POSTER SESSION 3

POSTER SESSION 3

THE IMAGING EXAMINATION

P646Simulator-based testing of skill in transthoracic echo

R. Winter1; P. Lindqvist2; F. Sheehan3

1Royal Institute of Technology, Stockholm, Sweden; 2Surgery and perioperative Sciences,Clinical Physiology, Umea, Sweden; 3University of Washington, Seattle, United Statesof America

Purpose: We developed a transthoracic echo simulator that can measure psychomotorskill in echo to assist in training as well as for certification of competence. The simulatordisplays cine loops on a computer in response to the user scanning a mannequin witha mock transducer. The skill metric is the deviation angle between the image acquiredby the user and the anatomically correct plane for the specified view. We sought to deter-mine whether the simulator-based test could distinguish levels of expertise.Methods: Attendees at an echo course or at the annual meeting of the Swedish HeartAssociation were invited to take a 15 min test on the simulator. On the test, the userscanned the mannequin and acquired 4 views: parasternal long axis (pLAX) in patient1, apical 4 chamber (a4c) and aLAX in patient 2, and pLAX in patient 3. Scan time waslimited to 15 min. Attendees were asked regarding current work status, position, andexperience with echo assessed from duration in years and procedure volume in thepast 12 months.Results: Of the 61 participants there were 22 sonographers, 2 nurses, and 37 doctorswho were all in practice except 1 doctor who was a resident. The data of nurses was com-bined with that of sonographers because their procedure volume was nearer to that ofsonographers (850+599 tests/yr) than doctors (312+393, p , 0.001). Doctors andnon-doctors had similar duration of experience (9+8 vs. 12+11 yrs, p=NS). The testwas not completed by 12 participants (18%) but unfamiliarity with the simulator mayhave contributed because the deviation angle for pLAX dropped between the firstand third patients (23+11 to 18+10 degrees, p,0.020). The average deviationangle over the 4 views was slightly lower for sonographers than for doctors (26+11 vs.30+14 degrees, p=NS). The deviation angle for pLAX (55+37 degrees) was higherthan for a4C (17+22 degrees) or either pLAX view (p,0.00001). pLAX was the onlyview whose deviation angle correlated significantly with experience and only withprocedure volume (r=-0.302, p=0.025).Conclusions: The results of this study demonstrate that the skill metric employed, angleof deviation between the plane of an acquired view and the plane of the anatomicallycorrect image for that view, can distinguish the relative experience of sonographersand doctors in practice. Simulation-based testing provides objective and quantitativeassessment of the psychomotor skill of image acquisition and may be of value in certifica-tion of trainees and in maintenance of certification examination of practicing sonogra-phers and doctors.

P647Clinical and echocardiographic characteristics of isolated left ventricularnon-compaction

A. Fazlinezhad; M. Vojdanparast; P. NezafatiMashhad University of Medical Sciences, Cardiology, Mashhad, Iran (Islamic Republic of)

Background: Although isolated left ventricular non-compaction (ILVNC) has beendescribed almost two decades age, our knowledge about its diagnosis, presentation,echocardiographic features and clinical outcome is spare. We aimed to assess echocar-diographic and clinical characteristics of ILVNC in a group of patients referred to ourcenter.Methods: Patients with primary diagnosis of dilated cardiomyopathy underwent compre-hensive echocardiographic evaluation. The diagnosis of ILVNC was made on the basis ofthe presence of two-structural layer in myocardium, ratio of non-compacted to compactedlayers more than 2, and excessive trabeculation in the left ventricle.Results: Final diagnoses of ILVNC were made in 42 patients. Mean age of patients was32.85+15.63 years. Non-compacted layers were detected in inferior and lateralsegments of apex in 97.6% of patients. A total of 26(61.9%) patients had left ventricle(LV) dysfunction (defined as ejection fraction less than 50%). The only factor thatshowed significant association with LV dysfunction was the number of affected segmentswith non-compaction (P = 0.008).Conclusion: Based on the result of the current study, it can be suggested that apex of theheart is the most common site of non-compaction and increasing numbers of affectedsegments might be associated with LV dysfunction.

P648Appropriate use criteria of transthoracic echocardiography and its clinicalimpact in an aged population

S. Martins Fernandes1; R. Teixeira2

1Lister Hospital, Cardiology Department, Stevenage, United Kingdom; 2UniversityHospitals of Coimbra, Cardiology Department, Coimbra, Portugal

Introduction: The relationship between the appropriateness of the transthoracicechocardiography (TTE) its clinical impact in the elderly is still a matter of debate.Objective: The aim of this study was to assess the degree of adherence to the appropriateuse criteria for echocardiography, as well as the clinical impact of the exam on patientmanagement, in an aged population of a tertiary hospital in the United Kingdom.Methods: 859 TTE’s performed during January 2014 were reviewed to assess its appro-priateness, and classified as appropriate, uncertain or inappropriate using the 2011guidelines. Subsequently, patient’s files were examined to determine the clinical impactof the TTE which was assigned to one of the following three categories: (1) activechange in care, (2) continuation of current care, or (3) no change in care. Patientswhich files were not available were excluded (49). All classifications were evaluated bytwo independent cardiologists, with no direct relation to the study. Two groups of patientswere created: Group A (age ≥75y) N=274; and Group B (age ,75y) N=585.Results: The mean age for Group A was 81.5+5.0 years while for Group B was 54.5+15.0 years. Both groups present with a gender balance. Elderly patients had a higherproportion of exams requested as inpatients (25.5 vs 15.4%, P,0.01). Regarding theresults of the echocardiograms, the percentage of significant findings was superior inGroup A, with respect to systolic dysfunction (13.9 vs 4.6%, P,0.01), severe valvularheart disease (8.8 vs 1.7%, P,0.01) and pulmonary hypertension (9.9 vs 2.9%, P,0.01).Regarding the appropriateness of the TTE requests, these were similar in both groups: inGroup A 78.1% were appropriate, 6.9% inappropriate and 9.9% uncertain; in Group B75.7% (P=0.44) were appropriate, 7.2% (P=0.89) inappropriate and 13.8% (P=0.10)were uncertain.With respect to the clinical impact of the TTE we noted that Group A patients had a higherproportion of a no change in care exam (13.9 vs 4.6%, P,0.01).Conclusion:Thequality of theTTErequestwassimilar forourolder sample,but thisgrouphad a higher chance to have a TTE without clinical impact.

ANATOMY AND PHYSIOLOGY OF THE HEARTAND GREAT VESSELS

P649Prevalence and determinants of exercise oscillatory ventilation in theEUROEX trial population

M. Pellegrino; G. Generati; F. Bandera; V. Labate; E. Alfonzetti; M. GuazziIRCCS Policlinico San Donato, Heart Failure Unit, San Donato M.se, Italy

Background: Cardiopulmonary exercise testing (CPET) with gas exchange analysisallows functional evaluation of cardiopulmonary diseases and definition of ventilatoryand metabolic parameters that may add to define the level of cardiovascular (CV) risk.Among CPET-derived variables, the occurrence of exercise oscillatory ventilation(EOV), a pathological ventilatory pattern, in the general population at risk for CV diseasesis not described in literature. We aimed at assessing the prevalence of EOV in a generalpopulation enrolled in the EUROEX study.Methods: 599 healthy subjects (60+14 years; male 48.4%; BMI 28+6 kg/m2)under-went a maximal CPETwith personalized incremental ramp protocol. Subjects had differ-ent CV risk factors, but no previous CV events. A subgroup (n=230; 62+13 years; male48.7%; BMI 29+5 kg/m2) also underwent echocardiography within 6 months.Results: A prevalence of 15.9% EOV was observed. The EOV group showed higherprevalence of diabetes (25 vs 14%, p,.05) and female sex (71 vs 47%, p,.05). EOVpatients showed reduced exercise tolerance (workload 109+46 vs 121+49 W,p,.05), impairment of oxygen consumption (VO2)-related variables (peak VO2 15.1+3.8 vs 20+7.2 ml/min/kg, p,.01) and worse ventilator efficiency (VE/VCO2 slope:27.7+4.6 vs 25.7+3.6; peak PETCO2: 36.5+4.5 vs 39.1+4.3 mmHg, p,.01); alower heart rate at peak exercise (125+21 vs 135+23 bpm, p,.01) and heart rate recov-ery (14+9 vs 16+9 beats, p,.05). Echocardiographic data showed a reduction of end-systolic dimensions of both ventricles (LV ESVi: 13.5+4 vs 15.5+6 ml/mq, p,.05; RVESA: 6.9+1.6 vs 7.8+2 cmq, p=.01)and right atrial area (14.8+4 vs 16.8+4 cmq,

Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2015

doi:10.1093/ehjci/jev277

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p,.01) in the EOV group. At a multivariate analysis the EOV determinants were TAPSE,E/A and BMI.Conclusion: EOVsubjects exhibited a higher prevalence of diabetes, worse exercise per-formance and ventilation efficiency. EOV determinants in this population were an index ofRV systolic function, LV diastolic function and BMI. These findings may provide the basesfor a more in-depth definition of abnormal exercise phenotypes in the prediction of CV risk.

Abstract P649 Table.

EOV determinants OR P value

TAPSE 0.16 0.03BMI, kg/m2 0.07 0.04E/A 1.12 0.09

ASSESSMENT OF DIAMETERS, VOLUMES AND MASS

P650Left atrial remodeling after percutaneous left atrial appendage closure

X. Iriart1; ML. Dinet1; Z. Jalal1; H. Cochet2; JB. Thambo2

1university hospital of Bordeaux. Department of congenital heart disease,Bordeaux-Pessac, France; 2bordeaux universite hospital, department of cardiovascularimaging, pessac, France

Objectives: The importance of the left atrial appendage (LAA) on left atrial (LA) hemo-dynamics is unknown. We sought to evaluate the effect of LAA percutaneous closure(LAAPC) on left atrial remodeling in patients with paraxysmal atrial fibrillation (AF) andpermanent AF.Methods: All patients refered for LAAPC with Amplatzer Cardiac Plug (ACP) andWatchman device were enrolled. Cardiac computed tomography (CT) for LA volumemeasurement and transthoracic echocardiography (TTE) for diastolic function assess-mentwere performedatbaseline and3monthsafter LAAPC.Anaverage of3consecutivesmeasurements were performed for TEE parameters in all patients.Results: Sixty-three patients (mean age 73 + /- 9 years) were included. 38% (n=24) insinus rythm (SR) at baseline and 55% (n=35) in permanent AF. Patients in SR at baselineand permanent AF at 3 months were excluded (n=4, 7%).The mean CHA2DS2-VAScscore was 4,3 + /-1,3. There was non significant difference in the functionnal statusand BNP level (155,6 + /-107 vs + /-150,7 pg/ml; p=0,85) between baseline and 3months follow-up. Left atrial volume excluding the LAA (145 + /-55 cm3 baseline vs144 + /-50 cm3 at 3 months; p=0,30) showed no significant change after 3 months inoverall population, neither in the SR (99,7 + /-19,1 vs 103,8 + /-21 cm3; p=0,32) or thepermanent AF groups (173,2 + /-54 vs 171,7 + /-48,6 cm3; p=0,59). MV peak E-wave(84,2 + /-22,7 vs 86,7 + /-26 cm/s; p=0,62) and A-wave velocities (65,4 + /-14,4;68,5 + /-22,2 cm/s; p=0,66) dit not differ between baseline and follow-up but E/E’ ratiowas increased in the overall population after LAAPC (7,9 + /-2,1 vs 9,1 + /-3,6cm/s;p=0,038) and there was trend to higher E/E’ ratio in the SR group (7,7 + /-1,6 vs 9 +/-3,3 cm/s, p=0,46).Conclusions: There is no evidence for early LA remodeling after LAAPC, but diastolicfunction might be negatively influenced by LAAPC suggesting the potential role of LAAin atrial function. Further studies are warranted to confirm the prelimary results.

P651Global atrial performance with tyrosine kinase inhibitors in metastatic renal cellcarcinoma

S. Moustafa; TH. Ho; P. Shah; K. Murphy; BK. Nelluri; H. Lee; S. Wilansky; F. MookadamMayo Clinic, Scottsdale, United States of America

Purpose: Renal cell carcinoma (RCC) is the most common malignant kidney tumor. Tyro-sine kinase inhibitors (TKIs) had a major impact on the therapy of metastatic RCC. Weaimed to explore the hypothesis that incipient atrial dysfunction, secondary to TKIs inmetastatic RCC patients, could be signaled using velocity vector imaging.Methods: Echocardiography images were acquired from the apical 4-chamber view in 23patients. All patients had baseline and at least a 3 month follow up echocardiograms post-TKIs. The atrial subendocardium was traced to obtain atrial volumes and dynamic func-tion.Results: Mean age was 67+9 years with 92 % men. Conventional indices of ventricularfunction as well as atrial volumes/ejection fraction did not change significantly. Nonethe-less, right atrial reservoir and conduit functions were borderline reduced with TKIs (table).Conclusions: The current study underscores the influence of TKIs on atrial function. Theright atrium is more prone to damage by TKIs.


Pre-TKIs Post-TKIs P-Value

LEFT ATRIUMEJECTION FRACTION (%) 64+12.4 61.8+13.3 0.21RESERVOIR FUNCTION

Abstract P651 Table. Continued

Pre-TKIs Post-TKIs P-Value

1-Filling Volume (ml) 37.6+13.1 33.6+18.1 0.142-Expansion index (%) 59.2+22.2 52.8+27.6 0.12CONDUIT FUNCTION1-Passive emptying (%) of total emptying 36.9+13.1 32.9+18.1 0.14BOOSTER FUNCTION1- Active emptying (%) of total emptying 18.1+9.2 16.3+11.1 0.15RIGHT ATRIUMEJECTION FRACTION (%) 59.1+12.8 56.3+12.4 0.2RESERVOIR FUNCTION1-Filling Volume (ml) 30.8+12.5 25.03+11.3 0.0412-Expansion index (%) 51.5+17.5 43.6+17.1 0.046CONDUIT FUNCTION1-Passive emptying (%) of total emptying 30.1+12.6 24.3+11.4 0.04BOOSTER FUNCTION1-Active emptying (%) of total emptying 14.1+9.7 11.6+7.1 0.19

P652Early right ventricular response to cardiac resynchronization therapy: impact onclinical outcomes

D. Stolfo; E. Tonet; M. Merlo; G. Barbati; M. Gigli; B. Pinamonti; F. Ramani; M. Zecchin;G. SinagraUniversity Hospital Riuniti, Cardiovascular Department, Trieste, Italy

Purpose: We sought to investigate whether cardiac resynchronization therapy (CRT)favorably influences the right ventricular function (RVF) acutely after implantation, impact-ing on long-term outcomes.Methods: Patients who successfully underwent CRT implantation from January 2005to January 2014 were retrospectively analyzed. RV dysfunction was defined by aRV-fractional area change,35%. Post-procedural echocardiographic evaluation wasperformed at a median time of 2 days (IQR 1-6). Primary end-point was a composite ofall-cause mortality and urgent heart transplantation.Results: A total of 194 patients with available pre- and post-procedural RVF assessmentwere included. Sixty-two (32%) presented an impaired RVF before procedure. Of them,32% promptly normalized RVF following CRT. This occurred in parallel with a largeimprovement in pulmonary arterial pressure, mitral regurgitation, E/E’ ratio and diastolicfunction. Pre-implantation independent predictors of early RVF normalization were left-bundle branch block (p=0.034) and higher systolic blood pressure (p=0.026). Improve-ment in RVF was independently associated with a better long-term prognosis at multivari-able analysis (HR 0.124; 95% CI 0.016–0.966, p=0.04), significantly increasing theaccuracy of the long-term risk stratification compared to the baseline Cox model(p=0.04 at 48 months and p=0.048 at 96 months).Conclusions: Acute normalization of RVF can be observed after CRT along withhemodynamic improvement, resulting as independent predictor of transplant-freesurvival.

P653Parameters of speckle-tracking echocardiography and biomechanical valuesof a dilative ascending aorta

M. Bieseviciene1; JJ. Vaskelyte1; V. Mizariene1; V. Lesauskaite2; R. Verseckaite1;R. Karaliute1; R. Jonkaitiene1

1Lithuanian University of Health Sciences, Academy of Medicine, Department ofCardiology, Kaunas, Lithuania; 2Institute of Cardiology of Kaunas University, Kaunas,Lithuania

Parameters of speckle-tracking echocardiography and biomechanical values of a dilativeascending aortaBackground: Biomechanical changes of the aorta can be evaluated by a 2D speckle-tracking echocardiography (2D-ST), as aortic wall strains are indicators of biomechanicalchanges of the aorta.Purpose: To compare 2D-ST and biomechanical parameters of an ascending aortabetween two groups according to diameter of aorta.Methods: The study included 44 pts with dilative pathology of the ascending aorta (78.3%males, age 55.4+14.7 y). The pts were divided in to 2 groups according to diameter: inthe first group diameter was ≤45 mm, in the second .45 mm.Results: Both anterior and posterior walls having statistically significant larger DT andDL in smaller aortic diameter group. There is a tendency, that an aortic strain rateswas bigger in less dilated aorta group. Values of VL of anterior aortic wall was largerin the first group. (Table 1). The arterial stiffness parameters of of ascending aorta(strain and distensibility) was significantly higher in larger aortic group (strain 7.48+7.55vs.3.91+3.10, p=0.048 and distensibility 0.29+0.34 mmHg-1vs.0.13+0.11mmHg-1, p=0.037).Conclusion: 1. The values of longitudinal and transversal displacement, longitudinalstrain and velocity of both anterior and posterior walls of ascending aorta, estimated byspeckle – tracking echocardiography, was bigger in smaller aortic diameter group. 2.

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The arterial stiffness parameters of ascending aorta (aortic strain and distensibility) wassignificantly higher in larger aortic group.

Abstract P653 Table. 2D-STechocardiographic parameters

Diameter of ascending aorta1st group ≤45 mm 2nd group .45 mm P-value

Longitudinal displacement(DL) of aortic PW, mm

24.12+3.99 23.74+2.80 ns

Longitudinal displacement(DL) of aortic AW, mm

213.29+6.18 28.21+4.83* 0.010

Transversal displacement (DT)of aortic PW, mm

5.50+2.70 3.45+2.52 0.029

Transversal displacement (DT)of aortic AW, mm

28.10+2.16 25.09+3.51 0.008

Longitudinal strain (SL) ofaortic PW, %

20.88+10.09 13.90+12.13 ns

Longitudinal strain (SL) ofaortic AW, %

23.24+13.55 14.77+14.21 ns

Longitudinal velocity (VL) ofaortic PW, cm/sec

26.11+2.01 25.65+1.68 ns

Longitudinal velocity (VL) ofaortic AW, cm/sec

26.02+1.73 24.52+1.50 0.014

AW, anterior wall; PW, posterior wall; values are mean (standard deviation); *p,0.05 comparedwith the ≤45 mm group

ASSESSMENTS OF HAEMODYNAMICS

P654Right atrial hemodynamics in infants and children: observations from3-dimensional echocardiography derived right atrial volumes

S. Patel1; L. Li2; M. Craft2; D. Danford1; S. Kutty1

1Children’s Hospital and Medical Center, omaha, United States of America; 2University ofNebraska Medical Center, Omaha, United States of America

Background: Right atrial (RA) volume is a marker of right ventricular (RV) pressure loadand diastolic dysfunction that correlates with RA pressure, but neonatal and pediatricdata are lacking. We sought to prospectively obtain RA volumes (by 2 and 3 dimensionalechocardiography: 2DE, 3DE), systemic venous dimensions and flow in conjunction withsimultaneous central venous catheter pressure measurements, with the goal of non-invasively estimating RA pressures.Methods: Inclusion criteria consisted of patients in the neonatal and pediatric intensivecare units with: (a) central venous catheters suitable for RA pressure transduction, (b)biventricular heart, (c) no inotropic support, (d) at least 24 hours after any surgical proced-ure, and (e) sinus rhythm. Demographic data including gender, age, height, and weightwere recorded and body surface area (BSA) calculated using the Haycock formula.Vital signs and RA pressure were recorded immediately prior to 2DE and 3DE. Image ana-lysis for chamber dimensions and volumes was performed using dedicated workstations(McKesson CPACS Version 13.1 and TomTec Image-Arena Version 4.6 Build 4.6.2.12).Results: Thirty subjects, (17 male and 13 female) of median age 29 days (1 to 1153 days)and mean weight of 5.39 kg (range 1.91 to 13.7 kg) have been enrolled. Of these, 26patients (86.6%) had echocardiograms that were adequate for 2DE and 3DE RA analysis.The mean diameters (mm) of the inferior and superior vena cava (IVC and SVC) were 6+2.3 and 4.7+1.4 respectively. The mean RA pressure was 7.7+3.6 mmHg (2 to 13mmHg). The mean 3D RA end diastolic volume indexed to BSA (3DRAEDVi) was28.5+14.2 ml/m2 (7.7 to 64.3 ml/m2). The mean 2D RA end diastolic volume indexedto BSA (2DRAEDVi) by 2DE single plane area-length method was 20.1+8.14 ml/m2(8.2 to 30.47 ml/m2) and by the single-plane modified Simpson’s method was 21.99+9.65 ml/m2 (8.7 to 48.5 ml/m2). The 3DRAEDVi was significantly higher than RAEDVi mea-sured by either 2DE method (p,0.005).Conclusion: Our preliminary results show that it is feasible to determine RA volumes by3DE in infants and young children. We observed significant divergence among 3DEand 2DE measured volumes, with the former consistently larger. The limitation of usinggeometric assumptions in the 2DE methods may be responsible for the underestimation.

ASSESSMENT OF SYSTOLIC FUNCTION

P655One-point carotid wave intensity predicts cardiac mortality in patients withcongestive heart failure and reduced ejection fraction

O. Vriz1; M. Pellegrinet2; C. Zito3; S. Carerj3; V. Di Bello4; A. Cittadini5; E. Bossone6;F. Antonini-Canterin2

1Department of Cardiology, San Antonio Hospital, Ass4, San Daniele del Friuli, Italy; 2SantaMaria degli Angeli Hospital, Pordenone, Italy; 3Dipartimento di Medicina Clinica eSperimentale, Cardiology, Messina, Italy; 4Universita di Pisa, Cardiology, Pisa, Italy;5Universita Federico II, Internal Medicine, Napoli, Italy; 6UTIC, Cava de’ Tirreni-Costa D’Amalfi, Cardiology, Salerno, Italy

Background: Wave intensity (WI) is a hemodynamic index used to evaluate the inter-action between the heart and the arterial system, measured with an echo-Doppler

system at the level of the common carotid artery. WI has two peaks: W1 during earlysystole that represents left ventricular (LV) contractility, and W2 in late systole that isrelated to the inertia force during isovolumetric relaxation. The aim of this study was to de-termine whether WI parameters improve the prediction of poor outcome in patients withheart failure and reduced ejection fraction (HFrEF).Methods: Sixty-two patients (mean age 69.4+11.5 years) in NYHA class II-III were fol-lowed up for 43.5 months. They underwent routine clinical work-up, transthoracic echo-cardiography and WI measurement. A stratified survival analysis was conducted usingthe Kaplan-Meier method.Results: During follow-up, 23 patients died from cardiovascular causes. Survivors andnon-survivirs were similar in age, blood pressure, heart rate and echocardiographic para-meters, except for LVend-diastolic volume indexed to body surface area, E/A ratio (higherin non-survivors) and deceleration time (lower in non-survivors). W2 (1950+1006 vs1117+708 mmHg m/s3, p=0.001) was significantly lower in non-survivors, whereasW1 (6951+4119 vs 5748+3891 mmHg m/s3, p=NS) was similar. At the end of follow-up, cardiovascular mortality was higher in patients with W1 ≤3900 mmHg m/s3(p=0.02) and W2 ≤1000 mmHg m/s3 (p=0.0002). Only E/A (cut-off 1.5) was predictiveof mortality (p=0.05).Conclusions: In patients with HFrEF, WI parameters derived from the carotid artery betteridentified patients with poor prognosis and were significant predictors of cardiovascularmortality.

P656Persistence of cardiac remodeling in adolescents with previous fetal growthrestriction

S I. Sarvari1; M. Rodriguez2; M. Sitges3; A. Sepulveda-Martinez2; E. Gratacos2; B. Bijnens4;F. Crispi21Oslo University Hospital, Rikshospitalet, Department of Cardiology, Oslo, Norway;2Hospital Clinicde Barcelona, Maternal-Fetal medicine, Barcelona, Spain; 3Hospital Clinicde Barcelona, Cardiology, Barcelona, Spain; 4University Pompeu Fabra, Information andcommunication, Barcelona, Spain

Purpose: About 5% to 10% of newborns are affected by fetal growth restriction (FGR)which is associated with increased cardiovascular mortality in adulthood. We haveshown earlier that FGR induces primary cardiac changes that persist into childhood.Our main objective in this 5 year follow-up was to evaluate if changes demonstrated inchildhood persisted into adolescence.Methods: Within a cohort of fetuses with growth restriction identified in fetal life andfollowed-up into adolescence, echocardiography was performed in 58 adolescentswith FGR (defined as birthweight below 10th centile) and 94adolescents with normal birth-weight centile.Results: Compared with control subjects, adolescents with FGR had a different cardiacshape, with increased transversal diameter and more spherical left ventricle (LV). LV ejec-tion fraction and cardiac index were similar. However, subclinical longitudinal LV systolicdysfunction (decreased mitral annular excursion and myocardial peak velocity) and dia-stolic changes (increased E/A and E/e′ ratios, and increased isovolumetric relaxationtime) were present in adolescents with FGR (Table).Conclusions Our results imply that primary cardiac changes present in FGR fetusespersist into adolescence. The persistence of these changes could explain the increasedpredisposition to cardiovascular disease in adult life. Strategies preventing cardiac re-modeling is warranted in the FGR population.

Abstract P656 Table. Left ventricular echocardiographic data

Controls (n=94) FGR (n=58) p-value

Sphericity index 2.05+0.17 1.86+0.17 ,0.001Ejection fraction, % 59+4 59+4 0.5Cardiac index, L/min/m2 3.0+0.7 3.0+0.5 0.9Mitral annular plane systolic excursion, mm 15.8+1.9 14.8+1.8 0.001Lateral systolic myocardial peak velocity, cm/s 10.9+2.0 9.7+1.8 ,0.001E/A ratio 1.91+0.40 2.06+0.40 0.03E/e’ 6.2+1.3 6.8+1.3 0.01Isovolumic relaxation time, ms 48+15 55+13 0.004

Data expressed as mean+SD. Right column shows P-values for Student’s t-test. A, peak late dia-stolic filling velocity; E, peak early diastolic filling velocity; e’, peak early diastolic myocardial vel-ocity; FGR, fetal growth restriction

P6572D speckle tracking-derived left ventricle global longitudinal strain and leftventricular dysfunction stages: a useful discriminator in moderate-to-severeaortic regurgitation

M. Santos; L. Leite; R. Martins; R. Baptista; A. Barbosa; N. Ribeiro; A. Oliveira; G. Castro;M. PegoUniversity Hospitals of Coimbra, Cardiology, Coimbra, Portugal

Purpose: 2D speckle tracking-derived left ventricle (LV) global longitudinal strain (GLS) isa validated method for LV systolic function assessment and a useful technique in the clin-ical practice due to its low dependency on operator expertise. We aimed to study GLS

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predictive power for impaired systolic function against 2D LVejection fraction (LVEF) in anaortic regurgitation (AR) population.Methods: We conducted a prospective, single-centre study of 73 patients referred forechocardiography at a tertiary centre with moderate or severe isolated AR (vena contracta. 3 mm and mean transvalvular gradient , 20 mm Hg); patients with unsuitable imagesfor GLS analysis were excluded. An independent operator confirmed the LVEF (biplaneSimpson method), followed by off-line GLS analysis by investigators blinded to theLVEF. Statistical analysis included LVEF and GLS correlation - linear regression, ROCcurves construction for GLS according to LVEF cut-offs 50 and 40%, and optimal cut-offdetermination (Youden index). We compared the results with an age and gender-matchedgroup of 50 patients without significant valvular heart disease.Results: Mean agewas 71+10years, 58% were male and 25% had severe AR. The meanLVEF was 56.2+11.6 % and mean GLS -16.6+4.7%, which were strongly correlated(r=-0.74, p,0.01). The sensitivity and specificity of GLS to predict LVEF.50% was92% and 82%, respectively (c-statistic 0.89, p,0.01), for a -14.8% GLS cut-off, with posi-tive predictive value 94% and negative predictive value 76% (see figure). The optimal GLScut-off for discriminating LVEF.40% was -12.4%, with 90% sensitivity and 83% specificity(c-statistic 0.93, p,0.01). In the control population, the GLS cut-off for LVEF.50% was-15.6% (c-statistic 0.96, p,0.01, sensitivity 89% and specificity 94%) and -12.7% forLVEF.40% (c-statistic 0.94, p,0.01, sensitivity 72% and specificity 100%).Conclusions: GLS analysis was strongly correlated to LVEF and was accurate in the dis-crimination of AR patients with normal LV function from those with progressive mild andmoderate dysfunction. The absolute GLS cut-off for mild dysfunction is lower in ARpatients possibly signaling subclinical LV myocardial damage in this population.

P658Global longitudinal strainand strain rate in type two diabetespatients with chronicheart failure: relevance to circulating osteoprotegerin

A. Berezin; T. Samura; A. KremzerState Medical University, Zaporozhye, Ukraine

Background: Biomechanical stress and inflammatory biomarkers relate to global con-tractility dysfunction, however, adding these biomarkers into a risk model constructedon clinical data does not improve the prediction value in euvolemic chronic heart failure(CHF).Objectives: The aim of this study was to evaluate the interrelationship between left ven-tricular global contractility function and circulating biomarkers in diabetic patients withischemia-induced CHF.Patients andMethods: The study retrospectively evolved 54 T2DM patients who had sys-tolic or diastolic ischemia-induced CHF, that was defined as left-ventricular ejection frac-tion ≤45% or 46-55% respectively assessed by quantitative echocardiography and otherconventional criteria according to current clinical guidelines. Two-dimensional transthor-acic echocardiography and Tissue Doppler Imaging were performed according to a con-ventional method. Serum adiponectin, NT-proBNP, osteoprotegerin, and hs-CRP weredetermined at baseline by ELISA.Results: We found lower global longitudinal strain and strain rate in T2DM patients withLVEF ,45% when compared with those who did not have (R=0.001 for all cases). Multi-variate logistic regression reported that NT-proBNP (r=0.432; P=0.001 and r=0.402;P=0.001 respectively), osteoprotegerin (r=0.422; P=0.001 and r=0.401; P=0.001 re-spectively), hs-CRP (r=0.408; P=0.001 and r=0.404; P=0.001 respectively) were inde-pendently inversely associated with global longitudinal strain and global longitudinalstrain rate in CHF patients. Using C-statistics for Models with NT-proBNP, hs-CRP, osteo-protegerin and adiponectin as Continuous Variables we found that adding osteoprote-gerin to the based ABC model (NT-proBNP) improved the relative IDI by 9.8% fordecreased global left ventricular function defined as worsening both global longitudinalstrain and global longitudinal strain rate. Osteoprotegerin in combination with hs-CRPadded to ABC model improved the relative IDI by 10.1%. In patient study population forcategory-free NRI, 5% of events (p=0.001) and 11% of non-events (p=0.001) were cor-rectly reclassified by the addition of osteoprotegerin to the base model (NT-proBNP) fordecreased global left ventricular functionConclusion: we suggest that osteoprotegerin may be useful for improvement ofNT-proBNP based model as predictor of decreased global contractility function in euvo-lemic T2DM patients with CHF

P659Analysis of left ventricular function in patients before and after surgical andinterventional mitral valve therapy

S. Stoebe; A. Tarr; D. Pfeiffer; A. HagendorffUniversity of Leipzig, Department of Cardiology/Angiology, Leipzig, Germany

Purpose: Left ventricular (LV) function is markedly influenced by regurgitant volume inpatients (pts) with mitral regurgitation (MR). In compensated chronic MR the total strokevolume (toSV) increases due to the increase of the regurgitant volume whereas the effect-ive stroke volume (effSV) remains constant or is slightly reduced. We hypothesised thatafter surgery LV function represented by LV ejection fraction (EF) and global longitudinalpeak systolic strain (GLPSS) is normalised (LVEF . 55%;GLPSS , -18%) in these pts. Incontrast, LV function in symptomatic pts with severe MR is markedly impaired and toSVand effSV are reduced. We hypothesised that after surgery or interventional treatmentLVEF and GLPSS is improved.Methods: In 13 pts with asymptomatic or compensated severe MR and in 11 pts withsymptomatic severe MR with myocardial contraction failure conventional

echocardiography was performed prior and after surgical mitral valve reconstruction(MVR). In 9 pts echocardiography was performed prior and directly after MitraClip andin 7 pts prior and directly after Carillon intervention. The biplane Simpson analysis of LVwas performed to evaluate total stroke volume (toSV) representing the amount of theforward stroke volume and the regurgitant volume. Speckle tracking analysis was per-formed GLPSS determination.Results: In pts with asymptomatic or compensated MR with increased LVEF and GLPSSboth parameters significantly decrease after MVR. In 5 of 13 pts, however, GLPSS wasbelow normal ranges one year after surgery. In pts with symptomatic MR with reducedLV function LVEF and GLPSS significantly increase after MVR. All basal longitudinalstrain values remain reduced presumably due to the effect of annuloplasty. In pts afterMitraClip LVEF was significantly improved directly after intervention, whereas no signifi-cant changes were obtained for GLPSS. In pts after Carillon LVEF and GLPSS did notshow any changes directly after intervention.Conclusions: For evaluation of the effect of treatment LVEFand GLPSS are only suitable ifthe pre-interventional state is exactly defined regarding complete compensation or thedegree of contraction failure. Pts with asymptomatic and compensated MR shouldhave normal GLPSS values after surgery to demonstrate successful treatment. In ptswith symptomatic MR with reduced LV function improvement of LVEF and GLPSSequates to successful therapy. In pts with MitraClip increased LVEF can be documenteddirectly after intervention, whereas therapeutical effects on LV function in pts after Carillonintervention have to be assumed after a longer time interval.

P660Left ventricular end-diastolic volume is complementary with global longitudinalstrain for the prediction of left ventricular ejection fraction in echocardiographicdaily practice

N. Benyounes Iglesias1; C. Van Der Vynckt1; O. Gout2; JM. Devys3; A. Cohen4

1Fondation Ophtalmologique A. de Rothschild, Cardiology Unit, Paris, France; 2FondationOphtalmologique A. de Rothschild, Neurology, Paris, France; 3FondationOphtalmologique A. de Rothschild, Paris, France; 4Hospital Saint-Antoine, Cardiology,Paris, France

Purpose: Transthoracic echocardiography (TTE) assesses left ventricular ejection frac-tion (LVEF), a major prognostic factor in cardiovascular diseases. The recommendedmethod is the modified Simpson’s biplane method (SB), a method prone to intra- andinter-observer variability.Global longitudinal strain (GLS)which assesses myocardial deformation is more reprodu-cible. However, it has not yet entered into routine. Furthermore, it is dependant ofload conditions;hence, the use of GLS alone for the prediction of LVEF has little sense.Methods: We investigated how two-dimensional GLS in association with LV end-diastolicvolume(LVEDV), considered herein to reflect load conditions, could predict LVEF (SBmethod) in echocardiographic daily practice, with all the measurements performed online, as part of routine practice, without post-processing. The analysis involved 490 con-secutive TTEs, performed by a single sonographer. Patients were in sinus rhythm.Results: Mean (+SD) LVEF was 64+11%, GLS was–18.0+4.0%, LVEDV was 82+29ml. The age was 58+18 years and 261 (53%) were men.There were reasonable and comparablecorrelations between LVEF and GLS and LVEFand LVEDV (both r = –0.51; p , 0.0001). GLS and LVEDV were weakly but significantlycorrelated (r = 0.30; p , 0.0001).The obtained regression equation for LVEF by GLS was: predicted LVEF = 38.7 -1.41GLS; F(1, 488) = 88.3, p , 0.0001 where 26% of the variance in LVEF is predicted fromGLS. For every one unit increase in GLS, a 1.45 unit decrease in LVEF isexpected.The obtained regression equation for LVEF by LVEDV was: predicted LVEF = 79.9 -0.19LVEDV; F(1, 488) = 79.4, p , 0.0001 where 26% of the variance in LVEF is predictedfrom LVEDV. For every one unit increase in LVEDV, a 0.19 unit decrease in LVEFis expected.When multiple regression was run to predict LVEF from GLS and LVEDV, the obtainedequation was: predicted LVEF = 56.6 – 1.1 GLS- 0.15 LVEDV; F(2, 487)=109.3, p ,

0.0001, where 40% of the variance of LVEF is predicted from the two variables.ConclusionGLS andLVEDV statistically significantly predicted LVEF.These two variablesadded significantly to improve the predictionyielded by each separately, in a daily echolab echocardiographic practice.

P661Left ventricular assist device, right ventricle function, and selection bias: the lightside of the moon

B. De Chiara1; F. Musca1; L. D’angelo1; MG. Cipriani1; M. Parolini2; A. Rossi1;GM. Santambrogio1; C. Russo3; C. Giannattasio4; A. Moreo1

1Niguarda Ca’ Granda Hospital, Cardiovascular Department, Milan, Italy; 2CNR Institute ofClinical Physiology, Milan, Italy; 3Niguarda Ca’ Granda Hospital, Cardiac Surgery, Milan,Italy; 4Niguarda Ca’ Granda Hospital, Cardiovascular Department, UniversityMilano-Bicocca, Milan, Italy

Purpose: RV failure (RVF) after Left Ventricular Assist Device (LVAD) implant may occur ina variable percentage of cases and identification of pre-operative factors should lead toimprove outcome. Aim of the study is to explore whether a more complete RV pre-operative assessment may have clinical implications with respect to standard evaluation.Methods: From 2011 to February 2015, clinical, hemodynamic, and comprehensive RVtransthoracic echocardiographic variables were collected in 36 patients (2 females,mean 57+8 yrs) before elective LVAD implant. RV linear dimensions with sphericity

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index and right-to left-ratio, indexed right atrial volume, tricuspid annular plane systolic ex-cursion (TAPSE), pulsed tissue Doppler imaging on the tricuspidal lateral annulus (S’),and the RV fractional area change (FAC) were calculated according to ASE/EACVI recom-mendations. From 2013, images for RV free wall longitudinal strain (RVLS) analysis werestored. An off-line evaluation using a commercially available semi-automated software(EchoPac, GE) was performed. During the post-operative period we recorded the dur-ation of intravenous inotrope (RVF if .14 days) and inhaled nitric oxide (RVF if .2days), according to current definition.Results: 76% of patients had TAPSE ,17 mm, 72% showed FAC,35%, and 72% had S’,9.5 cm/sec. Median RVLS was -15.5% (IQR-14%; -18%) and we reached a good feasi-bility of signal tracking in 75% of patients. To evaluate the impact of RVLS in patient’s se-lection, the overall population was divided in 2 groups according to RVLS presence(n=18, Group 1) or absence (n=18, Group 2, period of observation 2011-2012 or inad-equate image quality). Interestingly, the prevalence of RVF decreased after the introduc-tion of RVLS (6% Group 1 vs 56% Groups 2, p,0.01). Among all pre-operative variablesthe Groups were significantly different only in prevalence of ischemic heart disease (44%Group 1 vs 83% Groups 2, p=0.035) and in impaired RV sphericity index (.0.60 in 11%Group 1 vs 60% Groups 2, p,0.01). In Group 1, even though the patients were justselected based on their “satisfactory” RV function, RVLS maintained a correlation withthe duration of inotropic support (p=0.01, r=-0.58) and inhaled nitric oxide (p=0.005,r=-0.63).Conclusions: In our experience RVLS has proved to be useful after its introduction on topof standard parameters for patient’s selection before LVAD. The feasibility, lower than innormal subjects, depends on the RV dislocation in marked left ventricle dilation, thepossible presence of atrial fibrillation, and the compliance of severely ill patients.

P662Assessment of right ventricular function in patients with anterior STelevationmyocardial infarction; a 2-d speckle tracking study

A. Soliman; M. Moharram; A. Gamal; A. RedaMenoufia Faculty of Medicine, Cardiology Department, Shebeen ElKom, Egypt

Background:Recent studies suggest that RV function isan independent predictor of mor-tality and morbidity in post-MI patients with known LV dysfunction. Two dimensional (2-D)speckle tracking echocardiography (STE) provides more accurate estimates of RV func-tion when compared to cardiac magnetic resonance imaging (MRI) references.Aim of the work: RV function assessment using STE in Anterior STEMI patients.Subjects &Methods: This prospective study was performed on 45 subjects; 25 patients(group I) with anterior STEMI (within 1 week of presentation) and 20 age and sex matchedcontrols (group II). Conventional 2-D, M-Mode and TDI measurements for the LV and RVwere also taken. 2-D STE was done to evaluate peak longitudinal systolic strain (PLSS)and strain rate at peak systole (SRs s-1) for RV and LV walls. Global RV PLSS (averagePLSS of RV free wall and septum) and Global LV PLSS (average PLSS of its 6 walls)were estimated. Coronary angiography excluded patients with . 50% luminal diameterstenosis in the Right coronary system.Results: Global RV PLSS was significantly reduced in the patient group (Mean+SD-18.276+3.956) when compared to the controls (Mean+SD -23.120+1.959)(p,0.005). No significant difference was found between the two groups regardingaverage RV free wall PLSS or average peak sytolic strain rate (SRs s21). However,septal wall average PLSS and SRs s21 were significantly reduced in group I in compari-son to group II with Mean+SD (-10.627+6.106 & -0.766+0.268 vs -19.683+2.569 &-1.228+0.317 respectively) (p,0.005). Other parameters as TAPSE and RV FACshowed asignificant reduction in group I. Furthermore, DTI showed a significant reductionin lateral tricuspid annulus peak S wave along with elevated MPI values in group I. GlobalLV PLSS was significantly reduced in group I and there was a positive correlation (r =0.578) between Global RV PLSS and Global LV PLSS (p?0.005).Conclusions: The Global RV PLSS is significantly reduced in patients with anterior STEMImainly due to reduction of average septal PLSS. Other RV parameters as TAPSE, FAC,MPI and DTI peak S wave on lateral tricuspid annulus are also affected. Furthermore,LAD territory infarction affects the PLSS and SRs s-1 of a wide area of the LV.

P663Right ventricular systolic function assessment in sickle cell anaemia usingechocardiography

O. Oni; A. Adebiyi; A. AjeIbadan University College Hospital, Cardiology unit,Department of Medicine, Ibadan,Nigeria

Sickle cell anemia (SCA) is themost common heritable hemoglobinopathy worldwide andis characterized by recurrent vaso-occlusive crises and anemia. Mortality has been un-acceptably high but it has improved over the last few decades, with more people survivingto adulthood. With this comes a rise in the prevalence of chronic complications such asretinopathy, nephropathy and pulmonary hypertension. While increase in the size ofcardiac chambers has been noted, especially on the left, there is a paucity of studies onright ventricular function in sickle cell anemia, considering that right ventricular dysfunc-tion in strongly linked to poor prognosis.Purpose: The objectives were to determine right ventricular systolic function in subjectswith sickle cell anemia using echocardiography and compare results with age and sex-matched controls.Methods: The study design was a descriptive, cross sectional type. Ethical approval wasobtained. Informed consent was taken. Questionnaires were administered and blood

samples for packed cell volume estimation were taken. Echocardiography was done,using 3 MHz cardiac probe of Toshiba Xario echocardiography machine. 2- dimensional,M-mode, and Doppler (Pulsed wave, Continuous wave and Tissue doppler imaging)studies were done. Tricuspid annular plane systolic excursion (TAPSE), peak systolic vel-ocity of the tricuspid annulus (S′) and right ventricular fractional area change (RVFAC)were measures of systolic functionResults: Seventy seven subjects with SCA and seventy two subjects with Hemoglobin A(HBA) were recruited. The sickle cell group had a mean age of 27.8(7) while controls were30.2 (9.1); p value: 0.07. Their sex distribution was comparable. RVFAC 0.4(0.1) vs0.4(0.1); p value 0.367 was not significantly different between both groups. However,TAPSE 29.4(4.5) vs 23.3(3.7); p value 0.00001 and S′ 15.8(3.1) vs 13.7(2.6); p value0.00001 were significantly increased in the sickle cell group as compared against thosewith HBA.When the frequency and severity of crises was taken into consideration, people with morefrequent crises had significantly higher packed cell volume 26.5 (5.3) vs 23.2 (4.7); pvalue-0.031 more jaundice and higher body mass index (BMI) 20.0(2.9) vs 17.8 (2.0); pvalue-0.001.Conclusion: Right ventricular systolic function is largely preserved in the sickle cell popu-lace. The frequency of crises had no significant effect on the systolic function, likelybecause they were in steady state.

ASSESSMENT OF DIASTOLIC FUNCTION

P664Prognostic value of transthoracic cardiopulmonary ultrasound in cardiac surgeryintensive care unit

F. Ricci1; R. Aquilani2; G. Dipace2; V. Bucciarelli1; F. Bianco1; E. Miniero2; G. Scipioni2;R. De Caterina1; S. Gallina1

1G. D’Annunzio University, Institute of Cardiology and Center of Excellence on Aging,Chieti, Italy; 2SS. Annunziata Hospital, Heart Department, Chieti, Italy

Purpose: Acute decompensated heart failure (ADHF) after cardiac surgery is associatedwith a very poor prognosis. Early diagnosis of ADHF is key to ensure prompt and effectivetreatment and requires at least two essential pieces of clinical information: the status ofextravascular lung water and left ventricular (LV) end-diastolic pressure. The goal of thisstudy was to evaluate the prognostic value of pulmonary and haemodynamic congestion,as assessed by cardiopulmonary ultrasound (CPUS), for the prediction of the 1-year com-posite outcome of cardiac death, cardiovascular hospitalizations and worsening NYHAfunctional status, in a cohort of patients admitted to the cardiac surgery intensive careunit of our hospital.Methods: We enrolled 55 consecutive patients (mean age: 69.6+2.7 years), who under-went CPUS immediately before and after cardiac surgery. Haemodynamic congestionwas assessed by echocardiographic indices of LV diastolic dysfunction: E/A ratio,Tissue Doppler E/e’ ratio, ratio of transmitral peak E-wave velocity to flow propagation vel-ocity (E/Vp), E-wave deceleration time and left atrial volume indexed to body surface area.Pulmonary congestion was assessed by absolute ultrasound lung comets number vari-ation (DULCs) before and after heart surgery. The prognostic value of pulmonary andhaemodynamic congestion was calculated by Nelson-Aalen survival analysis, and bothunivariate and multivariate logistic regression analyses.Results: The diagnosis of postoperative ADHF was adjudicated in 28 (50.9%) patients.Mean postoperative ejection fraction was 49.3+12.8 (range 15-65)%. During the follow-up 30 events occurred: 3 cardiac deaths, 12 cardiac-related hospitalizations and 15 wor-sening NYHA functional status. The 12-month event-free survival was significantly lower inpatients with postoperative haemodynamic congestion as compared with patients withnormal LV filling pressures (Log-rank, p= 0.002). Univariate predictors of the compositeoutcome were postoperative ADHF, LV diastolic dysfunction, DULCs ≥15, difficultweaning fromcardiopulmonary bypass requiring inotropic support, worsening renal func-tion and beta-blocker therapy (inverse predictor). Multivariable analysis revealed that LVdiastolic dysfunction was the only independent predictor of the composite outcome(P=0.038).Conclusions: CPUS provides unique opportunity for early detection and non-invasivebedside monitoring of pulmonary and haemodynamic congestion. In the postoperativeperiod after cardiac surgery left ventricular diastolic dysfunction is an early prognostic in-dicator of cardiovascular outcome.

P665Comparativeefficacy of renin-angiotensinsystem modulatorsonprognosis, rightheart and left atrial parameters in patients with chronic heart failure and preservedleft ventricular systolic function

LR. Tumasyan; KG. Adamyan; AL. Chilingaryan; LG. TunyanInstitute of Cardiology, Yerevan, Armenia

The aim of study was to compare efficacy of long-term therapy with ramipril (R, 10 mg),valsartan (V, 320 mg) alone and their combination with spironolacton (S, 50 mg)and each others on prognosis, right ventricular (RV), right (RA) and left (LA) atrial para-meters, BNP and hsCRP levels in pts with III NYHA FC CHF and preserved LV ejectionfraction (PEF).Methods: 130 pts (age 63.2) were randomly assigned to groups A (n=27, receiving R), B(n=26, receiving V), C (n=26, receiving R + S), D (n=26, receiving V + R) and E (n=25,receiving V + S) in addition to diuretics and beta-blockers. RV fractional area changes(FAC), tricuspid annulus plane systolic excursion (TAPSE), transtricuspidal E/A ratio,

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pulmonary artery ejection time (PAET), relation of pulmonary vein (PV) systolic and dia-stolic fraction (S/D), systolic contribution (SC), difference between duration of reversalatrial flow (Ar) and late (A) transtmitral filling, RA and LA functional index (FI), BNP andCRP levels were assessed at baseline, 3, 6, 12, 24 and 36 months.Results: 1-, 2- and 3-year mortality (%) were 33.3, 40.7 and 48.1 in A; 30.8, 38.5 and 46.2 inB, 26.9, 30.8 and 38.5 in C; 26.9, 34.6 and 42.3 in D and 24, 28 and 36 in E groups. Survivalanalysis revealed lower probability (RR reduction, %) of 1, 2, and 3-year mortality at 19.2,24.3 and 20 with R + S (p,0.05), compared to group A. Similarly, V + S use associatedwith significant decrease of (RR reduction, %) of 1, 2, and 3-year mortality at 22.1, 27.3 and22.1 with V + S (p,0.05), compared to group B. Combined treatment with R + V didn’tresulted do mortality changes. R and V use significantly improved (% from baseline)BNP at 23 and 23.5, CRP at 40.9 and 40.6, E/A at 18.3 and 18.6, RA at 30.2 and 30.5, LAFI at 30.2 and 28.9, PAET at 9.5 and 9.3, Ar-A at 55.2 and 55.4, PV CS at 26.4 and 26.6after 6 months, TAPSE at 28.5 and 28.3, RV FAC at 21.3 and 21.2 and PV S/D at 24.9and 25.1, respectively, after 12 months. R + S and V + S therapy significantly changedBNP at 22.1 and 22.4, CRP at 37.9 and 38.1, RA FI at 27.3 and 27.1 after 3 months, E/Aat 26.1 and 25.9, LA FI at 28.3 and 28.5, PAET at 10.9 and 11.1, Ar-A at 57.5 and 57.3,PV SC at 29.2 and 29.4, S/D at 24.7 and 24.5 after 6 months, TAPSE at 29 and 29.3 andFAC at 21.6 and 21.8 after 12 months.Conclusions: 1) Decrease of BNP≥50 and CRP≥40%, increase of RA, LA FI and PVCS≥50% and PA ET≥25% after 12 months identified pts with cardiac risk reduction.2) R + S and V + A treatment reduced mortality in pts with CHF and PEF due to highlyexpressed improvement of right heart, LA parameters, neurohormonal and inflammationstatus

P666Left atrial volume index is the most significant diastolic functional parameter ofhemodynamic burden as measured by NT-proBNP in acute myocardial infarction

KH. Kim; JY. Cho; HJ. Yoon; Y. Ahn; MH. Jeong; JG. Cho; JC. ParkChonnam National University Hospital, Gwangju, Korea, Republic of

Background: NT-proBNP is a well-known cardiac biomarker reflecting hemodynamicburdens and prognostic marker in patients with acute myocardial infarction (AMI). Theaim of this study was to investigate the significant diastolic functional parameters reflect-ing cardiac hemodynamic burdens as measured by NT-proBNP in patients with AMI.Methods: A total of 478 patients with AMI who had available images and could measurediastolic functional parameters including left atrial volume index (LAVI) were included thepresent study. The following diastolic functional parameters were measured; E, A, E/A,and DT on PW Doppler of mitral inflow, Em, Am, and Sm on septal tissue Dopplerimage, E/Em, LA dimension, LA area, and LAVI. The correlation between NT-proBNPand diastolic functional parameters were evaluated.Results: The level of NT-proBNP was 3246.3+6822.6 pg/mL. The correlation betweenNT-proBNP and diastolic parameters were summarized in the table. The level ofNT-proBNP showed significant positive correlation with E, A, E/Em, LA dimension, LAarea, LAVI, and negative correlation with Sm and DT. However, Em, Am, and E/A did notshow significant correlation with NT-proBNP. Among these significant variables, LAVIshowed the most significant correlation with NT-proBNP. The correlation between LAVIand NT-proBNP was comparable to the correlation between left ventricular ejection frac-tion (55.7+15.6 %) and NT-proBNP (r=0.463, p,0.01).Conclusion: LAVI was the most significant diastolic functional parameter of cardiacburden as measured by NT-proBNP in patients with AMI. Therefore, the measurementof LAVI would be useful in the risk stratification or prognostication of AMI.

Abstract P666 Table. The correlation between NT-proBNP and di

Mean value r value p value

E (m/s) 0.67+0.21 0.172 ,0.01A (m/s) 0.75+0.22 0.180 ,0.01DT (msec) 199.8+64.0 20.108 ,0.05E/Em 12.4+5.9 0.240 ,0.01Sm (m/s) 0.07+0.02 20.212 ,0.01LA dimension(mm) 38.5+5.9 0.234 ,0.01LA area (cm2) 19.3+5.5 0.252 ,0.01LAVI (ml/m2) 36.4+15.1 0.424 ,0.01

DT, deceleration time; LA, left atrium; LAVI, left atrial volume index

P667Preventive echocardiographic screening. preliminary data

B A. Popa1; A. Popa2; G. Cerin1

1San Gaudenzio Clinic, Department of Cardiology, Novara, Italy; 2ScientificEchocardiography, Casanova Elvo, Italy

Background: Echocardiographic screening (ES) may be considered a powerful tool incardiovascular (CV) preventive medicine. In countries where the investments preventionare low but CV mortality rates are high, this allows early diagnosis of a variety of clinicallysilent but serious conditions. Here are some examples: the aortic aneurism, significantaortic regurgitation. Early diagnosis is crucial for a better management of these patients.Methods: A Provincial Campaign of Echo Screening (it.abr. CA.PR.E.S.A) was organizedin the italian prov. of Vercelli, from October 2014 since May 2015. This was a pilot study,focused on small cities, under 10.000 inhabitants. It was organized with logistic support

from local Administrations. Clinical anamnesis, basic anthropometric data and a com-plete TT echo was performed using a GE Vivid I with a M3S transducer. Patients withknown heart conditions, who underwent heart surgery or had recent echo exams wereexcluded. Special attention was paid to: 1. LV systolic and diastolic function; 2. Ascendingaortic diameters; 3. Valvular function. Each patient received a report and was referred tohis GP and/or other specialists, as required. For patients features and echo results seetable 1. There were 823 participants. An interim analysis of the data interestinglyshowed that greater ascending aortic diameters were associated to higher BSA valuesbut not with the presence of the arterial hypertension or hypercholesterolemia (if effective-ly controlled). Three pts with aortic aneurysm underwent surgery.Conclusions: This ongoing pilot study demonstrates that TTecho screening is a powerfultool indiagnosisofcardiovascular asymptomaticandsilent disease. If extended to a large/national scale it may allow significant reduction of cardiovascular costs. The early diagno-sis of one aortic aneurysm/dissection saves a life but also, accounting for a DRG of 23.000euro, allows significant cost savings equal the cost of this entire study.

Abstract P667 Table. Patient data and echo findings

Age(y) Male Weight (kg) BSA (m2) Hypertension Dyslipidemia Diabetes Smoke

55+11 437 (53.1%) 70.1+10 1.78+0.2 181 (22%) 78 (9.5%) 20(2.4%)

88(10.7%)

Diastolicdisfunction

Ao dilation(.40mm)

Asc AoAneurysm(.50mm)

Severe AoInsuff.

BicuspidAoV

MVProlapse

210(25.5%) 45(5.5%) 7(0.6%) 25 (3.1%) 9(1%) 23(2.5%)

P668Assessment of the atrial electromechanical delay and the mechanical functions ofthe left atrium in patients with diabetes mellitus type I

K. Yiangou1; CH. Azina2; A. Yiangou1; C. Georgiou1; M. Zitti1; M. Ioannides3;S. Chimonides2

1The Cardio Clinic Heart Center, Nicosia, Cyprus; 2Nicosia General Hospital, Departmentof Internal Medicine, Diabetes Clinic, Nicosia, Cyprus; 3Nicosia General Hospital,Department of Cardiology, Nicosia, Cyprus

Introduction-Aim: Diabetes Mellitus (DM), as a classic risk factor for coronary arterydisease, is linked with the development of diastolic dysfunction of the left ventricle,before symptoms and signs of cardiac disease occur. Structural, mechanical and electric-al changes that take place in the left atrium, reflect the burden of the alteration of the dia-stolic function. Aim of our study is the evaluation of the electrical and mechanical changesof the left atrium in patients with DM type I.Methods: A group of patients with DM type I and no other risk factors for coronary arterydisease and a group of healthy subject as control group have been aged-gender-bodysurface area paired. They all underwent a thorough echocardiography study whichincluded the calculation of the atrial electromechanical delay (EMD) as it was calculatedby the tissue Doppler recording of the left and right ventricle, and its correction accordingto the heart rate. End-systolic and end-diastolic volumes of the left atrium have been cal-culated using the biplane method of surface-length.Results: The intra and inter atrial EMD were statistically significant higher in patients withDM type I compared with the healthy subjects (21.4 + /-4.5 vs 14.4 + /-1.5, 25.0 + /-4.5 vs19.4 + /-0.5 R,0.001 kai R,0.005 respectively). The left atrial volume index (LAVI) wassignificantly higher in the DM type I group (54.2 + /-22.0 vs 46.3 + /-12.2 p,0.05)Conclusions: The early diastolic dysfunction of the left ventricle that is observed inasymptomatic patients with DM type I is confirmed by the use of EMD and LAVI. Thesemethods may be used for the early detection of subclinical electrical and structuralchanges of the left atrium and therefore to the on-time intervention for the avoidance of dia-betic cardiomyopathy

ISCHEMIC HEART DISEASE

P669Coronary flow velocity reserve by echocardiography as a measure ofmicrovascular function: feasibility, reproducibility and agreement with PET inoverweight patients with coronary artery disease

R H. Olsen1; LR. Pedersen1; M. Snoer1; TE. Christensen2; AA. Ghotbi2; P. Hasbak2;A. Kjaer2; SB. Haugaard3; E. Prescott11Bispebjerg Hospital, University of Copenhagen, Department of Cardiology, Copenhagen,Denmark; 2Rigshospitalet, University of Copenhagen, Department of Clinical Physiology,Nuclear Medicine & PET, Copenhagen, Denmark; 3Amager and Hvidovre Hospital,University of Copenhagen, Department of Internal Medicine, Copenhagen, Denmark

Background: Coronary flow velocity reserve (CFVR) measured by transthoracic Dopplerechocardiography of the LAD is used to assess microvascular function but validationstudies in clinical settings are lacking. We aimed to assess feasibility, reproducibilityand agreement with myocardial flow reserve (MFR) measured by PET in overweightand obese patients.Methods: Participants with revascularized coronary artery disease were examined byCFVR. Subgroups were examined by repeated CFVR (reproducibility) or PET (agree-ment). To account for time variation, results were computed for scans performed within

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a week (1-week) and for all scans regardless of time gap (total) and to account for scartissue for patients with and without previous myocardial infarction (MI).Results: Eighty-six patients with median BMI 30.9 (IQR 29.4-32.9) and CFVR 2.29(1.90-2.63) were included. Twenty-six (30%) had previous MI involving the LAD-territory.CFVR was feasible in 83 (97%) using a contrast agent in 14%. For reproducibility overall(n=21) limits of agreement (LOA)=(-0.75;0.71), coefficient of variation (CV) within-subjects=11%, and reliability=0.84. For reproducibility within 1-week (n=13)LOA=(-0.33;0.25), CV within-subjects=5%, and reliability=0.97. Agreement with MFR(n=35) was without significant bias and overall LOA=(-1.40;1.46) which tended to bebetter for participants without MI of the LAD-territory (n= 23) and examinations performedwithin 1-week LOA=(-0.68;0.88).Conclusions: CFVR was highly feasible with a good reproducibility on par with other con-temporary measures applied in cardiology. Agreement with MFR was acceptable, thoughdiscrepancy related to prior MI has to be considered. CFVR of LAD is a valid tool in over-weight patients.

P670Influence of cardiovascular risk in the occurrence of events in patients withnegative stress echocardiography

A. Cacicedo; S. Velasco Del Castillo; V. Gomez Sanchez; A. Anton Ladislao;J. Onaindia Gandarias; I. Rodriguez Sanchez; O. Jimenez Melo; E. Garcia Cuenca;G. Zugazabeitia Irazabal; A. Romero PereiroGaldakao Hospital, Galdakao, Spain

The influence of cardiovascular risk (CVR) in p with negative stress echocardiography(SE) has not been evaluated. Objectives: 1.To know the prognostic value of SE in ourpopulation. 2. To know if CVR influences in the risk of events in p with negative SE.Methods: We retrospectively included 1778 p with negative SE, of whom 434 p (24,7%)had known coronary artery disease (CAD) and 1354p (75,73%) did not. The 10 yearCVR could be estimated in 1206 of the 1354 p without known CAD and negative SEusing European SCORE and it was: SCORE , 5% in 76,86% of the p, SCORE 5-9% in17,5% of the p and SCORE.10% in 5,6% of the p. P were classified in 4 groups: onegroup with known CAD and negative SE and 3 more groups without known CAD andnegative SE according to risk SCORE: ,5%, 5-10% and .10% respectively. Follow-upwas carried out through electronic records, telephone and mortality registry. Theprimary endpoint included: cardiac death (death by heart failure, unexplained suddendeath and fatal acute coronary syndrome), non fatal SCA (identifying separatelyNSTEACS (non STacute coronary syndrome) and STEACS (STelevation acute coronarysyndrome)), angina and late revascularization.Results: Mean age was 63,5(10,69) years, median follow up time was 38(24-56) months.The primary endpoint event rate was similar in the group with known CAD and in the groupwith SCORE.10% (9,91% vs 8,82%), and significantly higher in both groups comparingto p with SCORE ,10% (event rate,3%). Analyzing according to the type of event, we didnot find a significantly increased rate of death by heart failure, sudden death or non fatalSTEACS in any of the 4 groups. P with known CAD and p with SCORE .10% had a similarrate of NSTEACS (2,94 vs 2,53%; p,0,001) and late revascularization (5,88% vs 6,68%, p, 0,0001) and this rate was significantly higher than the rate of these type of events in pwith SCORE ,10% (Event rate in SCORE ,5% and SCORE 5-10% respectively: laterevascularization: 1,94% and 1,42% and NSTEACS: 0,54% and 0%). Event- free survivalat the end of follow up was94% in p with SCORE,5%, 97% in p with SCORE 5-10%, 88% inp with SCORE.10% and 85% in p with known CAD (p,0,0001)Conclusion: P with negative SE have in general a low risk of events, however this riskdepends on CVR. In p with negative SE and SCORE .10%, the risk was similar to thatof p with known CAD, mainly based on non fatal events (NSTEACS and late revasculariza-tion) and significantly higher in both groups comparing to p with SCORE ,10%.

P671Prevalence of transmural myocardial infarction and viable myocardium in chronictotal occlusion (CTO) patients

L. Monti; B. Nardi; G. Di Giovine; G. Malanchini; C. Scardino; L. Balzarini; P. Presbitero;GL. GaspariniHumanitas Research Hospital, Rozzano, Italy

Purpose: contrasting data exist on the prevalence and extension of myocardial infarctionin patients with CTO: we sought to review our series, using Cardiac Magnetic Resonance(CMR) with Late Gadolinium Enhancement (LGE) as the reference method for the diagno-sis of a previous myocardial infarction.Methods: 59 consecutive patients with a documented CTO, without clinical angina andwithout other relevant stenosis, underwent an adenosine stress CMR + LGE in order toquantify the amount of viable myocardium subtended to the occlusion. ECG and echocar-diographic (Echo) data were available for all: Q waves . 40 msec and akinetic areas +reduced wall thickness on echo were considered diagnostic for a previous myocardial in-farction. The myocardial segments with perfusion defects (visual analysis) and with LGEwere graded according to the transmurality of the signal abnormality: for perfusion0:absent, up to 2: . 50%, using 50% steps; for LGE 0: absent up to 4: .75%, using25% steps.Results: Globally, Q waves on ECG were present in 32% of patients. Akinetic areas onechocardiography in 52%. Abnormal adenosine myocardial perfusion was detected in100% of patients, whereas LGE in 68%. CMR showed a mean LV volume of 173 ml, andLVEF = 55%; mean RV volume was 136 ml and RVEF = 62%.

19 patients (32%) had no LGE: Q waves were surprisingly present in 3 (16%), and akineticareas in 1 (5%).22 patients (37%) had LGE 1 to 50%: Q waves were observed in 6 (27%), and akineticareas in 13 (59%).17 patients (29%) had LGE 51 to 100%: Q waves were observed in 10 (59%), and akineticareas in 16 (94%); among them, 11 patients (18,6%) showed a mean LGE transmurality .

75% in the CTOterritory: i.e.absence of a reasonable amountof viablemyocardium. In thissubgroup, ECG was positive in 45% of cases, and echo in 91%.Conclusions: at least 18% of CTO patients show a transmural myocardial infarction onLGE CMR; ECG and Echo underestimate this prevalence. On the other hand, about30% of CTO patients show no LGE: in this case ECG and Echo overestimate the preva-lence of myocardial infarction. LGE CMR allows a better selection of patients who canbenefit from a CTO reopening procedure.

P672The impact of the interleukin 6 receptor antagonist tocilizumab on mircovasculardysfunction after non st elevation myocardial infarction assessed by coronaryflow reserve from a randomized study

E. HolteSt.Olavs University Hospital, Trondheim, Norway

Background: Coronary microvascular dysfunction (CMD) following acute myocardial in-farction (AMI) and percutaneous coronary intervention (PCI) is a multifactorial phenom-enon of diverse etiologies. In the absence of epicardial stenosis, impaired coronaryflow reserve (CFR) represents coronary microvascular dysfunction. Interleukin-6 (IL-6)has been shown to contribute to atherosclerotic plaque destabilization and myocardialinjury during ischemia-reperfusion. The aims of the study were (i) to compare the effectof a single dose of the anti-IL-6-receptor antibody, Tocilizumab, in patients with acutenon-ST elevation myocardial infarction (NSTEMI) in improving CFR assessed by trans-thoracic Doppler Echocardiography (TTE) at inclusion and at 6 months follow up. (ii)Evaluation of patients with CMD, defined with a CFR below the cut-off of 2.5.Methods: In a two-center randomized, double-blind, placebo controlled study with 117patients with NSTEMI, 42 patients (placebo n=20, Tocilizumab n=22) where includedin a study evaluating microvascular dysfunction assessed by CFR. CFR was measuredby TTE in the mid to distal LAD at inclusion and at 6 months follow up. Blood sampleswere obtained at 6 consecutive time points between day 1 and 3. High-sensitive CRP(hsCRP), high-sensitive Troponin T (hsTnT), were measured with area under the curve(AUC).Results: Our main findings were (i) no difference in CFR between the treatment groups atinclusion and at 6 month. (ii) CFR significantly increased at 6 months follow up in bothgroups, with no intergroup differences. (iii) CMD was present in 10 of 42 patients (23.8%), with a significant lower CFR at 6 months follow up in the group with CMD(p=0.001), however there was a normalization of the CFR in 9 out of 10 (90 %) patientswith CMD at 6 months follow up. (iiii) There was a trend of increase in hsCRP and hsTnTfrom baseline in the group with CMD. There was a significant correlation between CRPand TnT through all timepoints (r.0.5, p,0.003) in patients without and with CMD.Conclusions: Tocilizumab did not affect CFR and the progress of CFR at 6 months followup in patients with NSTEMI compared to placebo. CFR increases significantly during 6months after an NSTEMI. Coronary microvascular dysfunction was present in around 1

4of the patients with NSTEMI, with an improvement of the microvascular dysfunction at 6months follow up. Patients with coronary microvascular dysfunction have a significantlower CFR at 6 months follow up (p=0.001). Coronary microvascular dysfunction maybe connected to increased inflammation.

P673Impact of manual thrombus aspiration on left ventricular remodeling: theechocardiographic substudy of the randomized Physiologic Assessment ofThrombus Aspirtion in patients with ST-segment Elevatio

D. Orlic1; M. Tesic1; D. Zamaklar-Trifunovic1; B. Vujisic-Tesic1; M. Borovic2; D. Milasinovic2;M. Zivkovic1; J. Kostic2; B. Belelsin1; M. Ostojic2

1Clinical Center of Serbia, Belgrade, Serbia; 2Institute for histology, Belgrade, Serbia

Background: It has been reported that index of microcirculatory resistance (IMR) is lowerin STEMI patients who underwent thrombus aspiration before stent implantation com-pared to those tretaed with conventional primary PCI. The aim of this study was to evaluateimpact of improved myocardial perfusion by manual thrombus aspiration assessed byIMR on left ventricular remodeling in STEMI patients at mid-term follow-up.Method: The total of 115 patients entered the echocardiography substudy of the PATASTEMI (randomized Physiologic Assessment of Thrombus Aspirtion in patients withST-segment Elevation Myocardial Infarction) trial which evaluated eficacy of manualthrombus aspiration using Eliminate3 catheter (Terumo Europe, Leuven, Belgium). Echo-cardiography was done within the first 24 hours after the index procedure and after 4months. End-diastolic and end-systolic left ventricular (LV) volumes, ejection fraction(EF), cardiac sphericity index (CSI) and regional wall motion score index (WMSI) were cal-culated.Results: Regarding baseline characteristics, in patients with thrombus aspiration com-pared to those with conventional primary PCI, total ischemic time tended to be longer246,7+181,8 vs. 200,9+110,1 min, P=0,09 and AUC CK was smaller 40090+26158U/L vs. 52676+32013 U/L, P=0,026. Also, corrected IMR was lower in thrombus aspir-ation group 27,5+16,8 vs. 39,9+32,7 U/L, p=0,0079, while CFR (1,68+0,81 vs.1,61+0,67, P=0,6) and mean capilary wedge pressure (20,4+6,6 vs. 21,4+7,8

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mmHg, P=0,5) were similar. End-diastolic and end-systolic LV volumes per body surfacearea, EF, CSI volume and WMSI were similar between the thrombus aspiration and no as-piration group at baseline and at follow-up. At follow-up, percent change in WMSI tendedto be greater in thrombus aspiration group (decrease in WMSI 8,2% vs. increase in WMSI0,8%, P=0,094).Conclusions: Improvedmyocardial perfusion assessed by IMRhas no impact on left ven-tricular remodeling in STEMI patients at mid-term echocardiographic follow-up.

P674Acute heart failure in STEMI patients treated with primary percutaneous coronaryintervention is related to transmural circumferential myocardial strain

D. Trifunovic1; G. Krljanac2; L. Savic3; M. Asanin2; S. Aleksandric3; M. Petrovic3; N. Zlatic3;R. Lasica2; I. Mrdovic2

1Institute for cardiovascular disease, Clinical centre of Serbia, Belgrade, Serbia; 2ClinicalCentre of Serbia, Cardiology Clinic, Medical Faculty, Belgrade, Serbia; 3Clinical Centre ofSerbia, Cardiology Clinic, Belgrade, Serbia

Acute heart failure (HF) in pts with ST segment elevation myocardial infarction (STEMI)treated by primary percutaneous coronary intervention (pPCI) is important for prognosis.Speckle-tracking echocardiographic offer possibility to comprehensively explore left ven-tricular (LV) systolic function, beyond ejection fraction (EF), measuring myocardial de-formation by strain and strain rate.Aim: of this echocardiographic study was to analyze relation between LV myocardialmechanics and postprocedural HF (Killip class≥2) in STEMI pts treated with pPCI.Methods: in 50 consecutive STEMI patients treated with pPCI early echocardiographywas done including conventional echo parameters as well as longitudinal (L), radial (R)and circumferential (C) peak global strain (S;%) and peak systolic strain rate (SR;1/s)on endocardial (endo), medial (mid) and epicardial (epi) level. Transmural gradients ofLS (LSgrad) and CS (CSgrad) were calculated as difference between endocardial andepicardial values. Echo studies were done on VIVID 9-GE echo machine and EchoPackversion 13 was used for speckle tracking analysis.Results: 21% of all pts had HF. HF pts had significantly lower peak global LS on all threemyocardial levels (LSendo: -12.25+5.38 vs -16.33+4.35, p=0.012; LSmid 10.55+4.56 vs 14.02+3.53, p=0.010; LSepi -7.76+4.15 vs 11.09+3.16, p=0.004), lowerLSgrad (-2.18+1.95 vs -3.78+2.03, p=0.025) as well systolic LSr (-0.66+0.28 vs-0.93+0.23, p=0.01). CS was also impaired in pts with HF on all three myocardiallevels (CSendo: -21.42+4.49 vs -13.89+6.60, p=0.001; CSmid -14.90+3.32 vs10.08+4.89, p=0.004; CSepi: -10.64+2.67 vs -7.67+3.85, p=0.023) and CSgradwas lower in HF pts (-6.22+3.11 vs -10.78+2.69, p=0.001). Pts with HF had alsoimpaired RS (13.23+4.43 vs 7.74+3.64, p=0.005) and as expected lower EF(36.18+11.90 vs 51.58+9.10, p=0.001) and higher WMSI (1.75+0.40 vs 1.38+0.30, p=0.002). Comparison of area under a receiver operating characteristic (ROC)curves of all investigated parameters reveals that CSgrad has the largest urea (0.879,CI 0.697-1.061, p=0.002) with -7.41 as cut off with the best combination of sensitivity(86%) and specificity (92%) to identify HF patient.Conclusion: although STEMI pts with HF after pPCI have severely impaired myocardiallongitudinal, circumferential and radial myocardial mechanics, as well as EF, the best dis-criminator to identify HF from non-HF pts is transmural gradient of circumferential strain.These data suggest that preserved circumferential systolic LV function after pPCI is ofcrucial importance for HF appearance in STEMI pts.

P675Long-term prognostic value of infarct size as assessed by cardiac magneticresonance imaging after a first st-segment elevation myocardial infarction

G. Nucifora1; D. Muser1; D. Zanuttini1; C. Tioni2; G. Bernardi1; L. Spedicato1; A. Proclemer11Cardiothoracic Department, University Hospital “Santa Maria della Misericordia”, Udine,Italy; 2University of Udine, School of Medicine, Udine, Italy

Aim: In recent years, cardiac magnetic resonance (CMR) with late gadolinium enhance-ment (LGE) technique has emerged as an accurate imaging modality for the assessmentof myocardial necrosis and fibrosis. Aim of the present study was to investigate the long-term prognostic value of CMR in patients with a first ST-segment elevation myocardial in-farction (STEMI). METHODS. 107 patients with a first STEMI (mean age 59+12 years,82% male) were included. All patients underwent primary percutaneous coronary inter-vention (PCI). After a median of 8 days (IQ range 4-18) following admission, CMR withLGE imaging was performed to assess left ventricular (LV) function, infarct size (IS) and

microvascular obstruction (MO). In addition, the presence of traditional clinical prognosticparameters, including symptom onset-to-balloon time, post-PCI Thrombolysis in Myocar-dial Infarction (TIMI) flow, ST-segment resolution and peak value of cardiac Troponin I, wasdetermined. Patients were followed-up for a median of 97 months (IQ range 32-101); theprimary endpoint was defined as a composite of death, myocardial infarction and hospi-talization due to heart failure.Results: Median IS was 14% of the LV mass (IQ range 5-30); MO was observed in 32% ofpatients. The outcome event occurred in 22% of patients. At multivariate Cox proportional-hazards analysis, after correction for the traditional clinical prognostic parameters, age(HR 1.06, IC 1.01-1-10; p=0.013) and IS (HR 1.06, IC 1.03-1-09; p,0.001) were theonly variables significantly and independently related to the primary endpoint. CONCLU-SION. CMR assessment of IS after a first STEMI provides a significant and independentlong-term prognostic information.

HEART VALVE DISEASES

P676Prognostic value of LV global longitudinal strain in aortic stenosis with preservedLV ejection fraction

AC. Casalta1; E. Galli2; C. Szymanski3; E. Salaun1; C. Lavoute1; J. Haentjens1;C. Tribouilloy3; J. Mancini1; E. Donal2; G. Habib1

1la Timone Hospital, Marseille, France; 2University of Rennes, Rennes, France; 3UniversityHospital of Amiens, Amiens, France

Background: Decrease in left ventricular ejection fraction (LVEF) is a classic indication forsurgery in aorticstenosis (AS),but it appears late in thenatural history of the disease. Manyrecent studies have shown that a decrease in longitudinal contraction appeared earlier,and could be detected in many patients with AS, while their LVEF is still normal. This “lon-gitudinal dysfunction” can be easily assessed by the study of myocardial deformationusing 2D strain, but its prognostic value is still unclear.Objectives: The aim of our study was to assess the prognostic value of a longitudinal LVdysfunction, as assessed by measuring the global longitudinal strain (GLS) in a largepopulation of AS with preserved LVEF.Methods: This study included 582 patients with moderate or severe aortic AS and pre-served LVEF (≥50%). Severe AS were separated into 4 groups classified according toflow (, or .35ml/m2) and gradient (, or . 40mmHg).The GLS was performed byecho 2D speckle tracking. The main end-point was 2-year mortality.Results: During a 2.6 + /-.2 -year follow-up, 10% of patients died. Predictors of mortalitywere age (p,0.001, HR=1.1 [1.07-1.1]), sPAP .50mmHg (p,0.001, HR=4.7, [2.5-8.8]),E/A.1 (p=0.012, HR=2.03, [1.2- 3.5]), LVEF (p=0.037;HR=0.9[0.93-0.99]) and GLS.-13.75% (p=0.001, HR=2.49 [1.48- 4.18]).By multivariate analysis, only age, E/A . 1, and GLS . -13.75% remained associated withhigher mortality.After adjustment for clinical and echocardiographic variables, GLS remained a strong in-dependent predictor of all cause mortality (HR=2.47, [1.04-5.90], p=0.041). Survivalaccording to GLS was significantly reduced in patients with impaired GLS in all cohort(P=0.001), in the NFLG, NFHG, LFHG sub groups (p=0.002), but not in LFLG (p=NS).Conclusion: The GLS is a strong independent predictor of all-cause mortality in patientswith AS and preserved LVEF, with a threshold at -13.75%. This parameter should be takeninto account in the decision to operate patients with AS and normal LVEF.

P677Importance of longitudinal dyssynchrony in low flow low gradient severe aorticstenosis patients undergoing dobutamine stress echocardiography. amulticenter study (on behalf of the HAVEC group)

JL. Cavalcante1; A. Delgado-Montero1; A. Dahou2; L. Caballero3; S. Rijal1; J. Gorcsan Iii1;JL. Monin4; P. Pibarot2; P. Lancellotti31University of Pittsburgh, Cardiovascular Institute, Pittsburgh, United States of America;2Quebec Heart and Lung Institute, Medicine, Quebec, Canada; 3University Hospital ofLiege (CHU), Cardiology, Liege, Belgium; 4University Hospital Henri Mondor, Cardiology,Creteil, France

Background: Patients with reduced left ventricular ejection fraction (LVEF), low-flow low-gradient aortic stenosis (LFLG AS) represent a challenging cohort with high morbidity andmortality. Low-dose dobutamine stress echocardiogram (DSE) is recommended for as-sessment of flow reserve (FR, defined as ≥ 20% increase in stroke volume) which is prog-nostically important. We hypothesized that presence of longitudinal dyssynchrony (LD) isindependently associated with no FR during DSE.Methods and Results: 185 LFLG AS patients from 3 different institutions who underwentDSE between 1997 through 2013 were studied. The mean age was 74+9 yrs; LVEF 30+10%; indexed AV area 0.44+0.1 cm2/m2; mean AV gradient 24+7 mmHg; mean QRSwidth 126+32 msec and 28% of the cohort had a QRS width ≥ 130 msec. Baseline LD,transversedyssynchrony andstrain analysiswere feasible in 97%ofpatients (N=179).LD,pre-defined as maximum opposite wall delay ≥ 130 msec, was present in 83% (149/179)of study cohort, whereas FR on DSE was present in 54%. Coronary artery disease wasmore common in those without FR. Although baseline LVEF was not different accordingto FR status (p=0.23), greater LV stroke volume index (p=0.001) and longitudinal strain(p=0.004) were seen in those without FR. LD was more prevalent in patients without FR(90% vs 77%, p=0.02). On multivariate analysis (Figure 1), presence of LD (HR=4.58,p=0.01) was an independent predictor of no FR despite several adjustments.

Abstract P677 Figure. Predictors of NO Flow Reserve

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Conclusions: LD is very prevalent in patients with LFLG AS undergoing DSE. Quantifica-tion of LD provides important insights as LD is independently associated with no FR.Whether LD improves after valvular intervention and whether its correction confers abetter prognosis to these patients remains to be studied.

P678Predictive value of left ventricular longitudinal strain by 2D Speckle Trackingechocardiography, in asymptomatic patients with severe aortic stenosis andpreserved ejection fraction

K. Keramida1; N. Kouris2; V. Kostopoulos2; V. Giannaris2; E. Trifou2; L. Markos2;A. Mihalopoulos2; G. Mprempos2; CD. Olympios2

1Hammersmith Hospital, London, United Kingdom; 2Thriassio General Hospital, Athens,Greece

Left ventricular (LV) hypertrophy with good LV function often exists in patients (pts) withsevere aortic stenosis (AS). The aims of our study were to estimate LV deformationmechanics in severe AS, using 2D Speckle Tracking echocardiography (2DSTE) andthe predictive value of global longitudinal strain (LVGLS).Methods: We studied 54 consecutive pts (20 men, 43%) of mean age 75+10 years, withsevere AS based on criteria such as pressure gradient and calculated aortic valve area. Allpts had non-dilated, hypertrophied LV with good LV function (EF=59+6.1%) and theywere asymptomatic.Results:Patients were followed for15+4months.Fourptswere lost to followupand8ptsbecame symptomatic and proceeded to aortic valve replacement, so data were collectedfrom the remaining 42 pts. During that period, 27 pts were alive (Group 1, 64%) and 15 ptsdied (Group 2,36%). Data from both groups arepresented in Table 1.Analyzing thesedatait is clear that LVGLS is impaired in all pts with severe AS (LVGLS=-12.85+3.81%) al-though EF remains within normal limits. Only age and LVGLS were able to predictoutcome. LVGLS differed significantly between the 2 groups (p,0.02), was correlatedonly with LV hypertrophy (p=0.017, t=0.395) and was independent from all other vari-ables, age included. Multiple regression analysis showed that only LVGLS couldpredict survival (p=0.022), independently from all other variables.Conclusion: LV function is impaired in patients with severe degenerative AS. 2DSTE candetect these abnormalities before conventional echo, offering the possibility of betterfollow-up and timing of surgery. More importantly, LVGLS has superior predictive valuethan any other variable in predicting patients’ outcome.


VARIABLE GROUP 1 GROUP 2 P value

Age (years) 74.89+9.08 81.67+4.18 0.045Sex (male/female) 6/21 9/6 0.260LVEDD (mm) 49.39+5.26 49.44+4.00 0.400EF (%) 58.61+5.60 56.67+5.85 0.821MnPG (mmHg) 47.22+17.01 54.00+12.57 0.443AVAi (cm/m2) 0.51+0.09 0.46+0.09 0.940LVH 24 15 0.125LVGLS (%) 213.88+4.03 210.13+3.11 0.015

P679Clinical and echocardiographic characteristics of the flow-gradient patternsin patients with severe aortic stenosis and preserved left ventricularejection fraction

A. Calin; AD. Mateescu; M. Rosca; CC. Beladan; R. Enache; MM. Gurzun; P. Varga;C. Calin; C. Ginghina; BA. Popescu“Carol Davila” University of Medicine and Pharmacy, Euroecolab, Bucharest, Romania

Recently, low-gradient (LG) severe aortic stenosis (AS) with preserved left ventricular ejec-tion fraction (LVEF), as well as paradoxical low-flow (LF)/LG severe AS became increas-ingly important in clinical practice. These conditions reflect the discordance in currentlyused AS severity criteria and their prognosis and management are not clear yet.Purpose: We studied the clinical and echocardiographic characteristics of patients (pts)with severe AS and preserved LVEF (≥50%), according to the recently proposed flow-gradient classification.Methods: We enrolled 163 consecutive pts (66+11 yrs, 94 men) with AVA,1 cm2

(indexed AVA,0.6 cm2/m2) and preserved LVEF (62+6%), without evidence of ische-mic heart disease or more than mild mitral or aortic regurgitation. Patients were stratifiedby LV stroke volume index (,35 mL/m2 [low flow, LF] vs ≥35 mL/m2 [normal flow, NF])and mean aortic gradient (,40 mm Hg [LG] vs ≥40 mm Hg [high gradient, HG]) into 4groups: NF/HG, NF/LG, LF/HG, and LF/LG. Clinical assessment and a complete echocar-diogram were performed in all pts. LV global longitudinal strain (GLS) by speckle trackingwas available in 131 pts.Results: Paradoxical LF/LG severe AS was present in only 4 pts (2.5%) while most pts withLG severe AS had a normal transvalvular flow (29 pts, 17.8% of the study group). Com-pared to NF/HG (120 pts, 73.6%), NF/LG pts had a lower NYHA class, a lower prevalenceof syncope and chest pain and lower BNP values (p, 0.05 for all). Age, gender, bodymass index, prevalence of hypertension and diabetes were not statistically differentbetween groups. NF/LG pts had larger AVAs (0.47+0.06 vs 0.38+0.08 cm2/m2,p,0.001), lower LV mass index (p=0.002) and smaller LV volumes (p,0.004) when

compared to NF/HG pts. Although LVEF was similar between groups (62+6 vs 61+6%, p=0.6), worse parameters of LV longitudinal and diastolic function were found inNF/HG compared to NF/LG pts: lower GLS (-14.2+3.5% vs -16.9+2.7%, p=0.001),larger indexed left atrial volumes (p=0.02) and higher E/e’ ratios (p=0.03). LVstroke volume index was lower (43+4 vs 47+7 ml/m2, p=0.001) and LV outflow tractdiameter had lower values (20.4+1.6 vs 21.2+2.1 mm, p=0.04) in NF/LG comparedto NF/HG pts.Conclusions: We found a low prevalence of paradoxical low flow low gradient severe ASin our study group ofconsecutive ptswith severe AS and preserved LVEF.According to theproposed criteria, most pts with low gradient severe AS have a normal transvalvular flow.These pts have a better clinical and echocardiographic profile when compared to pts withnormal flow high gradient severe AS.

P6802D and 3D speckle tracking assessmentof left ventricular function in severeaorticstenosis, a step further from biplane ejection fraction

L. Almeida Morais; A. Galrinho; L. Branco; V. Gomes; A T. Timoteo; P. Daniel; I. Rodrigues;S. Rosa; J. Fragata; R. FerreiraHospital de Santa Marta, Lisbon, Portugal

Purpose: Aortic stenosis remains the most common valvular heart disease and leftventricular (LV) dysfunction in these patients confer a dismal prognosis. Recent studiesproposed 2-dimension speckle tracking (2D ST) parameters, notably 2D globallongitudinal strain (2D GLS), as early markers for LV dysfunction, allowing an earlierselection of patients for surgical intervention. We aim to study the LV function assessedby 2D STand 3-dimension speckle tracking (3D ST) in severe aortic stenosis patients.Methods: We performed a prospective observational study from September 2014 untilApril 2015 of consecutive patients with isolated severe aortic stenosis referred to surgicalaortic valve replacement. Patients included were submitted to a standardized pre-operative transthoracic echocardiography (TTE), which included aortic stenosis severityassessment and left ventricular function evaluation by means of 2D biplane ejection frac-tion (2D EF), 2D ST (GLS), 3D EF and 3D ST (GLS, Global Circumferential Strain – GCS,Global Radial Strain – GRS and Strain Area - SA). Statistical correlations among aorticstenosis features and TTE left ventricular function parameters were determined usingSpearman’s test and linear regression models.Results: From the 26 patients (54% females; 73.8+7.1 years) enrolled, 53.8% were inNYHA class III-IV and presented an average functional Aortic Valve Area (AVA) of0.7cm2 and a mean transaortic pressure gradient (mTAPG) of 54.8+14.2mmHg. 2DEF and 2D GLS showed independent correlation with mTAPG (r=0.44 and r=0.48, re-spectively), all p,0,05. 3D EF had a stronger correlation with mTAPG (r=0.56), while3D GLS (r=0,46), 3D GRS (0,46) and 3D SA (r=0,40) revealed a correlation with anatom-ical AVA, all p,0,05, but wasn’t significantly associated with mTAPG. In this cohort ofpatients, 3D EF showed association with 2D GLS (r=0.45), 3D GLS (r=0.53) and other3D ST derived parameters (3D GRS r=0.50 and 3D SA r=0.44), all p,0.05, but did notshow correlation with 2D EF. A linear correlation was also noted between 2D and 3DGLS (r=0.46, p=0.02).Conclusions: Despite being used for LV function evaluation in severe aortic stenosispatients, biplane ejection fraction accuracy was recently questioned with 2D GLS appear-ing as a more sensible parameter to assess subclinical LV dysfunction. 3D EF and 3D GLSshowed good correlation with stenosis severity and were better associated with 2D GLSthanwithbiplane ejection fraction. More studiesshould bemade toevaluate the prognosisimpact of these different methods.

P681Functional evaluation in aortic stenosis: determinant of exercise capacity

F. Bandera; G. Generati; M. Pellegrino; F. Carbone; V. Labate; E. Alfonzetti; M. GuazziIRCCS Policlinico San Donato, Heart Failure Unit, San Donato Milanese, Italy

Background: Aortic stenosis (AS) is clinically characterized by dyspnea and intoleranceto exercise. Clinical interpretation of such symptoms is often difficult due to the advancedage of AS patients. We aimed at identifying cardiac determinants of exercise intolerance inAS (Aortic Vmax .3 m/s).Methods and results: We performed cardiopulmonary exercise test (CPET) simultan-eously combined with exercise echocardiography in 43 patients with AS referred for func-tional assessment. Severe AS were evaluated because of symptoms not certainly relatedto valvular disease. Patients underwent a symptoms-limited maximal exercise, consider-ing the 75% of predicted VO2 consumption as a marker of preserved functional capacity.Twenty-three patients had preserved functional capacity (group A), showing higherwork, maximal VO2, O2 pulse and better VE/VCO2 and heart rate recovery. No differenceswere found in terms of rest systolic function and AS severity, while group A had higherpeak heart rate (HR), higher peak cardiac power output (cardiac output x systolic pres-sure) and higher peak-rest transaortic mean gradient difference (DMG). At multivariateanalysis, only DMG resulted independently associated with impaired functional capacity(p =0.048; CI 1.001-1.323).Conclusions: AS patients can present functional impairment which is related to cardiacresponse to exercise rather than to stenosis severity. These results suggest the role of ino-tropic and contractile reserve supporting the routinely evaluation of cardiac reserve as adeterminant of symptoms development.

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Group A (n=23) Group B (n=24) P Univariate P MultivariateRest Peak Rest Peak Rest Peak Rest Peak

Heart rate, bpm 71+9 126+20 75+11 113+22 ns 0.47 nsMean aorticgradient, mmHg

38+14 52+18 37+16 45+19 ns ns

Delta (peak-rest)mean aorticgradient, mmHg

14+7 8+7 0.008 0.048

Cardiac poweroutput, Watt

1.09+0.31 2.62+0.63 1.15+0.28 2.00+0.40 ns 0.04 0.064

Workload, Watt 93+41 60+20 0.002Peak VO2, mlO2*Kg-1*min-1

19.7+6.7 12.6+2.6 0.000

Peak O2 pulse,ml/beat

11.4+3.5 8.4+2.6 0.004

VE/VCO2, slope 27.6+4.6 30.4+4.9 0.06Heart raterecovery, bpm

16.1+8.7 7.5+7.7 0.002

P682Left ventricular mechanics: novel tools to evaluate left ventricular function inpatients with primary mitral regurgitation

E. Galli1; C. Leclercq1; E. Samset2; E. Donal11Hospital Pontchaillou of Rennes, Cardio-Thoracic Department, Rennes, France;2University of Oslo, Oslo, Norway

Backgroud: Left ventricular (LV) pressure–strain loops (PSLs) have been recently vali-dated as a non-invasive index of myocardial performance. Aim of the present study is tocompare average cardiac work (avgCW), positive work (avgPW), negative work(avgNW) and work efficiency (WE) in normal subjects (NOR) and in patients with severeprimary mitral regurgitation (MR) and preserved left ventricular ejection fraction (LV EF).The standard deviation of the integrals of the strain peaks (SDpeak) was also used as ameasure of energy dispersion during systole.Methods: we included in this study 20 NOR and 20 MR patients (mean age: 43+13 vs65+11 years). Strain traces and valvular event times were used for the calculation ofLV-PSLs.Results: no differences in LVEF (65+4 vs 67+6%, p=NS), GLS (-23%+2 vs -24+3%,p=NS), avgCW (2130+206 vs 2151+405 mmHg%, p=NS), and avgPW (2338+204vs 2461+392 mmHg/%, p=NS) were found between NOR and MR patients. Withrespect to NOR, MR patients showed a reduction in avgNW (96+70vs174+67mmHg%, p=0.01) and an increased WE (96+3 vs 92+3, p=0.0001). Despite this, aslight but significant increase in energy dissipation during systole was observed in MR,as shown by the higher SDpeak (1.21+0.33 vs 0.97+0.25, p=0.01).Conclusions: in patients with severe MR and normal LV performance, avgCW, andavgPW are preserved, with MR in the left atrium being probably responsible of the signifi-cant reduction in the LV avgNW. Despite this, a certain degree of dyssynchrony in LV seg-ments activation was present, which explains increased the slightly energy dissipationduring systole. Further studies on larger cohorts of patients are necessary to clarify thevariation of these indexes in the different phases of the MR continuum and to evaluatetheir applicability in clinical practice.

P683Plasma B-type natriuretic peptide level in patients with isolated rheumatic mitralstenosis

H M. Kamal; MA. Oraby; A Z. Eleraky; M A. YossuefSuez Canal University, Faculty of Medicine, Ismailia, Egypt

Background: A biochemical marker for assessing severity of mitral stenosis and its rela-tion to symptoms and echocardiographic parameters could be of clinical value.Purpose: To evaluate the plasma B-type natriuretic peptide (BNP) level in patients withisolated rheumatic mitral stenosis (MS) and its correlation to functional status and echo-cardiographic parameters.Methods: Forty-one patients with isolated rheumatic MS and sinus rhythm (7 males and34 female) aged36+9y,and 40age- andgender-matched healthy volunteers underwentassessment of NYHA functional class, transthoracic echocardiography, and measure-ment BNP.Results: The BNP level in MS patients was higher (171.06+112.09 pg/ml) compared to(13.95+6.24 pg/ml) the control group with P value = 0.001. In both univariate and multi-variate analysis, plasma BNP level was correlated with left atrial diameter (r = 0.6; P =0.001), left atrial volume index (r= 0.9, P = 0.001), peak pulmonary artery pressure (r0.8; P=0.001), right ventricular end diastolic diameter (r= 0.9; P=0.001), NYHA functionalclass (r=0.9; P=0.001), mean diastolic mitral pressure gradient and mitral valve area (r=-0.9; P=0.001). The level of BNP rose with increasing severity of MS. In mild cases (n=17)it was 68.88+34.2 pg/ml, in moderate cases (n=17) it was 215.62+77.65 pg/ml and insevere cases (n=7) it was 311+80.68 pg/ml with P value, 0.001. A receiver operatingcharacteristic (ROC) curve identified a BNP value of 26 pg/ml as the best cut-off for theidentification of patients with mitral stenosis with a sensitivity 92.6%, specificity 100%,positive predictive value 100% and negative predictive value 93%. BNP value of 113 pg/

ml has a sensitivity 95.83%, specificity 94.12%, positive predictive value 95.8% and nega-tive predictive value 94.1% for prediction of presence of moderate/severe mitral valvestenosis. However, BNP of 166 pg/ml has sensitivity of 100%, specificity of 70.6%, positivepredictive value of 41.2% and negative predictive value of 100% for prediction of presenceof severe mitral valve stenosis.Conclusion: Plasma B-type natriuretic peptide level increases with the severity of rheum-atic MS and was increasing with higher NYHA functional class, RV diameter and pulmon-ary artery pressure. This can be of significant clinical importance in assessing whether themedical treatment is of an effective value or there will be a need of resorting to othermethods of intervention as percutaneous mitral valvuloplasty or valve replacement.

P684Quantitative assessment of severity in aortic regurgitation and the influence ofelastic proprieties of thoracic aorta

L. Leite; R. Baptista; R. Teixeira; N. Ribeiro; AP. Oliveira; A. Barbosa; G. Castro; R. Martins;L. Elvas; M. PegoCentro Hospitalar e Universitario de Coimbra, Coimbra, Portugal

Purpose: The guidelines for the quantitative assessment of aortic regurgitation (AR) se-verity vary among scientific societies. We aimed to evaluate the predictive value ofseveral Doppler indexes and to assess their interaction with the elastic properties of thor-acic aorta.Methods: Transthoracic echocardiography was used to examine 117 patients with an AR:22 (18.8%) severe, 67 (57.3%) moderate and 28 (23.9%) mild, according to vena contractacriteria. Sixteen patients without AR were used as control group. Regarding elastic prop-erties of the thoracic aorta, the distensibility (2(As– Ad)/[Ad(Ps– Pd)]) and the stiffnessindex b1 (ln(Ps/Pd)/(As–Ad)/Ad) of ascending aorta were calculated.Results: The complete sample included 133 patients (age 68.2+13.1; 57.9% males).There were no significant differences in aortic distensibility and stiffness according toAR severity. In ROC curve comparison, we found that tissue velocity index (TVI) of the re-versal flow in the thoracic descending aorta was the best predictor of severe AR (c-statistic0.824, 95% CI 0.739-0.910, p,0.001), better than end-diastolic velocity (c-statistic 0.815,95% CI 0.714-0.916, p,0.001) or TVI diastolic/TVI systolic ratio (c-statistic 0.698, 95% CI0.592-0.804, p=0.005) in the thoracic descending aorta. Pressure half-time (c-statistic0.719, 95% CI 0.576-0.862, p=0.018) and proximal isovelocity surface area (PISA)method (EROA, c-statistic 0.701, 95% CI 0.544-0.859, p=0.029; Regurgitant volume,c-statistic 0.719, 95% CI 0.576-0.862, p=0.018) were also inferior to quantitative assess-ment in descending aorta. A multivariate analysis, using vena contracta as the continuousdependent variable, revealed that the best model (R squared 0.293) included only TVI ofthe reversal flow,ageand aortic distensibility. In thismodel, TVI of the reversal flow(b: 0.17;p,0.001) and aortic distensibility (b: -94.36; p=0.04) emerged as independent predic-tors of AR severity.Conclusions: In our series the best predictor of AR severity was the TVI of the reversal flowin the descending aorta, but the aortic elastic properties independently influenced the se-verity of AR.

P685Characterization of chronic aortic and mitral regurgitation using cardiovascularmagnetic resonance

CL. Polte1; SA. Gao1; KM. Lagerstrand2; AA. Johnsson2; O. Bech-Hanssen2

1Sahlgrenska University Hospital, Sahlgrenska Academy, Institute of Medicine,Gothenburg, Sweden; 2Sahlgrenska University Hospital, Gothenburg, Sweden

Purpose: The purpose of this study was to identify method-specific thresholds for theregurgitant volume index (RVI) and fraction (RF) indicating hemodynamically significantchronic aortic (AR) or mitral regurgitation (MR) benefiting from surgery using cardio-vascular magnetic resonance (CMR). Accurate CMR assessment of regurgitation severityis essential for appropriate clinical decision-making and is usually based on echocardio-graphic thresholds.Methods: This prospective study comprised 38 AR patients (moderate (n=15), severe(n=23)) and 40 MR patients (moderate (n=15), severe (n=25)). Echocardiography andCMR was performed in all, including a second post-surgical scan (10+1 month) in oper-atedpatientswithsevere AR/MR(n=48).ARquantification byCMR wasperformedusingadirect (aortic flow) and an indirect method (left ventricular stroke volume (LVSV) - pulmon-ary stroke volume (PuSV)), and MR quantification using two indirect methods (LVSV -aortic forward flow (AoFF) and mitral inflow (MiIF) - AoFF).Results: All operated patients experienced post-surgical reduction in end-diastolicvolume index ≥ 15% and/or relief of symptoms. In all operated patients the applicationof current guideline RF thresholds (.50%) led frequently to discordant grading by CMRas moderate or mild compared with echocardiography (Table). The discriminatoryability between moderate and severe AR was strong for RVI . 20 ml/m2, RF . 30%(direct method) and RVI . 31 ml/m2, RF . 36% (LVSV-PuSV) with a negative likelihoodratio (NLR) ≤ 0.2. In MR, the discriminatory ability was very strong for RVI . 32 ml/m2,RF . 41% (LVSV-AoFF) and RVI . 20 ml/m2, RF . 30% (MiIF-AoFF) with a NLR , 0.1.Conclusions: CMR grading of chronic AR/MR severity based on current guideline criterialead to frequently discordant grading with 2DE. The CMR grading should be based onmodality- and method-specific thresholds, to assure appropriate clinical decision-makingand timing of surgery.

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Mild Moderate Severe Mild Moderate Severe

Aortic Flow LVSV-PuSVAorticRegurgitation

9% 39% 52% 4% 22% 77%

LVSV-AoFF MilF-AoFFMitralRegurgitation

0% 28% 72% 4% 52% 44%

P686Functional mitral regurgitation: a warning sign of underlying left ventricularsystolic dysfunction in heart failure with preserved ejection fraction.

P. Martinez Santos1; I. Vilacosta2; E. Batlle Lopez3; B. Sanchez Sauce3; J. Jimenez Valtierra3; E. Espana Barrio3; R. Campuzano Ruiz3; A. De La Rosa Riestra3; J. Alonso Bello3;F. Perez Gonzalez3

1Hospital de Fuenlabrada, Cardiology, Madrid, Spain; 2Hospital Clinic San Carlos,Cardiology, Madrid, Spain; 3University Hospital Alcorcon Foundation, Cardiology, Madrid,Spain

Background: and aims: Left atrial (LA) enlargement can result in mitral annulus dilatationand cause FMR. Although LA dilatation is a common finding (even a diagnostic criteria) inheart failure with preserved ejection fraction (HFpEF), the impact of FMR among thesepatients has not been largely studied.The aim of this study was to evaluate the role ofFMR among acute decompensated HFpEF patients.Methods and Results: We prospectively analysed 154 consecutive patients who wereadmitted for HF and had a LVEF.50%. Patients with end-stage renal disease, highoutput HF, valvular prosthesis, severe mitral or aortic native valve disease were excluded.Patients with mitral valve prolapse, rheumatic and degenerative valve disease (includingmitral annular calcification) were not included. The echocardiographic study includedmost common diastolic dysfunction parameters (E wave velocity, E/e mitral ratio). Therate of left ventricular (LV) pressure change during the isovolumetric contraction period(dP/dt) was obtained by measuring the interval between 1 m/s and 3 m/s on the MR vel-ocity spectrum in CW Doppler. Average age was 81 years (SD 9), 63% female. Out ofthe 154 patients, 82 had no prior history of HF. 57 patients (37%) had FMR (mild or mod-erate). FMR was associated to high left ventricular filling pressures (82.4% E/e mitral ratio.15, p=0.014) and to LA enlargement (80.5% LA volume .40 ml/m2, p=0.043). Patientswith moderate FMR had worse systolic function than those with mild FMR (Table 1). In theunivariate analysis, the combination of FMR and a LV dP/dt ,1000 mmHg/s was asso-ciated to an increase of readmission for HF at follow-up (RR 3.03; 1.14 – 8.06, CI 95%,p = 0.028).Conclusion: Functional mitral regurgitation is associated to high left ventricular fillingpressures and left atrial enlargement among HFpEF patients. It may reflect a worse sys-tolic function, despite preserved LVEF.


Mild functional mitralregurgitation? (SD)

Moderate functionalmitral regurgitation?(SD)

p

Left ventricular ejection fraction(Simpson)

65.8 (7.3) 59.0 (7.1) 0.022

dP/dt mmHg/s 1980 (699) 1194 (310) 0.003Left atrial volume ml/m2 43.8 (15.6) 92.1 (8.6) ,0.0001Mitral E wave cm/s 87 (28) 112 (17) 0.030E/e mitral ratio 14.2 (6.1) 16.3 (4.6) 0.377

Echocardiographic differences according to FMR degree

P687Secondary mitral valve tenting in primary degenerative prolapse quantified bythree-dimensional echocardiography predicts regurgitation recurrence aftermitral valve repair

CN. Jin1; S. Wan2; JP. Sun1; AP. Lee1

1Prince of Wales University Hospital, Division of Cardiology, Institute of Vascular Medicine,Hong Kong, Hong Kong SAR, People’s Republic of China; 2Prince of Wales UniversityHospital, Division of Cardiothoracic Surgery, Department of Surgery, Hong Kong, HongKong SAR, People’s Republic of China

Purpose: Recurrence of mitral regurgitation (MR) can occur after successful repair ofmitral valve (MV) prolapse (MVP) despite adequate surgical techniques. We sought toidentify quantitative three-dimensional (3D) echocardiographic morphology of the MVthat are associated with recurrent MR after MV repair.Methods: The MV morphology of 98 patients (age=58+10y, 73 men) undergoing MVrepair for severe MR due to MVP was assessed preoperatively using 3D transesophagealechocardiography. Dedicated software was used to quantify the preoperative valvemorphology. Echocardiographic follow-up of valve function was studied at 1-month,1-year and 2-year after surgery.

Results: Fourteen patients (14%) developed non-trivial (2 + , n=11; 3 + , n=3) MR at2-year. Preoperative annular size and geometry, leaflet dimensions, prolapse volume,chordal rupture, ring sizes/types, and surgical techniques did not predict postoperativeMR recurrence. However, patients with recurrent MR had higher preoperative tentingheight of the non-prolapse leaflet segments (Table). Preoperative tenting height was inde-pendently associated with recurrence of MR (adjusted odds ratio=1.42, 95% confidenceinterval: 1.09-1.86, P=0.010).Conclusions: Secondary leaflet tenting attributed to primary MVP with MR is associatedwith reduced durability of initially successful MV repair, potentially due to increased surgi-cal difficulty to achieve optimal coaptation.

Abstract P687 Table. 3D mitral valve geometry

Variables RMR- (n=84) RMR + (n=14) P

AHCWR, % 14.2+4.0 15.3+4.9 0.336Circumference, mm 124+16 118+9 0.163Area, mm2 1129+303 1018+164 0.185Anterior leaflet surface area, mm2 766+210 741+185 0.924Posterior leaflet surface area, mm2 644+206 590+155 0.352Tenting height, mm 5.1+2.2 6.9+2.5 0.019Prolapse height, mm 5.8+3.1 6.1+3.4 0.741Anterior leaflet prolapse, n (%) 56 (67) 11 (79) 0.375Chordal rupture, n (%) 58 (69) 13 (93) 0.065Chordal length (anterolateral), mm 23.3+4.7 23.3+6.6 0.996Chordal length (posteromedial), mm 25.3+5.5 25.0+7.6 0.886

RMR indicates recurrent mitral regurgitation; and AHCWR, annular height to commissuralwidth ratio.

P688Advanced heart failure with reduced ejection fraction and severe mitralinsufficiency compensate with a higher oxygen peripheral extraction to a reducedcardiac output vs oxygen uptake response to max

G. Generati; F. Bandera; M. Pellegrino; F. Carbone; V. Labate; E. Alfonzetti; M. GuazziIRCCS, Policlinico San Donato, Heart Failure Unit, San Donato Milanese, Italy

Background: in heart failure (HF) the mitral regurgitation (MR) is clinical and prognosticrelevant. Cardiopulmonary exercise testing (CPET) allows evaluating functional capacityand provides indexes for HF risk stratification such as peak oxygen consumption (VO2).Since MR determines a severity-related backward flow to left atrium, it may result in an un-favorable central blood flow exercise redistribution that is physiological relevant to VO2increase.Aim: To evaluate the cardiac output (CO) and VO2 exercise-response in HF reduced ejec-tion fraction (HFrEF) patients according to MR severity to dissect what mechanism may bepredominant in the VO2 increase.Methods: 104 HFrEF patients (mean age 64+11 y, male 72%, ischemic etiology 68%,mean LVEF 34+9%) underwent a maximal CPET (incremental ramp protocol) combinedwith exercise-echo. CO was non-invasive estimated by echo.Results: Population was divided into 2 groups according to the rest MR: group A (n=80)non-severe MR and B (N=24) severe MR. Despite the groups did not differ in rest CO (A vsB 3.8+1 vs 3.4+1.8 L/min, p=ns) and VO2 (0.27+0.06 vs 0.28+0.09 L/min, p=ns)group B showed higher peripheral extraction (C(a-v)O2 8+2 vs 9+4 mL/100 mL,p=0.036) already at rest (Figure). At peak exercise group B had an impaired increaseboth in CO (7,0+2,0 vs 5,2+3,3 L/min) and VO2 (1,0+0,3 vs 0,8+0,3 L/min,

Abstract P688 Figure.

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p=0.001) partially compensated by a greater C(a-v)O2 contribution (15+4 vs 18+5 forA vs B, p=0.047).Conclusions: Severe MR and consequent partial abnormal CO redistribution to the pul-monary circulation seems a relevant pathophysiological mechanisms that limits overallexercise performance in HFrEF. In this high risk subset of patients peripheral extractioncompensates for the reduced CO and makes the basis for novel perspectives in thesepatients.

P689Predictors of acute procedural success after percutaneous mitraclip implantationin patients with moderate-to-severe or severe mitral regurgitation and reducedejection fraction

M. Reali; S. Cimino; T. Salatino; E. Silvetti; M. Mancone; M. Pennacchi; A. Giordano;G. Sardella; L. AgatiSapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology& Geriatrics, Rome, Italy

Purpose: Percutaneous Mitral valve repair using the MitraClip implantation has become avalid alternative for patients with severe mitral regurgitation (MR) and high surgical risk.Aim of the present study was to identify anatomical and periprocedural factors that mayhave an impact on acute procedural success (APS).Methods: We enrolled 22 consecutive patients with moderate-to-severe or severe MRundergoing MitraClip implantation screened with Trans-esophageal echocardiography.The evaluated parameters were the etiology of MR (functional, ischemic and degenera-tive), the severity of MR (regurgitant volume, EROA, vena contracta), annulus diameter,valve area, coaptation depth, coaptation length, the length of the anterior and posteriorleaflets, tricuspid regurgitation (TR) and pulmonary artery systolic pressure (PASP).APS was defined as successful clip implantation with residual MR grade ≤ 2 + .Results: Study population was divided in two groups according to the success of the pro-cedure (APS in 18 and failure in 4 pts). No difference in MR etiology, leaflets’ length andvalve area was found. Patients with APS presented with a less severe pre-implant MR, asmaller regurgitant volume (45+11 vs 53+9, p=0.02), EROA (0.34+0.1 vs 0.49+0.4, p,0.001), vena contracta (0.65+0.11 vs 0.79+0.17, p,0.001) and coaptationdepth (9.7+1.1 vs 11+2.3, p=0.023). TR and PASP were significantly lower in APSpatients (41+16 vs 67+6 mmHg, p,0.001). At multivariate analysis, only EROA andPASP were independent predictors of APS (respectively, 0.015 (0-0.983), p=0.023, and0.892 (0.832-0.955), p=0.01). There were no differences in number of clip implantedbetween the two groups.Conclusions: Percutaneous MV repair using MitraClip is a safe technique in high-risk sur-gical patients. A significant acute reduction of MR was achieved in the majority of patients.However, end-stage patients with high-grade pre-implant MR and TR and high value ofPASP may not benefit from the procedure.

P690The value of transvalvular gradients obtained by transthoracic echocardiographyin estimation of severe paravalvular leakage in patients with mitral prostheticvalves

M. Kalcik1; M. Yesin1; S. Gunduz1; MO. Gursoy1; MA. Astarcioglu1; S. Karakoyun2;E. Bayam1; S. Cersit1; M. Ozkan2

1Kosuyolu Kartal Heart Training and Reserch Hospital, Cardiology, istanbul, Turkey;2Kafkas University, Cardiology, Kars, Turkey

Background: Paravalvular leakage (PVL) is one of the serious complications after pros-thetic valve replacement. Although transesophageal echocardiography (TEE) is the fun-damental diagnostic method, transthoracic echocardiography (TTE) may predict thepresence of PVL necessitating further evaluation of the patient by TEE. We aimed to evalu-ate the value of transmitral gradients by TTE in prediction of PVL.Methods: Three groups of patients with prosthetic mitral valves (129 patients with severePVL, 91 patients with mild to moderate PVL and 100 control patients without PVL) were en-rolled retrospectively in this study. All subjects had undergone TTE and subsequently TEEexamination for evaluation of prosthetic mitral valves. No patient had a diagnosis of ob-structive valvular pathology. The mean and maximum transmitral gradients obtained byTTE were recorded. The heart rate was maintained between 60-80 beats/min during echo-cardiographic examinations.Results: The mean gradients by TTE did not differ significantly between patients withsevere PVL, mild to moderate PVL and controls (7.6+1.2; 7.4+0.9 and 7.3+1.2 re-spectively p=0.207) (Fig. 1a) while there was a significant difference in terms ofmaximum gradients between the groups (20.2+2.8; 15.1+2.6 and 11.6+2.1

respectively p,0.001) (Fig. 1b). A maximum transmitral gradient of .21.5 while meangradient was normal predicted severe PVL with an excellent specificity (AUC 0.90, sensi-tivity 33%, specificity 100%, p,0.001) by receiver-operating characteristic curve analysis.Conclusion: Increased transthoracic maximum gradients in patients with normal meangradients may be a predictor for mitral PVL necessitating further TEE examination.

P691Characteristics of infective endocarditis in a non tertiary hospital

A. Cacicedo; S. Velasco Del Castillo; V. Gomez Sanchez; A. Anton Ladislao;J. Onaindia Gandarias; I. Rodriguez Sanchez; O. Jimenez Melo; O. Quintana Razcka;A. Romero Pereiro; G. Zugazabeitia IrazabalGaldakao Hospital, Galdakao, Spain

The data published on infective endocarditis (IE) come from tertiary hospitals, in which dif-ferent parameters such as mortality can be influenced by the fact of being referral centersfor most ill patients.Objetives:1)To know incidence,clinical,microbiological andechocardiographic charac-teristics of IE in our population (non tertiary Hospital). 2) To find out prognosis and prog-nostic factors.Methods: We retrospectively reviewed IE episodes between January 2007 and June2014, and we collected clinical, microbiological and echocardiographic parameters aswell as p evolution, need for surgery, realized surgery and mortality.Results: We found 115 IE (incidence 5,1 episodes/100.000/ year). The mean age was 65,5years and 63,5% of p were males. 55% of IE were in native valve, 35% were prosthetic valveIE and 10% were IE on devices. The most common clinical findings were fever (80%) andanemia (17%). The most frequent germs were staphylococcus (55%) of which 50% weres. aureus, followed by streptococcus (23%) and 5,5% of blood cultures were negative.First transthoracic and transesophagic echocardiograms were diagnostic in 59% and91% of the p respectively. Echocardiographic findings were: vegetations 77,4% andcardiac complications as follows: valvular perforation (21,7%), abscesses (20%), pros-thetic dehiscence (7%) and 2 fistula (0,01%).The most frequent clinical complication was heart failure (29%) followed by embolization(17,4%). 68,7%of the p had surgical indication, being heart failure (49%) the most frequentreason for surgery. The second most frequent reason for surgery was myocardial invasion(18%). Global mortality at the end of the episode was 33%.Although myocardial invasion detected by echocardiography was predictor of mortality inthe univariate analysis, the unique predictors of mortality in the multivariate analysis were:staphylococcus caused IE, heart failure, septic shock and the abscence of surgical inter-vention when it was indicated.Conclusion: IE in our population has an incidenceof 5,1 episodes/100000/year.Themostfrequent germ is staphylococcus. First trasthoracic echocardiography is diagnostic onlyin the 59% of the p. Up to 50% of the p had an associated cardiac complication. Globalmortality at the end of the episode was 33%, and predictors of mortality were clinicaland microbiological but not echocardiographic.

P692Infective endocarditis: predictors of severity in a 3-year retrospective analysis

H. Nascimento; M. Braga; L. Flores; V. Ribeiro; F. Melao; P. Dias; MJ. Maciel; P. BettencourtSao Joao Hospital, Porto, Portugal

Introduction: The infective endocarditis (IE) incidence has not changed in the past fewdecades. Indeed, its morbidity and mortality cannot be underestimated. The aim of thisstudy was to conduct an epidemiological, clinical and echocardiographic analysis onIE patients in order to identify early predictors of adverse outcome.Methods: This study was based on a retrospective analysis of 173 consecutive patients ad-mittedinatertiarycenter fordefiniteorpossible IE,betweenJuly2011andJuly2014.Datawascollected from the electronic clinical process and registered in a uniform base. The primaryendpoints were a composite outcome of major complications (shock, heart failure, heartblock, systemic embolism and neurologic complications) and death during hospital stay.Results: Mean age was 61.9+17.7 years, 61.8% males. According to modified Duke cri-teria, 131 cases were definite IE. Only 4.6% were right-sided. Native valve IE was diagnosedin 48%, prosthetic valve IE in 38.7% and device-related IE in 7.5% of the cases. The majorcausative microorganisms were Staphylococcaceae (39.9%), followed by Streptococca-ceae (16.1%). No microorganism was identified in 19.1% of the cases. Major complicationsoccurred in 67.6% and in-hospital mortality rate was 27.2%. Complications were more fre-quent inpatients without fever (93% vs.61.9%, p,0.001),withdenovovalvular regurgitation(81% vs. 55.8%, p,0.001), leukocytosis (p,0.001) and neutrophilia (p=0.01). In multivari-able logistic regression, the predictors of major complications were de novo valvular regur-gitation (OR 2.899, 95% IC 1.358-6.190, p=0.006) and absence of fever (OR 7.942, 95% IC2.280-27.667,p=0.001). A sub analysisof the complicationsshowed that large (.10mm)ormultiplevegetations(OR2.553,95%IC1.147-5.681,p=0.022)wereassociatedwithsystem-ic embolism and the evidence of abscess was a risk factor for heart block (OR 4.575, 95% IC1.229-17.03, p=0.023). Independent predictors of in-hospital mortality by multivariate logis-tic regression modeling were age (OR 1.030, 95% IC 1.004-1.056, p=0.021), non-surgicaltreatment (OR 3.871, 95% IC 1.821-8.233, p,0.001) and acute heart failure (OR 2.842,95% IC 1.334-6.057, p=0.007).Conclusion: Our study shows absence of fever and de novo valvular regurgitation asindependent risk factors for major complications. Moreover, age, non-surgical treatmentand acute heart failure were significantly associated with in-hospital death. The identifica-tion of patients at risk of deleterious outcome may improve the therapeutic approachin the future.Abstract P690 Figure.

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P693New echocardiographic predictors of early recurrent mitral functionalregurgitation after mitraclip implantation

C. Ferreiro Quero; M D. Mesa Rubio; M. Ruiz Ortiz; M. Delgado Ortega;J. Sanchez Fernandez; E. Duran Jimenez; C. Morenate Navio; M. Romero; M. Pan;J. Suarez De LezoCardiology Department. University Hospital Reina Sofia, Cordoba, Spain

Purpose: Available criteria for MitraClip implantation (MCI) are those used in the EVERESTtrial, but new parameters might be needed for the selection of patients for MCI in order toimprove outcome. Our aim was to analyze the mitral valve (MV) anatomy and quantitativeparameters of functionalmitral regurgitation (MR) inpatients referred forMCI anddeterminewhich of them could predict early recurrence of regurgitation nafter MCI.Methods: we analyzed trantoracic (TTE) and transesophageal echocardiography(TEE) atbaseline, and TTE at discharge and first follow-up of patients referred for MCI to our institu-tion from October 2012 to January 2015 with symptomatic severe functional MR. On 2D-3DTEE MR grade(I-IV), jet origin and direction, annulus diameter, length of both leaflets, coap-tation length and depth, effective regurgitant orifice (ERO) and vena contracta by means3DETE color(vc3D) were analyzed. On baseline TTE we also analyzed left ventricular ejec-tion fraction (LVEF), left ventricular end left size. We developed receiver-operating charac-teristic (ROC) curves of parameters significantly associated with early MT recurrence.Result: MC implantation was susscesfully performed in 22 patients (2 clips implanted in 5,mean age 62+15 years and 72% male. The NYHA functional class at baseline was ≥III/VIin 70%, left ventricle end-diastolic volume was 203+50ml, LVEF 31%+13 and ERO was0.49+0.09. At discharge 20 patients were alive (2 exitus), 16 had MR grade ≤II and 4 hadMRgrade .II.At4.5+2month follow-up, MRgrade wasdetermined in17patients (2add-itional patients were deceased, 1 lost to follow-up): 4 persisted with MR grade. II, 10remained with MR grade ≤II, but 3 had worsened to grade .II (23%). In patients withMR which had MR≤II at discharge, those ones who presented MR.II in the first follow-upwere younger (42+24 versus 66+9, p=0.022) and presented a larger basal vc3D(0.47+0.01 cm2 versus 0.41+0.04,p=0.046) than those who remained with MRgrade ≤II. ROC analysis identified a 0.45 cm2 (AUC 0.94(95% CI 0.01-1, p=0.02)as theoptimal cut-off point for predicting MR recurrence. No significant differences werefounded between both groups in the rest of echocardiographic data.Conclusions: A greater vena contracta 3DETE could be more accurate than other para-meters to discriminatepatients withmore probablility ofworsening of functionalMRduringfollow up. This finding suggests that more extensive anatomical and functional selectioncriteria, beyond the EVERESTcriteria, could contribute to optimize MCI results in this highrisk patient population.

P694Transesophageal echocardiography can be reliably used for the allocation ofpatients with severe aortic stenosis for tras-catheter aortic valve implantation

S. Kazum; M. Vaturi; D. Weisenberg; D. Monakier; A. Valdman; H. Vaknin- Assa; A. Assali;R. Kornowski; A. Sagie; Y. ShapiraRabin Medical center, Cardiology, Petach Tikva, Israel

Background: Transesophageal echocardiography (TEE) in not universally implementedin the screening process of patients with aortic stenosis (AS) referred for trans-catheteraortic valve implantation (TAVI). Therefore, we looked at our institutional data on theimpact of TEE on patients’ allocation for TAVI, and its results.Methods: Our institutional database was sought for patients with native valve AS under-goingTEE screening forTAVI.Real-time 3-dimensionalTEE (RT3D) was used in wheneveravailable. Sizing was reconfirmed by a dedicated TAVI team. We looked at valve sizing asdetermined by pre-procedural TEE and its relation to post-procedural outcome.Results: During a 70 months period (11/2008-08/2014), 294 following patients underwentTAVI due to severe AS in native valve; 260/294 (88%) patients (age 82+4.12, 148 female,56%) underwent TEE for determination of valve choice, as part of TAVI screening,RT3D-TEE was available in 147/260 (56%) of patients. The transplanted models were Cor-evalve in 181 patients (70%), and Edwards Sapien in 79 patients (30%). In 243/260 (93%)patients there was an appropriate matching between TEE-based recommendations andimplanted valve size, whereas it was larger or smaller in 5 (2%) and 12 (5%) patients, re-spectively. The immediate post-procedural perivalvular leak (PVL), as determined byechocardiography in (254 patients) was≤ mild, mild to moderate and≥ moderate in217(85.4%), 36(14.2%), 1(0.4%) patients, respectively. The corresponding PVL grade atone month was 186 (78.5%), 44(18.6%), 6 (2.5%) out of 237 patients, respectively. In 3/6 patients, the possible reason for significant PVL at one month was bicuspid nativevalve, deep implantation, and undersizing. There was one case of valve migration andone case of fatal root rupture.Conclusion: Valve choice for TAVI can be reliably planned by TEE sizing, with a very smallrate of significant perivalvular leak or serious valve-related complications.

P695Annular sizing for transcatheter aortic valve selection. A comparison betweencomputed tomography and 3D echocardiography

S. Madeira; R. Ribeiras; J. Abecasis; R. Teles; M. Castro; A. Tralhao; E. Horta; J. Brito;M. Andrade; M. MendesHospital de Santa Cruz, Lisbon, Portugal

Introduction: Tri-dimensional imaging techniques such as CTangiography (CT) and 3Dtransesophageal echocardiography (3D TEE) have been used to study the anatomy, size

and calcification of the aortic annulus before transcatheter aortic valve implantation(TAVI).Aim: To compare the measurements and agreement of different imaging modalities invalve selection: CT (using two different softwares, the Osirix 32bit version and3Mension (3M) 2.0 version) and 3D TEE (Philips - 3DQ - MPR).Methods: Single centre retrospective analysis of 20 patients in whom both CTand 3D TEEwere used to study the annulus before TAVI.Three independent observers were blinded toeach other and to the type of implanted prosthesis (16 auto-expandable and 4 balloon ex-pandable). The following annulus variables were compared: orthogonal diameters in thesagittal and coronal planes, area, perimeter and mean diameter. The correlation analysisbetween the different methods was performed using the Spearman coefficient. The inter-method measurement differences were assessed by the Wilcoxon and Sign tests.Agreement was assessed by the construction of Bland-Altman plots.Results: There was a good correlation between CT measurements using Osirix and 3M (r..74 p , 0.02). The correlation was moderate between the measurements of CTand 3DTEE (r 0.46/0.66 for sagittal diameter/area and intermediate in the remaining variables p,0,05) and it was slightly superior for the 3M measurements. The 3D TEE measurementswere significantly inferior than the CTones, with the exceptions for the sagittal diameter inall comparisons (p,0.142) and for the coronal diameter when compared to the 3M results(p=0.064) (Table)Conclusion: The aortic annular diameters and areas measured by CT (Osirix, 3M) and 3DTEE (MPR) showed a fair correlation. Measurements by 3D TEE were significantly inferior,except for sagittal diameter (measured by CT- 3M and3D TEE–MPR), which was the mostconsistent variable among the three modalities.

P696Association between aortic dilatation, mitral valve prolapse and atrial septalaneurysm: first descriptive study.

JM. Villagra; G. Avegliano; R. Ronderos; MG. Matta; M. Camporrotondo; F. Castro;G. Albina; A. Aranda; D. NaviaInstituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina

Background: The association between aortic dilatation and mitral valve prolapse inMarfan syndrome is well established. In addition, several studies have demonstratedthat redundant subvalvular apparatus is a coexisting condition in patients with bicuspidaortic valve and aortic dilatation.Despite this evidence, the relationship between aortic dilatation with trileaflet aortic valve,atrial septal aneurysmand mitral valveprolapse has notbeendescribed.Weproposed theuse of mitral-aortic complex (MAC) for this entity.Purpose: The aim of this study was to examine a population with MAC and its character-istics.Methods: MAC was define by the coexistence of: ascending aortic dilatation (. 40 mm or. 22mm/m2), atrial septal aneurysm and mitral valve prolapse.Between 2010 and 2015 we included consecutive outpatients, aged ≥18 years, whoachieved the criteria of MAC in the Doppler echocardiography study. We excludedpatient with MArfan Syndrome and bicuspid aortic valve.Results:Atotal of47patientswithMACwere recorded withamaleproportion of76% andamean age of 53.4+8 years. Forty-four percent had hypertension, 34.04% were currentsmoking status, 23.40% had dyslipmeia and only 10.63% had COPD.The reasons for medical visits were: routine (14 patients), dyspnea (8), atrial fibrillation(3), atrial extrasystole (7), supra ventricular arrhythmias (14) and ventricular extrasystoles(2). Sixty-eight percent of the patients with arrhythmia complained for palpitations.The echocardiographic parameters are depicted in Table 1.Conclusions: This is the firs study that describe the MAC. Almost all patients were youngadult. The principal location of the aortic dilatation observed was in the sinuses of valsalvaand the most frequent medical complaint were palpitations in close relationship witharrhythmias.

Abstract P696 Table. Echocardiographic parameters.

Aortic dimensions mm (Median-RIC)

Maxima aortic dimension 43 (40-48)Annulus 24 (21-26)Sinuses of Valsalva 43(38-48)Sinotubular junction 41 (32-48)Proximal ascending 41 (36-46)

CARDIOMYOPATHIES

P698Cardiac resynchronization therapy by multipoint pacing improves the acuteresponse of left ventricular mechanics and fluid dynamics: a three-dimensionaland particle image velocimetry echo study

D. Muraru1; M. Siciliano1; F. Migliore1; S. Cavedon1; F. Folino1; G. Pedrizzetti2; M. Bertaglia1; D. Corrado1; S. Iliceto1; LP. Badano1

1University of Padua, Department of Cardiac, Thoracic and Vascular Sciences, Padua,Italy; 2University of Trieste, Department of Engineering and Architecture, Trieste, Italy

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Purpose: Multipoint pacing (MPP) is supposed to provide a more effective CRT than con-ventional biventricular pacing (BIV). We compared the acute effects of MPP versus BIVand no pacing (CRT-OFF) on LV function in CRT responders.Methods: In 9 consecutive CRT patients (65+11 years) receiving a quadripolar LV lead(QuartetTM) and showing a positive clinical response at 6 months, 3D echocardiography(3DE) and particle image velocimetry (Echo-PIV) were performed for each setting (MPP,BIV and CRT-OFF), during the same session. 3DE datasets were randomly analysed ina blinded fashion to obtain LV volumes, ejection fraction, strain and systolic dyssynchronyindex (SDI). Flow force angle (FFA) by Echo-PIV reflected the dominant direction of bloodflow momentum (08 when flow forces are parallel with LV long axis, and 908 when flowforces are transversal); accordingly, a lower FFA would reflect a more efficient bloodflow dynamics within the LV.Results: MPP resulted in a shorter QRS duration and in a significant reduction of LV 3Dvolumes in comparison with CRT-OFF and BIV (p,0.03). Moreover, MPP resulted inbetter LV ejection fraction (39 vs 34%), cardiac output (2.5 vs 2.1 ml/m2), 3D longitudinalstrain (-14.8 vs -12.1%), 3D circumferential strain (-16.6 vs -15.4%) and more synchronousLV contraction (SDI 5.5 vs 7.0%) than CRT-OFF (p,0.05 for all comparisons). FFA byEcho-PIV was significantly lower for BIV vs CRT-OFF (41.5 vs 48.38, p=0.002), and alsofor MPP vs BIV (38.1 vs 41.58, p=0.002, Figure).Conclusion: 3DE and Echo-PIV enabled to identify an acute improvement in LV systolicfunction and blood flow dynamics during MPP. This pilot study suggests that FFA byEcho-PIV could be a more sensitive echocardiographic index for evaluating the subtleeffects of various CRT modalities.

P699Long-term natural history of right ventricular function in dilated cardiomyopathy:innocent bystander or leading actor?

M. Gobbo1; M. Merlo1; D. Stolfo1; P. Losurdo1; F. Ramani1; G. Barbati1; A. Pivetta1;B. Pinamonti1; GF. Sinagra1; A. Di Lenarda2

1University Hospital Riuniti, Cardiovascular Department, Trieste, Italy; 2CardiovascularCenter A.S.S. 1 of Trieste, Trieste, Italy

Background: Right ventricular systolic function (RVF) is a known prognostic predictor indilated cardiomyopathy (DCM). However, whether RVF changes over time better predictlong-term disease progression has not been investigated. We analyzed the prognosticrole of RVF longitudinal trends in a large cohort of DCM patients.Methods and Results: From 1993 to 2008, we enrolled 635 DCM patients (46 [36-55]years, left ventricular ejection fraction 32 [25-41]%, with a potential follow-up ≥72months). Data at baseline and at pre-specified follow-up of 6, 24, 48, 72 months were con-sidered. RV dysfunction was defined as RV fractional area change (RV-FAC),35% at2D-echocardiography.At enrolment 128 (20%) patients had RV dysfunction. During follow-up, 89 (70%, 14% ofthe overall cohort) normalized RVF at a median time of 6 months, whereas 38 (6%,median time 36 months) exhibited a new-onset RV dysfunction. On baseline multivariateanalysis, RV dysfunction showed a borderline significance towards death/heart trans-plantation (HR=1.49, 95% CI 0.94–2.36, p=0.081). In time-dependent Cox model, theprognostic value of RVF revaluation was stronger than baseline assessment (HR=2.05,95% CI 1.2-3.6, p=0.01), with a progressively increasing effect over time. At ROC analysis,the time-dependent model showed abetter accuracy with respect to the baseline model ateach follow-up revaluation.Conclusions: DCM patients frequently present with RV dysfunction at first evaluation.However, a complete recovery of RVF is largely observed early after optimization ofmedical therapy. Systematic RVF revaluation throughout the regular follow-up conferredadditive long-term prognostic value to the baseline evaluation.

P700Right to left ventricular interdependence at rest and during exercise assessed bythe ratio between pulmonary systolic to diastolic time in heart failure reducedejection fraction

G. Generati; F. Bandera; M. Pellegrino; V. Labate; F. Carbone; E. Alfonzetti; M. GuazziIRCCS, Policlinico San Donato, Heart Failure Unit, San Donato Milanese, Italy

Background: the oxygen uptake (VO2) response to exercise, measured during cardio-pulmonary exercise testing (CPET), has prognostic value in heart failure (HF). The

increase in VO2 is due to the increase in cardiac output (CO) and arterial-mixed venousoxygen content difference (C(a-v)O2). How much (C(a-v)O2) contribute to VO2 increasemay be estimated by the CO/VO2 ratio.Aim: To study the cardiac and functional phenotype associated with CO/VO2 ratio at peakexercise in HF with reduced ejection fraction (HFrEF).Methods: 104 HFrEF patients (mean age 64+11 y, male %, ischemic etiology 68%,mean LVEF 34+9%) underwent a maximal CPET (incremental ramp protocol) combinedwith exercise-echo.Results: Study population was divided into 2 groups according to the peak exerciseCO/VO2 (cutoff 0.49, CO/VO2 median value) Group A (n=52) with CO/VO2 ,049 andB (n=52) with CO/VO2 ≥0.49. Despite similar peak VO2 (13.8 vs 12.6 mL/min/kgp=ns) patients with impaired CO exercise response (Group A) showed worse cardiacremodeling (LVEDV indexed 101+33 vs 91+23 mL/m2 p=0.09, E/e’28+15 vs 22+11 p=0.02) and more severe mitral regurgitation at rest and peak exercise (ERO rest22+10 16+9 mm2 p=0.02, peak 33+13 vs 25+12 mm2 p=0.03). Group A patientsexhibited also more impaired right ventricular function (TAPSE rest 17+5 vs 19+4 mmp=0.0001, peak 19+5 vs 21+4 p=0.04) associated with ventilatory inefficiency (VE/VCO2 slope 36+11 vs 31+7 p=0.01). The two Groups presented with similaraverage Hb levels.Conclusions: In advanced HF population, the worse exercise performance is associatedwitha reduced CO /VO2 ratio during maximal exercise, that for a similar peak VO2 as com-pared to the population with a high CO/VO2 ratio, is suggestive of “optimal” peripheral O2extraction as compensation to a reduced O2 delivery.

P701Exercise strain imaging demonstrates impaired right ventricular contractilereserve in patients with hypertrophic cardiomyopathy

A. D’andrea1; E. Di Palma1; L. Baldini1; M. Verrengia1; R. Vastarella1; G. Limongelli1;E. Bossone2; R. Calabro’1; MG. Russo1; G. Pacileo1

1Chair of Cardiology - Second University of Naples, Naples Italy, Italy; 2University ofSalerno, Heart Tower Department of Cardiology Salerno, Salerno, Italy

Background: The significance of reduced right ventricular (RV) deformation reported inpatientswith hypertrophic cardiomyopathy (HCM) is still unclear, highlighting thepossibleinvolvement of RV function in such pathologic left ventricular (LV) hypertrophy. The aim ofthis study was to assess RV functional reserve in HCM patients during exercise stressechocardiography (ESE).Methods: Thirty-five HCM patients (38.5+15.4 years; 26 males) and 30 sedentaryage- and sex-comparable healthy controls performed incremental exercise by supinebicycle ergometer with simultaneous echocardiographic measures of RV function.Two-dimensional and color-coded Doppler acquisitions were used to quantify tricuspidannular plane systolic excursion (TAPSE), Doppler Myocardial Imaging peak systolic vel-ocity (Sm), peak systolic strain and strain rate (SRs) for the basal, mid, and apical RV freewall and interventricular (IVS) septal wall. As further surrogate of contractility, the RV end-systolic pressure-area relationship was calculated from the tricuspid regurgitant velocityand the RVend-systolic area. Changes in multiple measures obtained throughout exercisewere used to assess the affect of exercise on RV contractility.Results: Interventricular septal thickness and LV mass index were higher in HCM,whereas both LV and RV end-diastolic diameters were comparable between thetwo groups. TAPSE and peak Sm were comparable between HCM and controls atrest, while baseline RV strain and SRs were significantly reduced in HCM in both lateral(p , 0.01) and septal (p,0.0001) walls. During exercise, exercise-induced increasesin TAPSE and RV Sm were similar for HCM and controls. Conversely, increases of RVend-systolic pressure-area and RV lateral strain were lower in HCM patients (9.3+3.5

Abstract P698 Figure. Analysis of flow force angle by Echo PIV


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% of increase in HCM vs 15.5+4.5 % in controls; p,0.001). There was a strong correl-ation of RV global strain and both RV end-systolic pressure-area relationship during exer-cise (r = - 0.71, p , 0.0001) as well as with exercise capacity (r = - 0.56; p,0.001).Furthermore, in the overall population, by multivariable analysis RV global strain (beta co-efficient: - 0.46, p,0.0001) was a powerful independent predictor of maximal workloadduring exercise stress echo.Conclusions: Impaired RV contractile reserve during effort for HCM suggests that thelower resting values of RV in HCM may represent early subclinical myocardial damage,closely associated with exercise capacity.

P702Prevalence of overt left ventricular dysfunction (burn-out phase) in a portuguesepopulation of hypertrophic cardiomyopathy, a multicentre study

O. Azevedo1; I. Cruz2; E. Correia3; D. Bento4; L. Teles5; C. Lourenco6; R. Faria7;K. Domingues8; B. Picarra9; N. Marques4

1Alto Ave Hospital Center, Guimaraes, Portugal; 2Hospital Garcia de Orta, Almada,Portugal; 3Hospital Sao Teotonio, Viseu, Portugal; 4Algarve Hospital Center, Faro, Portugal;5University Hospitals of Coimbra, Coimbra, Portugal; 6Hospital Centre do Tamega e Sousa,Penafiel, Portugal; 7Medio Ave Hospital Center, Vila Nova de Famalicao, Portugal;8Hospital of Santarem, Santarem, Portugal; 9Hospital Espirito Santo de Evora, Evora,Portugal

Introduction: In hypertrophic cardiomyopathy (HCM), the left ventricular (LV) hyper-trophy is usually associated to normal or supranormal LV ejection fraction. A minority ofpatients with HCM, however, progress to a stage of LV dilation and overt systolic dysfunc-tion with reduced LV ejection fraction, also known as “burn-out phase”. The prevalence ofpatients with HCM in the “burn-out phase” ranges from 2.4 and 4.9% in recent studies.Aim: To characterize a Portuguese population of patients with HCM and to determine theprevalence of patients with HCM in the “burn-out phase”.Methods: Portuguese multicenter study involving 11 hospital centers and including allpatients diagnosed with HCM. We evaluated the clinical, genetic, electrocardiographic,echocardiographic and cardiac MRI data. We determined the prevalence of the“burn-out phase”, considering that “burn-out phase” was present when there was a LVejection fraction below 50%.Results: We included 461 patients with HCM, 60% males, mean age 61+15 years. About62% of patients were symptomatic, and dyspnea (54%), angina (18%) and syncope (11%)were the most commonsymptoms. The HCM was asymmetric in 75%, symmetrical in 11%and apical in 14% of patients. The average IVS thickness was 18+5 mm and the posteriorwall 11+3 mm. The average LV ejection fraction was 65+9%. Obstruction at rest wasfound in 27% of cases and latent obstruction in 12% of cases. Mitral regurgitation wasdetected in 18% of cases. Delayed gadolinium enhancement on cardiac MRI was foundin 63% of the patients. Most patients were in sinus rhythm (80%). A history of atrial fibrilla-tion was present on 20% of the patients and non-sustained ventricular tachycardia in 18%of the cases. About 5% of patients had pacemaker and 10% had ICD. Family history ofHCM was identified in 25% and family history of sudden death in 15% of cases. Genetictesting was performed in 223 patients (48%) and revealed genetic mutations in 39% ofthose cases. Cardiac death occurred in 1.7% of cases (mean follow-up of 5 years).In this portuguese population of patients with HCM, the prevalence of patients on the“burn-out phase” is 3.7%.Conclusions: In this Portuguese population of patients with HCM, the prevalence of the“burn-out phase” is 3.7%, which is consistent with the findings of recent studies.

P703Systolicanddiastolicmyocardialmechanics inhypertrophiccardiomyopathy andtheir link to the extent of hypertrophy, replacement fibrosis and interstitial fibrosis

G. Nucifora; D. Muser; P. Gianfagna; G. Morocutti; A. ProclemerCardiothoracic Department, University Hospital “Santa Maria della Misericordia”, Udine,Italy

Aim: Aim of the present study was to investigate the relations between myocardialmechanics and the extent of hypertrophy, replacement fibrosis and interstitial fibrosis inhypertrophic cardiomyopathy (HCM), using cardiac magnetic resonance (cMR)imaging. cMR imaging provides indeed the unique opportunity to non-invasively evaluateall these features during a single examination. METHODS. Forty-five consecutive patientswith HCM and 15 subjects without structural heart disease were included. Cardiac mag-netic resonance (cMR) with late gadolinium enhancement (LGE) imaging was performedto evaluate biventricular function, LV mass index and presence/extent of LGE, expressionof replacement fibrosis. Myocardial T1 relaxation, a surrogate of interstitial fibrosis, wasmeasured from Look-Locker sequence. Feature-tracking analysis was applied to LVbasal, mid and apical short-axis images to assess systolic and diastolic global LV circum-ferential strain (CS) and strain rate (CSr).Results: Peak systolic CS and CSr were significantly higher among HCM patients ascom-pared to control subjects (-25+8 vs. -22+3; p=0.015 and -1.66+0.61 vs. -1.33+0.27;p=0.007, respectively). The ratio of peak CSr during early filling to peak systolic CSr wassignificantly lower among HCM patients (0.88+0.25 vs. 1.11+0.17; p=0.002). At multi-variate linear regression analysis, LV mass index (b=-0.56; p,0.001) and %LV LGE(b=0.33; p=0.005) were significantly and independently related to peak systolic CS; LVmass index (b=-0.51; p,0.001) and %LV LGE (b = 0.30; p=0.023) were significantlyand independently related to peak systolic CSr; %LV LGE (b=0.31; p=0.021) and T1ratio (b=-0.37; p=0.006) were significantly and independently related to the ratio ofpeak CSr during early filling to peak systolic CSr.

Conclusions: LV systolic mechanics are enhanced and LV diastolic mechanics areimpaired in HCM. Extent of hypertrophy and replacement fibrosis influences the LV systol-ic mechanics while extent of replacement fibrosis and interstitial fibrosis influence the LVdiastolic mechanics.

P704Multimodality imaging and genotype-phenotype associations in a cohort ofpatients with hypertrophic cardiomyopathy studied by next generationsequencing and cardiac magnetic resonance

I. Cruz1; AC. Gomes1; LR. Lopes1; B. Stuart1; D. Caldeira1; G. Morgado1; AR. Almeida1;P. Canedo2; C. Bagulho3; H. Pereira1

1Hospital Garcia de Orta, Department of Cardiology, Almada, Portugal; 2Institute ofMolecular and Cell Biology, IPATIMUP, Porto, Portugal; 3Hospital Garcia de Orta,Radiology, Almada, Portugal

Hypertrophic cardiomyopathy (HCM) has a multiple phenotypic expression and geneticvariants, making it difficult to establish genotype-phenotype associations (GPA).Aim: Evaluate GPA in a genetically characterized HCM cohort, studied with cardiac mag-netic resonance(MR).Methods: Prospective clinical, electro/echocardiographic, MR and genetic testing studyof consecutive patients (pts) with HCM followed in a dedicated clinic.Results: 116 pts, 60 underwent MR (age 54.9+14.4y, 60% males): maximal wall thick-ness (MWT) of the left ventricle (LV) 19.3+5.0mm, asymmetric septal hypertrophy 80%,mass 159.4+69.6g, LV end-diastolic volume (LVTDV) 149.5+39.4ml, LV ejection frac-tion (LVEF) 60.9+11.5%; acceleration of flow in the LVoutflow tract (LVOT) in 51.7%; lategadolinium enhancement (LGE) in 44 pts (73.3%) distributed in 2.8+1.9 segments.Sarcomeric mutations identified in 30%. Sudden cardiac death risk at 5 years was2.73+4.28% (0.096-25.79). On echo, LVOT gradient .30 mmHg was detected atrest in 23% and at rest/provoked by exercise stress echo in 53.8%. The presence ofrest/provoked obstruction was associated with a higher prevalence of acceleration offlow in the LVOT (77.3vs23.5%, p=0.001) and SAM of the mitral valve(93.3vs26.7%,p,0.0005), as detected by MR; the same was not observed for the pres-ence of a LVOT gradient .30 mmHg only at rest. Echo LVOTobstruction was also asso-ciated with increased MWT (21.4+5.7vs17.7+4.4, p=0.035), increased mass(186.5+81.2vs137.9+42.2, p=0.024) and increased LVEF (63.9+10.6vs57.7+11.7%, p=0.037), evaluated by MR. Stroke during follow-up was associated with alower LVEF at MRI (47.5+15.6vs62.1+11.2%, p=0.020) and a higher number ofhypertrophied segments (5.5+1.3vs3.7+1.8, p=0.049). Non-sustained ventriculartachycardia (NSVT) was associated with higher ventricular dimensions at MR (LVEDV169.3+52.9vs140.3+34.4ml, p=0.037; LVESV 82.2+50.6vs53.7+19.5ml,p=0.009) and a trend towards lower LVEF (55.1+15.8vs62.5+9.2%, p=0.057).There was no relationship between the presence of LGE and NSVT. Pts with lowerLVEF showed a higher number of segments with LGE (5.0+1.8vs2.7+1.7,p=0.015). The presence of a MYH7 mutation was associated with lower mass(111.0+22.9vs158.9+63.2g, p=0.005) and lower blood pressure response to exer-cise (2.0+4.5vs 16.8+25.7mmHg, p=0.002); pts with MYBC3 mutations had ahigher rate of ICD implantation (23.1%vs3.7%, p=0.017).Conclusions: MR parameters were associated with events occurrence, such as strokeand NSVT. LVOT obstruction and SAM on MR can identify pts with latent obstruction.New GPA were detected with potential prognostic value.

P705Suddencardiacdeathriskassessment inapicalhypertrophiccardiomyopathy:dowe need to add MRI to the equation?

VC. Lozano Granero; A. Pardo Sanz; A. Marco Del Castillo; JM. Monteagudo Ruiz;LM. Rincon Diaz; F. Ruiz Rejon; E. Casas; R. Hinojar; C. Fernandez-Golfin;JL. Zamorano GomezUniversity Hospital Ramon y Cajal de Madrid, Cardiology, Madrid, Spain

Purpuse: Apical hypertrophic cardiomyopathy (AHCM) has long been considered abenign variant of hypertrophic cardiomyopathy (HCM), with a good long-term prognosisand a low risk of sudden cardiac death (SCD). The use of implantable cardioverter defibril-lators (ICD) in this population is usually not contemplated by clinicians, although somerecent evidence has shown that AHCM could be less benign than previously suspected.Last year, the European Society of Cardiology published a novel clinical risk predictionmodel for SCD in HCM, along with an on-line risk calculator that provides a 5-year SCDrisk estimation according to conventional risk factors (wall thickness ≥30 mm, non-sustained ventricular tachycardia, family history of SCD and unexplained syncope) and4 other parameters. The aim of our study was to describe our AHCM population riskprofile according to this novel tool.Methods: A case search over clinical and echocardiographic databases was conducted.Patients were considered to have AHCM if two independent clinicians agreed on the diag-nosis based on echocardiographic or magnetic resonance imaging (MRI) criteria. Demo-graphic, clinical, echocardiographic and MRI data was collected.Results: A total of 88 patients with AHCM were identified. 18 patients (20.45%) had at leastone predictor missing and thus their 5-year SCD risk could not be estimated. The remain-ing 70 patients, 38 men (54.29%) and 32 women (45.71%), had a median 5-year estimatedSCD risk of 1.36%, with 4 (5.71%) patients having an estimated risk ≥4% (1 of them ≥6%),the cut-off stated as ideal to consider ICD use. The 5-year SCD risk was significantly higherin patients with familial history of HCM than in patients without it (median 5-year 2,61% vs.1.28%, p=0.002), independently of the familial history of SCD. The 5-year SCD risk was

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also significantly higher in men than women (mean 5-year SCD risk 1.66% vs 1.21%, p=0.02), but this finding could be explained by the lower age of the men subpopulation(mean age in men 63 years vs. 74 years in women, p=0.003). Among the 70 patients ana-lyzed, 29 patients (41,43%) had underwent MRI examination, 21 of whom (71,41%) hadlate gadolinium enhancement. A difference in 5-year SCD between patients with orwithout LGE could not be seen (median 5-year SCD risk 1.46% vs 1.88%, p=0.73).Conclusion: A similar proportion of ≥4% 5-year estimated SCD risk could be seen in ourAHCM population compared to classical HCM, thus highlighting the need for a systema-ticalassessment ofSCD risk,especially in familial formsof the disease.LGEonMRIdidnothelp differentiate between high and low risk patients.

P706Prognostic value of left ventricular ejection fraction, proBNP, exercise capacity,and NYHA functional class in patients with left ventricular non-compactioncardiomyopathy

S F. Stampfli1; L. Erhart1; BE. Staehli1; BA. Kaufmann2; FC. Tanner11University Heart Center, Cardiology, Zurich, Switzerland; 2University Hospital Basel,Basel, Switzerland

Background: Left ventricular non-compaction cardiomyopathy (LVNC) is a potentially lifethreatening disease,characterized bya thin, compacted epicardial layer anda thickendo-cardial layer with prominent trabeculations and deep recesses. While parameters asses-sing left ventricular function, exercise capacity, and heart failure have been shown tocorrelate with clinical outcome in other cardiomyopathies, their value in LVNC is illdefined. In particular, the role of proBNP has never been assessed. The goal of thisstudy was to determine the prognostic value of left ventricular ejection fraction, proBNP,exercise capacity, and NYHA functional class in patients with LVNC.Methods: All 148 patients with isolated LVNC as diagnosed by echocardiography and/ormagnetic resonance imaging from the University Hospitals Zurich and Basel between1988 and 2015 were included in a patient registry. Left ventricular ejection fraction wasdetermined by biplane Simpson’s method, proBNP was assessed by the clinical chemis-try laboratories, and exercise capacity was determined by bicycle ergometer. Unadjustedand adjusted (for age and gender) Cox regression analyses were performed to analyzethe occurrence of death or heart transplantation.Results: Adjusted time to event analysis revealed a highly significant inverse relationshipbetween left ventricular ejection fraction and the risk of death or heart transplantation (HR0.91, 95%-CI 0.87-0.96, p,0.0001, n = 148). In line with this, higher proBNP levels (HR3.62, 95%-CI 1.71-7.64, p = 0.0003, n = 87) were strongly associated with an increasedrisk of death or heart transplantation. Similarly, an increase in NYHA class was associatedwith a worse outcome (HR 3.58, 95%-CI 1.57-8.15, p = 0.002, n = 105) The analysis of ex-ercise capacity revealed a trend in the same direction (p = 0.072, n = 86).Conclusion: This study provides novel evidence that impaired left ventricular systolicfunction as well as an increase in proBNP or NYHA functional class is associated with ahigher risk of death or heart transplantation in patients with LVNC.

P707The anti-hypertrophic microRNAs miR-1, miR-133a and miR-26b and theirrelationship to left ventricular hypertrophy in patients with essential hypertension

M. Marketou; J. Kontaraki; F. Parthenakis; S. Maragkoudakis; E. Zacharis; A. Patrianakos;P. VardasHeraklion University Hospital, Heraklion, Greece

Purpose: MicroRNAs modulate cardiovascular development and disease by post-transcriptional gene expression regulation and thus they are emerging as potential biomar-kers and promising therapeutic targets in cardiovascular disease. Left ventricular hyper-trophy is a significant risk factor for cardiovascular complications in hypertension. Recentstudies have shown that microRNAs (miRs) play a major regulatory role in severalaspects of physiological and pathological cardiac hypertrophy. MiR-1, miR-133a andmiR-26b have been shown in animal models to play a role in heart hypertrophy mainlyhaving anti-hypertrophic function. We evaluated whether the anti-hypertrophic microRNAsmiR-1, miR-133a and miR-26b were differentially expressed in peripheral blood mono-nuclear cells of hypertensive patients in relation to left ventricular hypertrophy.Methods: We assessed the expression levels of the microRNAs miR-1, miR-133a andmiR-26b, in 104 patients with essential hypertension (52 men, mean age 62.7+10years) and 32 healthy individuals (14 men, mean age 58.9+8.4 years). All patients under-went two-dimensional echocardiography. MicroRNA expression levels in peripheralblood mononuclear cells were quantified by real-time reverse transcription polymerasechain reaction.Results: Hypertensive patients showed significantly lower miR-133a (5.06+0.50 versus13.27+2.15, p,0.001) and miR-26b (6.76+0.53 versus 9.36+1.40, p=0.037) andhigher miR-1 (25.99+3.07 versus 12.28+2.06, p=0.019) expression levels comparedwith healthy controls. In hypertensive patients, we observed significant negative correla-tions of miR-1 (r=-0.374, p,0.001) and miR-133a (r=-0.431, p,0.001) and a significantpositive correlation of miR-26b (r=0.302, p=0.002) expression levels with left ventricularmass index.Conclusions: Our data reveal that miR-1, miR-133a and miR-26b show a distinct expres-sion profile in hypertensive patients relative to healthy individuals and they are associatedwith left ventricular mass index in hypertensive patients. Thus, they may be involved in thepathophysiology of left ventricularhypertrophy in hypertensivepatientsandmay beprom-ising therapeutic targets in hypertensive heart disease

P708Prevalence of left ventricular systolic dysfunction in a portuguese population ofleft ventricular non-compaction cardiomyopathy, a multicentre study

D. Bento1; K. Domingues2; E. Correia3; L. Lopes4; L. Teles5; B. Picarra6; P. Magalhaes7;R. Faria8; C. Lourenco9; O. Azevedo10

1Algarve Hospital Center, Faro, Portugal; 2Hospital of Santarem, Santarem, Portugal;3Hospital Sao Teotonio, Viseu, Portugal; 4Hospital Garcia de Orta, Almada, Portugal;5University Hospitals of Coimbra, Coimbra, Portugal; 6Hospital Espirito Santo de Evora,Evora, Portugal; 7Hospital Center of Tras-os-Montes and Alto Douro, Vila Real, Portugal;8Medio Ave Hospital Center, Vila Nova de Famalicao, Portugal; 9Hospital Centre doTamega e Sousa, Penafiel, Portugal; 10Alto Ave Hospital Center, Guimaraes, Portugal

Introduction: Left ventricular non-compaction cardiomyopathy (LVNC) may be compli-cated with left ventricular (LV) systolic dysfunction and heart failure. The prevalence ofLV systolic dysfunction in patients with LVNC ranges from 58 to 82% of cases in previousstudies. However, natural history of LVNC is not clearly established and recent studiesshow that prognosis of LVNC seems to be better than previously described.Aim: To characterize a Portuguese population of patients with LVNC and to determine theprevalence of LV systolic dysfunction in patients with LVNC.Methods: Portuguese multicenter study involving 11 hospital centers and including allpatients diagnosed with LVNC. We evaluated the clinical, electrocardiographic, echocar-diographic and cardiac MRI data. We determined the prevalence of LV systolic dysfunc-tion, considering it to be present when a LV ejection fraction was below 50%.Results: We included 81 patients with LVNC, 58% males, with mean age 46+20 years.Symptoms were present in 48% of patients, and dyspnea (37%) and palpitations (27%)were the most common symptoms. Most patients were in sinus rhythm (89%). A historyof atrial fibrillation was present in 10% of the patients and non-sustained ventricular tachy-cardia in 11% of the cases. Family history of LVNC was identified in 7% of cases.Diagnosis of LVNC was established by echocardiogram in 90% of patients. In this Portu-guese population of patients with LVNC, the prevalence of patients with LV systolic dys-function is 41%. The average LV ejection fraction was 47+16%. Mitral regurgitationwas detected in 15% of cases. Delayed gadolinium enhancement on cardiac MRI wasfound in 31% of patients submitted to cardiac MRI. Cardiac death occurred in 2.4% ofcases (mean follow-up of 48 months).Conclusions: In this Portuguese population of patients with LVNC, the prevalence of LVsystolic dysfunction is 41%, lower than previously reported in the literature, which sup-ports the current idea that prognosis of LVNC may be better than previously described.Larger studies are needed to better understand the natural history of LVNC.

P709Assessment of systolic and diastolic features in light chain amyloidosis: anechocardiographic and cardiac magnetic resonance study

D. Mohty1; C. Boulogne1; J. Magne1; T. Damy2; S. Martin1; MP. Boncoeur1; V. Aboyans1;A. Jaccard1

1University Hospital of Limoges - Hospital Dupuytren, Limoges, France; 2CHU Mondor,Department of cardiology, Creteil, France

Background: Cardiac involvement in systemic light-chain amyloidosis (AL) is character-ized by normal or slightly decreased left ventricular (LV) ejection fraction and diastolic dys-function with left atrial (LA) enlargement. To assess cardiac involvement, the Mayo Clinicstaging (MC) using NTproBNP and troponin, has been validated and allows stratificationof patients into 3 groups with different outcomes. Cardiac magnetic resonance (CMR)assesses accurately chambers size and function. We aimed to compare by TTE, featuresof LV systolic and diastolic function and by CMR, morphological functional parametersnamely LV myocardial late gadolinium enhancement (LGE) and indexed max LAvolume (LAVi) and emptying fraction (LAEF).Methods and Results: Forty-two consecutive patients (66+10 years, 57% males) insinus rhythm with confirmed systemic AL, underwent simultaneously TTE and CMRwithin 24 hours. LAEF was calculated after assessing maximal and minimal LAVi(by area/length formula) using 4 and 2 chambers views. Diastolic parameters and2D-LV global longitudinal strain (GLS) obtained by TTE were stratified according toLAEF, to LAVi and to the presence or not of LGE. Patients in MC stage III had the worseTTE and CMR parameters. LV GLS (-10.1+3.1 vs. -17.3+3.7, p,0.001), decelerationtime, E/A ratio and lateral E/e’ ratio, were significantly altered in patients with low LAEF, 17.5% vs. those with higher LAEF, whereas, they were not significantly differentaccording to maxLAVi. GLS was decreased in patients with LGE when compared tothose without.(fig)Conclusion: In systemic AL, reduced LV GLS is associated with presence ofLGE while impaired LV filling pressures are r related to decreased LA emptyingfraction. Multimodality imaging in patients with AL may allow better assessment of LVhemodynamics.


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P710Morbid obesity-associated hypertension identifies bariatric surgery bestresponders: Clinical and echocardiographic follow up study

V. Hernandez Jimenez1; J. Saavedra Falero2; MT. Alberca Vela2; L. Molina Blazquez2;R. Mata Caballero2; JA. Serrano Rosado2; R. Elviro2

1Hospital Rey Juan Carlos, Cardiology, Mostoles, Spain; 2Hospital Universitario de Getafe,Madrid, Spain

Purpose: Morbid obesity induces anatomic and functional changes in the heart, thusincreasing cardiovascular risk. These patients often have other associated comorbid-ities such as hypertension. Bariatric surgery (BS) has evolved as the most effectiveweight-loss treatment. A protective cardiovascular effect of such weight-loss hasbeen observed with subsequent improvement of both systolic and diastolic biventricu-lar function. We aimed to study the role of hypertension in identifying those morbidlyobese patients with a better response to BS by means of right ventricle (RV) systolicfunction.Methods: We consecutively included 38 morbidly obese patients undergoing BS anddivided them into 2 groups according to hypertension. Anthropometric measurements,blood tests and an echocardiogram were performed 1 month before and 6 months aftersurgery.Results: Our sample mean age was 44.6 years and 85.6% were females. 54.8% ofpatients had hypertension. BMI before surgery was similar in both groups (hypertensives:47.04 kg/m2 vs normotensives: 47.44 kg/m2, p=0,58). 6 months after surgery, overallmean weight loss percentage was 31.3%, although significantly greater in hypertensivesubjects (34,6% vs 28,3%, p=0,02).RV systolic function according to TAPSE was 25.6 mm before surgery and tended to belower in hypertensive subjects (hypertensives group 24.4 mm Vs normotensives group26,5 mm, p=0,08).Six months after BS, TAPSE significantly increased in hypertensive subjects but remainedunchanged in normotensives (hypertensive group 27.7 mm Vs normotensive group 26,3mm, p=0,006) (Graphic 1).Conclusions: Morbid obesity-associated hypertension identifies a group of betterresponders to BS by means of:1. A greater weight loss than normotensives.2. An improvement in RV systolic function.

P711Echocardiographic markera for overhydration in patients under haemodialysis

R. Gascuena; C. Di Gioia; I. Fernandez Rozas; MC. Manzano; JI. Martinez Sanchez;M. Molina; J. PalmaHospital Universitario Severo Ochoa, Madrid, Spain

Chronic fluid overload is common and difficult to be assessed in haemodialysispatients, and it associates with higher cardiovascular morbidity and mortality. Multifre-quency bioimpedance spectroscopy (BIS) allows objective definition of individualoverhydration status. There are limited data on echocardiographic parametersevaluating hydration status in patients undergoing dialysis. Our aim was to assess therelationship between hydration status and echocardiographic parameters in patientson haemodialysis.Methods: We conducted a cross-sectional, observational study in 76 clinically stablepatients with a median age of 63.14 (60.1-66.2) y.o., 52 men (68.4%), 40.8% diabetics,30.3% hypertensive. Demographic, biochemical and bioimpedance parameterswere obtained. Relative fluid overload (FO/ECW) and weekly fluid overload (TAFO)were calculated. Patients underwent echocardiography on the day following midweekdialysis. 2D, M-mode, Tissue and color Doppler registries were obtained, and indexedcavities dimensions and hypertrophy degree calculated.ANOVA and regressionmethods correlating and adjusting these parameters to TAFO and bioimpedance para-meters were employed.Results: Left atrial volume index (LAVI) showed a significant correlation with weekly TAFO(Spearman’s rho 0.29;p=0.013) but not with relative flow overflow (FO/ECW) (Spearmansrho 0.06; p=0.61). Hydration status defined by weekly TAFO, but not a FO/ECW .15%,kept a significant relationship with LAVI after adjusting for muscle mass and fatpercentages related to total weight, and diastolic function measured by transmitral E/Avelocities ratio (p=0.036). No significant relationship was found between Left ventricleHypertrophy (73.7% of patients), and hydration status (p=0.838), with a somewhat lessthan expected incidence of eccentric hypertrophy, and a tendence to dehydratation inthe management of these patient. Left atrial enlargement, yielded a moderate Sensitivity

(66.7%) and specificity (52%), with a good negative predictive value (85.5%), for detectingoverhydration (defined as TAFO.1.5 l/week).Conclusions: We found that left atrial volume index, but not left ventricle hypertrophy ordimensions of cavities, depends on hydration status based on bioimpedance measuredTAFO, and not on relative fluid overflow (FO/ECW). Atrial enlargement yields a moderatesensitiveandspecificity,but agood negativepredictive value, fordetectingbioimpedanceTAFO-defined overhydration. Our cross-sectional study includes a relatively smallnumber of patients from a single centre.

P712Gender aspects of right ventricular size and function in clinically stable hearttransplant patients

A. Ingvarsson1; A. Werther Evaldsson1; G. Radegran1; M. Stagmo1; J.Waktare2; A. Roijer1;CJ. Meurling1

1Lund University, Skane University Hospital, Department of Cardiology, Lund, Sweden;2Liverpool Heart and Chest Hospital, Liverpool, United Kingdom

Purpose: Impaired right ventricular (RV) longitudinal motion is a well described featurefollowing cardiac surgery. However, the possible impact of heart transplantation (HTx)on right ventricular size and function is complex and sparsely studied. The primary aimof the present study was to investigate if the transplanted heart exhibit gender-specificechocardiographic features regarding RV-size, function and cardiac mechanics.Methods:A total of 120 consecutiveHTx-patients (mean age55+16 years; 85men) wereprospectively evaluated 7+6 years (range 1-24 years) after transplantation. Patientswere examined with 2-D echocardiography using iE33 (Philips) and speckle trackingechocardiography (STE) analyses were performed offline using software Q-lab version10.1 (Philips). Data are expressed as mean+SD and statistical significance wasdefined as p,0.05.Results: RV size: RV outflow tract 31+5mm (male 32+5mm vs. female 27+4mm,p,0.001), RV basal diameter was 37+6mm (male 32+5mm vs. female 27+4mm,p,0.001), RV mid diameter was 32+6mm (34+6mm vs. female 29+5mm,p,0.01), RV longitudinal diameter was 66+11mm (male vs. female n.s). RV end-diastolic area was 9.2+3.1cm2/m2 and systolic area was 5.8+2cm2/m2 (male vs.female n.s). RV function: Tricuspid annular plane systolic excursion (TAPSE) was 15+4mm, Systolic tissue Doppler (S) 9+2cm/s, fractional area change (FAC) 38+7%,right index of myocardial performance (RIMP) 0.35+0.20 and isovolumetric acceleration(IVA) 2.3+1.0cm/s2. RV global longitudinal strain (RVGLS) and strain obtained fromaveraging the three segments of the RV lateral free wall (RVfree) were -15.1+4.1%(male -14.6+4.2% vs. female -16.6+3.1%, p,0.05) and -15.8+4.3 (male -15.3+4.4% vs. female -17.2+3.4%, p,0.05) respectively.Conclusions: Our study demonstrates that there are differences is RV-size based ongender when measuring absolute values such as diameters. Not surprisingly, malegender is associated with larger RV correlating to higher body surface area. Conventionalparameters of RV longitudinal function (i.e. TAPSE and S’) are slightly decreased whereasparameters measuring overall RV function, are normal and no gender-differences arenoted. Measures of active longitudinal contraction are reduced. Noteworthy, althoughnot normal, women have significantly better longitudinal strain. This study indicatesthat specific normal values based on gender is desirable. We also recommend that RVfunction should be assessed using as many of the parameters above possible, sincesolely measuring longitudinal function could underestimate RV-function in this patientgroup.

P713Evidence of cardiac stem cells from the left ventricular apical tip in patientsundergone LVAD implant: a comparative strain-ultrastructural study

M. Cameli1; FM. Righini1; S. Sparla1; C. Di Tommaso1; M. Focardi1; F. D’ascenzi1;D. Tacchini2; M. Maccherini3; M. Henein4; S. Mondillo1

1University of Siena, Department of Cardiovascular Diseases, Siena, Italy; 2Santa Maria AlleScotte Polyclinic, Siena, Italy; 3Department of Cardiovascular Diseases, Heart TransplantUnit, Siena, Italy; 4Heart Centre & Department of Public Health & Clinical Medicine, UmeaUniversity, Umea, Sweden

Background: Recent studies have challenged the dogma that the adult heart is a postmi-totic organ and raise the possibility of the existence of resident cardiac stem cells (CSCs).Our study aimed at exploring if the isolation of colonies of CSCs from “ventricular tip”obtained from patients with end-stage heart failure (HF) undergoing left ventricularassist device (LVAD) implantation was possible and how it correlated with LV dysfunction-al area extent.Methods: Four consecutive patients with ischemic cardiomiophathy and end-stage HFsubmitted to LVAD implantation were studied. The explanted “ventricular tip” was usedasasample ofapical myocardial tissue for the pathological exam.Patientsunderwent clin-ical and echocardiographic examination, both standard transthoracic echocardiography(TTE) and speckle tracking echocardiography (STE) before LVAD implantation.Results: All patients presented severe apical dysfunction, with apical akinesis/diskinesisand very low levels of apical longitudinal strain (-3.5+2.9%). Despite this, it was demon-strated the presence of CSCs in pathological myocardial samples of “ventricular tip” in allthe 4 patients. It was found 6 c-kit cells in 10 fields magnification 40x.Conclusions: Multipotent cells can be isolated in the LVapical segment of patients under-gone LVAD implantation despite LV apical fibrosis.


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SYSTEMIC DISEASES AND OTHER CONDITIONS

P714Speckle tracking assessment of right ventricular function is superior fordifferentiation of pressure versus volume overloaded right ventricle

A. Werther Evaldsson1; A. Ingvarsson1; J. Waktare2; U. Thilen1; M. Stagmo1; A. Roijer1;G. Radegran1; C. Meurling1

1Lund University, Department of Cardiology, Clinical Sciences, Lund, Sweden; 2LiverpoolHeart and Chest Hospital, Liverpool, United Kingdom

Background: Pulmonary hypertension (PH) may be caused by either pressure or volumeoverload which requires different medical treatment. Right ventricular (RV) function is con-ventionally measured with tricuspid annular plane systolic excursion (TAPSE) and tissueDoppler-derived tricuspid lateral annular systolic velocity (S). Speckle tracking derivedstrain (STE) analysis is a new tool for assessing myocardial function. The purpose ofthis study was to evaluate if conventional echocardiographic parameters and STEcould be used to differentiate these two causes of elevated pulmonary pressure. Materialand Methods: Consecutive patients (n=89) with echocardiographic elevated pulmonarypressure defined as a trans-tricuspid gradient .30 mmHg, was enrolled and examinedusing Philips iE33. Forty-five patients with PH due to pulmonary arterial hypertensionand chronic thromboembolic pulmonary hypertension (pressure overload) were com-prised with 44 patients with atrial septum defect (volume overload). TAPSE and S wereanalyzed with Xcelera. Right ventricular global longitudinal strain (RVGLS) and RV-freewall strain (RVfree), were analyzed offline with Philips Q-lab 10.1. RVfree was calculatedaveraging the three regional peak systolic strain values along the free lateral wall.Values are expressed as mean+SD and P,0.05 was considered statistical significant.Receiver operating characteristics (ROC) and area under the curve (AUC) was calculatedby the software (SPSS Statistics).Results: TAPSE was significantly lower in the pressure group (20+5mm) compared tothe volume group (24+7mm, p,0.001) as was S (11.1+3.1cm/s vs. 13.8+2.6 cm/s,p,0.001). AUC was 0.688 for TAPSE and 0.757 for S. RVGLS was significantly lower inthe pressure group (-13.2+3.2% vs -18.8+4.0 %, p,0.001) as was RV-free (-12.8+3.4 % vs. -19.8+3.9 %, p,0.001). Using analysis of the ROC a strain value of -16% forboth RVGLS and RVfree was useful for identifying RV pressure overload with an AUC of0.916 for RVGLS (sensitivity of 80%, specificity of 88%) and 0.918 for RV-free (sensitivityof 81%, 87 % specificity).Conclusion: This study suggest that parameters for assessing RV function have clinicalutility to differentiate patients with pressure overload from those with volume overload. Inthis study myocardial function by STE was a superior differentiator. This may be becauseTAPSE and S are unable to differentiate active deformation from passive entrainmentcaused by the left ventricle. We suggests a cut-off value of -16 % for both RVGLS andRV-free, where , -16% predicts RV pressure overload with high accuracy.

P715Prognostic value of pulmonary arterial pressure: analysis in a large dataset oftimely matched non-invasive and invasive assessments

S. Greiner; A. Jud; M. Aurich; HA. Katus; D. MerelesUniversity Hospital of Heidelberg, Internal Medicine III, Heidelberg, Germany

The accuracy and clinical relevance of non-invasively derived pulmonary arterial pressure(PAP) by Doppler echocardiography has been questioned over the past few years. Never-theless, this method remains a keystone examination for patients with dyspnea and sus-pected pulmonary hypertension (PH) according to current guidelines. The diagnosticreliability of non-invasively PAPassessment was shown last year in a large and unselectedstudy population. This subsequent analysis examines the prognostic value of non-invasive as well as invasive measured PAP.The study is based on data from a high-turnover cardiology center including invasivelymeasured PAP by right heart catheterization, Doppler echocardiography, serologicalparameters and a retrospective clinical follow-up for up to eight years.N=1,239 patients were included. 199 patients were lost to follow-up. Mean-follow up timewas 1,111 days. Invasively as well as non-invasively measured elevated PAP had

significant and comparable prognostic impact (x2=39.2 and x2=35.5, p,0.0001each). The cut-off values were mean PAP≥25mmHg for invasive and systolic PAP≥36mmHg for non-invasive measurements. For patients with invasively defined PH (n=700,67%), there was no significant difference in survival between patients with postcapillaryPH (n=618) or isolated pulmonary arterial hypertension (PAH as defined by mPA≥25mmHgandPCWP,15mmHg,n=82). Impaired right ventricular (RV) function byechocar-diography, as well as elevated NT-proBNP and cardiac troponin T levels, had incrementalprognostic value (x2=40.5, x2=41.1 and x2=42.8, p,0.0001 each).Non-invasivelyderivedPAPdelivers important prognostic information comparable to rightheart catheterization. It possesses augmented predictive power when RV function isdetermined by standard 2D echocardiography.

P716Effect of the glucagon-like peptide-1 analogue liraglutide on left ventriculardiastolic and systolic function in patients with type 2 diabetes: a randomised,single-blinded, crossover pilot study

MM. Michelsen1; R. Faber1; A. Pena2; ND. Mygind3; HE. Suhrs1; M. Zander4; E. Prescott11Bispebjerg University Hospital, Department of Cardiology Y, Copenhagen, Denmark;2Gentofte University Hospital, Department of Cardiology, Gentofte, Denmark;3Rigshospitalet - Copenhagen University Hospital, Department of Cardiology,Copenhagen, Denmark; 4Bispebjerg University Hospital, Department of Endocrinology,Copenhagen, Denmark

Purpose: Glucagon-like peptide-1 (GLP-1) is a promising new treatment option forpatients with diabetes, which has been speculated to improve myocardial function. Weinvestigated the short-term effect ofGLP-1 treatment on left ventricular systolic and diastol-ic function in patients with type 2-diabetes.Methods: Patients (n=20, 15 men, mean age 57+9 years) with type 2-diabetes and nocoronary artery disease (CAD) were treated with the GLP-1 analogue, liraglutide (1.2 mg),and no treatment for 10 weeks, in a randomized, single-blinded, crossover study with a 2weeks washout period. Systolic and diastolic function was assessed by 2D, Dopplerand speckle tracking transthoracic echocardiography. Including only examinations withadequate visibility, global longitudinal strain (GLS) was calculated as the average ofpeak systolic segmental values and GLS reserve as the difference between GLS duringdipyridamole-stress (0.84mg/kg) and rest.Results: Liraglutide reduced glycated haemoglobin (Hb1Ac) (p=0.01), systolic bloodpressure (BP)(p=0.01) and weight (p=0.03) compared with no treatment. Liraglutidedid not improve GLS, ejection fraction, left ventricular mass index, s’, E/e’, atriumvolume index, E/A or deceleration time. GLS reserve increased significantly in the liraglu-tide group compared with no treatment (table 1).Conclusions: Despite reduction of Hb1Ac, systolic BP and weight, short-term treatmentwith GLP-1 does not seem to improve systolic or diastolic function in patients with type2-diabetes and no CAD. However, it is possible that GLP-1 improves the myocardial func-tional reserve. Further studies, preferably in patients with more impaired myocardial func-tion are needed to confirm these findings.


Variable No treatmentperiod, valuebefore

No treatmentperiod, valueafter

p* Liraglutideperiod, valuebefore

Liraglutideperiod, valueafter

p* p**

GLS rest (%)(n=13)

218.9 (2.2) 219.5 (2.0) 0.36 219.3 (2.5) 219.2 (2.4) 0.60 0.46

GLS stress(%) (n=10)

220.9 (2.1) 221.4 (1.6) 0.49 221.1 (2.0) 222.0 (1.9) 0.09 0.20

GLS reserve(%) (n=10)

20.5(1.4) 21.9 (1.8) 0.03 20.5 (1.2) 23.3 (1.8) 0.003 0.03

Ejectionfraction(n=20)

53.9 (4.8) 54.4 (4.9) 0.64 54.5 (4.9) 53.8 (4.1) 0.48 0.75

E/e’ (n=20) 7.3 (2.5) 7.4 (2.0) 0.68 7.2 (2.1) 7.6 (2.1) 0.41 0.70

Variables are listed as mean (SD). *P-value is from two-sided paired t-tests. **P-value for the lira-glutide treatment effect compared with no treatment by analysis of variance for a 2x2 crossoverstudy (after ensuring no carry over effect). GLS: global longitudinal strain.

Abstract P713 Figure. Evidence of CSCs in HF hearts

Abstract P715 Figure. Survival PH/non-PH by Doppler Echo

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P717Tissue doppler evaluation of left ventricular functions, left atrial mechanicalfunctions and atrial electromechanical delay in juvenile idiopathic arthritis

AZZA. El Eraky; NESRIN. Handoka; MONA. Ghali; NAHED. Eldahshan; AHMED. Ibrahimfaculty of medicine-Suez canal university, Ismailia, Egypt

Purpose: Juvenile idiopathic arthritis (JIA) is a systemic chronic inflammatory disease.Studies for the evaluation of ventricular functions of children with JIA are lacking. Thepurpose of this study was to evaluate left ventricular function, left atrial mechanical func-tions and atrial electromechanical delay in JIA.Methods: A total of 34 patients with JIA (6 males /28 females, mean age13.97+4.77 years),without evidence of cardiac disease, and 34 controls (10 males/24 females, mean age12.55+3.54 years) were included. Systolic and diastolic left ventricular (LV) functionswere measured by using conventional echocardiography and tissue Doppler imaging(TDI). Left atrial volumes were measured by the method of discs in the apical four-chamberview.Results: Patients with JIA had lower ejection fraction (EF) and fractional shortening (FS)compared to controls but were within normal limits. Left ventricular filling abnormalitieswere found characterized by a reduced E/A ratio (1.11+0.55 vs. 4.74+1.45,p=0,005). E/Em was significantly higher in patients with JRA (6.72+1.6 vs. 4.74+1.45, p- 0.003). Left atrial (LA) mechanical function were significantly impaired, as LApassive emptying fraction was significantly decreased, LA active emptying volume wasincreased and LA active emptying fraction and LA total emptying volume were significant-ly increased in RA patients (p,0.0001, p= 0.022 respectively). Patients had significantlyprolonged PA lateral, inter-atrial (PA lateral-PA tricuspid) and intra-atrial (PA septum-PAtricuspid) electromechanical delays compared with healthy controls (0.045, 0.047 and0.013, respectively).Conclusion: Significant diastolic functional abnormalities exist in children with JIA.Atrial electromechanical coupling intervals delay, and LA mechanical functions wasimpaired in JIA.

P718Echocardiographicdetectionof subclinical left ventricular dysfunction in patientswith rheumatoid arthritis

H M. Kamal; A Z. Al-Eraky; M A. El Attar; A S. OmarSuez Canal University, Faculty of Medicine, Ismailia, Egypt

Background: Rheumatoid arthritis (RA) is the most common systemic autoimmunedisease. Cardiovascular (CV) involvement in RA represents one of the leading causesof morbidity and mortality and is not always symptomatic.Purpose: To evaluate left ventricular (LV) systolic and diastolic functions in patients withRA without clinical features of heart disease.Patients and Methods: Echocardiographic parameters, including tissue Dopplerimaging (TDI), were obtained from 73 patients with RA and compared with 73 age- andsex-matched healthy persons. Cardiac dimensions, left ventricular systolic and diastolicfunctions were evaluated with special regard to disease activity and duration. DiseaseActivity Score-28 of the American College of Rheumatology was calculated for RApatients.Results: TDI of mitral annular velocities showed a significantly lower values of the lateralannular S’ velocity and the average S’ of both annuli in the RA group than in the controlgroup but not to the level reflecting systolic dysfunction. Also RA group have significantlylower both lateral and medial annular E’ velocities and higher A’ velocity and E/E’ ratio. Inthe RA patients, we found high prevalence of LV diastolic dysfunction compared with con-trols (54.79% vs 5.48% respectively, P, 0.001). There were significant correlationsbetween TDI parameters of diastolic dysfunction and RA disease duration but not to itsactivity.Conclusion: Patients with RA without clinically evident cardiovascular disease have asignificant higher prevalence of altered LV systolic & diastolic echocardiographic para-meters than healthy Individuals, suggesting a subclinical myocardial involvement withdisease progression and the impact of chronic autoimmune inflammation on myocardialfunction.

P719Left ventricular strain values are unaffected by intense training: a longitudinal,speckle-tracking study

F. D’ascenzi1; A. Pelliccia2; F. Alvino1; M. Solari1; M. Cameli1; M. Focardi1; M. Bonifazi3;S. Mondillo1

1University of Siena, Department of Medical Biotechnologies, Division of Cardiology,Siena, Italy; 2Institute of Sport Medicine and Science CONI, Rome, Italy; 3University ofSiena, Department of Medicine, Surgery, and NeuroScience, Siena, Italy

Purpose: Left ventricular (LV) longitudinal strain, a recognized marker of LV function, hasbeen recently applied to the evaluation of the athlete’s heart. While several cross-sectionalstudies areavailable, little isknown about the influence of trainingon LVglobal longitudinalstrain (GLS) in athletes. The aim of this study was to prospectively investigate the impact oftraining on LV longitudinal strain in a cohort of top-level athletes.Methods: Ninety-one top-level athletes, practicing team sports and competing at nationalor international level, were analysed. Echocardiographic evaluation was performed at thebeginning of the season (low-training) and after 18+2 weeks of a supervised, intensivetraining program (peak-training). Results. A significant increase in LV mass (p,.0001), LVend-diastolic and end-systolic volume (p=.0001 and p,.0001, respectively) was found atpeak-training. LV basal and apical torsion (p=.59 and p=.43, respectively) and LV twisting(p=.78) did not change, and only a mild increase in LV GLS was evident after training

(p,.05). Conversely, neither global circumferential strain nor global radial strain did sig-nificantly change. Resting heart rate was identified as the only independent predictor of LVstrain after training (b=0.30, p=.005).Conclusions: A 18-week, intensive training program induces only a slight increase in LVGLS and neither in global circumferential strain nor in global radial strain did change intop-level athletes practicing team sports, despite marked morphologic cardiacchanges. Thus, markedly altered strain indexes are uncommon features in athlete’sheart, cannot be considered as a physiological adaptation to exercise training,andshould warrant further investigations to detect possibile early cardiomyopathies.

P720Diastolic left ventricular function in autosomal dominant polycystic kidneydisease: a matched-cohort, speckle-tracking echocardiographic study

L. Spinelli1; C A. Giudice1; E. Assante Di Panzillo2; D. Castaldo1; E. Riccio3; A. Pisani3;B. Trimarco1

1Department of Advanced Biomedical Sciences, Federico II University, Naples,, Naples,Italy; 2Department of Internal Medicine and Cardiology - University Federico II, Naples,Italy; 3Department of Nephrology,University Federico II, Naples, Italy

Purpose: Autosomal Dominant Polycystic Kidney Disease (ADPKD) is associated with earlyonset hypertension, left ventricular (LV) hypertrophy and diastolic dysfunction. Two-dimensional speckle tracking echocardiography is a non-invasive technique to quantify LVrotationalmechanics.Theearlydiastolicuntwistingrate isasensitiveparameterofLVdiastolicfunction. Aim of study was to explore LV rotation dynamics in a cohort of ADPKD patientsMethods:Westudied35ADPKDpatientswithnormalrenal functionormildtomoderaterenalinsufficiency, 35 age and gender-matched healthy subjects (C) and 35 patients with chronickidney disease (CKD), comparable to APKD patients for age, gender distribution and renalfunction. Speckle tracking echocardiography analysis was performed on 3 consecutivecardiac cycles. Rotation (degrees) and rotation rate (degrees/s) profiles in basal and apicalshort-axis planes were measured and instantaneous LV twist and twist rate were calculated.LV untwisting rate was calculated as the early diastolic negative peak on LV twist rate curve.Results: As compared to C, either APKD or CKD patients had higher LVM index and rela-tive wall thickness and greater left atrium volume. By speckle tracking analysis, ADPKDpatients exhibited lower global systolic longitudinal strain, LV twist and untwisting ratethan C (p,0.001) and CKD (p,0.001), while none significant difference was observedbetween CKD and C. In both patient groups LVM index and diastolic BP were independ-ently associated with early diastolic untwisting rate. In APKD group higher values of eitherLVM index (r=0.41, P,0.025) or diastolic BP(r= 0.46, p,0.01) associated to lesseruntwisting rates. In the CKD group at higher values of LVM index (r=-0.46, p,0.01) or dia-stolic BP (r=-0.39, p, 0.05) corresponded greater untwisting rate values.Conclusions: The present data throw light on the mechanisms of LV diastolic dysfunctionin ADPKD patients with preserved renal function and, for the first time, demonstrate a sub-clinical systolic impairment.

P721Relationship between adiponectin level and left ventricular mass and function

S. Stojanovic1; M. Deljanin Ilic2; S. Ilic2

1Institute of Cardiology, University of Nis, Niska Banja, Serbia; 2Institute of Cardiology,Medical Faculty University of Nis, Niska Banja, Serbia

Background: Adiponectin is an abundant plasma protein secreted from adipocytes. Inaddition to beneficial metabolic effects, adiponectin seems to have anti-inflammatory,anti-atherosclerotic and vasoprotective actions. In the heart, adiponectin serves as a regu-lator of cardiac injury through modulation of pro-survival reactions, cardiac energy metab-olism and inhibition of hypertrophic remodeling.Purpose: To examine the relationship between adiponectin level, left ventricular massindex (LVMI) and left ventricular systolic and diastolic function in patients with metabolicsyndrome (MetS).Methods: 100 subjects (mean age 53.19+15.05 years) were enrolled in the study. Basedon the presence or absence of MetS and or coronary artery disease (CAD), subjects weredivided in 4 groups: (A group: MetS2/CAD2), (B group: MetS + /CAD + ), (C group:MetS + /CAD2), (D group:MetS2/CAD + ). Each group had 25 subjects. In all subjectsserum adiponectin concentration by ELISA method was measured and standard 2D andDoppler echocardiography study was performed. Left ventricular diastolic function wasevaluated from transmitral flow (ratio E/A).Results: Serum adiponectin was the lowest in group B (1293,60+546,82 pg/mL) andC (1322.89+530,75 pg/mL) and highest in the A group (1738.60+485,77 pg/mL), and itwas significantly higher (p,0.01) than in B,C and D (1401.94+464,40 pg/mL) group. Theprevalence of left ventricular hypertrophy (LVH) in groups was: in A (0%), B(15%),C(17%),and D (8%); (p,0.001 for all comparisons). A negativecorrelation was found between adipo-nectin levelandLVMI (r=-0.225;P, 0,05).ValueofLVEFandratioE/Awashigher inA than inB,C and D group (P,0.001 and P,0.01; for all comparisons). A significant positive correl-ationwas foundbetweenadiponectin levelandLVEF(r=0.259,P,0.05 forallcomparisons),while therewasnotasignificantcorrelationbetweenadiponectin levelandratioE/A(r=0.073,P.0.05 for all comparisons). Value of adiponectin ≥1359.17 pg/mL was associated with alower risk of LVH and left ventricular systolic and diastolic dysfunction.Conclusions: Our findings suggest that there is strong relationship between adiponectinlevel, LVMI and left ventricular systolic and diastolic function. Patients with metabolic syn-drome have low adiponectin levels and this hypoadiponectinemia is associated with sig-nificant higher LVMI, lower LVEF and lower ratio E/A.

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P722Left atrial function is impaired in patients with multiple sclerosis

RI. Mincu1; LS. Magda2; M. Florescu1; A. Velcea2; D. Mihalcea1; A. Chiru3; BO. Popescu1;C. Tiu1; D. Vinereanu1

1University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; 2UniversityEmergency Hospital, Bucharest, Romania; 3Colentina University Hospital, Neurology,Bucharest, Romania

Background: Multiple sclerosis (MS) may cause cardiovascular dysfunction due to au-tonomous nervous system dysfunction, physical invalidity, oxidative stress and systemicinflammatory status, but the certain mechanisms are not elucidated. Our previousresearch demonstrated that MS patients had subclinical biventricular systolicdysfunction. Aim. To assess left atrial (LA) function and atrial-ventricular-arterial couplingin patients with MS, by comparison with matched controls (C). Methods. 90 subjects(35+10 years, 59 women) were studied: 60 patients with MS and 30 controls. LA functionwas measured from LA indexed volume and LA global longitudinal strain (LA-GLS, by 2DSTE);diastolic LV function fromE andAvelocities, E/A ratio, propagation velocity (Vp), iso-volumetric relaxation time(IVRT),E/Vp ratio, and 6basal segmentsaveraged early diastol-ic velocities (E’) and E/E’ ratio, and LV untwist rate (UTR); vascular function from intimamedia-thickness, carotid-femoral pulse wave velocity, and parameters of arterial stiffness.Results. Patients with MS had altered systolic LA function and subclinical diastolic LV dys-function (table), with normal arterial function.Conclusion: Patients with MS have impaired LA function and LV filling, with normalatrial-ventriculo-arterial coupling, suggesting an intrinsic myocardial disease probablythrough myocite structure alteration.


Parameter MS C p

LV Mass 85+31 67+16 0.009E 75+16 86+16 0.008A 54+12 60+13 0.03E/A 1.43+0.38 1.45+0.43 0.88LA Vol 25+7 27+8 0.5Vp 47+11 70+22 0.00IVRT 94+11 70+11 0.00E’ 9.3+2 10.6+2 0.01E/Vp 1.69+0.44 1.32+0.35 0.02E/E’ 6+1.4 6+3 0.93UTR 2105+38 2129+33 0.02LA-GLS 212+3.1 214.4+2 0.02

MASSES, TUMORS AND SOURCES OF EMBOLISM

P723Paradoxical embolization to the brain in patients with acute pulmonary embolismand confirmed patent foramen ovale with bidirectional shunt, results ofprospective monitoring

D. Vindis1; M. Hutyra1; E. Cechakova2; S. Littnerova3; M. Taborsky1

1Palacky University, Faculty of Medicine and Dentistry, 1st Dept of InternalMedicine-Cardiology, Olomouc, Czech Republic; 2Palacky University, Faculty of Medicineand Dentistry, Department of Radiology, Olomouc, Czech Republic; 3Institute ofBiostatistics and Analyses of Masaryk University, Brno, Czech Republic

Purpose: To demonstrate a higher incidence of ischemic lesions in the brain in patientswith acute pulmonary embolism and simultaneously present patent foramen ovale (PFO).Methods: Prospectively, 88 patients with acute pulmonary embolism (mean age 62.7years, median 66 years) were examined. Of those, 64 completed the monitoring. Accord-ing to the protocol, the patients were initially examined by contrast transesophageal echo-cardiography with a focus on the morphology and function of both ventricles and thedetection of PFO and intracardiac shunt. Magnetic resonance imaging (MRI) of thebrain was performed, focused on the detection of ischemic lesions. The brain MRI andtransthoracic echocardiography were repeated after 18 months. Based on the presenceof PFO, the patients were divided into the following groups: PFO + (n=34) and PFO-(n=50), and right to left (R-L) shunt + (n=30) and R-L shunt- (n=54).Results: In the PFO + group, a statistically nonsignificantly higher incidence of ischemiclesions in the brain was demonstrated by MRI at baseline (20 vs. 11 in the MR + vs. MR-subgroups, and 19 vs. 28 in the PFO- group; p=0.063) and in the R-L shunt + group(18 vs. 10) as compared with R-L shunt- group (21 vs. 29; p=0.098). The repeated brainMRI (18 months later) showed a clearly statistically significant increase in ischemiclesions in the brain in the PFO + group (7 vs. 14) as compared with PFO- (2 vs. 35;p=0.008), and R-L shunt + (7 vs.11) as compared with R-L shunt- (2 vs. 38; p=0.002).Also assessed were differences in laboratory and echocardiographic parametersbetween the PFO + and PFO- groups (NT-proBNP, hs-troponin T, PLAX EDD RV, PPG oftricuspid regurgitation, TAPSE, TDI of the tricuspid annulus and others). There were,except of hs-troponin T, no statistically significant differences in any of the parameterscharacterizing the prognostic severityof pulmonaryembolism,morphology, systolic func-tion of the right ventricle and severity of pulmonary hypertension.Conclusion: The presence of PFO with bidirectional flow is associated with an increasedrisk of ischemic lesions in the brain, especially in the long term follow-up and independent

of prognostic risk factors of pulmonary embolism, and could identify a group of patientseligible for PFO closure.

P724Following the European Society of Cardiology proposed echocardiographicalgorithm in elective patients with clinical suspicion of infective endocarditis:diagnostic yield and prognostic implications

F. Mantovani1; R. Lugli1; F. Bursi1; M. Fabbri2; MG. Modena2; G. Stefanelli3; C. Mussini4;A. Barbieri11Polyclinic Hospital, Department of Cardiology, Modena, Italy; 2University of Modena &Reggio Emilia, Modena, Italy; 3Hesperia Hospital, Department of Cardiac Surgery,Modena, Italy; 4Polyclinic Hospital of Modena, Department of Infectious Diseases,Modena, Italy

Background: Echocardiography plays a central role in diagnosing of infective endocar-ditis (IE). Accordingly, the European Society of Cardiology (ESC) has proposed a diag-nostic echocardiographic algorithm. However, to date its effectiveness in routinepractice has not been verified.Aim: To investigate the diagnostic yield and prognostic implications of ESC proposed al-gorithm for clinical suspicion of IE in clinical practice.Methods: Retrospective analysis of a series of elective patients undergoing ESC pro-posed algorithm for clinical suspicion of IE at our institution. We also examined the asso-ciation among echocardiographic results and clinical outcomes.Results: Between January 2009 and June 2013, 325 cases were managed by a multidis-ciplinary team for clinical suspicion of IE. Following the ESC proposed algorithm, 27 (8%)patients were diagnosed as positive for IE and 298 (92%) patients were diagnosed asnegative for IE. In 92% of cases, if a good-quality negative transthoracic echocardiog-raphy was associated with low level of clinical suspicion, transthoracic echocardiographywas considered sufficient. During a mean follow-up of 2.3+1.4 years, both groups ofpatients showed low rates and no difference of combined endpoint (death, stroke, atrio-ventricular block, heart failure, relapsing endocarditis) (24% vs. 22% in negative and posi-tive exams, respectively, p=0.9).Conclusions: In our experience, only a minority of patients with clinical suspicion of IEundergoing the ESC proposed algorithm had a final IE diagnosis. Therefore, in thecurrent cost-conscious era, echocardiography seems to be used as a screening testwith low diagnostic yield. However, this pragmatic echocardiographic diagnostic ap-proach allows the detection of a low-risk group of patients for whom TTE is adequate.

P725Metastatic cardiac18F-FDG uptake in patients with malignancy: comparison withechocardiographic findings

JE. Yi1; HJ. Youn2; JH. O3; HJ. Yoon3; HO. Jung2; GJ. Shin1

1Ewha University, Cardiology, Seoul, Korea, Republic of; 2Seoul St. Mary’s Hospital,Cardiology, Seoul, Korea, Republic of; 3Seoul St. Mary’s Hospital, Nuclear medicine,Seoul, Korea, Republic of

Objective: We sought to investigate the echocardiographic findings corresponding18F-FDG uptake in the heart.Methods and Results: 18F-FDG PET/CTof 43 consecutive patients (34 non-cardiac solidtumors, 8 lymphomas, 1 leukemia) with cardiac or pericardial lesions, confirmed by path-ology or on clinical grounds, were analyzed. The maximum standardized uptake values(SUVmax) of all lesions were measured. Transthoracic Doppler echocardiography(TTE) was performed within 1 month of 18F-FDG PET/CT. Among patients, the most fre-quent primary tumor sites were lung (n=15), lymph node (n=8), thymus (n=4) andbreast (n=3). Fifty-four lesions (30 pericardium, 9 in cardiac chambers, 9 great vessels,6 myocardium) were seen on 18F-FDG PET/CT, 43 (79.6%) of which showed abnormal

Abstract P724 Figure. Survival free from combined endpoint

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findings on TTE. In 30 lesions of pericardial involvement on 18F-FDG PET/CT, 11 lesions(36.6%) were not detected on TTE, and the mean SUVmax of these lesions was not signifi-cantly different from that of detected pericardial lesions (6.7+5.4 vs 7.4+4.6, p=0.688).Pericardial 18F-FDG uptake was shown as an increased pericardial thickness or echo-genecity (n=9, 50.0%), intrapericardial echogenic materials (n=8, 44.4%) and restrictedsliding movement (n=2, 11.1%) on TTE. Myocardial 18F-FDG uptake showed increasedmyocardial wall thickness (n=3, 50.0%) or regional wall motion abnormalities (n=4,66.6%). The great vessel lesions on 18F-FDG PET/CT were related to increase ofvenous inflow velocity on TTE (n=4, 44.4%).Conclusion: In patients with malignancy, cardiac uptake of 18F-FDG PET/CTshows different echocardiographic findings according to the metastatic sites. However,pericardial lesions on 18F-FDG PET/CT demonstrate the discrepancies with those onechocardiography.

DISEASES OF THE AORTA

P726Echocardiographic measurements of aortic pulse wave velocity correlate wellwith invasive method

G. Styczynski1; A. Rdzanek2; A. Pietrasik2; J. Kochman2; Z. Huczek2; A. Milewska1;M. Marczewska1; C A. Szmigielski11Medical University of Warsaw, Department of Internal Medicine, Hypertension & VascularDiseases, Warsaw, Poland; 2Medical University of Warsaw, 1st Department of Cardiology,Warsaw, Poland

Purpose: Aortic pulse wave velocity (aPWV) is a measure of aortic stiffness that has prog-nostic role in various cardiovascular diseases and in general population. However, manydifferent methods are used to measure aPWV, including several non-invasive methods,and also rarely performed, but regarded as a reference method, an invasive intraarterialstudy. Doppler echocardiography is one of potentially useful methods of non-invasiveaPWVassessment that may add further prognostic information to a standard echocardio-graphicstudy.Thereforewe decided tocompareechocardiographic aPWVmeasurementwith an intraarterial invasive study used as the reference method.Methods: Thirty patients (mean age 69 years, 60 % males) underwent simultaneousintraarterial pressure measurements and echocardiographic Doppler flow evaluationduring cardiac catheterization from femoral access. Patients with unstable clinical condi-tion, arrhythmia or proximal peripheral artery disease were not included. Proximal pres-sure waves and Doppler waveforms were acquired in the distal aortic arch. Distalpressure waves were registered in the right external iliac artery, and distal Doppler wave-forms were registered in the left external iliac artery. Transit time was measured as the timefromR waveonsurface electrocardiography to the beginning ofdistal pressure or Dopplerwaveform– time from R wave to the beginning of proximal pressure or Doppler waveform.Distance between proximal and distal sites was measured between the markers on theintraarterial catheter for invasive aPWV and over the body surface for echocardiographicaPWV measurement. aPWV was calculated as the distance divided by transit time.Results: Twenty eight patients (93%) had coronary artery disease (12 pts three-vesseldisease, 7 pts two-vessel disease, 9 pts one-vessel disease). Mean invasive aPWV was9.81 and echocardiographic aPWV was 9.91 (Student t-test, p=0.55). The Pearson’s cor-relation coefficient between methods was 0.93 (p,0.0001). Bland-Altman plot showedmean difference between invasive and echocardiographic aPWV of 0.09 m/s with the2SD limits of agreement of + 1.85 and – 1.66 m/s. Out of 30 patients, in 23 the differencebetween invasive and echocardiographic aPWV was ≤ 1m/s.Conclusions: Doppler echocardiography is a reliable method for aortic PWV measure-ment with a very good correlation with invasive intraarterial assessment.

P727Assessment of increase in aortic and carotid intimal medial thickness inadolescent type 1 diabetic patients

AHMED. Battah1; SOHA. Abd Eldayem2; ABO. El Magd El Bohy3

1Cairo University, Critical Care Department, Cairo, Egypt; 2National Research Centre,Pediatrics, Cairo, Egypt; 3Cairo University, Radiology, cairo, Egypt

Objective: to assess aortic intima-media thickness (aIMT) and carotid intima-media thick-ness (cIMT) in adolescent type 1 diabetic patients Patients and methods: The studyincluded 75 type 1 diabetic patients and 30 age and sex matched healthy volunteer.

Blood sample was taken for analysis of glycosylated hemoglobin (HbA1), lipid profileand urine sample was taken for analysis of albumin/ creatinine ratio. aIMT and cIMT viaultrasound were also done.Results: aIMT &cIMTwere significantly higher in diabetics (0.52+0.06 vs 0.4+0.03, P =0.0001 and 0.72+0.11 vs 0.46+0.04, P = 0.0001 respectively). aIMT was found to besignificantly higher than cIMT in diabetic patients (0.72+0.11 vs 0.52+0.06, P =0.0001). Ten of our patients (14%) with normal cIMT revealed significantly increasedaIMT. aIMT had a significant positive correlation with age of patients, waist/hip ratio & cIMT.Conclusion: Adolescent type 1 diabetic patients had increased aIMTand cIMTwith a rela-tively greater increase in the aIMT than in the cIMT. Because atherosclerosis begins first inthe intima of the aorta, these data suggest that the aIMT might provide the best currentlyavailable noninvasive marker of preclinical atherosclerosis in children. We recommendfrequent follow up of diabetic patients for early detection of diabetic complication.

STRESS ECHOCARDIOGRAPHY

P728Determinants and prognostic significance of heart rate variability in renaltransplant candidates undergoing dobutamine stress echocardiography

J. O’driscoll; A. Slee; V. Peresso; S. Nazir; R. SharmaSt George’s Hospital, Department of Cardiology, London, United Kingdom

Background: There are many determinants of high cardiovascular disease (CVD) inpatients with end stage renal disease (ESRD). These include, hypertension, fluid over-load, cardiomyopathy, and ischaemic heart disease. The determinants and significanceof heart rate variability (HRV) are less well known in this patient group. Using dobutaminestress echocardiography (DSE) as our model for cardiac structure, function and presenceof ischaemia, we aimed to determine the associates and prognostic significance of HRV ina group of renal transplant candidates.Method and Results: Between November 2010 and September 2011, 178 consecutiveESRD patients underwent DSE for the evaluation of suspected cardiac chest pain. Allpatients were followed up prospectively until September 2014 and the main outcomemeasure was major cardiac events. DSE was successfully completed in all subjectswith no adverse outcomes. Forty-one (23%) patients had a positive DSE result, 94(52.8%) had a normal study, and 43 (24.2%) had fixed wall motion abnormalities.During a mean follow-up of 3.6+0.8 years, there were 58 (32.6%) cardiac events and29 (16.3%) deaths, of which 22 (75.9%) were cardiac. HRV was significantly lower inpatients who developed myocardial ischaemia (1525+768 vs. 1862+1862.5 ms2,p=0.03). HRV significantly correlated with LA size (r2 0.18, p=0.02), LVend systolic diam-eter (r2 0.18, p=0.01), LV ejection fraction (r2 0.24, p=0.001), peak wall motion scoreindex (r2 0.2, p=0.007) and cardiac troponin T (cTnT, r2 0.37, p,0.001). In multivariateanalysis, important clinical determinants of a future cardiac event were new wall motionabnormality (HR 3.95; 95% CI, 2.78–14.3; p,0.001), HRV ,2000 ms2 (HR 1.99; 95%CI, 1.78–2.14; p=0.006), and raised cTnT (HR 3.43; 95% CI, 1.49–9.67; p=0.014).Conclusions: HRV is significantly lower in ESRD patients with underlying ischaemic heartdisease and an important predictor of outcome. HRVacts as a surrogate marker for ESRDpatients with increased cardiac damage.

P729Pattern of cardiac output vs O2 uptake ratio during maximal exercise in heartfailure with reduced ejection fraction: pathophysiological insights

G. Generati; F. Bandera; M. Pellegrino; V. Labate; F. Carbone; E. Alfonzetti; M. GuazziIRCCS, Policlinico San Donato, Heart Failure Unit, San Donato Milanese, Italy

Background: the oxygen uptake (VO2) response to exercise, measured during cardio-pulmonary exercise testing (CPET), has prognostic value in heart failure (HF). The in-crease in VO2 is due to the increase in cardiac output (CO) and arterial-mixed venousoxygen content difference (C(a-v)O2). How much (C(a-v)O2) contribute to VO2 increasemay be estimated by the CO/VO2 ratio.Aim: To study the cardiac and functional phenotype associated with CO/VO2 ratio at peakexercise in HF with reduced ejection fraction (HFrEF).Methods: 104 HFrEF patients (mean age 64+11 y, male %, ischemic etiology 68%,mean LVEF 34+9%) underwent a maximal CPET (incremental ramp protocol) combinedwith exercise-echo.Results: Study population was divided into 2 groups according to the peak exercise CO/VO2 (cutoff 0.49, CO/VO2 median value) Group A (n=52) with CO/VO2 ,049 and B(n=52) with CO/VO2 ≥0.49. Despite similar peak VO2 (13.8 vs 12.6 mL/min/kg p=ns)patients with impaired CO exercise response (Group A) showed worse cardiac remodel-ing (LVEDV indexed 101+33vs 91+23mL/m2 p=0.09, E/e’28+15vs 22+11p=0.02)and more severe mitral regurgitation at rest and peak exercise (ERO rest 22+10 16+9mm2 p=0.02, peak 33+13 vs 25+12 mm2 p=0.03). Group A patients exhibited alsomore impaired right ventricular function (TAPSE rest 17+5 vs 19+4 mm p=0.0001,peak 19+5 vs 21+4 p=0.04) associated with ventilatory inefficiency (VE/VCO2 slope36+11 vs 31+7 p=0.01). The two Groups presented with similar average Hb levels.Conclusions: In advanced HF population, the worse exercise performance is associatedwitha reduced CO /VO2 ratio during maximal exercise, that for a similar peak VO2 as com-pared to the population with a high CO/VO2 ratio, is suggestive of “optimal” peripheral O2extraction as compensation to a reduced O2 delivery.

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P730Prognostic value and predictive factors of cardiac events in patients with normalexercise echocardiography

S. Velasco Del Castillo; A. Anton Ladislao; V. Gomez Sanchez;A. Cacidedo Fernandez Bobadilla; JJ. Onaindia Gandarias; I. Rodriguez Sanchez;A. Romero Pereira; O. Quintana Rackza; O. Jimenez Melo; G. Zugazabeitia IrazabalHospital Galdacano, Cardiology, Galdacano, Spain

Earlier studies suggested that prognosis after normal exercise echocardiography is favor-able,Aims: 1. To know the outcome of a large group of patients after normal exercise echocar-diography (EE) and the cardiac event free survival at different moments during the followup. 2 To identify predictors of subsequent cardiac events.Methods: The outcome of 1,788 patients who had normal EE was examined. Treadmillexercise testing was performed on all patients. End points were cardiac event-free sur-vival. Cardiac events were defined as cardiac death (sudden death, fatal cardiac heartfailure or fatal acute coronary syndrome), nonfatal acute coronary syndrome and coron-ary revascularization. The cardiac event- free survival was examined at 1,2,3 years. Patientcharacteristics were analyzed in a univariate and multivariate manner to determine if anywere associated with an increased hazard of subsequent cardiac events.Results: Mean age was 62,35 (11,84) y, 53,8% men. 434 patients had history of coronaryartery disease (CAD). The median of follow up was 38 months (24-56). The cardiac event-free survival rates at 1, 2 and 3 years were 98,4%, 97% and 95,5%, respectively. Univariatepredictors of cardiac events were: Male, age, smoking, hypertension, dyslipemia, dia-betes mellitus, creatinine clearance, chest pain history, SCORE ≥ 10 (SCORE: Ten-yearrisk of fatal CVD in Europe), previous CAD, betablockers, ACEI/ARB, statins, antiplatelettheraphy, dyastolic blood pressure, LVEF %, wall score motion index, % peak Heartrate, METS and double product. Multivariate predictors were: previous CAD,EUROSCORE ≥ 10, creatinine clearance , 60 ml /m2, left ventricular ejection fraction(LVEF) and double product after exercise (systolic blood pressure × heart rate). Thecardiac event-free survival rates at 1, 2 and 3 years were 96,5%, 93,1% and 89,9 %, re-spectively in patients with previous CAD and 97,1%, 95,6% and 88,5 % when SCORE≥10 (vs 99,1%, 98,2%, 97,8% in patients SCORE , 5 and 98,6%, 98,3% and 97,5% inpatients SCORE 5-9 at 1,2,3 years).Conclusions: 1. The initial outcome after normal EE is very good but in the third year of thefollow up the cardiac events free survival was , 90% in p with previous CAD and high car-diovascular risk, in spite of normal exercise echo. 2. Previous coronary disease, a risk car-diovascular SCORE ≥ 10, renal failure, low LVEF and low double product during exerciseecho were predictive of cardiac events and should be considered in the clinical interpret-ation of a normal exercise echocardiogram.

P731Right ventricular mechanics during exercise echocardiography: normal values,feasibility and reproducibility of conventional and new right ventricular functionparameters

D. Voilliot; O. Huttin; C. Venner; R. Deballon; V. Manenti; T. Villemin; A. Olivier; N. Sadoul;Y. Juilliere; C. Selton-Sutyuniversity hospital of Brabois ILCV, cardiology, NANCY, France

Introduction: RV assessment during exercise is useful to stratify the risk of patients invalvular and pulmonary hypertension diseases. However, exercise assessment of newparameters such as RV systolic strain (RV1) and strain rate (RV 1r) remains poorlyexplored. We established normal values, feasibility of conventional and new RV para-metersMaterial and Methods: Thirteen healthy volunteers underwent a semi-supine exerciseechocardiography. Conventional RV parameters (tricuspid annular plane systolic excur-sion (TAPSE), systolic velocity of RV lateral wall (S’), RV fractional area change (RVFAC)and RV1 and RV 1r (mean of 3 lateral and 3 inferior wall segments) were estimated atrest, 50 % (100 bm), 60 % (120 bpm) and 70% (140 bpm) of maximal theoretical heartrate (MTHR). Values were averaged on 3 measurements. Intra and inter observer reprodu-cibility were calculated for RV1 and RV1r.

Results: Feasability of TAPSE and S’ were excellent. Feasability of RVFAC, RV1 and RV1rprogressively decreased from rest to 70% step. TAPSE and RV1 absolute value increasedfrom rest to 50% step then demonstrated a plateau. S’ and RV1r absolute value increasedfrom rest to 60% step then demonstrated a plateau. RVFAC increased from rest to 70%step. Variability of RV1 and RV1r were good and stable at each step (Table 1).Conclusion: RV1 and RV1r assessment remains challenging at peak exercise despitetechnology advances but gives interesting information on RV mechanics. Longitudinaldisplacement (TAPSE) and deformation (RV1) increase from rest to 100 bpm then demon-strate a plateau whereas longitudinal velocity (S’) and deformation rate (RV1r) continue toincrease until 120 bpm. Increase of RVFAC at 140 bpm suggests that free wall radial dis-placement might also play a role in the RV response to exercice.

Abstract P731 Table. Normal RV function values for each step

rest 50% of MTHR 60% of MTHR 70% of MTHR Anova P value

RVFAC, % /feasability

46.6+6.1 / 92% 46.6+7.6 / 85% 50.7+9.6 / 92% 57.7+8.7 † / 69% 0.009

TAPSE, mm /feasability

23.9+3.2 /100%

26.3+2.7 † /92%

27.1+3.9 † /100%

28.5+4.5 † / 92% 0.02

S’, cm/s/feasability

15.5+2.6 /100%

18.6+2.3 † /100%

20.9+1.5 † ‡ /100%

21.4+2.1 † ‡ /100%

,0.0001

RV1, % /feasability

-26.3+1.8 /100%

-28.2+3.1 /92%

-30.3+3.1 † /85%

-28.9+4.1 / 62% 0.02

VariablityIntra/

Inter-observer 10% / 5 % 10% / 8% 8% / 11% 4% / 12%

RV1r, s-1/feasability

-1.85+0.15 /100%

-2.47+0.63 † /92%

-3.48+0.53 † ‡ /85%

-3.86+1.06 † ‡ /62%

,0.0001

VariabilityIntra/

inter-observer 9% / 6% 13% / 10% 14% / 12% 12% / 18%

† p,0.05 vs. rest ‡ p,0.05 vs. 50% of MTHR

P732The added value of exercise-echo in heart failure patients: assessing dynamicchanges in extravascular lung water

MC. Scali1; A. Simioniuc1; GE. Mandoli1; FL. Dini1; M. Marzilli1; E. Picano2

1University Hospital of Pisa, Cardio-Thoracic Department, Pisa, Italy; 2Institute of ClinicalPhysiology, CNR, Pisa, Italy

Background: Exercise stress echo (ESE) is helpful for evaluation of heart failure (HF)patients.Lung ultrasound (LUS) allows dynamic assessment of extravascular lungwater through B-lines.Aim: To assess B-lines during ESE in HF.Methods: We performed transthoracic and LUS evaluation during semi-supine ESE in 68NYHA class I-III pts (15 females; age=61+12 years). B-lines were measured by scanning28 intercostal spaces on anterior chest, both at rest and peak ESE. All patients also under-went spiroergometry testing and resting BNP assay.Results: LUS was feasible and interpretable in all pts with additional scanning time , 3min. Significant (.5) B-lines were present at rest in 32 and at peak stress in 58 pts (47vs 85 %, p,.01). The overall B-lines number increased from 8+9 (mean+SD, rest) to30+23 (peak stress, p=.0001 vs. rest): see Figure.The 42 pts with .15 B-lines during ESE (Group I) compared to 26 with ,15 B-lines (GroupII) showed significantly lower resting left ventricular ejection fraction (Group I=29+6 vs.II=40+5 %, p.,0001), higher resting pulmonary artery systolic pressure (I=39+7 vs.II=30+5 mmHg, p,.0001), lower total peak oxygen consumption (VO2 max, I= 14+4 vs. II=21+5 mL/Kg†min, p,.0001), higher prevalence of severe stress -induced


Abstract P732 Figure. B-lines at rest and peak stress

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mitral insufficiency (I=11/42 vs. II=1/26, p,0.01) and higher plasma BNP levels(I=831+1425 vs. II=141+235 ng/L, p=0.01).Conclusion: B-lines are frequently observed in HF patients and often increase duringstress. Exercise-induced B-lines are associated to greater hemodynamic congestion,with higher resting natriuretic peptides plasma levels and reduced exercise capacity.LUS expands the information provided by standard transthoracic echo, and might beeasily incorporated in ESE for direct imaging of extra-vascular lung water.

P733Applicability of appropriate use criteria of exercise stress echocardiography inreal-life practice: what have we improved with new documents?

A. Garcia Campos1; M. Martin-Fernandez1; JM. De La Hera Galarza1; C. Corros-Vicente1;V. Leon-Aguero1; E. Velasco-Alonso2; S. Colunga-Blanco1; A. Fidalgo-Arguelles1;J. Rozado-Castano1; C. Moris De La Tassa1

1University Hospital Central de Asturias, Oviedo, Spain; 2Hospital de Cabuenes, Gijon,Spain

Background: International associations (ASE/AHA) have developed consensus docu-ments on exercise stress echocardiography (EE) “Appropriate Use Criteria” (AUC) in2008, 2011 and 2013. We aimto study AUCapplicability in real life practice in a tertiary hos-pital and evaluate differences among them.Methods: We reviewed EEindications requested inour institutionduring1year. Indicationswere classified following 2008, 2011 and 2013 AUC as “appropriate”, “uncertain” and “in-appropriate”. If no criterion was applicable the indication was “unclassifiable”. We com-pared 2013 AUC with 2008 and 2011 AUC in the context of stable ischemic heart disease(we excluded acute situations and valvulopathies as these settings were not included in2013 AUC) [SetA]. We also compared 2008 with 2011 AUC in all other settings [SetB].Results: We studied 302 EE indications: 278 (92%) corresponded with SetA, 24 (8%) withSetB. 2011 AUC allowed for a more complete classification in both settings (unclassifiableSetA: 5,8% 2008 AUC vs 1,4% 2011 AUC vs 2,5% 2013 AUC; Set B: 37,5% 2008 AUC vs12,5% 2011 AUC, p-value 0,00) and reclassifies 75% of unclassifiable indications with 2008AUC and 57% with 2013 AUC in SetA (.50% as inappropriate) and 67% of unclassifiable indi-cations with 2008 AUC in SetB (66% as appropriate). In SetA appropriate indications are fre-quent under the view of all documents (87% 2008, 84% 2011, 89% 2013) and very few ofthen change their classification with different AUC criteria (.90% appropriate indicationsremain appropriate after being classified following other AUC document). Inappropriate anduncertain indications are more frequent with 2011 classification in SetA (inappropriate: 5%2008, 8% 2011, 6% 2013; uncertain: 2% 2008, 7% 2011, 3% 2013). In SetB we found alower frequency of appropriate indications, although this is higher with 2011 AUC (33%2008 vs 50% 2011). 87% appropriate indications with 2008 AUC remain appropriate after clas-sification with 2011 AUC.Conclusions: Actual AUC allow for classifying more than 95% exercise echocardiog-raphy indications. 2011 AUC are the most exhaustive indication classifier in all possiblesettings. Stable ischemic heart disease is the most uniform setting regarding appropriate-ness classification.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

P7343D-TEE guidance in percutaneous mitral valve interventions correcting mitralregurgitation

B. Opitz1; ME. Stelzmueller1; W. Wisser1; W. Reichenfelser2; W. Mohl11Medical University of Vienna, Cardiac surgery, Vienna, Austria; 2Technical University ofVienna, Vienna, Austria

Purpose: 3D transesophageal echocardiography (3D-TEE) has rapidly become stand-ard in assessment of heart diseases. Particularly for guidance of percutaneous transcath-eter procedures in mitral valve (MV) repair it represents an essential element. Additionally,via 3D-TEE it is possible to put the individual patient’s valve geometry and the implanteddevice in an anatomical context.Our aim is to ameliorate interventions in minimal-invasive MV repair based on 3D visual-ization. With our unique concept of virtual construction and transcatheter implantationof a MV device, we tried to link the cardiologists’ domain with other specialists’ fieldsinvolved in treatment of heart pathologies, like cardiac surgeons. Since most of the path-ologies in both ischemic and functional MR result from the posterior mitral leaflet (PML),our widget should cover this part only leaving the anterior mitral leaflet (AML) unaffected.Method: For design of a feasible device, we assessed the submitral apparatus via softwaresupported by3D-TEE. Havingmarked theannulus,AMLand PMLand pointofcoaptation,amultiplanar reconstruction (MPR) of the MV is produced which outlines a device correctingthe pathologic valve. The device is set up in mid-systole thus end-diastolic and end-systolicpointof the heart cycle need to bedetermined. Having marked the aortic valve, itscontinuityto MV is displayed in the 3-chamber view of the TEE. The diameters of AML and PML aremeasured and subsequently, allowing determination of the length necessary for posteriorleaflet extension in order to re-establish a sufficient closing plane. The posterior leafletarea is calculated which should finally be covered by the device. In the short-axis view,the distance of the papillary muscle (PM) tips is defined, enabling measurement of thechordal lengths from their origin of the PM to the leaflets. Distance to the commissuresfrom mid-P2 is identified for catheter implantation of the widget.Results: Prototypes of devices for pathologies of PML, i.e. P2-prolapse, Barlow’s diseaseand annulus dilatation have been constructed. 3D-TEE was able to measure the essentialvariables.Conclusion: 3D-TEE has become a crucial component of valve assessment. Undoubted-ly, it is a feasible and precise tool for minimal-invasive surgery as it facilitates identifying the

location of the pathology. MPR allows an excellent “en face” view of the valve and its sur-rounding structures. Moreover, with 3D-TEE accurate measurements of the parametersrequired are obtained, thus improving percutaneous interventions.

CONTRAST ECHOCARDIOGRAPHY

P735Pulmonary transit time by contrast enhanced ultrasound as parameter for cardiacperformance: a comparison with magnetic resonance imaging and NT-ProBNP

IHF. Herold1; S. Saporito2; M. Mischi2; RA. Bouwman1; HC. Van Assen2;HCM. Van Den Bosch3; A. De Lepper4; HHM. Korsten1; P. Houthuizen5

1Catharina Hospital, Anesthesiology and Intensive Care, Eindhoven, Netherlands;2Eindhoven University of Technology, Electrical Engineering, Signal Processing Systems,Eindhoven, Netherlands; 3Catharina Hospital, Radiology, Eindhoven, Netherlands;4Cardiovascular Research Institute Maastricht (CARIM), Biomedical Engineering,Maastricht, Netherlands; 5Catharina Hospital, Cardiology, Eindhoven, Netherlands

Purpose: Pulmonary transit time (PTT) is an indirect measure of preload and left ventricu-lar function, which can be estimated using contrast-enhanced ultrasound (CEUS). In thisstudy we first assessed the feasibility of CEUS-PTT by comparing it with dynamiccontrast-enhanced magnetic resonance imaging (DCE-MRI). Secondly, we tested the hy-pothesis that CEUS-derived PTTcorrelates with the severity of heart failure as assessed bythe level of NT-pro-BNP.Methods: Patients referred to our hospital for cardiac resynchronization therapy (CRT)underwent standard and contrast echocardiography, DCE-MRI, and NT-pro-BNP measure-ment. Ineachpatient,PTTwasestimated bythedifferenceof themean transit times(MTTs)ofthe left and right ventricle after a low-dose bolus injection of an ultrasound-contrast-agent(sulfur hexafluoride). MTTs were derived from acoustic-intensity dilution curves obtainedfromregionsof interest drawn in each ventricle. Onthesameday,aDCE-MRIwas performedafter injectionof0.1mmol(gadoteric acid)gadolinium. InbothCEUSand DCE-MRI,PTTwasnormalized by multiplying PTT by the heart rate in beats per second, in order to indicate thenumber of stroke volumes needed to pass the pulmonary circulation. The agreementbetweenPTTbyCEUSandbyDCE-MRIwastestedusingcorrelation-andBlandAltmanana-lysis. The correlation of PTTand normalized PTT (nPTT) with NT-ProBNP was also tested.Results: In 20 patients, 60 CEUS measurements were available of which 58 were suitableforanalysis. Themean PTTby CEUS was10.5+2.4s compared to 10.4+2.0s forPTT byDCE-MRI (P=0.88). Correlation coefficient between CEUS and DCE-MRI was r=0.75(95% confidence interval, CI, 0.46–0.90; P=0.0001) and r=0.76 (95% CI, 0.49-0.90;P=0.0001) for PTT and nPTT, respectively. Bland Altman analysis revealed a bias of0.1s (limits ofagreement, LoA, -3–3.2s) and 0.1 (LoA, -3.9–3.7) forPTTand nPTT, respect-ively. Both PTT and nPTT by CEUS correlated well with NT-pro-BNP (r=0.54 (95% CI,0.09-0.80; P,0.05) and r=0.68 (95% CI, 0.31-0.87; P,0.01), respectively).Conclusions: Measurement of PTT by CEUS is an easy to perform and feasible param-eter which shows strong agreement with the DCE-MRI. Given the good correlation withNT-pro-BNP level, this measure might be a novel and clinical feasible measure ofcardiac performance and heart failure.

REAL-TIME THREE-DIMENSIONAL TEE

P736Optimal parameter selection for anisotropic diffusion denoising filters applied toaortic valve 4d echocardiographs

CESAR. Veiga;JAVIER. Randulfe Juanjo Andina Jose Fanina Francisco Calvo Emilio Paredes-GalanPablo Pazos Andres IniguezHospital of Meixoeiro, Cardiology, Vigo, Spain

Introduction: Noise affects echocardiographic images, reducing image quality, so it hasto be removed. Denoising filters cause loss of detail and border information. Therefore,theymustachievea tradeoff betweennoise elimination anddetail preservation. Anisotrop-ic Diffusion (AD) filters can be used with this purpose.Objectives: Several parameters of AD filters (number of iterations, sigma, and conduct-ance) affect performance. The objective of this work is to determine sets of parametervalues allowing the best possible signal-to-noise (S/N) ratio to be achieved in 4D echocar-diographic sequences of the Aortic Valve (AoV) while preserving the internal structure ofimages.Methods: A method for selecting optimal parameter values for AD filters was implemen-ted. AoVechocardiographic sequences were filtered with a parametric approach, and theeffect of parameter variations on filtering results was evaluated.Results: Noise suppression, image preservation, and structural similarities were mea-sured, and optimal parameter values were selected accordingly. There is an important in-fluence of AD filter parameters on S/N ratio variations and also in terms of image andstructure preservation. Results demonstrate that it is possible to identify the set ofoptimal parameter values.Conclusions: Denoising is a crucial step to increase image quality in electrocardiograph-ic sequences. There is a set of parameters that provide the best results in terms of noisesuppression and information preservation. The proposed method allows the best pos-sible restored image to be obtained, as shown in Figs. 1 to 3.

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P737Left ventricle systolic function in non-alcoholic cirrhotic candidates for livertransplantation: a three-dimensional speckle-tracking echocardiography study

M. Santos Furtado; A. Rodrigues; G. Leal; O. Silvestre; J. AndradeRadiology Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil

Background: Asymptomatic left ventricular (LV) systolic dysfunction, seen in end-stageliver disease, has the potential to progress to severe heart failure under the demands ofa liver transplantation. Three-dimensional echocardiography (3DEcho) has beenproven a useful tool for the diagnosis and management of patients with sub-clinicalheart failure. More recently, the association of strain imaging analysis has strengthenedthis technique. Our aim was to investigate possible associations between end-stageliver disease and LV systolic strain impairment, using 3DEcho.Methods: Patients awaiting transplantation underwent 3DEcho including speckle track-ing analysis. Liver disease was assessed by the Model for End-Stage Liver Disease(MELD). A cut-off MELD score of 15 was used to classify patients according to theirchances of complications: lower risk (MELD≤15) and higher risk (MELD.15).Results: 79 consecutive patients (54 with MELD≤15 and 25 with MELD.15) werestudied. The median current age was similar in both groups (50.4 vs. 47.2 years,p=0.24), respectively. The median ejection fraction was similar in both groups: 54.4%(MELD≤15) vs. 51.3% (MELD≤15) (p= 0.08). Mean global longitudinal strain was not dif-ferent: -17.6% (-8% to -22%) vs. -17.1% (-12% to -21%) (p=0.31), respectively. Neverthe-less, mean global circumferential strain was significantly higher among patients withMELD≤15, compared to patients with MELD.15: -25.6+0.7 % vs. -22.9+0.7%(p=0.03).Conclusions: Impairment of LV global circumferential strain detected by 3DEcho wasassociated with higher severity in this group of non-alcoholic cirrhotic patients. Includingthis new technology in the follow-up of patients in liver transplantation awaiting list mayhelp to identify those with greater chances of developing severe heart failure underextreme perioperative stress.

TISSUE DOPPLER AND SPECKLE TRACKING

P738Optimizing speckle tracking echocardiography strain measurements in infants:an in-vitro phantom study

UM. Khan; JJ. Hjertaas; G. Greve; K. MatreUniversity of Bergen, Department of Clinical Science, Bergen, Norway

Purpose: Examine the effects of ultrasound frequency and frame rate on 2D SpeckleTracking Echocardiography (STE) in infants.Methods: An infant sized left ventricular phantom was made of polyvinyl alcohol andattached to a pump. Sonomicrometer (SM) crystal pairs were inserted at mid-wall forboth longitudinal and circumferential directions in order to measure longitudinal strain(LS) and circumferential strain (CS). Stroke rates (SR) of 120 SPM and 180 SPM wereapplied, and the stroke volume (SV) range was 3-25 ml at 120 SPM and 3-15 ml at 180SPM at 1 ml intervals. At each SV, cineloops for 15 different settings of frequency andframe rate (FR), using two different pediatric cardiac probes (6 MHz and 12 MHz), wererecorded. In total, 1140 cineloops were analyzed. STE strain was compared to SMstrain in order to assess STE accuracy, while STE reproducibility was assessed by calcu-lating intra-class correlation coefficients for both inter- and intra-observer variability in 20cineloops for each view.Results: Agreement with sonomicrometry as well as reproducibility was better for STE LSthan STE CS. The table shows agreement between STE and SM strain at optimal settings.Intra-observer correlation coefficients for STE LS and STE CS were 0.999 and 0.956 andthe corresponding inter-observer correlation coefficients were 0.998 and 0.987. The LSmeasurements were also more robust with regards to FR, being relatively accurateacross the entire examined FR range (57.7 FPS- 186.1 FPS), and were not affected byprobe frequency. CS was less accurate at FR lower than 130 FPS and the STE softwarereported faulty tracking for a combination of high SR, large SV, and low FR for the low fre-quency probe.Conclusions: STE LS measurements were accurate at high SR and robust with regard toFR and frequency settings. STE CS was accurate at FR above 130 FPS and for a FR/SRratio higher than 1 FPS/SPM. In addition, STE CS was more sensitive to probe frequency.

Abstract P738 Table. Optimal settings for strain accuracy

Direction SR (SPM) FR (FPS) Probefreq.(MHz)

Octave/ Fundamentalimaging mode

Acquisitionfreq. (MHz)

Meanoffset(%)

2SD(%) r

LS 120 162.4 12 Fundamental 12 0.01 0.59 0.998LS 180 133.2 6 Octave 3.1/6.2 0.33 0.71 0.996CS 120 149.7 12 Fundamental 9 0.012 1.25 0.997CS 180 149.7 12 Fundamental 9 2.65 2.74 0.978

Freq.= frequency; r= Pearson Correlation Coefficient

P739Usefulness of vascular mechanics in aortic degenerative valve disease toestimate prognosis: a two dimensional speckle tracking study

L. Leite1; R. Teixeira1; R. Baptista1; A. Barbosa1; N. Ribeiro1; G. Castro1; R. Martins1;N. Cardim2; L. Goncalves1; M. Pego1

1Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; 2Hospital Luz, Lisbon,Portugal

Purpose: The prognostic value of vascular mechanics in degenerative aortic valvedisease remains unknown. We aimed to study the vascular mechanics prognostic utilityin patients with aortic valve disease.Methods: Exploratory analysis including 118 patients (age 73.5+10.1, 56.8% male): 45with isolated aortic stenosis (AS) with an aortic valvular area ≤0.85 cm2/m2 and 73 withaortic regurgitation (AR) with vena contracta .3 mm. Regarding aortic deformation, thecircumferential ascending aorta strain (CAAS) and strain rate (CAASR) were used, andan average of six segments of arterial wall deformation were calculated. The correctedCAAS was calculated as the CAAS/pulse pressure. The following outcomes were ana-lyzed: all-cause mortality; cardiovascular (CV) mortality; aortic valve replacement; heartfailure hospitalization; and a combined endpoint. The median follow-up time was 332(265–875) days.Results:Themean CAASwas 9.5+5.2%, themean corrected CAASwas 0.2+0.1% andthe mean CAASR was 1.4+0.8 s-1. Global mortality was 16.1% and CV mortality was10.2%. CAAS (6.5+3.4 % vs 9.9+5.3 %, P,0.01), corrected CAAS (0.1+0.4% vs0.2+0.1%, P,0.001) and CAASR (0.8+0.4 s-1 vs 1.5+0.8 s-1, P,0.001) were signifi-cantly lower for the patients that had a CV death. Similar associations for aortic mechanicswere found for the other endpoints. A CAASR cut point of 0.88 s-1 showed 83.3% sensitiv-ity and 73.5% specificity to estimate CV mortality during follow up (AUC, 0.79; 95% CI:0.66-0.93, P,0.01)–Fig 1. In the multivariate analysis adjusted for age and left ventricularejection fraction, CAASR ≤ 0.88 s-1 (OR 7.93; 95% CI: 1.52-41.49, P=0.02) remained in-dependently associated with CV mortality.Conclusions: Aortic mechanics has an important prognostic value in patients with de-generative aortic valve disease.

P740Vascular mechanics in aortic degenerative valve disease: a two dimensionalspeckle-tracking echocardiography study

L. Leite; R. Teixeira; R. Baptista; A. Barbosa; N. Ribeiro; G. Castro; R. Martins; N. Cardim;L. Goncalves; M. PegoCentro Hospitalar e Universitario de Coimbra, Coimbra, Portugal

Purpose: Degenerative aortic valve disease is currently viewed as a complex disease thatchange the arterial wall rigidity and compliance. We aimed to assess the ascending aorticmechanics with two-dimensional speckle-tracking (2D-ST) echocardiography in patientswith aortic stenosis and aortic regurgitation.Methods: We included 142 patients (mean age 70.5+13.5, 57.7% male gender): 45with isolated aortic stenosis (AS) with an aortic valvular area (iAVA) ≤0.85 cm2/m2;73 with aortic regurgitation (AR) with vena contracta (VC) .3 mm; 24 with no aorticvalve disease, used as control group. Regarding aortic deformation, the global circumfer-ential ascending aorta strain (CAAS) and strain rate (CAASR) were the parametersused,andan averageofsixsegmentsofarterial walldeformation werecalculated. Thecor-rected CAAS was calculated as the global CAAS/pulse pressure. We also calculatedsystemic arterial compliance (SAC), total vascular resistance (TVR) and the stiffnessindex (b1).Results: Waveforms adequate for measuring CAAS and CAASR were present in 789(92.6%) of the 852 arterial segments evaluated. The aortic mechanics were significantlydifferent in AS, AR and in the control group, considering CAAS (P,0.01), correctedCAAS (P,0.01) and CAASR (P,0.01) – Picture 1. The results were similar after match-ing for age and gender. The b1 stiffness index was 7.25+ 4.42 for AS, 4.05+ 2.90 forAR and 3.25+2.99 for the control group (P,0.01). Contrary to the vascularmechanics, SAC (P=0.99) and TVR (P=0.43) were similar for the three groups ofpatients.


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Conclusions: Aortic mechanics were significantly lower for AS patients, suggesting amore significant impairment of aortic elastic properties.

P741Statins and vascular load in aortic valve disease patients, a speckle trackingechocardiography study

L. Leite1; R. Teixeira1; R. Baptista1; A. Barbosa1; AP. Oliveira1; G. Castro1; R. Martins1;N. Cardim2; L. Goncalves1; M. Pego1

1Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; 2Hospital Luz, Lisbon,Portugal

Purpose: Our group has recently reported the usefulness of aortic mechanics obtainedwith two-dimensional speckle tracking (2D-ST) echocardiography as a surrogate of thevascular load, in patients with aortic valve disease. We aimed to study the associationof statin therapy with the vascular load of patients with aortic stenosis (AS) and aortic re-gurgitation (AR).Methods: We included 118 patients (mean age 73.5+10.1, 56.8% male gender): 45 withisolated ASwithanaortic valvulararea≤0.85cm2/m2and73withaortic regurgitation (AR)with vena contracta .3 mm. Current medication was analysed. Regarding aortic deform-ation, the circumferential ascending aorta strain (CAAS) and strain rate (CAASR) wereused. We also assessed systemic arterial compliance (SAC), total vascular resistance(TVR) and the stiffness index (b1).Results: The mean CAAS was 9.5+5.2% and the mean CAASR was 1.4+0.8 s-1. Theuse of statin therapy (n=64, 54.2%) was associated with a lower CAAS (8.7+5.2 vs.11.0+5.2 %, P=0.03) and CAASR (1.3+0.8 vs. 1.6+0.8 s-1, P=0.02). Theb1 stiffnessindex was higher in the group of patients taking statins (6.6+5.3 vs. 3.4+7.8, P=0.02).No differences were found between groups regarding age, left ventricular ejection frac-tion, SAC or TVR. The use of angiotensin-converting-enzyme inhibitors, angiotensin II re-ceptor blockers, mineralocorticoid receptor antagonists, calcium channel blockers andbeta blockers was not associated with differences in aortic mechanics.Conclusions: According to our data, statin therapy in degenerative aortic valve diseasewas associated with a higher vascular load, probably reflecting a more advance state ofarteriosclerosis.

P742Is Left Bundle Branch Block only an electrocardiographic abnormality? Study ofLV function by 2D speckle tracking in patients with normal ejection fraction

K. Keramida1; N. Kouris2; V. Kostopoulos2; L. Markos2; CD. Olympios2

1Hammersmith Hospital, London, United Kingdom; 2Thriassio General Hospital, Athens,Greece

2D-speckle tracking echocardiography (2D-STE) is a method of quantitative assessmentof myocardial function, evaluating different pathophysiological properties of the myocar-dium from the ones expressed by ejection fraction (EF). 2D-STE has been used so far inpatients (pts) with heart failure and Left Bundle Branch Block (LBBB), who are candidatesfor CRT. Purpose: The aim of this study is to assess deformation mechanics in pts withLBBB and normal systolic function estimated by EF.Our study population comprised of 62 consecutive pts with LBBB without history of heartdisease. Of them we excluded 12 pts due to the presence of valvular disease, heart failureand CADproven fromthediagnostic work up,so finally we included50 ptswith LBBB(39%men, with mean age 68+10 years) and normal LVEF and 50 healthy controls (46%women with mean age 65+10 years). We excluded pts with LBBB and heart diseaseand all underwent a full echocardiographic study. Additionally, global longitudinal and

circumferential strain of the LV (LVGLS and LVGCS) were estimated off-line from thethree apical views and from the parasternal short axis mid-LV view (papillary muscleslevel) using EchoPac 110 workstation (GE Vingmed Ultrasound).There was no statistical difference between the two groups neither in EF (58.85+3.48 vs60.69+5.47%), nor in LV end-diastolic diameter (46.84+2.57 vs 48.15+3.87mm).However, pts with LBBB had significantly impaired LVGLS (-12.60+3.95 vs -19.6+1.33%, p,0.001) and LVGCS (-11.38+4.11 vs -22+2%, p,0.001) compared to con-trols. Assessing longitudinal strain in the different segments of the LV, we found thatthere was substantial difference between the two groups (Table 1).Consequently, the presence of LBBB, even without or before affecting EF, is not benign, asit impairs longitudinal and circumferential deformation of the left ventricle.


Group 1 (LBBB) Group 2 (Controls) p value

Basal Septal 210.46+7.40 213.46+5.06 0.019Mid Septal 213.92+3.27 218.6+3.15 0.0001Apical Septal 214.54+6.87 222.5+4.44 0.0001ApicalLateral

210.77+10.14 219.1+5.46 0.0001

Mid Lateral 210.92+6.71 217.59+2.9 0.0001Basal Lateral 214.15+7.43 217.8+4.6 0.0039

P743Dominant inheritance of global longitudinal strain in a population of healthy andhypertensive twins

AA. Molnar1; A. Kovacs1; AD. Tarnoki2; DL. Tarnoki2; M. Kolossvary1; A. Apor1;P. Maurovich-Horvat1; G. Jermendy3; P. Sengupta4; B. Merkely1

1Semmelweis University, Heart and Vascular Center, Cardiovascular Imaging ResearchGroup, Budapest, Hungary; 2Semmelweis University, Department of Radiology andOncotherapy, Budapest, Hungary; 3Bajcsy-Zsilinszky Hospital, 3rd Department of InternalMedicine, Budapest, Hungary; 4Mount Sinai School of Medicine, Zena and Michael AWiener Cardiovascular Institute, New York, United States of America

Purpose: Left ventricular (LV) strain parameters sensitively detect early changes of LVfunction. Even though its diagnostic and prognostic value is well aknowledged, data ontheir determinant factors are still limited. The aim of our study was to estimate the extentof genetic and environmental factors determining LV deformation phenotypes by quanti-fying myocardial strain parameters in a population of twin pairs.Methods: Ninty three twin pairs were recruited (55 monozygotic and 38 same-sex dizyg-otic twin pairs, mean age 58+9 years). Siblings with obstructive coronary artery diseaseproved by coronary computed tomography angiography or siblings with any cardiomy-opathy and severe valvular heart disease were excluded. Beyond the standard echocar-diographic protocol, parasternal short axis- and apical views were obtained, optimized forspeckle tracking analysis. Using dedicated software (TomTec 2D Cardiac PerformanceAnalysis), global longitudinal (GLS), circumferential (GCS), and radial (GRS) strainswere calculated by averaging the corresponding values of the 16 LV segments. Apicalcounter-clockwise, basal clockwise rotation and their net difference, the LV twist werealso measured. Subgroup analysis was performed involving 25 concordant hypertensive(17 monozygotic, 9 dizygotic) and 44 normotensive (29 monozygotic, 15 dizygotic) twinpairs.Results: The LVejection fraction (EF) and mass (LVM) were in normal range in all siblings.Despite normal EF, 27% (51/186) of our twin population had GLS≥-20% and 86% (44/51)of this latter group had at least one known cardiovascular risk factor. The univariate addi-tive genetic (A), dominant genetic (D) and unique environmental (E) effects modelshowed high dominant genetic component in the variance of GLS (D: 77%) and high addi-tive genetic effects in the variance of GCS (A: 75%), GRS (A: 67%), basal rotation (A: 62%),apical rotation (A: 71%) and twist (A: 71%) after adjustment for age, sex and body surfacearea. However, moderate heritability was revealed regarding EF (A: 56%) and LVM(A: 57%). The intraclass correlations were higher in hypertensive monozygotic pairscomparing to normotensive monozygotic pairs for all strain parameters but not for EFor LVM.Conclusion: Our work demonstrated high heritability of LV deformation with dominantgenetic effects contributing to the variability of GLS in a population of healthy and hyper-tensive twins. Cardiovascular risk factors may affect genetic susceptibility to reduced LVdeformation. These findings support further investigation of potential candidate genes de-termining LV strain parameters.

P744Mechanical differences of left atria in paroxysmal atrial fibrillation: Aspeckle-tracking study.

P. Rio; A. Viveiros Monteiro; A. Galrinho; T. Pereira-Da-Silva; L. Moura Branco; A. Timoteo;J. Abreu; A. Leal; F. Varela; R. Cruz FerreiraHospital Santa Marta, Department of Cardiology, Lisbon, Portugal

Background: Left atrial (LA) function plays an important role in patients with paroxysmalatrial fibrillation (AFib) and has been assessed using several noninvasive methods.The purpose of this evaluated the differences in LA speckle tracking indices using two-dimensional echocardiography in patients with AFib.Methods: We identify fortyconsecutivepatients (55.2+10.4 years, 55% male) selected forcatheter ablation (CA) for symptomatic paroxysmal AFib, and forty consecutive patients



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(53.4+9.6 years, 65% male) who underwent transesophageal echocardiogram for evalu-ation of cardio embolic source without a history of AFib. Baseline LA dimensions, volumes,ejection fraction and mechanical function determined by speckle tracking echocardiog-raphy was performed in all patients in sinus rhythm andcompared between the twogroups.Bidimensional global maps of LA strain (LAs-s), and strain rate were obtained during ven-tricular systole (LAsr-s), early diastole (LAsr-e) and late diastole (LAsr-a).Results: There were no significant differences in clinical characteristics between groups.However patients with paroxysmal AFib had significant larger LA anteroposterior (AP)diameter (23+4 vs 20+3 mm/m2, p=0.004), LA maximum volume (33+11 vs 225+6 mL/m2, p=0.003), LA preA volume (22+410 vs 17+7 mL/m2, p=0.031), LAminimum volume (15+9 vs 9+4 mL/m2, p=0.001), LA total ejection fraction (55+14vs 66+11 %, p=0.004), LA active ejection fraction (33+19 vs 49+12 %,p,0.001) and marked attenuation in the various speckle tracking indices, LAs-s (22+11 vs 39+10, p,0.001), LAsr-s (1.03+0.42 vs 1.67+0.40, p,0.001), LAsr-e(-1.27+0.57 vs -1.61+0.56, p=0.019) and LAsr-a (-1.13+0.47 vs -2.29+0.59,p,0.001), and increased stiffness (0.66+0.28 vs 0.22+0.09, p,0.001). LAs-s,LAsr-s, LAsr-e, LAsr-a correlates with age, LA diameter, LA volumes and LA ejection frac-tion. LAs-s was independent associated with LA maximum and minimum volume index,LA AP diameter, E/A ratio, E-deceleration time, and E-prime instead E-prime was theonly independent factor of LAsr-a. LAsr-a had the higher area under the curve in predictingpatients with AFib (0.942, 95% confidence interval 0.992-0.892, p,0.001), with 93% sen-sitivity and 81% specificity for a cut-off value of 1.8.Conclusions: Our findings demonstrate that function of left atrial shown by two-dimensional speckle tracking in patients with paroxysmal atrial fibrillation is reduced com-pared with age-matched controls. LAsr-a can better differentiate patients with paroxysmalatrial fibrillation.

P745Different distribution of myocardial deformation between hypertrophiccardiomyopathy and aortic stenosis

MS. Huang; LT. Yang; WC. TsaiNational Cheng Kung University Hospital, Cardiology department, Tainan, Taiwan, ROC

Purpose: The characterization of layered left ventricular (LV) deformation in LV hyper-trophy remains unclear. We aim to explore the difference of sub-endocardial and sub-epicardial myocardium strain between hypertrophy cardiomyopathy (HCM) and moder-ate/severe aortic stenosis (AS).Methods: In consecutive patients with HCM (n=33) and moderate/severe AS (n=24),comprehensive echocardiography was performed. LV deformation parameters in layerwere obtained by two-dimensional speckle tracking echocardiography, including longitu-dinal strain of the sub-epicardial myocardium (LSepi) and sub-endocardial (LSendo). Thegradient of strain (GS) was defined as the difference between LSepi and LSendo (DLS),divided by the global longitudinal strain(GLS).Results:Thebaselineage,LVmass index, bloodpressure, heart rate,andLVejection frac-tion are statistically comparable between HCM and AS. On the other hand, patients withHCM had poorer LSepi (-10.51vs. -12.32%, p= 0.021), LSendo (-13.65 vs.-16.56%,p=0.004), DLS (3.15 vs. 4.25%, p=0.001) and GS (0.26 vs. 0.31, p=0.026) as comparedto severe AS. Moreover, LV filling pressure, represented by peak early filling velocity totissue Doppler mitral annular early diastolic velocity ratio (E/E’), is significantly higher inAS group (13.38 vs. 19.54, p=0.003) and is not linearly correlated to GLS.Conclusion:ComparedwithHCM,ASgrouphasbettersub-epicardialandsub-endocardialmyocardium longitudinal strain as well as more prominent between-layer difference.

Abstract P745 Table. Baseline and Echocardiographic parameter

HCM (n=33) AS (n=24)

Age 64.6+14.4 66.3+12.3 p= 0.64LV mass index 144.2+42.6 149.7+68.7 p= 0.71SBP 130.7+16.8 136.7+17.8 p= 0.20HR 69.2+17.0 73.3+14.7 p= 0.36LVEDV 60.9+18.6 79.7+46.5 p= 0.04mean Mitral E/E’ 13.4+5.6 19.5+9.4 p= 0.003LSepi 210.5+3.1 212.3+2.5 p= 0.021LSendo 213.7+4.0 216.6+3.1 p= 0.004GLS 212.0+3.5 214.0+2.8 p= 0.025DLS 3.1+1.2 4.3+1.1 p= 0.001GS 20.26+0.08 20.31+0.08 p= 0.026

GS=(LSepi-LSendo)/GLS

P746Left atrial mechanics in patients with chronic renal failure. Incremental value foratrial fibrillation prediction

C. Papadopoulos; K. Mpaltoumas; A. Fotoglidis; K. Triantafyllou; E. Pagourelias;E. Kassimatis; S. Tzikas; G. Kotsiouros; E. Mantzogeorgou; V. VassilikosAristotle University of Thessaloniki, Thessaloniki, Greece

Purpose: Left atrial (LA) myocardial analysis using 2D speckle tracking echocardiog-raphy (2DSTE) gets much of attention in recent years. Patients with chronic renal failure(CRF) are at increased risk of cardiovascular events and paroxysmal atrial fibrillation(AF). We evaluated LA mechanics in a small cohort of CRF patients in order to estimatethe possible predictive value of novel 2DSTE indices over standard ones in AF recurrence.Methods: 28 end-stage CRF patients (17 men, mean age 57+17) under dialysis (51+64 months dialysis history) on sinus rhythm comprised the study population. All

demographic data were recorder including the history of paroxysmal AF. Left ventricular(LV) and LA volumes, LV ejection fraction, LA ejection fraction and LA expansion fractionwere estimated using 2D echocardiography. LA longitudinal Strain (reservoir function), LAlongitudinal Strain Rate (pump function) and LV longitudinal Strain were obtained using2DSTE.Results:12 outof28patients hadahistory ofAF.These patientswere older andhad longerperiod of dialysis history. LV, LA volumes, LVEF, LAEF and LA ExF were comparablebetween the 2 groups such as LV Strain and E/e.LA Strain was significantly lower in AF patients (19,3 vs 27,8 %, p=0.03) together with LAStrain Rate (-1,15 vs -1,79 1/s, p=0,027). Using regression analysis mean LA Strain Ratewas the most significant index of AF history (b -0,508, p=0,031).Conclusions: Novel indices of LA myocardial function such as LA Strain and LA StrainRate may enlight LA mechanics reflecting possibly ageing of the heart and fibrosis.Further studies are needed in order to evaluate the role of 2DSTE in predicting AF recur-rence in high risk group patients such as those with CRF.

P747Subclinical myocardial dysfunction in cancer patients: is there a direct effect oftumour growth?

L. Venneri; F. Calicchio; R. Manivarmane; N. Pareek; J. Baksi; S. Rosen; R. Senior;AR. Lyon; RS. KhattarRoyal Brompton Hospital, London, United Kingdom

Background: Animal models of cancer cachexia have shown a direct deleterious effect oftumor growth on myocardial function. In cancer patients, although cardiotoxicity is arecognized complication of chemotherapy, it is not known whether cancer per secauses myocardial dysfunction. 2D speckle tracking strain imaging is a recognized tech-nique for detecting early left ventricular dysfunction even in the presence of a normal ejec-tion fraction (EF). The aim of this study was to compare myocardial strain in 3 groups ofindividuals: (i) patients receiving cancer drug therapies, (ii) patients with as yet untreatedcancer and (iii) healthy controls.Methods and Results: We evaluated 79 patients (age 58+10 years, women 62%) withcancer referred to our cardio-oncology clinic with 2D echo-derived LVEF≥55% and echoimages amenable to speckle tracking analysis for global longitudinal (GLS), circumferen-tial (GCS) and radial strain (GRS). Seventy-one patients also underwent same day high-sensitivity troponin I and BNP assays and 66(83%) underwent CMR imaging. Forty-threepatients had current or previous exposure to cancer drug therapies (Group 1) and 36patients had not yet received treatment (Group 2). Twenty healthy age matched controlsalso underwent strain imaging. Comparison of strain findings are shown in the tablebelow. CMR showed loss of torsion and/or fibrosis in 11 of the 66 cancer patients (17%).Conclusions: Our findings showed that cancer patients with preserved EF, whether or nothaving received cancer drug therapies, had evidence of sub-clinical myocardial dysfunc-tion manifest as reductions in GCS and GRS. This finding raises the possibility that tumourgrowth per se might have an intrinsic deleterious effect on myocardial function and needsfurther investigation.


Group 1 Cancer + CT(n=43)

Group 2 Cancer CTnaive (n=36)

Group 1 + 2(n=79)

Controls (n=20)

GLS% 219,3+3,5 220,3+3,1§ 219,7+3,4 221,4+2,1*GCS% 223+4,6 222,9+6,4§ 223+5,5 230+4,5*}GRS% 30+15,5 34,1+12,7§ 31,9+14,3 42+9,8*}

§ p=ns Group 2 versus Group 1; *p,0.05 Controls versus Group 1; } p,0.05Controls versusGroup 2

P748The abnormal global longitudinal strain predicts significant circumflex arterydisease in low risk acute coronary syndrome

R. Onut; C. Marinescu; S. Onciul; D. Zamfir; O. Tautu; M. DorobantuEmergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania

Aims: To investigate the relationship between longitudinal strain (LS) parameters and thepresence of significant coronary artery disease (CAD) in patients presenting with low riskacute coronary syndrome (ACS).Methods: 96 consecutive patients (47.9% female, mean age 61.83+12.2 yrs) presentingwith low risk ACS, without wall motion abnormalities on conventional two-dimensional(2D) echocardiography underwent longitudinal strain analysis by 2D speckle trackingechocardiography (2DSTE). All patients underwent coronary angiography. SignificantCAD was defined as the presence of ≥70% stenosis of the epicardial coronary arteries.Nonparametric ROC (receiver operating characteristic) curve analyses were performedto assess the discriminatory capacity of AUC of the different LS parameters to predict sig-nificant CAD.Results: GlobalLShadhigherpredictivevalue for significantCAD localized in thecircumflexartery (Cx) territory (AUC=0.708, p=0.04), than in the left anterior descending (LAD) andright coronary (RC) arteries (AUC=0.569 and 0.514, respectively). In predicting Cx signifi-cant disease, global LS had higher accuracy than regional LS parameters such as apicallong axis LS (AUC=0.658), apical four chamber LS (AUC=0.625) or apical two chamberLS (AUC=0.693). A cut-off value of global LS of -12.5% predicted significant Cx diseasewith a sensitivity of 100% and a specificity of 87%. In a segmental approach, none of the16 segments LS analyzed didnt show predictive power for significant CX disease.

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Conclusions: In low risk ACS patients, global LS may be a powerful tool in diagnosingsignificant CAD only in the Cx territory, with lower diagnostic value in the other coronaryterritories. Among LS parameters, global LS may have higher predictive value than the re-gional or segmental LS in predicting significant Cx disease.

P7493D-Speckle tracking echocardiography for assessing ventricular funcion andinfarct size in young patients after acute coronary syndrome

E. Casas Rojo; A. Carbonell San Roman; LM. Rincon Diez; A. Gonzalez Gomez;S. Fernandez Santos; C. Lazaro Rivera; C. Moreno Vinues; M. Sanmartin Fernandez;C. Fernandez-Golfin; JL. Zamorano GomezUniversity Hospital Ramon y Cajal, Department of Cardiology, Madrid, Spain

Background: Infarct size in acute coronary syndromes may be assessedby quantification of maximum troponin value. The relevance of infarct size is specially im-portant for prognosis in young patients. Left ventricular function (LVF) estimated by ejec-tion fraction (LVEF) after myocardial infarction is known to be closely related with infarctsize and troponin. However, LVEF is difficult to assess in patients with regional contractilityabnomalities. 3D-speckle tracking (3DST) allows semiautomated estimation of LVEF andadds further parameters from 3D strain analysis. This approach may be useful in patientswith good ultrasound quality which is common among young patients. Our purpose wasto test the feasibility of semiautomated evaluation of LVEF and strain in these patients andto investigate the relationship between infact size and the new parameters of 3D strain.Methods: 40 patients aged under 55 from a study cohort of young patients admitted foracute coronary syndrome underwent 3DST echocardiography with measurement of leftventricle volumes, LVEF and strain parameters before discharge. Maximum troponin Iduring admission was compared with 3DST parameters.Results: The mean age was 47,5+6,4 years.The semiautomated process was successfullin 38 patients. In 2 cases thedatasetdid not have enoughquality for processing.Mean valuesfor 3DST parameters were: 3D LVEF 53,8+13,8; 3D strain 28,9+9,4; radial strain 27,5+9,5; longitudinal strain -12,9+3,4; circumferential strain -26,5+6; area strain -36,4+7,5.Troponin showed significant correlation with 3D-LVEF (r=-0.398; p=0,013), 3D longitu-dinal strain (r=0,412; p=0,010), 3D circumferential strain (r=0,346; p=0,036) and areastrain (r=0,406; p=0,013). On the other hand, no significant correlation was observedbetween troponin and 3D left ventricle volumes, global 3D strain and 3D radial strain.Conclusions: 3D-speckle tracking study is feasible in most young patients after an acutecoronary syndrome. Infarct size is related with lower values of LVEF and shortening 3Dstrain parameters like longitudinal, circumferential and area strain. Thickening 3DST para-meters like 3D and radial strain are not affected by infarct size and therefore they may beless appropiate for assessing the amount of myocardial damage.

P750Evaluation of left ventricular dyssynchrony by echocardiograhy in patients withtype 2 diabetes mellitus without clinically evident cardiac disease

F. Bayat1; T. Alirezaei1; AS. Karimi21Shahid beheshti medical university, Echocardiography,Cardiovascular researchcenter,Modarres hospital, Tehran, Iran (Islamic Republic of); 2tehran azad university,emergency department of booali hospital, tehran, Iran (Islamic Republic of)

Purpose: because diabetes mellitus substantially increases the risk of development ofheart failure,we ought to establish early alterations in left ventricular function by evaluationof asynchrony in diabetic patients without clinically evidence of heart disease.Methods: asynchrony was evaluated in 100 patients with type 2 diabetes mellitus withoutclinically evident cardiac disease.patients had no symptoms or signs of heart disease.ex-clusion criteria were any history of coronary artery disease,LV hypertrophy and albumin-uria as a marker of cardiovascular risk in DM.intraventricular dyssynchrony was evaluatedusing the calculation of the septal to lateral wall delay,the SD of the time from the Q wave tothe peak systolic wave of 6 basal and 6 mid segments by tissue doppler imaging.Results: there was significant LV dyssynchrony in 36 patients according to total asynchronyindexmorethan32.6andseptal to lateralwalldelaymorethan60msec.alsopatientswithdys-synchrony significantly had higher HbA1C(P value,0.001)compared with other patientsConclusion: in our study ventricular dyssynchrony was seen in 36% of diabetic patientswithout clinically evidence of heart disease and Hb A1C was significantly higher than inthese patients.so strict control of serum glucose is principal for prevention of cardiomyop-athy and also prophylactic treatment by ACEIs or beta blockers in diabetic patients withdyssynchrony may be helpfull in prevention of diabetic cardiomyopathy.

P751Differences in myocardial function between peritoneal dialysis and hemodialysispatients: insights from speckle tracking echo

C. Aggeli; V. Kakiouzi; I. Felekos; V. Panagopoulou; G. Latsios; M. Karabela; D. Petras;D. TousoulisHippokration Hospital, University of Athens, 1st Department of Cardiology, Athens, Greece

Purpose: Hemodialysis is capable of inducing subclinical myocardial dysfunction andthis phenomenon is primarily related to hemodynamic instability. In contrast, peritonealdialysis has until recently been considered to exert little, if any, significant hemodynamiceffects. The aim of the current study was to assess whether speckle tracking echocardiog-raphy could assess differences in myocardial function between patients who undergoperitoneal dialysis and those who are treated with haemodialysis.Methods: Thirty-seven patients with ESRD were enrolled. Patients were stratified into twogroups according to the dialysis modality (i.e. 21 on hemodialysis and 16 on peritonealdialysis). All patients underwent comprehensive 2D echocardiographic study. Apartfrom standard 2D and Doppler measurements, GLS was measured using the obtained

apical views. Cross-sectional comparisons of the derived parameters were madebetween the two groups.Results: There was no difference in mean age (64.5+10.9 vs. 57.7+7.9, p= 0.07) anddialysis duration (mean 83.8+106.7 vs 50.63+57.2 months, p=0.4) between the twogroups. Moreover, mean left atrial (39.8+6.4 vs 41.6+8.9mm, p=0.5), intra-ventricularseptum (10.5+1.8 vs. 9.9+1.9mm, p=0.4), EF (48.6+12.3 vs. 45,6+8.7%, p=0.4)and E/Em (9.4+4.5 vs. 10.1+4.8, p=0.7) measurements were not different interms of statistical significance. However, GLS was lower in the hemodialysis group(-11.7+3.9 vs. -15.4+4.5, p=0.04).Conclusion: Patients, who undergo haemodialysis, exhibit lower global longitudinalstrain values, in comparison to those treated with peritoneal dialysis. This could be attrib-uted to different hemodynamic effects of each dialysis modality on myocardial function.

P752Appraisal of left atrium changes in hypertensive heart disease: insights from aspeckle tracking study

S. Ben Kahla; L. Abid; D. Abid; S. KammounHedi Cheker Hospital, Department of Cardiology, Sfax, Tunisia

Purpose: Left atrium (LA) experiences several morphological as well functional changesin response to increasing overload in arterial hypertension (HTN). The goal of our study isto assess LA modifications through speckle tracking imaging (STI) in HTN cohort.Methods: Twenty seven HTN patients (mean age= 50.5+10 years; 14 men) were en-rolled and compared to 30 age and sex-matched healthy subjects. In addition to standardechocardiography, STI analysis was performed to evaluate left ventricle (LV) and LAmechanics. We calculated 10-year atrial fibrillation (AF) risk through Framingham HeartStudy AF score.Results: There were 16 patients with LV hypertrophy and concentric phenotype was pre-dominant (13 patients). AF score was significantly higher in HTN patients (3.88+3 vs.1.9+1%; p=0.002). LA maximal volume was also greater in patients (30+6 vs. 27+6ml/m2; p=0.04). Total LA emptying fraction was significantly altered (65+6 vs. 69+4%;p= 0.01) and LA active emptying fraction was stronger than controls (46+11 vs. 41+7%; p=0.04). LA longitudinal systolic strain was lower in HTN patients (29.5+5 vs. 54+10%; p,0.0001). This finding was proven for early diastolic peak as well as late diastolicpeak LA strain (16.7+5 vs. 31.2+8% and 13+3 vs. 23+7% respectively; p,0.0001).LAsystolicstrainwassignificantly impairedinHTNpatientswithabnormaldiastolic functionin comparison to remaining patients (27.7+4 vs. 33.2+5%; p=0.005). LA systolic strainexhibited negative correlations with systolic and diastolic blood pressure (R= -0.59 and-0.53 respectively; p,0.0001) as well as AF risk score (R= -0.39; p=0.009). LA systolicstrain was 78% sensitive and 70% specific to predict 10-year AF risk in HTN patients witha threshold of 33% (Area under ROC curve was 0.75; p=0.004).Conclusion: Our study highlighted the major contribution of LA strain parameters in theassessment of LA mechanics in response to HTN.

P753Left ventricular rotational behavior in hypertensive patients: Two dimensionalspeckle tracking imaging study

L. Abid; S. Ben KahlaHedi Chaker University Hospital, Sfax, Tunisia

Background: The aim of this study was to investigate the differences in left ventricular (LV)twisting behavior between patients with systemic hypertension HTN regarding their LVremodeling.Methods: Thirty one patients with HTN (mean age 51+10 years) and 30 age andsex-matched control subjects were evaluated. After a standard echocardiogram, LVtwist was analyzed using 2D speckle tracking imaging (STI).Results: Concentric LV hypertrophy was predominantly found in 14 HTN patients (45.1%)followed by concentric remodeling in 10 patients (32.2%). Six patients had eccentric LVhypertrophy and only one patient had normal LV geometry. Within HNT patients, LV twisttended to be higher as compared to controls (21.3+8 vs. 17.5+78; p=0.06). A positivecorrelation was revealed between LV twist and systolic as well as diastolic blood pressure(R= 0.32; p=0.01 and 0.27; p=0.03 respectively). There was no difference between HTNpatients regarding their basal rotation, however, patients with concentric hypertrophyhad greater apical rotation comparing to patients with eccentric phenotype (15.7+4 vs.10.3+58; p=0.02). LV twist was higher in patients with concentric hypertrophy when com-pared to patients with concentric remodeling (24.6+5 vs. 17.8+78; p=0.03).Conclusion: Our study revealed different features of LV twist in HTN patients dependingon LV remodeling. Patients with concentric hypertrophy had greater LV twist.

COMPUTED TOMOGRAPHY & NUCLEAR CARDIOLOGY

P754Effectiveness of adaptive statistical iterative reconstruction of 64-slicedual-energy ct pulmonary angiography in the patients with reduced iodine load:comparison with standard ct pulmonary angiogra

JH. Choi1; JW. Lee2

1Pusan National University Hospital, division of cardiology, departement of internalmedicine, Pusan, Korea, Republic of; 2Pusan National University Hospital, departement ofradiology, Pusan, Korea, Republic of

Introduction: To assess the effectiveness of the adaptive statistical iterative reconstruc-tion (ASIR) at dual energy computed tomography pulmonary angiography (DE-CTPA)

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with reduced iodine load. We hypothesized that virtual monochromatic spectral (VMS)images with ASIR in the patients with reduced iodine load would offer comparableimage quality compared with standard CTPA.Method: 140 consecutive patients (76 male; 64 female; mean age, 53.4 years+13.4)who referred for chest CT were randomly divided into 2 groups: DE-CTPA group withreduced iodine load (n = 70) and standard CTPA group (n = 70). Quantitative and quali-tative image quality was compared between VMS images with filtered back projection(VMS-FBP) and those with 50% ASIR (VMS-ASIR). Also, quantitative and qualitativeimage quality between VMS-ASIR and standard CTPA images were compared.Results: Signal intensity of pulmonary artery, contrast-to-noise ratio, signal-to-noise ratiowere superior in VMS-ASIR (P , .001). About 30% of noise was reduced with adding ASIR.Also, all qualitative indicies except degree of pulmonary arterial enhancement weresuperior in the VMS-ASIR (noise, P = .003; overall image quality, P = .028). Noise andsignal-to-noise ratio of VMS-ASIR were superior to those of standard group (P , .001and P = .007, respectively). Signal intensity of pulmonary artery was superior in standardgroup (P , .001). In the qualitative indicies, noise was significantly lower in the VMS-ASIRgroup (P = .001).Conclusion: The ASIR technique tends to improve the qualitative image quality of VMSimaging. DE-CTPA with ASIR enables the reduction of contrast medium volume andshows comparable image quality compared with standard CTPA. Future study abouteffect of ASIR to VMS images with patient with reduced tube currents and iodine load iswarranted.Clinical Application: Dual-energy monochromatic imaging at 70 keV with ASIR canreduce iodine load for pulmonary angiography with comparable image quality comparedwith standard CTPA. Total iodine (gram iodine) was only 14.2 g for CTexamination. Thatcan be helpful to reduce the dose-related side effect of iodinated contrast media.

P755Clinical prediction model to inconclusive result assessed by coronary computedtomography angiography

M. Barreiro Perez; M. Martin Fernandez; SM. Costilla Garcia; E. Diaz Pelaez;C. Moris De La Tassa

University Hospital Central de Asturias, Oviedo, Spain

Introduccion and purpose: Noninvasive coronary angiography performed bymultidetector computed tomography has become a diagnostic alternative to invasive cor-onary angiography. Its indications and application have been extended exponentially.This technique exhibits an excellent correlation with invasive techniques and it alsoprovides prognostic information. However a percentage of studies are inconclusivemost of them due to the existence of artifacts, usually associated with an excess of coron-ary artery calcium.Ouraimwas thedevelopment ofapredictivemodel of inconclusive studybased onclinicalvariables that would increase the profitability of the technique.Methods: All noninvasive coronary angiography performed between 2006 and 2012in our center with the intention of rule-out ischemic heart disease in symptomaticpatients were included. Clinical, analytics and related with non-invasive coronary angiog-raphy variables were collected. Statistical analysis was made using logistic regressionmethods.Results: A total of 243 patients were enrolled. The 65% of our sample had low or moderatecardiovascular riskstratified with clinical sore. In our center non-invasive coronary angiog-raphy allowed rule-out significant coronary arterydisease in83% of patients.Among thesepatients, 90% of those with non-invasive coronary angiography made as first diagnosticstep and negative result, were discharged from outpatients clinic without other diagnostictest. However, 9% of studies were inconclusive, 86% of them in relation with high levels ofcoronarycalcium. Usingastepbinary logistic regression analysiswe developedapredict-ive model of uninterpretable results based on clinical variables: age (OR 1,043[IC95%(1,001-1,087)], p-value 0,04); sex (OR 3,351 [IC95%(1,155-9,719)], p-value0,02); and total cholesterol serum levels (OR 1,018 [IC95%(1,002-1,035)], p-value0,03). The model rates were 0,209 of goodness of fit, 92,5% of correct predicted classifica-tions and an area under curve of 0.73.Conclusions: Based in our results, a clinical prediction model in order to preselectpatients with an inconclusive result by coronary computed tomography angiographywas successfully developed, including age, sex and total cholesterol serum levels aspredictor variables.

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