraction (LLWC) and interventricular delay (IVMD). Tissue Doppler imaging (TDI) measured the maximal difference of time to peak systolic velocity in 4 basal segments (Ts-4b) and standard deviation among 12 segments (Ts-SD). 2D speckle tracking calculated the anteroseptal-to-posterior delay in radial strain (Trs-AS-P). Results: By using TDI or speckle tracking parameters, the prevalence of dyssynchrony is similar between wide and narrow QRS groups, except for Ts-SD while is more
Parameters LPEI!140ms FT-RR 40% IVMD!40ms LLWC Ts-4b!65ms Ts-SD!33ms Trs-AS-P!130ms Whole group 28% 21% 26% 24% 60% 59% 42% Wide QRS 41% 32% 41% 25% 59% 63% 47% Narrow QRS 12%* 8%* 10%* 24% 61% 54% 36%

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Real-time 3-dimensional echocardiography reveals early signs of global left ventricular dyssynchrony in high-risk patients with type II diabetes and no coronary artery disease.
E. De Marco1; F. Loperdo1; G. Savino1; F. Gabrielli1; R. Natali1; E. Bock1; L. Bonomo1; F. Crea1 1 Catholic University of the Sacred Heart, Rome, Italy Background: Preclinical left ventricular (LV) dysfunction is common in type II diabetes mellitus, as revealed by tissue Doppler imaging (TDI) and derived techniques. Realtime 3-dimensional echocardiography (RT-3DE) quantitatively assesses LV global dyssynchrony by measuring the systolic dyssynchrony index (SDI). No data exist on the value of SDI for detecting preclinical LV dysfunction in diabetic pts. Purpose: We sought to determine if preclinical LV dysfunction, i.e. early signs of global (longitudinal, radial, or circumferential) LV dyssynchrony at RT-3DE, is more frequent in high-risk patients with type II diabetes than in those without. Methods: We examined 22 consecutive asymptomatic high-risk pts (Framingham risk score . 20%). In all patients, the presence of ischemic heart disease was carefully excluded by both stress testing and evidence of no coronary artery lumen reduction at 64-slices computed tomography (CT). The Agatston coronary artery calcium (CAC) score was obtained. Echocardiographic studies were performed using a ie33 Philips system. Longitudinal LV dyssynchrony was measured by TDI as the septal-to-lateral peak systolic velocities delay (SLD). Global LV dyssynchrony was measured by RT-3DE as SDI (derived off-line as the time dispersion to minimum regional volume apart from 16 LV segments time-volume curves), using a dedicated software (Q-LAB). Results: All pts were in sinus rhythm; their mean age was 59+ 16 yrs; there were 12 men and 10 women; the QRS length was , 120 msec in all. LV ejection fraction was 61+ 16%. A total of 10 pts (40%) had compensated type II diabetes (HbA1c 5.9 1.2%). Diabetic and non diabetic patients were similar with regard to age (56+ 11 vs 60+ 17 years), gender (60% vs 58% males), HDL (35+ 5 vs 34+ 6 mg/dl) and LDL cholesterol (142+ 15 vs 138+ 16 mg/dl), BP (130/75 vs 128/78 mmHg), and smoking status (60% vs 58% ). There was a trend for higher CT CAC score in diabetic pts (69+102 vs 14+23 HU, p=0.06). Pts with and without type II diabetes had similar TDI SLD (43+ 38 vs 61+ 39 msec; p = 0.3). In contrast, RT-3DE SDI was signicantly higher in diabetic pts (7.2%+ 7.6 vs 2.2%+ 2.7%; p , 0.02).

*p, 0.001, p,0.05 vs Wide QRS.

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Conclusions: In high-risk pts with type II diabetes early signs of global LV dyssynchrony may be detected by RT-3DE, as possible sign of preclinical LV dysfunction.

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Left ventricular mechanical asynchrony in diabetic patients
M. Przewlocka-Kosmala1; M. Cielecka1; H. Szczepanik-Osadnik1; W. Kosmala1 1 Wroclaw Medical University, Wroclaw, Poland Systolic and diastolic left ventricular mechanical asynchrony (LVMA), which might contribute to LV contraction and relaxation impairment, has been demonstrated in heart failure, coronary heart disease and hypertension (HT). Less in known about this abnormality in diabetes mellitus (DM). Aim: To assess systolic and diastolic LVMA in DM patients with asymptomatic myocardial dysfunction. Material and methods: 98 patients with DM aged 59+12, 58 of them with coexisting HT, and without coronary heart disease were enrolled in the study. 44 healthy agematched persons served as controls. Widening of QRS complexes in ECG was the exclusion criterion. Echo study with tissue Doppler imaging included the analysis of mean peak systolic velocity (S mean) and mean peak early diastolic velocity (E mean), being the averaged values from the 6 basal segments of LV, which served as estimates of global myocardial function. The measure of systolic and diastolic LVMA was the maximal difference in TS and in TE between any two of 12 mid and basal segments, where TS and TE were the time from the beginning of QRS complex in ECG to peak systolic velocity and to peak early diastolic velocity in tissue velocity curve, respectively. Results: Systolic and diastolic LVMA as indicated by higher values of TS and TE differences was demonstrated in both groups of DM patients, being however more advanced in subjects with coexisting HT. The independent predictors were for systolic LVMA: LV mass index (b0.23,p,0.001), diastolic blood pressure (b0.19,p,0.01) and S mean (b-0.38,p,0.001), and for diastolic LVMA: LV mass index (b0.15,p,0.04), diastolic blood pressure (b0.27,p,0.001) and E mean (b-0.32,p,0.001). Conclusions: In patients with DM (1) systolic and diastolic LVMA is a part of myocardial affection by the disease and is closely related to LV function impairment; (2) coexistence of HT potentiates both systolic and diastolic LVMA which parallels LV functional abnormalities.
Table 1 Results DM TSdifference [ms] TEdifference [ms] S mean [cm/s] E mean [cm/s] 78+26* 60+15* 6.6+1.0* 6.9+1.1* DMHT 99+27*# 77+17*# 5.7+0.9*# 5.1+1.0*# Controls 50+24 44+10 7.4+0.6 8.5+1.4

echocardiography with measurements of LV dimensions, systolic function parameters, eccentricity index, LV myocardial performance index (LV-MPI), Doppler myocardial isovolumic relaxation time (DM-IVRT). Results: RV systolic pressure was 81+41 mmHg in GrA, 96+38 mmHg in GrB (p0.37 vs GrA), 22+4 mmHg in GrC (p,0.01 vs GrA and B). LV function parameters are presented in the Table. Conclusions: Our results suggest that LV geometry changes resulted from RV pressure overload, with RV dilation, are associated with LV diastolic dysfunction only in patients with arterial PH, and not in those with pulmonary valve stenosis.

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Right ventricular function in patients with idiopathic pulmonary hypertension
G. Nasr1 1 Suez Canal University, Ismailia, Egypt Background and Aim: In patients with idiopathic pulmonary hypertension (IPAH), its progression and survival are related to the capability of the right ventricle to accommodate chronically elevated pulmonary artery pressure. So the aim of this study was to assess right ventricular function in these patients. Methods: A descriptive, cross-sectional, hospital based clinical trial enrolling 15 patients (5males and 10 females) diagnosed as having idiopathic pulmonary arterial hypertension. All patients underwent a complete transthoracic echocardiographic study including standard two-dimensional echocardiographic evaluation (2D-ECHO) of RV size and function. In addition, right ventricular end-diastolic and end-systolic areas were measured from the apical 4-chamber view to calculate right ventricular fractional area change. Eccentricity Index using the mid-ventricular short axis image at the level of the papillary muscles in both systole and diastole and right ventricular Myocardial Performance Index were calculated as well . (Total isovolumic ejection time index IRT ICT/ET). ). Results: Most of parameters of right ventricular dysfunction were altered with a P , .00001. This was higher in females than males. Among the patients only 10 had abnormal RV systolic function measured by fractional area change and Eccentricity Index .The combined myocardial performance unmasked the presence of right ventricular dysfunction in 13of them. There was associated right ventricular dysfunction with increasing right ventricular systolic pressure P , .00001 Conclusion: A comprehensive echocardiographic assessment of RV function allows a tool for risk stratication of patients with IPAH. RV Tei Index is a real addition.

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Impact of right ventricle function in mortality in patients with pulmonary arterial hypertension
P Loureiro1; R. Placido1; A. Nunes Diogo1; S. Martins1; J. Marques1; S. Ribeiro1; . A. Almeida1; M. Lopes1 1 Hospital Santa Maria, Lisbon, Portugal Introduction: Pulmonary arterial hypertension (PHA) denes a group of diseases associated with a high mortality and mobility. In spite of recent advances in genetics and biological PAH determinants, the pathogenesis of the majority forms of PAH remains unclear. The mortality rate associated to this pathology remains high and prognostic variables are not well established despite the recent therapeutics. Objectives: This study aimed to assess the mortality rate and the impact of clinical variables and echocardiographic parameters on the prognosis of patients (pts) with PAH. Methods: We conducted a retrospective study of pts with PAH included consecutively in a Pulmonary Hypertension Ambulatory Clinic, in the period of 2002 to 2008.The selected endpoint was mortality. The prognostic signicance of the following variables were analyzed: a) age, gender, BMI, NYHA class, cardiac rhythm; b) Echocardiography: left ventricle (LV) diastolic dimension and wall thickness, right ventricle (RV) diastolic dimension, pulmonary artery systolic pressure (PASP), maximal velocity of tricuspid regurgitation (Vmax), mitral E and A velocity, tricuspid annular plane systolic excursion (TAPSE), RV maximal longitudinal strain. Results: 36 pts were included, 24 women (66.7%), 64+13 years-old, BMI 28.91+6.78kg/m2. Twenty pts (55.55%) were in class III/IV NYHA. Mortality was 28% at a follow-up period of 23,9/-20,3 months (0,3 a 79). Considering the two groups, with and without mortality, only TAPSE and RV longitudinal strain showed values signicantly lower in the mortality group, with p,0.001 and p=0.013, respectively. Conclusion: The present study shows a high mortality rate associated with PAH in a follow-up period less than 7 years. The analysis of risk variables shows that only the RV function indexes, TAPSE and RV maximal longitudinal strain, were associated with a high mortality. These ndings suggest a signicant impact of RV function in the prognosis of PAH.

*=p,0.05 vs controls; #=p,0.05 vs. DM.

PULMONARY DISEASES
246
Left ventricular response to increased pressure afterload in the right ventricle comparison between pulmonary hypertension and pulmonary valve stenosis
RO. Jurcut1; E. Floares2; D. Iorgoveanu2; R. Ticulescu2; BA. Popescu1; I. Ghiorghiu2; IM. Coman2; C. Ginghina2 1 Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; 2Institute of Cardiovascular Diseases Prof. Dr. CC Iliescu, Bucharest, Romania Purpose: Ventricular interdependence is a known cardiac pathophysiological process. Anatomical remodeling of the right ventricle (RV) as a response to increased pressure afterload leads to geometrical changes in the left ventricle (LV). LV function remains a very important prognostic predictor in this setting. We compared LV function parameters in patients with pulmonary stenosis (PS) versus patients with arterial pulmonary hypertension (PH) using echocardiography. Methods: We included 36 age- and gender-matched patients (pts): group A (10 pts, mean age 32.0+18.3y) with valvular PS; group B (13 pts, 39.1+15.8) with arterial PH; group C (13 normal subjects, 38.1+14.7y). All pts had standard

Parameters

Group A Pulmonary valve stenosis N=10 31+6 1.4+0.2* 64+6 1.3+0.3 4.7+2.1 70+7 0.41+0.14

Group B Pulmonary hypertension N=13 47+9* 1.6+0.4* 58+15 1.0+0.4* 10.3+4.5*,# 108+36* 0.57+0.20*,#

Group C Controls N=13 29+6 1.0+0.4 65+5 1.4+0.3 7.2+3.6 66+25 0.44+0.12

P ANOVA ,0.001 ,0.001 NS 0.04 0.003 0.002 0.01

RV end-diastolic diameter (mm) LV Eccentricity index LV ejection fraction (%) LV mitral E/A ratio LV E/E ratio LV DM-IVRT (ms) LV-MPI

249
Left ventricular global dysfunction is related to pulmonary artery pressure in patient with chronic obstructive pulmonary disease
Elzbieta E. Suchon1; W. Tracz1; A. Prokop1; P Nalepa1; P Podolec1 . . 1 John Paul II Hospital, Krakow, Poland Background and aim: Several studies have shown that patients with right ventricle pressure overload often have impaired diastolic left ventricle function. The study aimed to evaluate the effects of chronic obstructive pulmonary disease (COPD) on the global left ventricle function (measured on the basis of myocardial performance index - MPI) and its relation to the pulmonary artery pressure.

Posthoc analysis: *p,0.05 vs controls, #p,0.05 vs GrA.

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Abstracts
251
Ultrasound lung comets in systemic sclerosis: a chest sonography hallmark of pulmonary interstitial brosis
L. Gargani1; M. Doveri2; L. Derrico3; MC. Scali4; S. Mondillo4; S. Bombardieri2; D. Caramella3; E. Picano1 1 CNR Istituto di Fisiologia Clinica, Pisa, Italy; 2Rheumatology Division, University of Pisa, Pisa, Italy; 3University of Pisa, Department of Diagnostica & Interventional Radiology, Pisa, Italy; 4Policlinico Santa Maria Alle Scotte, Siena, Italy Background: Pulmonary interstitial brosis is present in over 70% of patients with systemic sclerosis (SSc) and is a signicant determinant of outcome in these patients. High resolution computed tomography (HRCT) of the chest is the current undisputed gold standard to assess pulmonary brosis. Ultrasound lung comets (ULC) are a recently described sign of interstitial lung brosis, detectable with chest sonography. Aim: To assess the correlation between ULC and HRCT to evaluate pulmonary brosis in SSc patients. Methods: We enrolled 33 consecutive SSc patients (age 54+ 13 years, 30 females) in the Rheumatology Clinic of an University. In all, we independently assessed ULC and chest HRCT within 1 week. ULC score was obtained by summing the number of ULC on anterior and posterior chest. Pulmonary brosis by HRCT was quantied with a previously described 30-point Warrick score. Results: Presence of ULC (dened as a total number . 10) was observed in 17 (51%) SSc patients. Mean ULC score was 37+50, higher in the diffuse than in the limited form (73+ 66 vs. 21+ 35, p,.05). A signicant positive linear correlation was found between ULC and Warrick score (r .72, p , .001). Conclusions: ULC are often found in SSc, are more frequent in the diffuse than the limited form, and are reasonably well correlated with HRCT-derived assessment of lung brosis. They represent a simple, bedside, radiation-free hallmark of pulmonary brosis, of potential diagnostic and prognostic value.

Material and methods: Fifty patients mean age of: 60.9+ 8.5, range: 55 - 78 years with COPD without any additional cardiac diseases and 30 age and sex matched healthy subjects were enrolled into the study. All patients underwent pulmonary function tests and transthoracic echocardiography. The LVMPI was calculated as (a2b)/ b, were a is the interval between the cessation and onset of mitral inow, and b is the ejection time. Results: Our results are presented in the Table 1. LVMPI was signicantly higher in COPD patients in comparison to the controls (0.54+ 0.1 vs 0.32+ 0.07; p , 0.001). There was a signicant negative correlation between LVMPI and forced expiratory volume in 1 second expressed as the % of the predicted value - FEV1% (r = - 0.45; p,0.01). Moreover we found a signicant and strong correlation between LVMPI and RVSP (r = 0.7; p,0.001). Conclusion. The global LV function is impaired in COPD patients despite of preserved left ventricular ejection fraction and it is related to the increase in the pulmonary artery pressure.

Table 1. COPD group (n=50) Age (years) FEV1 (% of predicted) RVSP (mmHg) LVMPI LV diameter (mm) LV EF (%) 60.9+ 8.5 40+ 9.5 40.2+ 12.3 0.54+ 0.1 48.9+ 6.9 61.2+ 6.5 Controls (n=30) 61.1+ 7.9 98+ 4.9 21.3+ 2.9 0.32+ 0.07 50.1+ 8.1 63+ 4.1 p NS ,0.001 ,0.001 ,0.001 NS NS

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250
Non-invasive assessment of murine pulmonary arterial pressure: validation and application to models of pulmonary hypertension
B. Kurtz1; H. Thibault1; M. Raher1; RS. Shaik1; A. Waxman1; G. Derumeaux2; K. Bloch1; M. Scherrer-Crosbie1 1 Massachusetts General Hospital, Boston, United States of America; 2Universite Claude Bernard, Lyon, France Background: Genetically modied mice offer the unique opportunity to gain insights into the pathophysiology of pulmonary arterial hypertension (PAH). In mice, right heart catheterization is the only available technique to measure right ventricular systolic pressure (RVSP). However, it is a terminal procedure and does not allow serial follow-up. Our objective was to validate a non-invasive technique to assess RVSP in mice. Methods: Right ventricle catheterization and echocardiography were simultaneously performed in mice with pulmonary hypertension induced acutely by infusion of a thromboxane analogue, U-46619 or chronically by lung-specic over-expression of interleukin 6 (IL-6). Pulmonary acceleration time (PAT) and ejection time (ET) were measured in the parasternal short axis view by pulsed-wave Doppler of pulmonary artery ow. Results: Infusion of U-46619 acutely increased RVSP shortened PAT, and decreased , PAT/ET. The pulmonary ow pattern changed from symmetric at baseline to asymmetric at higher RVSPs. In mice with chronic PAH and wild-type mice, the PAT correlated linearly with RVSP (r2=20.67; p,0.0001), as did PAT/ET (r2=20.76, p,0.0001). Sensitivity and specicity for detecting high RVSP (.32 mmHg) were 100% (7/7) and 86% (6/7), respectively, for both indexes (cutoff values: PAT ,21 ms and PAT/ET ,39%). Intra-observer and inter-observer variability of PAT and PAT/ET were less than 6%. Conclusions: Right ventricular systolic pressure can be estimated noninvasively in mice. Echocardiography allows the monitoring of acute changes of RVSP and the detection of pulmonary hypertension. This technique enables the follow-up of PAH evolution easily and repeatedly in mice.

252
Echocardiographic assessment of right ventricular and right atrial functions in patients with pulmonary hypertension of different etiologies and severities
O. Ciftci1; N. Ozer1; E. Atalar1; K. Ovunc1; S. Aksoyek1; F. Ozmen1; S. Kes1; H. Ozkutlu1 1 Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey Purpose: Pulmonary hypertension (PHT) is a chronic disorder characterized by a chronic increase in afterload of right ventricle, which may lead to progressive right heart dysfunction and death. Left heart diseases, collagen tissue diseases, and chronic obstructive lung diseases are common clinical secondary causes of PHT. Our objective was to assess right heart functions in PHT as well as to study the differences in right heart functions in varying PHT etiologies and severities. Methods: A total of 83 patients with PHT and 49 controls were enrolled. The PHT etiology was a left heart disease in 39 patients, a connective tissue disorder in 23, and a respiratory disease in the remaining 21. Two-dimensional echocardiographic, conventional Doppler echocardiographic, and tissue Doppler echocardiographic examinations with myocardial velocity proles and strain/strain rate imaging were performed, by which right ventricular and right atrial functions were evaluated. Furthermore, patients with mild, moderate, and severe PHT and patients with different pulmonary hypertension etiologies were compared with each other. Results: In PHT a right ventricular systolic dysfunction is detected by TAPSE (16,2 (+5,0) vs 20,7 (+2,7); p,0,001), tricuspid lateral annulus systolic myocardial velocity (Sm) (12,8 (4,6-27,2) vs 16,4 (10,7-22,2); p,0,001), right ventricular lateral wall basal segment strain (16,6 (7,4- 38,2) vs 20,6 (6,3-55,0); p,0,01), and interventricular

Correlation between RVSP and PAT.

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
septum basal segment strain (17,8 (+5,10) vs 22,8 (+5,0);p,0,001). Right ventricular diastolic dysfunction is detected by right ventricular lateral wall basal segment diastolic strain rate ratio (0,8 (0,2-6,3) vs 2,3 (0,3-8,5); p,0,01) and tricuspid lateral annulus diastolic tissue Doppler velocity ratio (1,0 (0,4-6,6) vs 1,7 (0,6-6,3); p,0,001). Right ventricular dysfunction particularly involves the basal segments and the basal involvement becomes more prominent with increasing severity of PHT. Different PHT etiologies show only minor differences in right ventricular functions. Right atrial contractile functions were preserved, whereas right atrium behaved more as a reservoir than a conduit chamber. Conclusions: PHT causes right heart dysfunction and right ventricular involvement most prominently occurs in the basal parts. This segmental predilection becomes more apparent as the severity increases. PHT etiologies seem to affect right heart in a similar manner. Right atrium contractile functions are preserved, with a more compliant right atrium.

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and AF), less frequently occured isolated IVD 237, 0+32,1ms (8119), higher than in group one. Ts-12- 105,0+54,7ms (30250ms) and SD-Ts-39,0+23,7 (11-103) were higher than among patients with QRS,120ms. Conclusions: Duration of QRS doesnt correlate with the size of LV chambers, severity of mitral regurgitation and LV EF in patients with CHF. In narrow QRS isolated types of dyssynchrony are often. Patients with wide QRS and LBBB usually have intraventricular and mixed dyssynchrony, of Ts-12 and SD-Ts are signicantly higher.

255
Differential prevalence of left ventricular dyssynchrony between acute decompensated heart failure and chronic stable heart failure revealed by tissue Doppler imaging
Q. Zhang1; APW. Lee2; YT. Liu2; GWK. Yip2; YJ. Liang2; RJ. Li2; JM. Xie2; CM. Yu3 1 Li Ka Shing Institute of Health Sciences, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 2Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 3Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Background: Left ventricular (LV) dyssynchrony has been recognized as an important component of cardiac dysfunction which contributes to progressive deterioration of heart failure (HF), in particular in patients with wide QRS complexes. However, it remains unclear whether LV dyssynchrony is also related to the development of acute decompensated HF. Methods: 100 patients with systolic HF (LV ejection fraction ,50%) were enrolled in whom 50 patients were hospitalized for acute exacerbation of HF and 50 patients had chronic stable HF without HF hospitalization during the past 6 months. The 2 groups were matched for age, gender, ejection fraction and QRS duration (Table). LV systolic dyssynchrony was assessed by tissue Doppler imaging using the standard deviation (Ts-SD) and maximal difference (Ts-Diff) of the time to peak systolic velocity among the 12 segments. Results: Despite similar LV ejection fraction and QRS duration, patients with acute exacerbation of HF had signicantly prolonged Ts-SD and Ts-Diff than those with chronic stable HF. By using Ts-SD!33ms or Ts-Diff!100ms as a cutoff, the prevalence of systolic dyssynchrony was much higher in the acute HF group (Table). Conclusions: LV systolic dyssynchrony detected by tissue Doppler imaging is more prevalent in patients with acute decompensated HF. This implicates that changes in mechanical dyssynchrony may predispose to HF exacerbation and hospitalization, which might warrant further studies.

CARDIAC RESYNCHRONISATION THERAPY


253
Left ventricular torsion is reduced during left ventricular pacing after an experimental acute anterior myocardial infarction
A. Kaladaridou1; D. Bramos1; E. Skaltsiotes1; D. Takos1; C. Pamboucas1; G. Kottes1; A. Antoniou1; ST. Toumanidis1 1 Dpt. of Clinical Therapeutics, Alexandra Hospital, Athens, Greece Purpose: A signicant number of patients with ischemic cardiac failure are characterized as non-responders to biventricular pacing (P). Previous studies have shown the pivotal role of torsion on LV contractility. The purpose of this study is to examine the effect of different LV pacing modes and sites on LV torsion after an experimental acute anterior myocardial infarction. Methods: In 5 healthy pigs atrio-ventricular or ventricular epicardial P at LV apex or lateral wall was performed before and 30 min post LAD ligation, in a random order. Totally, 80 P were performed. LV torsion was calculated by measuring LV basal and apical rotation from basal and apical short-axis epicardial planes with speckle tracking technique using EchoPAC platform. LV torsion in sinus rhythm post LAD ligation was compared to LVtorsion in every P mode and site. Moreover, comparative evaluation of LVtorsion between the different P modes and sites was performed. Results: LV ejection fraction post LAD ligation reduced signicantly (32+8% vs 53+8%, p,0.01). LV torsion reduced signicantly in every P mode and site (atrioventricular 5.42+3.55, p,0.001 and ventricular 4.22+3.34, p,0.05 apical P as well , as atrio-ventricular 4.20+2.29, p,0.05 and ventricular P 3.53+3.43, p,0.04 of the lateral wall) in comparison to sinus rhythm, post LAD ligation (8.09+4.57). None of the P mode or site revealed any superiority. Conclusions: LV pacing exerts adverse effect on LV torsion after an acute anterior myocardial infarction experimentally. Further clinical studies are indicated to evaluate the role of LV torsion in LV contractility under pacing, in patients with cardiac failure.

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Table 1

Comparison btw Acute & Chronic stable HF Acute HF 67+14 (72%) 32.5+9.2 125+31 (56%) 45.7+15.6 (84%) 135+44 (80%) Chronic HF 68+15 36 (72%) 32.4+8.5 124+31 29 (58%) 34.0+18.7 24 (48%) 92+48 22 (44%) P value .659 1.000 .971 .836 .843 .001 ,0.001 ,0.001 ,0.001

Parameters Age, year Gender/Male, n (%) LV ejection fraction, % QRS duration, ms QRS group/wide, n (%) Ts-SD, ms Systolic dyssynchrony by Ts-SD, n (%) Ts-Diff, ms Systolic dyssynchrony by Ts-Diff, n (%)

254
Correlation between cardiac morphological and functional indices,myocardial dyssynchrony and intraventricular conduction in patients with congestive heart failure of various ethiology.
Maria M. Trukshina1; M. Sitnikova1; D. Lebedev1; E. Shlyakhto1 1 Federal Center of Heart, Blood and Endocrinology n.a.V.A.Almazov,, St.Petersburg, Russian Federation Purpose: To evaluate the distribution of various types of left ventricular dyssynchrony with ECG abnormalities and indices of left ventricular (LV) function in patients with congestive heart failure (CHF) II-IV class. Methods: Inclusion criteria: CHF II-IV class, LVEF 35%, optimal medical treatment. Exclusion criteria: signicant valvular disease, acute coronary syndrome. 26 patients were screened, 84% men, 58,0+13,4 y.o.; 76% had coronary artery disease (CAD), 24%-dilated cardiomyopathy (DM). All patients were examined with electrocardiogram, echocardiography (Echo). Echo with Tissue Doppler Imading (TDI) was assessed using Vivid 7 Dimension Ultrasound System (GE Vingmed Ultrasounds A/S, Norway) for evaluation of interventricular (IVD) and intraventricular (INVD) dyssynchrony. IVD was assessed as difference between aortic and pulmonary preejection time (cut-off IVD .40ms); INVD was assessed using time-to-peak systolic velocities (Ts-12) in 12 segments (middle and basal) of LV (cut-off: Ts-12 . 100 ms) and Ts-12 standard deviation (SD-Ts, cut-off: SD-Ts.32). In the presence of IVD or INVD dyssynchrony was considered to be isolated, in the presence of both IVD and INVD dyssynchrony was considered to be mixed. Results: According to QRS duration patients were divided into 2 groups, rst group (53%) include patients with QRS,120ms (100,0+7,5ms), second group (47%) with QRS !120ms (150,0+24,7ms) and complete left bundle branch block (LBBB). Groups were compared by CHF class (3,0+0,6), LV EDD (73,5+7,5mm and 75,0+8,8mm), LV ESD (60,5+5,8mm and 65,0+8,4mm), LV EF (27,0+6,9% and 28,5+5,4%), degree of mitral regurgitation (2,0+0,7). Among patients with QRS,120ms CAD, DM, atrial brillation (AF), isolated IVD or isolated INVD occurred equally; 30% of patients with AF had no dyssynchrony . In DM INVD and mixed dyssynchrony were common. In the narrow QRS group IVD was 27,0+24,2ms (293ms), INVD - Ts-12 95, 0+40, 0ms (42200ms), SD-Ts 235, 9+18,6 (1345). Group with QRS!120ms had more isolated INVD and mixed dyssynchrony (especially in CAD

36

28 42 40

256
Arrhythmias and sudden death in patients with advanced heart failure and high grade of asynchrony
W. Brzozowski1; A. Tomaszewski1; A. Wysokinski1 1 Medical University, Lublin, Poland Heart failure (HF) patients who have complex conduction disturbances and the high grade of intra- and interventricualr asynchrony are prone to a variety of arrhythmias. Most of them are asymptomatic, however they have prognostic signicance and sometimes provide to cardiac arrest (CA)or suden cardiac death (SCD). The aim of this study was to evaluate symptomatic and asymptomatic arrhtythmias in patients with advanced HF and conduction disturbances followed by high grade of contraction asynchrony. Group of 88 patients (76 men, 12 women; mean age 60,8+ 12,2 y, EF ,= 40 %) were subjected to 1year follow-up with 48 hours Holter monitoring every three months

Table 1

Arrhythmias and SCD in HF patients (% of 11,38 47,73 15,91 44,32 27,27 29,55

chronic atrial brillation proxysmal atrial brillation/agellation spraventricular tachycardia vetricular tachycardia (VT) vntricular brillation (VF) CA (VT or VF)

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Abstracts
dependence of the VO2 max increase and MPEP reduction [VO2 max increase=0,08x(MPEP reduction)4,7;], independently to the relative ESV reduction in multifactorial analysis (p=ns). For the remodeling dependent" subgroup, there was no correlation of VO2 increase with the retiming of the cardiac cycle, but signicant correlation with the LV remodeling (p=0,036). There was signicantly more responders in the resynchronization dependent" than in the remodeling dependent" subgroup (84% vs 36% p=0,0038) and the degree of response was higher, VO2 increase 5,04 vs 1,89 ml/kg/min (p=0,0041). Conclusion: The response to CRT is heterogeneous. For almost half of the patients LV resynchronization is the mechanism which mainly predicts response to CRT, independently of the remodeling. The resynchronization sensitive patients have a higher rate and a higher degree of response.

(Diagnostic Monitoring, Premier IV, ver. 3.3).All documented data of arryhthmias and SCD were collected and analyzed. During 1-year follow-up 14 patients died (16 % of group; 4 patients died suddenly recurrent VT/VF). Conclusions: 1.Patients with HF and conduction disturbances followed by high grade of contraction asynchrony commonly died suddenly. 2.The incidence of ventricular arrhythmias is as common as the incidence of supraventricular ones in investigated group of patients 3.Serious arrhythmias are frequently asymptomatic and require longer periods of Holter monitoring

257
Are there any echocardiographic predictors for appropriate therapies by the debrillator in patients with an implanted cardiac resynchronization therapy debrillator device?
Ana Teresa AT. Timoteo1; A. Galrinho1; LM. Branco1; MM. Oliveira1; M. Nogueira Silva1; J. Feliciano1; A. Leal1; RC. Ferreira1 1 Hospital Santa Marta, Lisbon, Portugal The signicant risk of sudden arrhythmic death (SD) in patients (P) with congestive heart failure and electro-mechanical ventricular dessyncrony has contributed for the increase in cardiac-ressynchronization therapy (CRT) combined with cardioverterdebrillator (D). Objectives: To evaluate in P submitted to CRT-D what are the echocardiographic variables that could predict the occurrence of appropriate therapies (AT) for ventricular tachydysrithmia. Methods: We evaluated 38 consecutive P (60+ 12 years 63% males) with echocardiographic evaluation before and 6 months after CRT-D implantation. We identied P with AT in a mean follow-up of 471+ 323 days (median 425 days). A standard echocadiographic study with tissue Doppler imaging (TDI) included, was performed. Responders were dened as P with improvement in NYHA class !1 in the rst six months, and reverse remodelling as a decrease in left ventricular end-systolic volume !15% and/or an increase in left ventricular ejection fraction (LVEF) !25%. Results: The responders0 rate was 74%, and reverse remodelling rate was 55%. In 21% of P there were AT. These P presented with higher end-diastolic left ventricular internal diameter (LVID) before implantation (86+ 8 vs. 76+ 11 mm, p0.03) and at 6 months (81+ 8 vs. 72+14 mm, p0.08), increased end-systolic LVID (66+ 14 vs. 56+ 14 mm, p 0.03) and lower LVEF (24+ 6 vs. 34+ 14%, p 0.08) in the evaluation at 6 months. In the group with AT, responder rate was lower (38 vs. 83%, p0.03), without signicant differences for reverse remodelling (60 vs. 38%, p0.426) and for the other variables. By univariate analysis, predictors for AT were end-diastolic LVID (OR 1.12, 95% CI 1.011.23) and end-systolic LVID (OR 1.08, 95% CI 1.01.18). Age, gender, ischemic etiology, use of anti-arrythmic drugs, reverse remodelling and TDI of mitral annulus could not predict AT. In multivariate logistic regression analysis, only end-diastolic LVID before implantation showed a trend for prediction of AT (OR 1.31, 95% CI 0.96 1.78, p0.08). Conclusions: In P submitted to CRT-D, episodes of ventricular tachydysrithmia can occur independently of the echocardiographic response, with end-diastolic LVID before implantation showed some trend to predict AT in medium-term. These results reinforce the importance of combined devices with the capacity for cardioversion-debrillation.

259
Right ventricular pacing changes left ventricle radial contraction pattern in patients with congestive heart failure and baseline intraventricular dyssynchrony.
Alexandra Ioana A I. Vasile1; D. Constantinescu1; C. Iorgulescu1; D. Zamr1; N. Dumitrescu1; M. Dorobantu1; R. Vatasescu1 1 Emergency Hospital of Bucharest, Bucharest, Romania Background: Baseline mechanical intraventricular dyssynchrony showed only a weak correlation with response to CRT in patients with congestive heart falure (CHF) and wide QRS. Currently the effects of right ventricular (RV) pacing during CRT on quantity and pattern of the intraventricular dyssynchrony are not explored. Objective: To evaluate the effects of RV pacing on intraventricular dyssynchrony and on the location of the maximum LV delay area in CHF patients and wide QRS. Methods: Speckle tracking radial strain was performed in 20 consecutive CHF patients with left bundle branch block (LBBB) one week after implantation of a biventricular pace-maker (9 ischemic etiology, 61+10 years, 9 women, NYHA class 3.2+ 0.4, LV ejection fraction 21+5%). All patients were in sinus rhythm with a normal PR interval and they have signicant baseline mechanical intraventricular dyssynchrony (time difference in peak septal wall-to-posterior wall strain !130 ms on speckle tracking radial strain). RV lead was placed in the interventricular septum by mapping (aiming for the narrowest QRS with as normal as possible axis). Maximum LV delay area was dened in sinus rhythm (ODO mode) and in RV pacing (DDD with short AV delay) as the segment with the latest systolic peak from the 6 regional colorcoded time-strain curves. Results: RV septal pacing did not changed signicantly the quantity of intraventricular dyssynchrony (330+103 ms vs. 344+61msec during sinus rhythm, pNS). However, the location of the maximum delay area shifted in 17 out of 20 patients. Baseline maximum delay area was located on the lateral wall in 11 patients (55%), on the inferior wall in 4 patients (20%) and on the infero-lateral wall in 5 patients (25%). During RV pacing maximum delay area was located on the infero-lateral wall in 15 patients (75%) and on the inferior wall in 5 patients (20%). Conclusions: RV septal pacing maintains signicant intraventricular dyssynchrony and changes the location of maximum LV delay area. This might explain the weak correlation of baseline mechanical intraventricular dyssynchrony assesed during intrinsic rhythm and the response to CRT.

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260
An assessment of the effect of different sonographers on the reproducibility of tissue Doppler imaging dyssynchrony analysis
RP Beynon1; RA. Argyle1; KA. Pearce1; NC. Davidson1; SG. Ray1 . 1 University Hospital of South Manchester, Manchester, United Kingdom Purpose: Tissue Doppler imaging (TDI) is in widespread use for the selection of patients for cardiac resynchronisation therapy (CRT). The reproducibility of TDI time to peak systolic contraction (Ts) has been quoted in most trials, but all have concentrated on the ability of analysers to repeat measurements on a pre scanned image. The impact of the sonographer on reproducibility has been poorly studied in previous trials yet this is as important as the reproducibililty of analysis for the technique to be robust. This study set out to investigate the effect of different sonographers on the reproducibility of TDI data. Methods: 20 normal subjects were recruited. All subjects had a QRS duration of , 110 msec. TDI images were obtained by two highly experienced sonographers using a VIVID 7 machine. Images were optimised independantly by both sonographers for depth, sector width and gain. Time to peak systolic contraction (Ts) was calculated from the onset of the QRS complex in 6 basal and 6 mid LV segments. Ts 4S was the maximal difference in Ts in the basal septal, lateral, anterior and inferior segments. TS SD was taken as the standard deviation of the Ts in all 12 segments. All 40 sets of images were analysed twice off line using ECHOPAC software by the same operator allowing the impact of intersonographer reproducibility to be compared with the analysers own intraobserver reproducibility. Coefcients of variation were calculated for all comparisons.
Table 1 Results Ts Intersonographer Intraobserver 14% 9% Ts 4S 30% 15% TS SD 41% 17%

258
Resynchronization versus remodeling dependent responders to biventricular pacing for congestive heart failure
Andrada A. Labecka1; T. Chwyczko1; M. Sterlinski1; B. Firek1; A. Maciag1; A. Kraska1; I. Kowalik1; H. Szwed1 1 Institute of Cardiology, Warsaw, Poland Purpose: The aim of the study was to evaluate whether the left ventricle resynchronization by biventricular pacing in heart failure was related to an improvement of the exercise capacity independently of the left ventricle reverse remodeling in long-term observation. Methods: We enrolled 44 patients who had a standard indication for cardiac resynchronization therapy (CRT) and who were able to perform an exercise test prior to implantation. Peak oxygen consumption (VO2 max) during cardiopulmonary exercise testing and echocardiographic parameters were measured prior to CRT and at least 3 months after the implantation. Responders to CRT were dened by an increase in VO2 max by minimum 2ml/kg/min. Left ventricle (LV) reverse remodeling was dened by a reduction of the end-systolic volume (ESV) by minimum 15%. LV resynchronization was assessed by the reduction of the mechanical pre-ejection period (MPEP), dened as the period from the onset of the mitral regurgitation ow signal and the onset of the aortic ow signal. Results: As conrmed by the exercise testing 56,8% patients positively responded to CRT; 45,4% patients had reverse LV remodeling and in 61,3% patients MPEP was reduced. The increase in VO2 max signicantly correlated with the LV reverse remodeling (r=0,4164, p=0,0049), but not with the MPEP reduction for the whole group of patients. Two subgroups of patients were distinguished: 19 patients (43,2%) with VO2 increase dependent on resynchronization (MPEP reduction) and 25 patients (56,8%) with VO2 increase dependent on remodeling (ESV reduction). For the resynchronization dependent" subgroup there was an excellent (R2=0,84, p,0,0001) linear

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
Conclusion: Intraobserver reproducibility of Ts was found to be in keeping with previous studies. Reproducibility however signicantly worsened when images from different sonographers were assessed. This study is likely to be a conservative estimate of real world reproducibility as all subjects were taken from a normal population where Ts measurements are typically easier than in patients with dilated ventricles. The results of this study suggest that the impact of the sonographer requires further investigation in future trials.

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and specicity of 92%. This was much higher than for the AS-P (cut off 130ms, AUC0.81, sensitivity 73%, specicity 71%) and Rs -SD12 (cut off 90ms, AUC0.79, sensitivity 75% specicity 75%). Conclusion: A radial strain delay parameter based on both the timing and amplitude of segmental strain has a stronger predictive value in determining CRT response compared to parameters based on segmental timing alone.

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Right atrial size and deformation predict echocardiographic response to cardiac resynchronization therapy in patients with dilated cardiomyopathy
Antonello A. Dandrea1; P Caso2; R. Scarale1; L. Riegler1; G. Salerno1; R. Cocchia1; . R. Gravino1; R. Calabro1 1 Chair of Cardiology - Second University of Naples, Naples Italy, Italy; 2Ospedale Vincenzo Monaldi, Naples, Italy Background: Right atrial (RA) enlargement has been depicted as a signicant independent predictor of unfavorable outcome in patients with pulmonary hypertension. Aim of the study: To detect by standard echo and by two-dimensional strain (2DSE) RA morphology and function in patients with dilated cardiomyopathy (DCM), and to assess if RA measurements may predict response to cardiac resynchronization therapy (CRT). Methods: The study population included 130 patients (54.4 plus or minus 10.2 years) with either idiopathic (70 patients) or ischemic (60 patients) DCM selected for CRT, and 60 healthy controls. All the patients underwent at baseline clinical examination, standard Doppler echo and non-Doppler two-dimensional RA Strain by Vivid 7 ultrasound system (General Electrics - Horton - Norway). After 6 months from CRT, DCM patients were considered as echocardiograc responders to CRT if left ventricular end-systolic volume decreased by 15%. Results: All the DCM patients were in NYHA class III before CRT implantation. The mean LVEF was 29.2+5.5%. Six months after CRT, 94 patients (72.8 %) were in NYHA functional class I-II. The patients were subdivided into echocardiographic responders (n 85; 66.1 %) and non responders (n 45; 33.9 %) to CRT. Left ventricular and right ventricular dimension and function were not signicantly different between the two groups. Conversely, tricuspid regurgitation velocity (p,0.01), inferior vena cava diameter (p,0.01) and both RA area index (19.7+5.5 cm/m2 in non responders vs. 13.2+4.4 cm/m2 in responders; p,0.001) and myocardial deformation of RA lateral wall (22.3+10.2 % in non responders vs. 40.2+8.9 % in responders; p,0.001) were signicantly different between the two groups. By ROC curve analysis, a RA area index . 16 cm/m2 showed a sensitivity and a specicity respectively of 80.7% and 88.8% (p,0.0001) to predict negative response to CRT. By multivariable analysis, RA area index (OR: 3.1; 95% CI: 2.13.9; p,0.001) and ischemic aetiology of DCM (OR: 1.3; 95% CI: 1.11.9; p,0.01) were powerful independent determinants of response to CRT. Conclusions: This study evaluated for the rst time RA size and reservoir function in patients with DCM. RA enlargement was an excellent independent predictor of response to CRT.

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Is left ventricular end-systolic volume the best echocardiographic indicator of clinical response to cardiac resynchronization therapy?
A. Zaroui1; Patricia P Reant1; P Ritter1; A. Deplagne1; A. Mignot1; P Bordachar1; . . . R. Roudaut1; S. Latte1 1 Hopital Cardiologique Haut-Leveque, Bordeaux, France Background: Common denition of response to cardiac resynchronization therapy (CRT) for severe refractory heart failure is based on NYHA class improvement. Left ventricular (LV) end-systolic volume improvement !15% has been used in some studies to dene echocardiographic LV reverse remodeling after CRT. Objectives: To analyze evolution of echocardiographic parameters and their association to clinical response after CRT. Materials and Methods: Ninety-six patients have been investigated before and 6 months after implantation of a CRT device with conventional indication according to ESC guidelines. Echocardiographies including measurements of LV dimensions, and contraction by 2-dimensional strain were performed at baseline and at 6 months. Response to CRT was clinically dened by an improvement of NYHA class to grade II at 6 months. Results: Seventy-four (76%) patients were clinically dened as responders to CRT at 6 months. Reduction of LV end-systolic volume !15% was observed in 63 patients (65%) and, in univariate analysis, was associated in 80% of the case with clinical response (p,0.05, OR 1.5 [CI 0.9-2.4]). Global longitudinal strain was improved from 29.7+2.7% to 211.2+2.2% in clinical responders (p,0.01) versus 28.2+2.9% to 28.1+4.9% (p ns) in non responders and, !15% relative improvement of this parameter was associated in 95% of the cases with clinical response to CRT at 6 months (p,0.001, OR 6.4 [CI 1.5-26.2]). Moreover, 87% of the patients without degradation of global longitudinal strain at six months were clinically improved (p,0.04, OR 3.2 [CI 1.4-7.2]). Conclusion: In this study, we observed that global longitudinal strain improvement !15% was better associated to clinical response after CRT than LV end-systolic volume reduction.

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Ideal dyssynchrony parameters for predicting the response to cardiac resynchronization therapy in the canine model of pacing-induced heart failure
YS. Wang1; X. Gong1; YG. Su1; Xianhong XH. Shu1 1 Zhongshan Hospital of Fudan University, Shanghai, China, Peoples Republic of Background: Tissue Doppler imaging (TDI), real-time three-dimensional echocardiography (RT3DE) and speckle tracking strain imaging (STSI) are methods for the assessment of left ventricular (LV) dyssynchrony. In this study we used dogs with rapid ventriucular pacing-induced heart failure to evaluate which method can detect the mechanical dyssynchrony in the canine model and to investigate which parameter is the best to predict the response to cardiac resynchronization therapy (CRT). Methods: Twelve adult beagle dogs were randomly divided into three groups. Eight of them underwent right ventricular pacing to induce heart failure (Group A&B). When their LVEF decreased below 35%, dogs in Group A received CRT and meanwhile dogs in Group B were given no therapy except termination of rapid ventricular pacing. The other 4 dogs were used as sham controls without connection to the pacemakers (Group C). Right ventricle was paced at 260 beats/min in Group A&B. TDI, RT3DE and STSI were performed in conscious animals at baseline, 3 weeks after pacing, 4 weeks after CRT in Group A, 4 weeks after deactivation of the pacemakers in Group B and 7 weeks after surgery in Group C. The systolic dyssynchrony parameter derived from TDI was the standard deviation of time to maximum systolic velocity of the 12 LV segments (Ts-12SD). As for the dyssynchrony index derived from RT3DE, we used the standard deviation of time to minimum regional volume of the 16 LV segments (Tmsv-16SD). STSI dyssynchrony indexes included standard deviation of time from onset of QRS to peak radial strain (Trs-6SD) and peak circumferential strain (Tcs-6SD) of the 6 middle LV segments. LV ejection fraction (LVEF), end diastolic volume (LVEDV) and end-systolic volume (LVESV) were measured by RT3DE. Results: In Group A&B, rapid RV pacing worsened LVEF, enlarged LVESV and dyssynchronized LV segments. Although in Group B LVEF partially returned to baseline and LVESV reduced obviously, LVEDV remained persistently enlarged up to a 4-week recovery period. After 4 weeks of CRT, LVEDV reduced dramatically from 37.35+9.53ml to 28.95+3.98ml with the improvement of LVEF and LVESV in Group A. Dened as a 15% decrease of LVEDV for predicting the response to CRT, preliminary receiver-operator curve analysis showed good sensitivity and specicity of to detect dyssynchrony with heart failure. Conclusions RT3DE and STSI can effectively detect left ventricular dyssynchrony in rapid ventricular pacing-induced heart failure canines. Tmsv-16SD and Trs-6SD are the best parameters to predict response to CRT.

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Radial strain delay using speckle tracking echocardiography to predict response to cardiac resynchronization therapy: going beyond segmental timing alone
Fakhar FZ. Khan1; MS. Virdee2; D. Ohalloran1; PA. Read1; SP Fynn2; DP Dutka1 . . 1 Addenbrookes Hospital, Cambridge, United Kingdom; 2Papworth Hospital, Cambridge, United Kingdom Introduction: In the selection of patients for cardiac resynchronization therapy (CRT), echocardiographic dyssynchrony parameters based upon the timing of regional contraction alone are limited by being inherently independent of consideration of underlying myocardial contractility. We hypothesised that patient selection to predict CRT response would be enhanced using a strain-based parameter based not only on the timing of myocardial segmental motion, but also on the amplitude of contraction, a potential measure of contractile reserve. We assessed a novel radial strain delay index to predict response to CRT. Methods: Radial 2D strain speckle tracking analysis was performed in 35 patients with heart failure scheduled for CRT (age 65 /2 8 years, 21 males, QRS 151 /2 12ms, NYHA III/IV 32/3, EF 22 /2 7%). Radial strain-delay (RSD) was calculated as the sum of the difference in peak radial strain and strain at aortic valve closure in the 12 non apical segments. All patients underwent CRT and response to treatment was dened as a .15% reduction from baseline in LV end systolic volume (LVESV) at 3 months. The predictive value of the RSD to predict CRT response was compared to previously reported dyssynchrony measures including the standard deviation (SD) of time to peak myocardial longitudinal velocity of 12 segments (Ts SD12), the anteroseptal-posterior wall radial strain delay (AS-P delay) and the SD of time to peak radial strain of 12 segments (Rs-SD12). Results: Echocardiographic response to CRT was seen in 21/35 patients. Signicant differences were seen between responders and non responders in the RSD (89 /2 42 vs 28 /2 13%, p,0.01), AS-P delay (249 /2 152 vs 91 /2 83ms) and the Rs-SD12 (140 /2 59 vs 73 /2 49ms). There was no difference in the Ts SD12 between responders and non responders. The RSD had the best correlation with LVESV reduction (r0.64, p,0.001) and using an optimal cut off of 41% (AUC0.92), the RSD was able to predict response to CRT with a sensitivity of 91%

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Conclusions: Some methods to assess timing of regional motion were affected by myocardial contraction and others not. This discrepancy may at least partly explain why CRT indication evaluated by various parameters is contradictory. We should devise a parameter that reects true mechanical dyssynchrony for CRT indication.

Effects of chronic right ventricular pacing on left ventricular cardiomechanics in patients with complete heart block
Kai Thorsten KT. Laser1; P Hauffe1; B. Hansky1; D. Kececioglu1 . 1 Heart and Diabetes Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany Purpose: We assessed the clinical and cardiomechanical effects of right ventricular pacemaker (PM) therapy on our PM-dependent patients. Methods: 55 patients (25m, 5m.-29y., median 14y., 49 DDD, 2 biventricular) with congenital and postoperative complete AV-block were ex-amined by echocardiography. They were compared with 45 age, sex and BSA matched healthy children. 3D-Echo (Tomtec) and speckle tracking (2D Strain, GE) were used to assess volumetric data, Strain and timing values that were normalized to heart rate . Results: Duration of PM stimulation was 7.5+5 years, 5 patients were classied ! NYHA 3. QRS duration was 140.1+41 ms in patients vs 66.5+14 ms in controls. Mean EF was 53.2+10% (3 pts , 40%, SDI 16 was .10 in 8 pts). We calculated decreased peak systolic longitudinal (PSS) and global radial (GRS) strain values, segmental timing was shorter in the patients compared to controls (data below). Patients had decreased maximal torsion (7.2+5.28 vs 10.3+5.58, p,0,05) and less time difference between apical and basal rotation (5.5+26.3% vs 18.2+15.3%, p,0,05). Conclusions: Clinically chronic RV-stimulation is tolerated well in our patients. 3D-Echo and speckle tracking are interesting tools to assess changes of three dimensional LV mechanics. To estimate their value in the individual follow-up further investigations are needed.

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Analysis of the temporal delay in myocardial deformation throughout the cardiac cycle: utility for selecting candidates to cardiac resynchronization therapy
Etelvino E. Silva1; V. Delgado1; D. Tamborero1; B. Vidal1; JM. Tolosana1; LL. Mont1; J. Brugada1; M. Sitges1 1 Hospital Clinico Universidad de Barcelona, Barcelona, Spain Background: Analysis of myocardial strains based on 2D echocardiography has been proposed to assess left ventricular (LV) mechanical dyssynchrony by measuring time differences in peak systolic strains from opposing LV walls. Peak systolic strain may be difcult to identify. Our aim was to evaluate 1) LV dyssynchrony by assessing the overlap among the strain traces of the LV walls throughout the cardiac cycle and curves and 2) its usefulness to identify responders to Cardiac Resynchronization Therapy (CRT) Methods and Results: 50 patients with heart failure and LV systolic dysfunction undergone CRT. 2D echocardiographic images were acquired at baseline and at 6 months follow-up. Myocardial radial strain (RS) and circumferential strain (CS) were analyzed with a commercially available software. Strain curves were postprocessed with a mathematical script. Quantication of LV asynchrony was expressed as an index of temporal overlap from the analyzed traces. Responders to CRT were dened by a reduction !15% of the end-systolic LV at 6 moths follow up. Responders to CRT had higher LV asynchrony based on both RS and CS analysis. A cut off above 7% overlap for RS (area under the curve 0.76) and above 8.5% for CS (are under the curve 0.68) identied responders to CRT (Figure ) Conclusions: Quantifying the temporal superposition of LV wall deformations with a computed algorithm allows measurement of LV intraventricular asynchrony throughout the cardiac cycle. The derived index is useful to identify responders to CRT.

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Differences in dyssynchrony assessment based on time-to-peak velocity, displacement, strain and strain rate: why are they different?
A. Yoshida1; S. Nakatani2; M. Amaki1; J. Tanaka3; H. Kanzaki1; M. Kitakaze1 1 National Cardiovascular Center, Suita, Osaka, Japan; 2Osaka University Graduate School of Medicine, Osaka, Japan; 3Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan Purpose: Although various echocardiographic parameters have been used to predict the effectiveness of cardiac resynchronization therapy (CRT), results of assessed dyssynchrony are often contradictory. We hypothesized that these parameters might be affected by regional contraction irrespective of the true mechanical delay leading to such contradiction. Methods: We obtained left ventricular short-axis images at the mid level in 30 patients with dilated cardiomyopathy (DCM), 22 with ischemic cardiomyopathy (ICM) and 30 normal controls using Vivid 7 (GE). We set a region of interest on the posterior subendocardium and measured the time from QRS onset to peak velocity, peak displacement, peak strain and strain rate. Posterior wall thickening was measured using M-mode echocardiography. Results: Time-to-peak velocity was signicantly longer in DCM and ICM than controls (250+62 vs. 197+51 vs. 166+28 ms, p,0.001, p,0.05 vs controls) whereas time-topeak displacement and time-to-peak strain showed no differences among the three groups. Time-to-peak velocity showed signicant correlations with wall thickening (DCM: r0.49 p,0.01, ICM: r0.59 p,0.01, Total: r0.53 p,0.001). However, time-to-peak displacement, peak strain and strain rate did not correlate with wall thickening.

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Impact of functional mitral regurgitation on left ventricular reverse remodeling after cardiac resynchronization therapy
YJ. Liang1; Q. Zhang2; JWH. Fung1; JYS. Chan1; GWK. Yip1; Q. Shang1; CM. Yu3 1 Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 2Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China; 3Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Purpose: To examine whether the presence of pre-pacing functional mitral regurgitation (MR) and its improvement would affect the extent of left ventricular (LV) reverse remodeling after cardiac resynchronization therapy (CRT); and compare the relative contribution of early- and late-systolic MR. Methods: This study enrolled 83 patients, of whom 48 had more than mild MR and 35 showed no MR at baseline. MR volume was computed by the continuity equation based on Doppler ow. Instantaneous MR ow rate was measured by proximal ow convergence method at early and late systolic phases. Echocardiography was performed at baseline and 3 months for changes in MR and LV reverse remodeling. Results: At 3 months, there was reduction in total MR volume (38+20 vs. 33+21ml) with decrease in both early- (71+52 vs. 60+51ml/s) and late-systolic (49+46 vs. 42+46ml/s) MR ow rate (all p,0.05). The improvement in total MR volume of !11% was associated with LV reverse remodeling (dened as reduction of LV endsystolic volume !15%) with a sensitivity of 90% and a specicity of 80% (AUC: 0.85, p,0.001), which was also signicant in multivariate analysis. The corresponding sensitivity, specicity and AUC were 95%, 84% and 0.88 for reduction in early-systolic MR and 75%, 54% and 0.74 respectively for late-systolic MR. The extent of reverse remodeling was greatest in patients with improvement in total MR (-29.8+12.0%), intermediate in those with mild or no MR at baseline (218.6+16.6%) and was the least in those without improvement in total MR (25.5+8.6%, p,0.01 among groups). Conclusions: Improvement of functional MR contributes to LV reverse remodeling response after CRT, in which reduction of early-systolic MR is a more powerful component than late-systolic MR.

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Persistence of secondary mitral regurgitation and response to cardiac resynchronization therapy
Fernando F. Cabrera Bueno1; MJ. Molina Mora1; J. Fernandez Pastor1; JL. Pena Hernandez1; J. Alzueta1; A. Barrera1; E. De Teresa1 1 Hospital Universitario Virgen de la Victoria, Malaga, Spain

Eur J Echocardiography Abstracts Supplement, December 2009

Abstracts
Background: Cardiac resynchronization therapy (CRT) improves survival and quality of life of patients with advanced heart failure. Although a signicant improvement in mitral regurgitation has been reported in these patients, its presence has also been associated with a worse response to CRT. Methods: 76 patients (28.9% women, 63+11 years) with dilated myocardiopathy in advanced stages of heart failure were included on this study. The presence of signicant mitral regurgitation (SMR), dened by a regurgitant orice area (ROA)!0.20 cm2, was assessed at baseline and its evolution six months after undergoing CRT. On follow-up, the potential role of persistence of SMR on clinical (death or readmission due to heart failure), echocardiographic response (reverse remodelling) and major arrhythmic events was studied. Results: Of the 76 patients, 32 (42.1%) had SMR. At follow-up six months after CRT, SMR had disappeared in 11 of the 32 patients (34.3%). The only independent predictive factor of persistence of SMR after CRT was the pre-implant ROA, with an OR of 1.25 (95% CI, 1.0311.575; p0.025). Additionally, seven (9.21%) patients without SMR prior to the implant developed it during the six-month follow-up. The presence of SMR after CRT was associated with higher rates of clinical events (46.4 vs. 18.7%, p0.011), less reverse remodelling (28.5% vs. 83.3%, p,0.001), and a greater incidence of arrhythmic events (35.7 vs. 14.5 %, p0.034). Conclusions: CRT can reduce moderate or severe baseline mitral regurgitation down to a non-signicant grade in one third of patients. However, persistence of SMR was associated with a worse clinical evolution, less reverse remodelling and a greater incidence of arrhythmic events.

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Conclusion: In the selection of the optimal site for LV lead placement the amplitude as well as the timing of segmental strain should be considered in order to enhance prediction of CRT response. This has important implications for the prospective targeting of LV lead placement.

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A comparison of the reproducibility of tissue Doppler imaging between research and clinical departments
RP Beynon1; RA. Argyle1; N. Abidin1; J. Fallon1; KA. Pearce1; . R. Aghamohammadzadeh1; SG. Ray1; NC. Davidson1 1 University Hospital of South Manchester, Manchester, United Kingdom Purpose: Since the publication of the PROSPECT trial, the role for tissue Doppler imaging (TDI) in cardiac resynchronisation therapy (CRT) has been called into question. A striking nding of the PROSPECT trial was the inter-centre coefcient of variation of 33.7%. Trials have characteristically been performed by highly trained researchers performing high volumes of studies. We compared the reproducility of TDI measures between our research and clinical departments in an attempt to assess if TDI could be transfered to main stream clinical practice. Methods: 10 patients with heart failure referred for dyssynchrony assessment underwent TDI 12 segment echocardiographic assessment using a VIVID 7 system. Images were analysed independently by four operators off line for time to peak systolic contraction. Two operators were already exposed to high volumes of TDI analysis as part of their MD research program (Research 1 and Research 2). The other two operators were highly experienced sonographers who had previously used TDI regularly as a clinical tool (Clinical 1 and Clinical 2). Results: 120 segments were analysed by all the operators. Coefcients of variation were calculated for all 120 TDI segments. The standard deviation of the 12 segments was calculated during each study to give the Yu index. Conclusion: The reproducibility of TDI measurements was signicantly better in our research group compared to our clinical group. This is likely to be due to the greater prior exposure to TDI amongst the research operators. Our results are in keeping with the PROSPECT trial and suggest that TDI is a useful research tool but its transfer to the clinical setting may be more difcult than previously assumed.
Table 1 Results Time to Peak TDI Research1 / Research2 Clinical1 / Clinical2 Research1 / Clinical1 Research1 / Clinical2 Research2 / Clinical1 Research2 / Clinical2 6.7% 15.3% 12.3% 8.7% 12.7% 10.9% Yu Index 14.8% 40.4% 21.8% 26.2% 26.1% 19.0%

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Absence of left ventricular apical rocking and atrial-ventricular dyssynchrony predicts non-response to cardiac resynchronization therapy

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Speckle tracking echocardiography reliably identies the optimal site for left ventricular lead placement in patients undergoing cardiac resynchronization therapy
Fakhar FZ. Khan1; MS. Virdee2; D. Ohalloran1; PA. Read1; SP Fynn2; DP Dutka1 . . 1 Addenbrookes Hospital, Cambridge, United Kingdom; 2Papworth Hospital, Cambridge, United Kingdom Introduction: In patients undergoing cardiac resynchronization therapy (CRT), left ventricular (LV) lead placement to the latest site of activation improves LV reverse remodeling and mortality whereas pacing areas of myocardial scar has detrimental effects. Speckle tracking echocardiography offers assessment of the timing and extent of segmental myocardial deformation. We hypothesised that assessments of the strain amplitude of the paced LV segment in addition to segmental timing determined by speckle tracking echocardiography would enhance the selection of the optimal site for lead placement compared to pacing the latest site alone. Methods: Radial 2D strain speckle tracking analysis was performed in 38 patients with heart failure scheduled for CRT (age 65 /2 8 years, 24 males, QRS 152 /2 14ms, NYHA III/IV 35/3, EF 23 /2 7%). All patients underwent CRT and the position of the LV lead was determined post implant from biplane uoroscopy and the paced segment determined. For the paced segment in each patient we determined the radial strain amplitude as well as the extent of segmental delay expressed as the ratio of the time (from QRS onset) to peak strain divided by the time to peak strain of the earliest segment (late/early L/E ratio). Response to treatment was dened as a .15% reduction from baseline in LV end systolic volume (LVESV) at 3 months. Results: Echocardiographic response to CRT was seen in 23/38 patients. Lead placement to delayed segments with a late/early ratio .1.5 predicted response to CRT with a sensitivity of 91% and specicity of 81% (AUC 0.89). The late/early ratio of the paced segment correlated well with the extent of LVESV at 3 months (r0.51, p,0.001). When the amplitude of the paced segment was additionally considered to the late/ early ratio, using a cut off of 10% the sensitivity of predicting response to CRT increased to 100% and the specicity increased to 85%.

Francois F. Tournoux1; D. Mccarty2; A. Chen-Tournoux2; RC. Chan3; R. Manzke3; JP Singh2; MH. Picard2; AE. Weyman2 . 1 Lariboisiere Hospital (AP-HP), Paris, France; 2Massachusetts General Hospital, Boston, United States of America; 3Philips Research North America, Boston, United States of America Background: Current non-invasive imaging techniques attempt to identify patients who may respond to cardiac resynchronization therapy (CRT). However, because response to CRT is dependent upon several factors, it may be clinically more useful to identify patients for whom CRT would not be benecial even under optimal conditions, thus avoiding unnecessary device implantation. Since mechanical dyssynchrony may affect both lling and ejection of the left ventricle (LV), we developed a composite echocardiographic index looking at 1) atrial-ventricular dyssynchrony (AV-DYS) and 2) intraventricular dyssynchrony and tested its the negative predictive value. Methods: Subjects with standard indications for CRT underwent echo before and during the month following device implantation. AV-DYS was dened as a percentage of LV lling time over the cardiac cycle. Intraventricular dyssynchrony produces a characteristic rocking of the LV apex, which indicates unopposed contraction of one wall due to delayed activation of the opposite wall. LV apical rocking was evaluated using displacement curves from tissue Doppler velocity recordings of the septal and lateral walls, and was quantied as the percentage of the cardiac cycle over which the displacement curves showed discordant behavior. CRT responder status was determined based on the early hemodynamic response to CRT, with responders dened as having an intra-individual percentage change of .25% in the Doppler-derived LV dP/dt over baseline. Optimal cut-points for which LV apical rocking and AV dyssynchrony predicted response status were determined using ROC analysis. Results: 40 consecutive patients (66+14 years, LV ejection fraction 27+6%, QRS duration 168+25 ms) were included. Optimal cut-points were 31% for LV apical rocking and 39% for AV-DYS. The combination of both parameters (presence of either apical rocking.31% or AV-DYS 39%) had a sensitivity of 95%, specicity of 80%, positive predictive value of 83%, and, most importantly, a negative predictive value of 94% for CRT response.

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Abstracts
Results: One-hundred-and-one patients (age 65+11, 69 men, 18 NYHA IV, QRS 173+23) scheduled for CRT were included. Mean follow-up was 16+9 months. The combined end-point was reached in 23 patients. SRSsept, DPsept, interventricular mechanical delay (IVMD) and NYHA class were independent predictors of the combined endpoint (all p,0.05). Baseline SRSsept, DPsept and IVMD correlated with reverse remodeling (all r.0.5, p,0.001) and neurohormonal response (r0.439, p,0.001; r0.286, p,0.001 and r0.493, p0.008 respectively) at 6 months follow-up whereas NYHA class was only mildly correlated with reverse remodeling (r 20.271 p0.015). Conclusions: Septal deformation pattern characteristics predict prognosis after cardiac resynchronization therapy and are related to treatment effects.

Conclusion: After pre-selection of candidates for CRT by QRS duration, application of a simple composite echocardiographic index may exclude patients who would be nonresponders to CRT despite optimal implantation, and thus improve the global rate of therapy success.

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Inter-ventricular delay at peak exercise in heart failure patients selected for cardiac resynchronisation therapy is independently correlated with left ventricular remodeling at three months
N. Piriou1; S. Abbey1; JP Gueffet1; JN. Trochu1 . 1 LInstitut du Thorax-CHU Nantes-Hopital G. et R. Laeunnec, Nantes, France Purpose: Cardiac resynchronisation therapy (CRT) improves survival and reverses left ventricle (LV) remodeling in heart failure (HF) patients presenting with severe LV systolic dysfunction and prolonged QRS interval. However, one third remain non-responders to CRT. We assessed whether exercise inter-ventricular dyssynchrony could be a relevant index for the prediction of response to CRT. Methods: Eighteen HF patients performed exercise echocardiography before device implantation. Inter-ventricular mechanical delay (IVMD) was recorded at rest and peak exercise. We determined correlations between IVMD at exercise and mitral regurgitation assessed by the effective regurgitant orice area (ERO), and right ventricular (RV) longitudinal systolic function assessed by peak tricuspid annulus S wave velocity in tissue doppler imaging. We looked for correlations between those parameters and the degree of LV reverse remodeling at three months follow-up, assessed by the percentage of change in LV end-sytolic volume (%DESV) and absolute value of change in ejection fraction (DLVEF). Results: Exercise-induced changes in IVMD only signicantly correlated with RV longitudinal systolic function (r = - 0.602; p = 0.01) at peak exercise. In a multivariate analysis by multiple linear regression (table 1), IVMD at peak exercise was independently correlated with %DESV and DLVEF at follow-up. Peak exercise ERO was independently correlated with %DESV. Conclusion: In HF patients, IVMD at peak exercise before device implantation seems to be a relevant independent predictor of mid-term LV remodeling after CRT. Its relation with RV longitudinal systolic function during exercise could provide a pathophysiological explanation.
Table 1 Exercise echo measurements % DESV IVMD at peak exercise ERO at peak exercise Peak exercise tricuspid annular S wave velocity IVMD at peak exercise ERO at peak exercise Peak exercise tricuspid annular S wave velocity Univariate analysis r = 0.447 : p = 0.07 r = 0.756 ; p , 0.001 r = -0.495 ; p= 0.05 r = -0.535 ; p = 0.02 r = -0.544 ; p = 0.02 r = 0.498 ; p = 0.04 Multivariate analysis b = 0.466 ; p=0.01 b = 0.808 ; p, 0.001 b = 0.175 ; p =0.39 b = -0.496 ; p=0.03 b = -0.311 ; p=0.23 b = 0.082 ; p =0.75

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A new ECG criterion of intraventricular dyssynchrony is superior to current criteria in cardiac resynchronization therapy outcome prediction
Andras A. Vereckei1; V. Kutyifa2; L. Geller2; M. Kiss1; G. Szenasi3; E. Zima2; I. Karadi1; B. Merkely2 1 3rd Department of Internal Medicine, Semmelweis University School of Medicine, Budapest, Hungary; 2Semmelweis University Cardiology Centre, Budapest, Hungary; 3 EGIS Pharmaceutical Works PLC, Budapest, Hungary Purpose: Current traditional and imaging criteria used to predict the functional improvement with cardiac resynchronization therapy (CRT) are suboptimal. Changes in QRS duration, the only ECG criterion used in patient selection for CRT, show poor correlation with the post CRT hemodynamic improvement. Intraventricular dyssynchrony is always associated with a prolonged total endocardial activation time. We hypothesized that the greater is the prolongation of endocardial activation time, the more effective CRT will be. Methods: A new ECG criterion (NC) considered as a surrogate marker of total left ventricular (LV) endocardial activation time was devised. To estimate the LV endocardial activation time, the difference between the intrinsicoid deections (ID) in leads V6 and V3 reecting the electrical potentials of the left ventricular apex, lateral wall and left side of the ventricular septum respectively was calculated and divided by QRS duration: (V6ID-V3ID)/QRS duration (in %). The NC was determined from ECGs recorded prior to biventricular pacemaker implantation in patients selected for CRT based on traditional criteria (TC) and arbitrarily if its value was .25% responder (R) diagnosis, if its value was 25% non-responder (NR) diagnosis was made. The rst author retrospectively analyzed ECGs from 126 patients with known CRT outcome, blinded to the patients clinical response to CRT. Results: During follow up 35/126(28%) patients were NR, thus using the TC correct diagnosis was established in the remaining 91/126(72%) R patients. Applying the NCTC together the correct diagnosis was made in signicantly (p,0.001) more [101/126(80%)] cases. Using NCTC together R diagnosis was made in 91/126(72%) patients, its sensitivity, specicity, () and (2) predictive values were 86,66,87 and 64% respectively, which were better than those recently reported for the best echocardiographic intraventricular dyssynchrony criteria, although no head-to-head comparison was made in this study, and the () predictive value was superior to that of TC alone (87% vs. 72%; p,0.01). Conclusions: NCTC together proved to be superior to TC alone in prediction of CRT outcome, have better sensitivity, specicity and predictive values than those recently reported for the best echocardiographic intraventricular dyssynchrony criteria and renders possible a new, very simple and more accurate patient selection strategy for CRT to be outlined in the presentation.

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D LVEF

Correlations between exercise echo measurements and LV remodeling.

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Clinical outcome after cardiac resynchronization therapy is related to septal deformation pattern characteristics on baseline echocardiography
Geert GE. Leenders1; BWL. De Boeck1; AJ. Teske1; M. Meine1; MD. Bogaard1; MJ. Cramer1; FW. Prinzen2; PA. Doevendans1 1 University Medical Center Utrecht, Utrecht, Netherlands; 2University of Maastricht, Maastricht, Netherlands Purpose: To assess whether clinical outcome after cardiac resynchronization therapy (CRT) can be predicted by septal deformation pattern characteristics at baseline and whether these characteristics are related to treatment effects. Methods: Before and 6 months after CRT echocardiographic studies and plasma BNP measurements were performed. Septal longitudinal deformation was determined at baseline using speckle tracking echocardiography. Systolic rebound stretch (SRSsept; all stretch after initial shortening in the septum) was determined and septal deformation pattern (DPsept) was categorized into three characteristic types (double peak, early single peak and late single peak during systole) . A combined clinical endpoint of death or cardiac transplantation was recorded in all patients.

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Reverse remodeling provoked by cardiac contractility modulation versus cardiac resynchronization therapy in patients with advanced congestive heart failure
Q. Zhang1; JYS. Chan2; JWH. Fung2; GWK. Yip2; YJ. Liang2; AKY. Chan2; CM. Yu3 1 Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China; 2Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR, Peoples Republic of China; 3Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, Peoples Republic of China Background: Cardiac Contractility Modulation (CCM) is a new form of device therapy for advanced heart failure with normal QRS duration and therefore not a current indication for cardiac resynchronization therapy (CRT). Left ventricular (LV) reverse remodeling response has been reported in patients receiving either device therapy, so it is interesting to compare between CCM and CRT. Methods: Four groups of patients (n30 in each) were included in this study. They all had NYHA class III or IV heart failure with LV ejection fraction (EF) ,35% despite optimal medical therapy before device implantation. Group 1: QRS,120ms received CCM; Group 2: QRS,120ms received CRT; Group 3: QRS 120-150ms received CRT; Group 4: QRS.150ms with typical LBBB received CRT. The CRT groups were matched with the CCM group in age, gender and etiology (Table). Echocardiography was performed at baseline and 3 months. Results: Baseline ejection fraction was comparable. Signicant LV reverse remodeling was observed in all the 4 groups with reduction in LV end-systolic volume (LVESV) and gain in LVEF. However, LV reverse remodeling was the greatest in Group 4 but similar in the other 3 groups. By using an increase in LVEF of ! 5%, the responder rate was the highest in Group 4, but was not different among the other 3 groups.

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Conclusions: CCM appears to exert a similar LV reverse remodeling response to CRT in normal and mildly prolonged QRS groups, but is less effective than CRT in very wide QRS with LBBB group.

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Table 1

Comparisons between the 4 study groups Group 1 CCMQRS ,120 Group 2 CRT QRS ,120 58+12 24/6 16/14 171+44 127+40 27.0+6.7 215+18 6.2+5.5 57 Group 3 CRT QRS 120-150 66+9 19/11 17/13 194+89 148+76 24.9+7.1 213+20 6.0+7.3 53 Group 4 CRT QRS .150 65+12 23/7 13/17 210+78* 163+71* 23.7+8.3 232+20D 10.9+7.9*D 77*D

Age, years Gender, male/ female Etiology, ischemic/nonLVEDV, baseline, cm3 LVESV, baseline, cm3 LVEF, baseline, % Change in LVESV, % Change in LVEF, % Responder rate, %

60+11 24/6 15/15 160+41 115+35 28.4+6.2 211+12 4.7+4.0 53

* p,0.05, p,0.001 vs Group 1; p,0.05 vs Group 2; Dp,0.05 vs Group 3.

not obtain signicant clinical benet from therapy and are termed non-responders. AV and VV optimisation of LVOT VTI may improve parameters of mechanical dyssynchrony on echocardiography, which may translate to subjective clinical improvement and response to therapy in this group of patients. Methods: We studied the acute effect of echocardiographically-guided AV and VV optimisation of LVOT VTI in a group of 16 patients (age 71.5+ 8.4, 69% male) with symptomatic heart failure (NYHA class 3.5+ 0.5; NT-proBNP 2570.4+ 421.2 ng/L (Normal range , 222 ng/L)) who had not obtained signicant clinical response following CRT. Results are expressed as mean+ standard deviation. Echocardiographic parameters of dyssynchrony were recorded pre- and immediately post-optimisation. Tissue doppler of the basal, septal, lateral and anterior walls were also recorded, with time from QRS onset to maximal systolic velocity calculated. Results: AV and VV optimisation resulted in signicant improvement in cardiac output, as assessed by LVOT VTI which improved from 76.3+ 12.1 cm/s pre-optimisation to 114.3+ 13.4 cm/s immediately post-optimisation (p,0.005). Interventricular dyssynchrony improved signicantly: aortic pre-ejection time reduced from 140.8+ 17.6 ms to 126.5+ 26.4 ms (p=0.05) and interventricular mechanical delay reduced from 46.6+ 10.2 ms to 12.0+ 6.8 ms (p,0.0005). Intraventricular dyssynchrony also improved signicantly: septal to posterior wall delay reduced from 159.7+ 88.1 ms to 94.6+ 84.3 ms (p,0.05). Tissue doppler of the septal and lateral walls showed signicant reduction in opposing wall delay from 96.0+ 56.5 ms to 55.3+ 42.7 ms (p=0.03). Conclusion: Echocardiographically-guided AV and VV optimisation of LVOT VTI in a group of CRT non-responders, results in signicant improvement in the parameters of both inter- and intraventricular dyssynchrony as assessed by echocardiography. Further studies are underway to determine whether these improvements are maintained with time, and whether they correspond to improvement in NYHA functional class, quality of life and clinical outcome.

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277
Prediction of response to cardiac resynchronization therapy: comparison between tissue doppler imaging and real-time three-dimensional echocardiography
Sebastiaan S. Kleijn1; J. Van Dijk1; CC. De Cock1; CP Allaart1; AC. Van Rossum1; . O. Kamp1 1 VU University Medical Center, Amsterdam, Netherlands Purpose: Recently, we have shown that there are marked differences in presence of mechanical dyssynchrony by tissue Doppler imaging (TDI) and real-time threedimensional echocardiography (RT3DE) in patients with a wide range of LV ejection fractions (EF) and different etiologies of cardiomyopathy when current cutoff values are applied, making interchangeability of these techniques uncertain. To ascertain which technique is superior, we performed a direct comparison of TDI- and RT3DEderived mechanical dyssynchrony to predict response to cardiac resynchronization therapy (CRT). Methods: A total of 27 patients underwent CRT after assessment of baseline mechanical dyssynchrony by TDI and RT3DE. Mechanical dyssynchrony was measured with TDI using the standard deviation of time to peak systolic tissue velocity of 12 LV myocardial segments. With RT3DE, the standard deviation of time from QRS onset to minimal volume of 16 LV subvolumes was assessed. Before CRT implantation and at 6-month follow-up, echocardiographic assessment of LV volumes and EF was performed and the clinical status including New York Heart Association functional class, 6-minute walking distance, and Minnesota quality-of-life score was assessed. Response was dened as a reduction of !15% in LV end-systolic volume after CRT. Results: Seventeen patients (63%) experienced a reduction of !15% in LV end-systolic volume and were classied as responders. All baseline characteristics were similar between responders and nonresponders, except for mechanical dyssynchrony assessed by RT3DE, which was signicantly higher in responders compared with nonresponders (10.0+ 2.8% versus 6.3+ 2.3, P0.001). ROC curve analysis demonstrated an optimal cutoff value for SDI by RT3DE of 6.7%, yielding a sensitivity of 88% with a specicity of 70% to predict response to CRT. Applying previously dened cutoff values for both techniques, a sensitivity of 88% and a specicity of 60% were derived from the RT3DE cutoff value of 6.4%. In comparison, a cutoff value of 32ms for SDI by TDI yielded a sensitivity of 59% with a specicity of 50% to predict response to CRT. Conclusions: Assessment of mechanical dyssynchrony by RT3DE might be an appropriate alternative to TDI for accurate prediction of response to CRT.

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Echo guided VV and AV delay programming: impact on response to cardiac resynchronization therapy
Hanaa H. Mohamed Fereig Hamed1; AM. Hamdy1; A. Abdel-Aziz2; MA. Nabih3; RM. Hamdy1 1 Al-Azhar University, Cairo, Egypt; 2CCU-Cairo University, Cairo, Egypt; 3Ain Shams University, Cairo, Egypt Background: Echo-Doppler is an effective method allowing immediate evaluation of cardiac efcacy in response to changing the interventricular (VV) and atrioventricular (AV) delays after cardiac resynchronization therapy (CRT). This work aimed at studying the impact of echo-guided programming of VV delay (simultaneous versus sequential) or programming of VV delay followed by AV delay on the response to CRT. Patients and Methods: 34 heart failure patients treated with CRT were evaluated with echo-Doppler & tissue Doppler parameters at different settings of VV delays ranging from 0 to 50 msec (simultaneous versus sequential VV delays) followed by different settings of AV delay programming ranging from 80 to 150 msec. Echo-Doppler measures included ejection fraction (EF), mitral and aortic velocity time integrals (M-VTI & Ao-VTI respectively). Tissue Doppler Dyssynchrony index (Ts-SD) was calculated as the standard deviation of times to peak systolic velocities (Ts) at 6 LV basal segments. We compared the effects of simultaneous versus sequential VV delays with LV pre-activation on these parameters without changing the preset AV delay. The effect of programming AV delay after optimizing the VV delay was further evaluated. Results: Both EF and Ao-VTI signicantly decreased with simultaneous biventricular pacing compared to the basic preset VV and AV delays. The EF, M-VTI and Ao-VTI were signicantly higher and TS-SD was signicantly lower at sequential VV delay with LV pre-activation compared to either basic preset VV & AV delays or simultaneous VV activation & preset AV delay (table I). The EF and M-VTI signicantly increased (p,0.001 & p,0.005 respectively) and TS-SD signicantly decreased (p,0.005) with further programming of AV delay after VV optimization compared to only optimizing VV delay. Conclusion: Sequential ventricular pacing with LV pre-activation is more benecial than simultaneous biventricular pacing. Echo guided optimization of both VV and AV delays has a good impact on cardiac function post CRT

Table I EF Preset VV & AV delays Simultaneous VV Sequential VV Programmed VV and AV 35.2+6.1 33.1+4.6 36.3+5.8 37.3+5.1 M-VTI 16.7+5.5 16.5+4.7 17.5+5.1 18.4+4.8 Ao-VTI 19.2+5.7 18.6+5.4 20.8+6.3 21.1+6.1 TS-SD 27.7+14.8 29.6+13.0 22.4+12.5 17.5+10.3

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Echocardiographically-guided AV and VV optimisation of LVOT VTI improves echocardiographic parameters of dyssynchrony following cardiac resynchronisation therapy in heart failure
Michael John M J. Daly1; K. Morrison1; K. Asheld1; R. Kirkpatrick1; LJ. Dixon1 1 Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, United Kingdom Purpose: Cardiac resynchronisation therapy (CRT) is a recognised treatment option for a select group of patients with heart failure, i.e. those with New York Heart Association (NYHA) class III-IV symptoms despite optimal pharmacological therapy, left ventricular ejection fraction 35% and either a QRS !150ms or a QRS 120-149ms with echocardiographic evidence of mechanical dyssynchrony. Despite these selection criteria to identify those patients most likely to benet from device implantation, 30% do

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Echocardiographic effects of changing atrioventricular delay in cardiac resynchronization therapy based on Tissue Tracking.
Nana N. Valeur1; T. Fritz-Hansen1; N. Risum1; R. Mogelvang1; PE. Bloch-Thomsen1; P Sogaard1 . 1 University Hospital, Gentofte, Denmark Aim: To study echocardiographic parameters as surrogates for hemodynamic effects of different AV-delay in cardiac resynchronization therapy (CRT).

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4.9(SD 1.5) to 5.9(SD 1.1), respectively) and VTILVOT (14.4(SD 1.7) to 15.5(SD 2.3) to 16.7(SD 2.6), respectively). Conclusion: Optimal AV-delay in CRT patients can be determined by echocardiographic tissue tracking evaluating longitudinal systolic performance, and offers a reliable and useful alternative to VTILVOT.

Methods: In 100 consecutive patients with systolic dysfunction with an LVEF,35 %, NYHA class III/IV and widened QRS .120ms, receiving optimal anti-congestive therapy, AV-delay optimization was performed by echocardiography after CRT implantation. We examined changes in tissue tracking and the relationship between tissue tracking and other echocardiographic parameters of left ventricular function. The longest possible AV-delay to provide biventricular capture was programmed, and then shortened to the shortest possible with intervals of 20ms, while measuring tissue tracking in 6 basal left ventricular segments (averaged to TTLV) and other echocardiographic measures. Results: The highest TTLV was reached by a single optimal AV-delay for each patient (g. 1) and was correlated to maximal VTI in the left-ventricular-outow-tract (VTILVOT) (r=0.82, p,0.0001) and E/e (r=-0.54, p,0.0001), but not with tissue tracking in the right ventricle. We also found a signicant increase from pre- to post-implant with standard setting, and from standard setting to optimal AV-delay in TTLV (4.1(SD 1.2) to

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Short term effect of AV optimization
Anita A. Sadeghpour1; L. Zahedi1; M. Haghjoo1; M. Esmaeilzadeh1; M. Parsaei1 1 Rajaei Cardiovascular Medical and Research Center, Tehran, Iran (Islamic Republic of) Purpose: The clinical syndrome of heart failure (HF) remains of leading cause of cardiac morbidity and mortality. The coming years will see a continues growth in device based therapy for HF that is effective in reducing HF morbidity and mortality. Cardiac resynchronization therapy (CRT) is an established adjunctive treatment for patients with systolic heart failure and ventricular dyssynchrony. The majority of recipients response to CRT with improvement in quality of life, New York Heart functional class, 6-min walk test and ventricular function. The goal of atrioventricular (AV) delay optimization are to improve left ventricular (LV) lling and timing of contraction and to minimize MR.The aim of our study was to evaluate the results of early AV optimization(AVO) by using echocardiography on symptoms and systolic function and compare it with another group without early optimization. Methods: 58 patients, 19 women, mean age+SD=57+12.9 years (range 18 to 80 years) which were suitable for CRT implantation were enrolled. After CRT they divided into two groups, one group had early AVO ( the day after CRT implantation) by echocardiography and in the other group AVO was not done. Ultimately, both groups were evaluated 3 months later. Results: Optimization performed in 32(55.2%) patients and 28 were responders. Responders were more in optimization groups [19(59.4%) compared to 9(34.6%); p=0.06]. Functional class and 6 min walk test was improved in AV optimized group(p = 0.008). Stroke volume by using LVOT VTI also increased signicantly (P: 0.000) although other objectives parameters include EF, LVESV, LVEDV, Tissue Doppler dyssynchrony indices, improved with CRT, but there was no signicant difference between two groups. Conclusion: Our ndings suggest that the short term effect of CRT that is more prominent with AV optimization is mostly on functional class and patient well being. Early AV optimization has no signicant effect on LV reverse remodeling in rst 3 months after CRT, so we suggest AV optimization only in nonresponder patients.

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TT-LV differences according to AV-delay.

Eur J Echocardiography Abstracts Supplement, December 2009