Echo

POSTER SESSION I

Thursday 10 December 2009, 08:30–12:30

Location: Poster area

ATRIAL FUNCTION AND CONTRACT

159Volume versus diameter measurements: Practical impact on reporting left atrialsize

H. Vyas1; K. Jackson1; A. Chenzbraun1

1The Royal Liverpool University Hospital, Liverpool, United Kingdom

Background: Left atrial (LA) size has been shown to correlate with the degree of dias-tolic dysfunction and to have significant prognostic value in cardiac patients. LA volumemeasurement (LAV) is supported lately as being more sensitive in detecting left atrialenlargement (LAE) and having a better prognostic power than diameter measurements(LAD). However, most echocardiography services still rely on the standard measure-ment of the LA antero-posterior diameter only.Purpose: Prospective study to assess the potential impact of switching to LAvolumetric measurement on the reported prevalence of LA enlargement, andthus, on the diagnosis of diastolic dysfunction and the risk stratification of cardiacpatients.Methods: LA antero-posterior diameter in the parasternal long axis view, and LAvolume by Simpson’s method in apical views were measured in 72 consecutivepatients (age¼68+10 yrs, males¼30) referred for routine echo studies. LAE by diam-eter and by volume measurements was defined using accepted guidelines. Wall thick-ness was used to calculate LV mass and flow and tissue Doppler were used tocharacterize diastolic function. LAE by both methods was correlated with clinical vari-ables, presence of LVH and degree of diastolic dysfunction.Results: LAE by LAD measurement was found in 28 patients (39%) and by LAVmeasurement in 46 (64%), p,0.01. There was agreement between the two methodsin 52 patients (72%). 19 of the 46 patients (41%) with LAE by LAV were missed byLAD measurements. Only one patient was diagnosed with LAE by LAD and not byLAV. Using body surface area indexed values did not improve the percentage ofpatients missed by LAD measurements: 26/46 (56%). Patients with LAE by LAV butnot by LAD measurements were older (72+11 vs. 67+9, p¼0.05), had smaller LAD(3.5+0.3 cm vs. 3.9+0.8 cm, p¼0.01) and more severe diastolic dysfunction byboth E’ velocity (5.7+1.9 cm/s vs. 7.2+2 cm/s, p¼0.02) and E/E’ ratio (16.6+7.9vs. 12.1+4.5, p¼0.05).Conclusion:1) Left atrial linear measurements miss a significant proportion of patients with LAE byvolume measurements. Indexing for body surface area does not improve the accuracyof the method.2) Under-diagnosis of LAE by LAD is associated with more severe (type 2) diastolicdysfunction. This underscores the importance of identifying these patients.3) Wide scale implementation of the volume standard for LAE may result in an expected40% increase in the number of patients reported as having left atrial enlargement, withimplications in terms of risk stratification and proportion of reported abnormal studies.

160Should we (re)consider pulmonary vein antrum in the assessment of left atriumvolume and shape remodeling?

DC. Cozma1; C. Mornos1; A. Ionac1; L. Petrescu1; C. Blaj1; SI. Dragulescu1

1Institute of Cardiovascular Medicine, Timisoara, Romania

Background: The border between left atrium (LA) and pulmonary vein (PV) and PVantrum implication/importance in the geometry of LA dilatation has not been comple-tely investigated. Current guidelines clearly specify that while assessing LA size“care should be taken to exclude PV from the LA tracing”. In the other hand there is

no clear indication in the guideline what kind of angulations should we take into con-sideration while assessing LA size apical four chamber view. Aim: to analyze the impli-cations of shape definition and size assessment using current recommendations vs anew methodology.Methods: 186 consecutive hospitalized patients (pts) aged 53+27 years, wereincluded. LA volume (LAV) was assessed using 2 methodologies: M1: current guide-lines recommendations and M2: LA tracing and automatic volume calculation aftervisualization of maximum number of PV and ostia definition. A new measurementwas introduced, the basal LA dimension (LAb) as the maximal transverse distance atthe base-roof of LA apical four chamber view. LA measurements were calculated atend-systole (maximal). Trapezoidal LA shape was defined if transverse dimension ,

basal dimension.Results: 52 pts had paroxysmal/persistent AF, 106 pts had arterial hypertension and 91had evidence of diastolic heart failure. LAV ranged 33.5–203.5 ml; LA assessed M1was ellipsoidal in 90% of pts. Trapezoid LA was found in 65% of pts using M2. Meannumber of PV (M2) was 2.3+0.5. LAV (M2) was 85.2+27.6 ml, significantly higherthan LAV (M1) 69.5+19 ml (p,0.0001) The difference between these values wasdue mainly to the pulmonary veins antrum which is increased in LA with moderateand severe dilatation. Trapezoid LA is more common in AF pts (85%), pts with diastolicheart failure (74%) and hypertension (68%). Increased left ventricular filling pressuremay induce subclinical earlier LA remodeling undetected using M1. The differencebetween LAV measurements using M1 and M2 increase in moderate (9.5+3.6 ml) tosevere LA dilatation (15.9+6.5 ml, p,0.0001), suggesting that progressive LA dilata-tion evolve to trapezoid shape. Trapezoid LA with atrialization of the pulmonary veinsand predominant dilatation of basal atrium than annular side may explain underestima-tion of LAV using ellipse model.Conclusion: Complete characterization of LA remodeling should include shape defi-nition and LAb. LAV is a reliable parameter to estimate LA dilatation, but the real LAVis still debatable with high inter and intraobservator variability due to lack of preciseguidelines definitions.

161Effect of aging on left atrial pump function in healthy subjects

L. Zhong1; CJ. Finn1; LK. Tan1; LH. Chua1; FQ. Huang1; RS. Tan1; ZP. Ding1

1National Heart Centre, Singapore, Singapore

Purpose: Left atrial (LA) function contributes to left ventricular (LV) filling. However, theimpact of age and gender on LA function has not been extensively studied.Methods: We performed echo studies (IE33, Philips) on normal healthy volunteers. Thetransmitral flow, pulmonary venous flow (PMF) and tissue Doppler imaging (TDI) wererecorded using standard echo. LA volumes were calculated using the biplane modifiedSimpson’s method. LA empting fraction (EF) was calculated as (LAmax-LAmin)/LAmax100%. Early and late diastolic mitral annular velocity Ea/Aa ratio by pulsedTDI was measured. E/Ea was obtained as a marker of LV filling pressure. LA ejectionforce was calculated as 1/3�mitral annular area�(peak velocity of A wave)^2 accord-ing to Newton’s law of motion and hydrodynamics.Results: There were 108 healthy volunteers (mean age 43+13 years, range 22 to 72years). ANOVA analysis revealed that there was no significant difference for LA volumeindices, emptying fraction (see Table). No age-related differences in pulmonary vein Svelocity and AR velocity. However, the Ea/Aa ratio declined significantly with age. TheE/Ea, pulmonary venous velocity S/D ratio and LA ejection force increased significantlywith age. When the group was stratified by gender, there were no significant differenceson LA ejection force.Conclusions: The increased LA ejection force appears to be the compensatoryprocess for age-related LV diastolic dysfunction. Hence, LA dysfunction may beused as a measure for the increased risk of heart failure.

Eur J Echocardiography Abstracts Supplement, December 2009

doi:10.1093/ejechocard/jep129

Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009.

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162Left atrium volume decreases after successful balloon mitral valvuloplasty: anechographic and hemodynamic study

S. Adavane1; S. Santhosh2; S. Karthikeyan2; S. Ederhy1; S. Rajagopal2; N. Haddour1;J. Balachander2; A. Cohen1

1AP-HP - Hopital St Antoine, Paris, France; 2Jawaharlal institute of post graduate medicaleducation and research, Pondicherry, India

Background: Left atrium (LA) remodelling is known to have a crucial impact on adverseoutcome and prognosis in mitral stenosis (MS). Limitations regarding LA evaluationusing LA diameters or areas have been reported. To our knowledge there is no studyabout LA volume variation immediately after balloon mitral valvuloplasty (BMV).The aim of the study is to assess the evolution of LA volume immediately and 1 monthafter successful BMV in patients in sinus rhythm.Methods: Thirty three consecutive patients (70% female, age 31 +8 years old; range19 to 45) with moderate to severe MS (i.e. mitral valve area (MVA) �1.5 cm2) whounderwent successful BMV (i.e. a 50% increase in MVA and/or a decrease in LApressure ,18 mmHg in the absence of mechanical complications) were prospectivelyincluded. Using 2D echocardiography, and according to the prolate ellipse method, LAvolume and LA volume indexed to body surface area were measured before BMV, 24hafter BMV and 1 month after BMV. Cardiac catheterization was systematically per-formed during procedure.Results: MVA increased from 0.88 +0.15 to 1.55 +0.26 cm2 (p,0.0001) andmitral valve mean gradient (MVG) decreased from 16 +9 to 6 +2 mmHg (p,0.0001)immediately after BMV. Indexed LA volume fell immediately from 56 +14 to 48 +12(p¼0.0003) then 45 +13 ml/m2 at 1 month (p,0.001). Though, only patients with LAvolume �55ml/m2 (median value) prior to BMV had a significant reduction of LAvolume (p¼0.0001). LA volume decrease was correlated to the immediate decrease inPA-RV peak diastolic gradient and MVG decrease at 1 month.Conclusion: In patients with MS in sinus rhythm, successful BMV results in an immedi-ate decrease in LA volume. This reduction is correlated to the variation of MVG, PA-RVpeak diastolic gradient and is significant when LA volume prior to BMV is very enlargedi.e. �55 ml/m2.

163Retrograde pulmonary vein flow can differentiate between atrioventricularorthodromic tachycardia and atrioventricular nodal reentrant tachycardia.

A. Alexandrescu1; R. Vatasescu1; N. Dumitrescu1; D. Constantinescu1; C. Caldararu1;L. Platica1; A. Scafa-Udriste1; M. Dorobantu1

1Emergency Hospital Bucharest, Bucharest, Romania

Background: Differential diagnosis between atrioventricular orthodromic tachycardia(AVRT) and typical atrioventricular nodal reentrant tachycardia (AVNRT) is sometimesdifficult without invasive electrophysiology testing. However sequential V-A activationduring AVRT vs almost concomitant V-A activation during ANRT might have differenthaemodynamic consequences.

Objective: To evaluate the value of pulmonary vein, mitral and aortic flows by pulsed-wave Doppler echocardiography as a noninvasive tool for differential diagnosis ofnarrow QRS complex tachycardia.Methods: In 30 patients referred for electrophysiological study (EPS) and ablation for anarrow QRS tachycardia, transthoracic echocardiography was performed during tachy-cardia and in sinus rhythm. Pulsed-wave Doppler was recorded with sample volumeplaced into the pulmonary vein, at the tips of mitral valve and in aortic ejection tract,measuring duration and peak velocity at the retrograde pulmonary venous flow (AR),left ventricular filling time and stroke volume. According to EPS, typical AVNRT wasdiagnosed in 17 patients and AVRT in 13 patients.Results: Retrograde peak velocity of the AR at the patients with AVNRT was signifi-cantly lower than in AVRT patients (30,5+4,89cm/s vs 36,20+1,03cm/s, p,0,002).However, defining a cut-off value was not possible due to low sample size. LV fillingtime was not significantly different (126+19,8ms in AVNRT group and113,2ms+13,7 in AVRT group, p¼NS). Stroke volume was reduced to a similarextent in both groups during tachycardia (from 71+6,4ml to 33,5+3,26ml in AVNRTand from 70+9ml to 34,8+3,48ml in AVRT, p¼NS).Conclusions: Recorded peak velocity pulmonary retrograde flow could be animportant tool for differential diagnosis between AVRT and AVNRT. In spite of atrialcontraction occuring always in AVNRT against closed atrioventricular valves, thepeak velocity of the AR is significantly lower in AVNRT group than in AVRT groupsuggesting that the mechanism remains unclear. Larges studies should be performedto evaluate a cut-off value of peak velocity pulmonary retrograde flow for differentialdiagnosis.

164Two-dimensional atrial systolic strain imaging may predict the onset of atrialfibrillation and supraventricular tachycardia at 4-year follow-up in patients withasymptomatic mitral stenosis

R. Ancona1; S. Comenale Pinto1; P. Caso1; G. Di Salvo1; R. Lo Piccolo1; G. Petrone1;F. Pisacane1; R. Calabro’11Ospedale Vincenzo Monaldi, Naples, Italy

Purpose: Mitral stenosis (MS) is a progressive disease in which, after a long period freeof symptoms, often the initial manifestation is the onset of atrial fibrillation (AF) andsupraventricular parossistic tachycardia (SVPT), that occur in about 30–40%. Theassessment of systolic left atrial (LA) reservoir function in asymptomatic MS wasstudied by two-dimensional (2D) strain (S) and strain rate (SR) imaging. Its power topredict the onset of AF or SVPT was evaluated at 4-year follow-up.Methods: Sixty-three asymptomatic patients (pts) with pure rheumatic MS and 60healthy controls were evaluated by standard echo-Doppler study (mitral valve area,mean gradient, systolic pulmonary pressure, left atrial (LA) width, LA volumes, LA ejec-tion fraction) and by 2D Speckle Tracking S and SR. The end-point at 4-year follow-upwas the onset of AF or SVPT.Results: LA width, volumes and systolic pulmonary pressure were significantlyincreased (p,0.001) and LA 2D S and SR were significantly compromised in MS pts(p,0.0001). Peak systolic LA myocardial 2D S and SR were significantly correlatedwith LA volumes (S: p: 0.01; R:-0.43; SR: p: 0.04; R:-0.34), with LA width (S: p:0.08;R:-0.31), with LA EF (S: p¼0.0006, R:0.55; SR: p:0.09; R: 0.29), systolic pulmonarypressure (S: p: 0.06; R:-0.35; SR: p: 0.03; R:-0.39). At 4-year follow-up 14 (22%) ptsshowed AF or SVPT at standard ECG or 24-h Holter ECG. In multivariate analysis,including age, PHT mitral area, LA volume, systolic pulmonary pressure, LA ejectionfraction, the best predictor of AF and SVPT was LA peak systolic S (P¼0.02; coefficient,0.22; SE, 0.098), with a sensitivity of 89%, specificity of 81%.Conclusions: LA myocardial deformation properties, assessed by 2D S imaging, areabnormal in asymptomatic pts with rheumatic MS. The degree of this impairment ispredictor of AF and SVPT a 4-year follow-up. 2D S Imaging could be helpful to recog-nize pts who will develop AF and SVPT, that is well-known to be associated with worseprognosis.

165Left atrial appendage velocities are affected by mitral annular motion

Z. Ashour1; MHS. Shalaby1; AA. El Amragy1

1Dept of Cardiology, Faculty of Medicine, Cairo University, Cairo, Egypt, Cairo, Egypt,Egypt

Background: In patients with Mitral stenosis, due to stagnation of blood in the leftatrium, the risk of thrombus formation is high. As the left atrial appendage (LAA) is afamous site for thrombus formation, a lot of attention has been paid lately to LAAfilling and emptying velocities as markers for LAA function. Recording of these vel-ocities usually requires transesophageal echocardiography, as by a conventional trans-thoracic study the LAA may not be well visualized. In this study we tried to determinewhether the LAA velocities correlated to Tissue Doppler measurements in an attempt toreplace a semi-invasive technique by a non invasive onePatients and Methods: Twenty nine patients with Mitral stenosis, 16 females and 13males with a mean age of 34.2 þ 15.2 years were examined by both transthoracicand transesophageal echocardiography. 20 were in sinus rhythm and 9 had atrial fibril-lation . Tissue Doppler measurements of the lateral Mitral annulus velocities wereobtained by transthoracic echocardiography and included Em, Am, And Sm. By trans-esophageal echo the LAA emptying and filling velocites were obtained.Results: The LAA emptying velocity correlated with both the Peak E ( r= 0.605, p,

0.001) and S velocities ( r= 0.705, p, 0.000) and in sinus rhythm patients (n=20) in

Table 1 LA size and function with age

Age ,31(n¼23)

31–40(n¼25)

41–50(n¼20)

51–60(n¼29)

.60(n¼11)

ANOVAP value

Maximal LA volumeindex (ml/m2)

24+5 24+3 22+5 25+5 25+3 0.34

Minimal LA volumeindex (ml/m2)

8+2 8+2 8+3 9+4 9+3 0.29

LA emptying fraction (%) 65+12 65+7 66+10 63+10 63+10 0.86Septal Ea/Aa 1.6+0.5 1.4+0.4 1.0+0.3 0.9+0.2 0.7+0.2 ,0.0001E/Ea ratio 7.6+1.6 7.6+1.4 9.0+1.8 9.6+1.9 10.3+1.2 ,0.0001Pulmonary venous S(cm/s)

48+10 53+11 55+11 58+13 53+10 0.64

Pulmonary venous D(cm/s)

52+11 53+11 47+11 44+11 38+6 ,0.001

Pulmoanry venous AR(cm/s)

25+4 28+15 29+15 28+5 29+4 0.64

S/D ratio 0.9+0.3 1.0+0.2 1.2+0.3 1.3+0.3 1.4+0.3 ,0.0001LA ejection force(kdynes)

4.2+2.3 5.1+2.2 7.8+4.0 8.0+3.9 13.7+6.2 ,0.0001

Table 1 LA volume variation after BMV

BeforeBMV

AfterBMV

1 monthafter

p value(before-after)

p value(before-1month)

MVA (cm2) 0.88+0.15 1.55 +0.26 1.59 +0.28 ,0.0001 ,0.0001MVG (mmHg) 16.25 +5.99 6.39 +2.63 7.13 +2.29 ,0.0001 ,0.0001LA volume (ml) 76.67 +22.28 66.00 +18.15 62.54 +18.45 0.0003 ,0.0001Indexed LAvolume (ml/m2)

55.79 +14.81 48.06 +12.12 45.63 +13.65 0.0002 ,0.0001

PVR (Woodunit)

2.52 +0.92 1.86 +0.43 1.85 +0.39 ,0.0001 ,0.0001

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

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

166Prognostic implication of the left atrial appendage mechanical function inpatients with lone atrial fibrillation after successful electrical cardioversion

E. Suchon1; M. Kostkiewicz1; A. Lesniak-Sobelga1; M. Krochin1; W. Tracz1; P. Podolec1

1John Paul II Hospital, Krakow, Poland

Aim: The study aimed to assess whether mechanical function of the left atrial appen-dage (LAA) enables prediction of atrial fibrillation (AF) recurrence after successful elec-trical cardioversion (CR) in patients with persistent lone AF after successful electricalcardioversion (CR).Methods: Fifty patients (mean age of 54 +13; range 23-73 years) with successfullycardioverted persistent lone AF lasting less than 3 months were enrolled. All patientsunderwent transthoracic and transesophageal (TEE) echocardiography before CR. InTEE we measured: left atrial appendage peak emptying flow velocity - LAAempvel,LAA fractional area change - LAAFAC % (calculated from maximal and minimal LAAarea) and LAA lateral wall peak systolic velocity measured by tissue pulsed Dopplerwith the sample volume placed 1cm from the orifice of LAA.Results: At one-year follow-up 33 (66%) patients remained in SR, whereas AF recurredin 17 (34%). There were no difference in age, gender, AF duration, LVEF, LA diameterbetween patients in SR and AF, but LAA empvel, LAA peak lateral systolic wall velocityand LAA fractional area change - LAAFAC (%) were significantly lower in patients whorecurred to AF (Table 1.)On multivariate logistic regression analysis only LAA empvel (p,0.001, chi(2)¼6.9,OR ¼ 2.6, CI95% 0.2–0.36) predicted recurrence of AF.Conclusion: Our data indicate that in patients with persistent lone AF the mechanicaldysfunction of the LAA may predict recurrence of AF after successful CR.

167LA size quantification and recurrence after pulmonary vein ablation: which isthe best option?

N. Calvo Galiano1; M. Sitges1; B. Vidal1; S. Montserrat1; D. Tamborero1;A. Garcia-Alvarez1; L. Mont1; J. Brugada1

1Hospital Clinico Universidad de Barcelona, Barcelona, Spain

Introduction: Left atrial (LA) size has been shown to be associated with the success ofthe pulmonary vein ablation (PVA) in patients with atrial fibrillation (AF). However, thedefinition of the best parameter to measure LA size in this setting and to predict AFrecurrence after PVA remains controversial.Methods: Patients with symptomatic and drug refractory AF undergoing PVE betweenOctober 2004 and October 2008 were included. Within 48 hours prior to the PVA a 2Dand 3D transthoracic echocardiography (TTE) were performed in order to asses leftatrial (LA) maximum, minimum and preA volumes and LA anteroposterior, longitudinaland transversal diameters. The left ventricular and LA ejection fraction (EF), and LAfunction (passive, active and reservoir), the late peak diastolic transmitral flow velocity(A) and the velocity-time integral (VTI) of the A wave were also measured. PVE wasdefined as successful if patients remained asymptomatic and in sinus rhythm (SR) ina 24 hours ECG Holter registry at 6-month follow-up.Results: A series of 176 patients were included. Patients without AF recurrence hadsmaller LA volumes and anteroposterior diameter and better LA function before the pro-cedure and more often were in sinus rhythm during the study (Table). In the multivariate

analysis, the best predictor of AF recurrence was LA anteroposterior diameter ( RR1.08, 95% IC 1.009 – 1.147, p ¼ 0.02) and LA volume measured by 3D TTE (RR1.03, 95% IC 1.005 – 1.062, p ¼ 0.02).Conclusions: A simple and widely available parameter, the LA anteroposterior diam-eter, is as accurate as LA volume determined by 3D echo for predicting AF recurrenceafter PVA.

168Dilated left atrium at presentation significantly decreases the chances forsuccessful rhythm control during 5-year-follow-up

T. Potpara1; B. Vujisic-Tesic1; M. Petrovic1; M. Polovina1; M. Ostojic1

1Institute for Cardiovascular Diseases, Clinical Center of Serbia, Belgrade, Serbia

Purpose: successful rhythm control in patients with atrial fibrillation (AF) depends onnumerous factors. The aim of present study is to examine the relationship betweenleft atrial (LA) anteroposterior diameter at presentation and progression to permanentAF during 5-year follow-up of patients with initially persistent AF.Methods: patients with persistent nonvalvular AF eligible for pharmacological or DCcardioversion were included. Baseline clinical and routine transthoracic echocardio-graphic parameters were recorded. During 5-year-follow-up cardioversion wasrepeated when needed and long-term antiarrhythmic therapy was applied, in concor-dance with current international guidelines for AF. The relationship between pro-gression to permanent AF and independent variables listed below was examinedusing multivariate logistic regression analysis.Results: out of 335 patients [mean age 53.9+11.7 years, 234 males (69.9%), hyper-tension 140 patients (41.8%), coronary artery disease 25 (7.5%), cardiomyopathies39 (11.6%), mild valvular regurgitation 34 (10.2%), heart failure at presentation 33patients (9.9%), diabetes mellitus 19 (5.7%), obesity 34 (10.1%), AF.48h beforeinitial cardioversion 278 (83.0%), LA anteroposterior diameter , 4cm 198 (59.1%)and reduced left ventricular ejection fraction 68 patients (20.3%)], at the end of5-year-follow-up 197 patients (58.8%) had permanent AF, i.e. rhythm control was suc-cessful in ,50% of study population. Multivariate logistic regression model identifieddilated LA, AF.48h before cardioversion and heart failure at presentation as indepen-dent predictors of progression to permanent AF (RR 2.3, 95%CI 1.8-4.9, p¼0.002, RR4.1, 95%CI 2.1-5.5, p,0.0001 and RR 5.0, 95%CI 4.0-6.6, p¼0.006, respectively).Conclusion: dilated left atrium at presentation significantly decreases the chances forsuccessful rhythm control (i.e. restoration and maintenance of sinus rhythm) during5-year-follow-up, despite active treatment.

169Left atrial ejection fraction as a predictor of cardiovascular events in patientswith left ventricular hypertrophy

MG. Trabulo Corte-Real1; P. Carmo1; N. Cardim1; P. Goncalves1; D. Ferreira1;V. Carmelo1; F. Pereira Machado1; J. Roquette1

1Hospital da Luz, Lisbon, Portugal

Introduction: Left atrial (LA) volume and E/E0 ratio are recognized predictors of cardi-ovascular events in various populations. LA ejection fraction has been less studied inthis context. The objective of this study was to assess whether LA ejection fraction(LAEF) had additional prognostic value in a population of high cardiovascular risk.Methods: We studied 58 consecutive patients (pts), 29 women, with more than 60years (70 + 7 years) with hypertension and moderate or severe left ventricular hyper-trophy (LVH) in echocardiography (defined as LV mass index exceeding 109 g/m2 inwomen and 132 g/m2 in men). We excluded pts with LV ejection fraction below 50%,significant valvular disease and atrial fibrillation. We assessed LA maximum andminimum volumes to obtain LAEF (Maximum volume-Mininum volume/ Maximumvolume and E/E0 ratio by analysis of pulsed wave mitral flow and tissue Dopplerpattern in lateral mitral anullus. We evaluated the occurrence of cardiovascularevents - death, myocardla infarction, stroke, CABG, PCI, and onset of atrial fibrillation(AF) in a median follow-up of 539 (509; 553) days.Results: During follow-up 7 CV events occurred (3 AF, 1 myocardial infarction, 2 PCIand one stroke). Mean E/E0 ratio in pts with events was 14.4 + 1.3 versus 11.0 +2.7 in pts without events (P ¼ 0.002). The median value of LAEF in patients withevents was 24% (22, 30) versus 46% (43, 50) in pts without events (P ,0.001). BothLAEF and E/E’ ratio had high accuracy for predicting events (area under the curve:0.86, 95% CI: 0.747 to 0.939) and 0.975, 95% CI: 0.895 to 0.997, respectively). Thebest cut-off for E/E0 ratio was .12 and for LAEF was � 33%. In multivariable logisticregression analysis LAEF was an independent predictor of events (Hazard Ratio ¼0.79, 95% CI: 0.69 to 0.91, P ¼ 0.001).Conclusion: This study suggests that LA contractile function in a population with sig-nificant LVH is a potent predictor of cardiovascular events, with additional prognosticvalue in relation to other factors most commonly assessed. This parameter could beincluded in the echocardiographic assessment of these patients.

170Biatrial longitudinal deformation assessment in a clinically diverse series ofoutpatients using two dimensional speckle tracking

A. Kiotsekoglou1; SC. Govind2; A. Younis1; JC. Moggridge1; SS. Ramesh2; AS. Gopal3;AH. Child1; SK. Saha4

Table 1.

SR (n¼33). AF (n¼17). P

Age (years) 51.9 + 9.9 52.3 + 10.5 NSMale 20 (64%) 11 (65%) NSLA diameter (mm) 45 + 2.3 46 + 2.1 NSLVEF (%) 53.8 + 3.8 54.1 + 4.2 NSLAAempvel (cm/s) 29.8 + 3.6 22.1 + 4.3 ,0.001LAAFAC (%) 0.33 + 0.12 0.21 + 0.13 ,0.01LAA lat. wall syst. vel. (cm/s) 7.4 + 1.2 6.3 + 1.4 ,0.05

No recurrence AF recurrence p

LA maximum volume 3D (ml) 52 + 14 64 + 22 p,0.05LA minimum volume 3D (ml 29 + 13 41 + 18 p,0.05LA anteroposterior diameter 2D (mm) 40 + 6 44 + 6 p,0.05LA Volume preA (ml) 38 +17 45 + 16 nsLA total emptying fraction (%) 23 + 9 23,5 + 14 nsLA passive emptying fraction (%) 14,7 + 8 17 + 13 nsLA active emptying fraction (%) 11 + 8,4 9 + 9 nsLAEF (%) 44 + 19 36 + 16 p,0.05Sinus rhythm during TTE 58 (74.4%) 35 (46.7%) p,0.05

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1St. George’s University of London, London, United Kingdom; 2VIVUS-BMJ HeartCenter, Bangalore, India; 3Saint Francis Hospital, New York, United States of America;4Sundsvalls Hospital, Sundsvall, Sweden

Purpose: Recent advances in echocardiography have led to the development of two-dimensional speckle tracking (2DST) as a useful tool in left ventricular (LV) myocardialfunction assessment. This technique has also been used in the evaluation of left atriallongitudinal deformation. The purpose of this study was to investigate whether 2DSTcan be implemented for biatrial deformation assessment in an outpatient setting.Methods and Results: 2D echocardiographic studies from 62 outpatients (mean ageof 53+12 years, 36 men) with different clinical diagnoses were retrospectively ana-lysed. From 4- and 2-chamber apical images of left and right atria (LA and RA) the fol-lowing measurements were obtained using the Simpson method: a) pre-atrialcontraction LA and RA volumes, (LAVpreA and RAVpreA) measured at the start of Pwave on the ECG; b) minimal LA and RA volumes (LAVmin and RAVmin) measured atthe mitral and tricuspid valve closure, respectively; & c) maximal LA and RA volumes(LAVmax and RAVmax), measured just before the mitral and tricuspid valve opening.From these measurements 3 indices were calculated: 1) LA and RA active emptyingfraction (LA AEF)¼(LAVpreA2LAVmin)/LAVpreA�100 and (RA AEF)¼(RAVpreA2

RAVmin)/RAVpreA�100, respectively; 2) LA and RA expansion index (LAEI)¼(LAVmax2

LAVmin)/LAVmin�100 and (RAEI)¼(RAVmax2RAVmin)/RAVmin�100, respectively; & 3)LA and RA passive emptying fraction (LAPEF)¼(LAVmax2LAVpreA)/LAVmax �100and (RAPEF)¼(RAVmax2RAVpreA)/RAVmax �100, respectively. 2DST was also usedto measure biventricular systolic parameters and strain/strain rate in contractile andreservoir periods and strain rate in conduit phase for both atria. Statistical analysisshowed that LA and RA reservoir strain were significantly correlated with LV and rightventricular global longitudinal systolic strain (r¼0.70, p,0.001 and r¼0.50, p,0.001,respectively). LA and RA EI were significantly correlated with LA and RA reservoirstrain (r¼0.57, p,0.001 and r¼0.43, p,0.001, respectively). LA and RA EI werealso correlated with LA and RA reservoir strain rate (r¼0.50, p,0.001 and r¼0.47,p,0.001, respectively). Multiple regression analysis including age, sex, body surfacearea, heart rate and global longitudinal ventricular strain showed that age, sex andLV systolic strain had an effect on LA deformation (p�0.003) whilst only age had animpact on RA deformation (p¼0.018). Conclusions: These findings suggest that2DST may be providing accurate atrial deformation analysis and could be used inter-changeably with the conventional atrial indices in the clinical setting.

1712D atrial longitudinal strain correlates well with left ventricular filling pressure: astudy in patients with hypertension and diabetes mellitus

M. Caputo1; M. Cameli1; M. Lisi1; E. Palmerini1; R. Urselli1; P. Ballo2; M. Galderisi3;S. Mondillo1

1University of Siena, Department of Cardiovascular Diseases, Siena, Italy; 2CardiologyOperative Unit, S. Andrea Hospital, La Spezia, Italy; 3Cardioangiology Unit with CCU,Department of Clinical and Experimental Medicine, Federico II Univers, Naples, Italy

Purpose: Speckle tracking imaging is a new echocardiographic technique and strain(S) imaging for the quantification of longitudinal myocardial left atrial (LA) deformationproperties have made it feasible to look at atrial myocardial dynamics in several patho-physiological conditions. However, the role of the LA longitudinal strain as a quantitat-ive measure of left ventricular (LV) diastolic dysfunction in patients with hypertensionand/or diabetes mellitus and left ventricular hypertrophy is not established. The aimof this study was to evaluate whether, in patients with hypertension and/or diabetes,LA longitudinal strain correlates with the Tissue Doppler E/Em ratio, assumed as anindex of LV filling pressure.Methods: In 94 consecutive patients with hypertension and/or diabetes mellitus, freefrom other significant cardiovascular diseases, Peak atrial longitudinal strain (PALS)was measured from apical views using a 12-segment model for the left atrium.Values were obtained by averaging all segments (global PALS) and by separately aver-aging segments measured in the 4-chamber and 2-chamber views.Results: A close negative correlation between global PALS and the E/Em ratio wasfound (R=20.74, p,0.0001). The strength of the relationship was similar for theaverage 4-chamber PALS (R¼0.73, p,0.0001) and the average 2-chamber PALS(R¼0.71, p,0.0001). In multivariate analysis, global PALS emerged as a determinantof the E/Em ratio, independent on other confounding factors.Conclusions: Global PALS, an index of LA function expressing LA longitudinal defor-mation dynamics, is independently related to LV filling pressures in patients with hyper-tension and/or diabetes.

172Left atrial strain and strain rate in patients with severe aortic stenosis

K. O’ Connor1; J. Magne1; M. Moonen1; LA. Pierard1; P. Lancellotti11CHU de Liege - Domaine du Sart Tilman, Liege, Belgium

Introduction: Global longitudinal left atrial (LA) function may be assessed by themeasurement of strain (SI) and strain rate (SR) using tissue Doppler imaging (TDI).The objective of this study was to evaluate the feasibility of SI and SR quantificationin patients with severe aortic stenosis (AS).Method and results: TDI, Doppler and 2D transthoracic echocardiography includingmeasurements of left atrium (LA) function and AS assessment were performed in 11healthy control subjects and in 48 patients with severe AS (71+14 years, 66% ofmale, aortic valve area (AVA), 0.68+0.2 cm2, mean gradient, 45+14mmHg). Systolic(S), early (E) and late diastolic (A) SI and SR, corresponding respectively to reservoir,conduit and contractile periods of the LA, were measured in lateral, septal, anterior andinferior LA wall and then averaged to obtain global longitudinal SI and SR. Controlgroup was significantly younger than AS group (47+14 vs. 71+14 years, p,0.01).There was no other difference between control and AS groups with regard to demo-graphic data. The E SI (i.e. conduit phase) was similar between groups. Conversely,S-SI, A-SI, and S-SR, E-SR and A-SR were significantly impaired in AS group asopposed to control group: S SI= 21+9% vs. 31.9+11%, p=0.0011, A-SI=14.9+6% vs. 19.7+5.5%, p=0.02, S SR= 1.7+0.5/s vs. 2.6+0.75/s, p,0.0001,E-SR was 21.5+0.6/s vs. 22.7+1.1/s and A SR= 22.3+0.86/s vs. 23.2+0.65/s.Aortic valve area was correlated with LA contractile function (A SI: r=0.39, p=0.01; ASR: r=0.44, p=0.005) but not with SI and SR of the LA reservoir and conduit function.Conclusion: By using SI and SR, reservoir, conduit and contractile functions of the LAare reduced in patients with severe AS. Moreover, the impairment of contractile functionof the LA is related to the severity of AS.

173Relationship of left atrial myocardial deformation with left ventricular fillingpressures in patients with severe aortic stenosis

A. Calin1; BA. Popescu1; C. Beladan1; M. Rosca1; D. Muraru2; F. Antonini-Canterin3;GL. Nicolosi3; C. Ginghina1

1“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania; 2Institute ofCardiovascular Diseases, Bucharest, Romania; 3Cardiology, ARC, “Santa Maria degliAngeli” Hospital, Pordenone, Italy

Background. Previous studies have emphasized the important role of the left atrium(LA) in cardiovascular performance in patients (pts) with left ventricular (LV) hypertro-phy. LA myocardial deformation properties were not studied yet in pts with aortic ste-nosis (AS).Purpose. We aimed to assess LA strain (e) and strain-rate (Sr) and their relationshipwith conventional indices of LV diastolic function and filling pressures in patients withsevere AS and preserved LV ejection fraction.Methods. We prospectively enrolled 35 consecutive pts (63+6 years, 28 men) withsevere AS (indexed aortic valve area, AVAi,0.6 cm2/m2), preserved LVEF (61+6%),and no significant coronary artery disease, and 19 age-matched normal subjects(58+11 years, 7 men). A comprehensive echocardiogram was performed in all, includ-ing TDI-derived parameters of LV diastolic function (E’ was measured at both septaland lateral sites from the apical 4-chamber view). LV filling pressures were assessedusing the E/E’ ratio. Longitudinal LA strain parameters were assessed from theapical 4-chamber view using a commercially available software (2D Strain). Left atrialreservoir function was assessed by peak systolic values of average segmental e andSr (LAe and SSr), LA conduit function by early diastolic Sr (ESr) and LA pump functionby late diastolic Sr (ASr).Results. In pts, NYHA class was 1.7+0.9, AVAi was 0.39+0.10 cm2/m2 and meantransvalvular gradient was 55+19 mm Hg. LV volumes and LVEF were similar in ptsand in normals (p.0.50 for all). There were no significant differences betweengroups regarding E/A ratio (p=0.30), E/Vp ratio (p=0.10), and indexed LA volumes(p=0.10). Pts with AS had higher E/E’ ratios both at the septal and lateral sites(p,0.001). In pts with AS peak LA e was significantly lower (19+7 vs 30 +7%,p,0.001) and LA strain rate parameters were significantly reduced (SSr, 0.9+0.2 vs1.2 +0.2 s-1; ESr, 20.6+0.3 vs 21.4+0.5 s-1; ASr, 21,2+0.5 vs 21.6+0.4 s-1,p,=0.002 for all). In pts with AS there was a significant correlation between LAe,ESr and ASr with indexed LA volume (p,0.05 for all), and both LA e and ESr correlatedto septal E’ (r=0.48, p=0.004 and r=20.70, p,0.001 respectively). A significant cor-relation was found between LAe, SSr, ESr, ASr and septal E/E’ ratio (r=20.49,p=0.003; r=20.42, p=0.013; r=0.51, p=0.002; r=0.51, p=0.002).Conclusions. In patients with severe AS and preserved LVEF, LA reservoir, conduit andbooster pump function are significantly reduced and are related to LV filling pressures.These findings support the important role of the LA in LV filling in pts with severe ASand normal LVEF.

174The improvement of left atrial function in patients with interatrial defectsundergoing atrial septal closure

S. Aggio1; C. Piergentili1; L. Conte1; G. Rigatelli1; N. Schenal1; F. Zanon1;A. Marcolongo2; L. Roncon2

1SOC Cardiologia, Rovigo, Italy; 2General Hospital, Rovigo, ItalyGlobal PALS - E/E0 correlation.

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Background: The atrial function in pts. with ASD is not usually evaluated even if under-going procedures leading to atrial septal correction.Methods: 39 consecutive pts. affected by different interatrial septal anathomy (patentforamen ovale [PFO], atrial septal defect [ASD], atrial septal aneurysm [ASA]) under-went atrial septal defect closure. Median age was 52,7 + 14(SD), 41 % men. All pts.underwent 2 standard TTE examination (using VIVID5 GE provided with ECHOPACor Philips iE33, both using a broadband frequency transthoracic 2nd harmonicprobe), the first in the 3 weeks before the procedure and the second the day after.Left atrial (LA) volumes (Vol.) during the cardiac cycle were obtained as average of four-chamber and two-chamber view values. Maximal Vol. of LA was indexed to BSA andthe (R-R)2 (VMAXi). Minimal Vol. (VMINi) and remaining measures were indexedin the same way. Passive emptying indexed Vol. (PEVi) was measured one frameafter the opening of mitral valve. Percentage (%) of passive emptying (%PE) was cal-culated: (VMAXi-PEVi)/VMAXi. % of active emptying (%AE) was calculated:(PEVi-VMINi)/VMAXi. LA indexed conduit function (LACi) was the difference betweenventricular and left atrial stroke Vol.Results: We used the paired samples T-test to compare results of echo-data beforeand after the procedure. We could observe significant differences of %PE, (withincrease of this parameter after the haemodynamic procedure (22,9 + 6,4 [SD] vs33,3 + 8,8 [SD], p ,0,001) and of atrial EF (with increase of this parameter afterthe haemodynamic procedure (55,1 + 7,4 [SD] vs 61,3 + 6,3 [SD], p ,0,001).Conclusions: differences in atrial function can be evidenced in pts with ASD, PFO,ASA, apparently ameliorating after haemodynamic procedure, with an increase of per-centage of passive emptying.

175Left atrial function in patients with pathologic atrial septum anatomy differsfrom healthy controls.

S. Aggio1; L. Conte1; C. Piergentili1; G. Pastore1; N. Schenal1; G. Rigatelli1; L. Roncon1

1General Hospital, Rovigo, Italy

Purpose: To evaluate the left atrial function in patients (pts.) affected by pathologicinteratrial septal anatomy compared to healthy controls.Methods: We analized data of two groups of subjects that underwent a transthoracicechocardiography (TTE). 108 pts. (Gr. A, median age 48,3+16 yrs (SD), 31 % men)affected by pathologic interatrial septal anathomy (patent foramen ovale [PFO], atrialseptal defect [ASD], atrial septal aneurysm [ASA]) and 101 healthy controls (Gr. B,median age 45 + 17 (SD), 37% men) were studied with complete TTE. Maximal(VMAXi) and minimal (VMINi) left atrial (LA) volumes (Vol.) were obtained as averageof four-chamber and two-chamber view values and indexed to BSA and the (R-R) inter-val square root. LA passive emptying indexed Vol. (PEVi) was measured one frameafter the opening of mitral valve and indexed in the same way. Atrial ejection fraction(AEF) was defined: VMAXi-VMINi/VMAXi. LA passive emptying fraction (%PE) was cal-culated: (VMAXi-PEVi)/VMAXi. LA active emptying fraction (%AE) was: (PEVi-MINi)/VMAXi. LA indexed conduit function (LACi) was the difference between ventricularand left atrial indexed stroke Vol. We used the independent samples T-test tocompare mean results of echographic and demographic data between groups aftera Levene’s test for equality of variances.Results: We found no demographic difference between groups nor difference aboutleft ventricular volumes and mass. However Gr. A showed a lower AEF, lower %PEand but higher %AE (Table, data expressed as means + SD). We found no differencebetween groups in LA indexed conduit function (LACi).

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

176Left atrial function in the elderly subjects with normal transmitral inflow velocitypattern elucidated by an automatic left atrial volume tracking technique

D. Mukaide1; T. Tabata1; H. Yokoi1; G. Ukai1; T. Kamata1; M. Yoshinaga1; H. Izawa1;M. Nomura1

Fujita Health University Second Hospital, Nagoya, Japan

Background: Newly developed automatic left atrial volume tracking (LAVT) methodcan create LA volume loop using two-dimensional tissue tracking technique. The trans-mitral inflow (TMF) velocity usually shows relaxation failure (RF) pattern in the elderlysubjects. However, there sometimes appear subjects with normal TMF pattern evenin the elderly more than 60 years old without significant cardiac diseases.Purpose: To elucidate the mechanisms of the normal TMF pattern in the elderly normalsubjects using LAV loop obtained by LAVT method.Methods: Subjects consisted of 21 normal volunteers with their ratio of early to latediastolic TMF velocity E/A .1 (N: , 60yrs), 40 elderly normal subjects with their E/A.1 (EN: . 60yrs), 30 elderly normal subjects with their E/A,1 (RF . 60yrs) and 13pseudonormal patients (PN: E/A .1) with congestive heart failure regardless of age.Image clops of the apical four chamber view were stored into the commercially avail-able EUB-6500 (Hitachi Medico, Japan). The LAV loop was created automaticallyusing a specifically customized program (E-tool Viewer) off-line. LAV index (LAVI) ata given cardiac phase was calculated dividing LAV by body surface area. The early(dV/dtE) and late (dV/dtA) diastolic LA emptying rates were calculated from the firstderivative of LAV loop. The early (E’) and late (A’) diastolic mitral annular tissue vel-ocities were also measured.Results: 1) In the EN, the E’ was significantly lower than in the N (9.7+1.9 vs14.5+2.2cm/sec, p,0.0001) similarly to the RF (8.1 +2.1cm/sec), and A’ was signifi-cantly lower than in the RF (9.6+2.9 vs 11.4+1.9cm/sec, p,0.05). The ratio of E/E’significantly increased in the order of N�RF�EN�PN. 2) The maximal LAVI was signifi-cantly greater in the EN (30.3+14.1ml) than in the N (22.3+9.6ml, p,0.05) and RF(27.4+11.0ml, p,0.05), while it was significantly lower than that in the PN(43.6+16.8ml, p,0.01). 3) The passive emptying LAVI (9.5+5.8 vs 6.9+3.5ml) anddV/dtE (139+78 vs 106+61ml/sec) were insignificantly greater in the EN than in theRF. The active emptying LAVI (6.9+3.7 vs 8.5+3.4ml, p,0.05) and dV/dtA (123 +49 vs 163 + 63ml/sec, p,0.001) were significantly smaller in the EN than in the RF.Conclusions: The left ventricular diastolic function in the EN was deteriorated as muchas in the RF with greater LA volume. The decreased active LA emptying with compen-satory increased passive LA emptying were resulting in E/A .1 TMF pattern in subjectswith EN. We conclude that the E/A . 1 in the elderly subjects were representing thedeteriorated LA functions.

177Echocardiographic predictors of cardiovascular mortality in hemodialyzedpatients

H. Ribeiro1; R. Margato1; S. Carvalho1; C. Ferreira1; A. Ferreira1; P. Mateus1; JI. Moreira1

1Centro Hospitalar de Traos Montes e Alto Douro, Cardiology Department, Vila Real,Portugal

Purpose: The prevalence of cardiovascular disease in end stage renal disease (ESRD)patients is high, being the most common cause of death in this group. Echocardiogra-phy has been widely used in prediction of cardiovascular risk in HD patients focusingmainly on the importance of hypertrophy and left ventricular dysfunction.The aim of this study was to evaluate the prognostic value of different echocardiogra-phy parameters in the clinical course of hemodialyzed (HD) patients.Methods: We studied 59 patients with ESRD on hemodialysis (HD) for 53þ-7 months(68% male, mean age of 61 years old). All had an echocardiogram immediately afterHD. Cardiac chambers dimensions (left ventricular end diastolic diameter - LVEDD,left ventricular end systolic diameter - LVESD, left atrial antero-posterior diameter –LAD), left ventricule mass index -LVMI, relative wall thickness - RWT and left ventricularejection fraction – LVEF were determined. We also recorded myocardial contractilityabnormalities, valvular calcifications and the presence of pericardial effusion. Patientswere followed for 24 months and study endpoint was cardiovascular mortality.Results: On univariate analysis increased LAD and LVEDD, decreased LVEF, presenceof pericardial effusion, myocardial contractility abnormalities and older age were pre-dictive of cardiovascular mortality. LVMI, RWT, LVESD and clinical features such asgender, co-morbidities (hypertension, diabetes, dyslipidemia) and nephropathy etiol-ogy were not predictive of worst prognosis.Multivariate analyses showed that LAD (OR= 2.2; 95% CI 1.8 - 4.4; p ¼ 0.034) andLVEF (OR ¼1.9, 95% CI 1.4 to 6.9; p ¼ 0.046) were independent predictors of cardio-vascular mortality.Conclusions: This study confirmed that a traditional echocardiographic predictor ofcardiovascular risk in HD patients such as decreased LVEF but not hypertrophy isan independent predictor of mortality. We also showed that a nontraditional predictorof cardiovascular mortality–increased LAD was a strong predictor of worst prognosisso that we speculate that LAD should be incorporated in cardiovascular risk stratifica-tion of HD patients.

VMAXi and PEVi pre- and after procedure.

AEF %PE LACi (ml/m2) %AE

Group A 54 + 10 % 23 + 7% 30,9+ 11,6 32 + 11 %Group B 61 + 11 % 37 + 12% 30,2 + 10,9 24 + 11p ,0,0001 ,0,0001 0,68 ,0,001

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

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178Is atrial dyssynchrony important in sinus node disease with or without atrialfibrillation?

M. Wang1; CP. Lau1; K. Lee1; XH. Zhang1; D. Siu1; GH. Yan1; WS. Yue1; HF. Tse1

1The University of Hong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China

Purpose: Atrial electromechanical dysfunction might contribute to the development ofatrial fibrillation (AF) in patients with sinus node disease (SND). The aim of this studywas to investigate the prevalence and impact of atrial mechanical dyssynchrony onatrial function in SND patients with or without paroxysmal AF.Methods: We performed echocardiographic examination with Tissue Doppler imagingin 30 SND patients with (n¼11) or without (n¼19) paroxysmal AF who received dualchamber pacemakers. Tissue Doppler indexes included atrial contraction velocities(Va) and timing events (Ta) were measured at mid left atrial (LA) and right atrial (RA)wall. Intra-atrial synchronicity was defined by the standard deviation and maximumtime delay of Ta among six segments of LA (septal/lateral/inferior/anterior/posterior/anterospetal). Inter-atrial synchronicity was defined by time delay between Ta fromRA and LA free wall.Results: There were no differences in age, P-wave duration, left ventricular ejectionfraction and LA volume and ejection fraction between with or without AF. Patientswith paroxysmal AF had lower mitral inflow A velocity (70+19vs.91+17cm/s,P¼0.005), LA active empting fraction(24+14vs.36+13%,P¼0.027), mean Va of LA(2.6+0.9vs.3.4+0.9cm/s,P¼0.028), and greater inter-atrial synchronicity(33+25vs.12+19ms,P¼0.022) than those without AF. Furthermore, a lower mitralinflow A velocity (Odd ratio[OR]¼1.12, 95% Confidence interval[CI] 1.01–1.24,P¼0.025) and prolonged inter-atrial dyssynchrony (OR¼ 1.08, 95% CI 1.01–1.16,P¼0.020) were independent predictors for the presence of AF in SND patients.Conclusion: SND patients with paroxysmal AF had reduced regional and global activeLA mechanical contraction and increased inter-atrial dyssychrony as compared withthose without AF. These findings suggest that abnormal atrial electromechanical prop-erties are associated with AF in SND patients.

179Effect of exercise based rehabilitation on myocardial blood flow reserve asmeasured by real-time contrast echocardiography in patients with nonischemicdilated cardiomyopathy

JM. Theotonio_Dos_Santos1; I. Kowatsch1; JM. Tsutsui1; NMV. Canavesi1; CE. Negrao1;C. Mady1; JAF. Ramires1; W. Mathias Junior11Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil

Background: Exercise training has been shown to be effective in improving functionalclass of the New York Heart Association and exercise capacity in patients with heartfailure. There is no a conclusive study demonstrating the cardiac contribution in thisclinical response to exercise. Real-time myocardial contrast echocardiography(RTMCE) is a new technique that allows quantitative analysis of myocardial bloodflow (MBF).Objective: We sought to determine the effects of exercise based rehabilitation on MBFreserve measured by RTMCE in patients with primary dilated cardiomyopathy (DCM).Methods: We prospectively studied 23 patients with DCM and left ventricular ejectionfraction ,45% who underwent RTMCE and cardiopulmonary exercise test before andafter 16 weeks of optimized medical treatment (control group; n=10) or optimizedmedical treatment associated with exercise training program consisted of three60-min exercise sessions/week with corresponding intensity between the anaerobicthreshold and 10% below the point of respiratory compensation (trained group;n=13). The replenishment velocity (b) and an index of MBF (An x b) reserves werederived from quantitative RTMCE. Results: The exercise training did not change leftventricular diameters, volumes or ejection fraction in patients with DCM. At baseline,b reserve was lower in trained group than control group [1.51 (1.10-1.85) versus1.72 (1.45–1.88); p=0.02] while no difference was observed in MBF reserve [1.81(1.28–2.38) versus 1.89 (1.67–1.98); p=0.39]. A 16-week of optimized medical treat-ment associated with exercise training program resulted in significant increase in theb reserve from 1.51 (1.10–1.85) to 2.20 (1.69–2.77); p,0.0001, and increase inMBF reserve from 1.81 (1.28–2.38) to 3.05 (2.07–3.93); p,0.001. On the otherhand, after 16 weeks of optimized medical treatment, the b reserve decreased from1.72 (1.45–1.88) to 1.46 (1.14–2.33); p= 0.03 and the MBF reserve decreased from1.89 (1.67–1.98) to 1.55 (1.11–2.27); p,0.01. Peak oxygen consumption increasedby 13.8% at 16 weeks of exercise training and decreased by 1.9% in the control group.Conclusions: Exercise training resulted in significant improvement of MBF reserveobtained by RTMCE in patients with DCM and heart failure.

180Predictors of optimal contrast dosing during dobutamine stress real timeperfusion contrast echocardiography

SS. Abdel Moneim1; M. Bernier1; SS. Abdelkader2; S. Moir1; PA. Pellikka1; SV. Mankad1;SL. Mulvagh1

1Mayo Clinic, Rochester, United States of America; 2Assiut University, Assiut, Egypt

Purpose: While contrast dosing methods for left ventricular opacification are well-established, optimal dosing for real-time perfusion contrast echocardiography(RTP-CE) is unclear. We sought to determine potential predictors for contrast dosingin RTP-CE during dobutamine stress based upon the available information at time of

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

181Real-time perfusion echocardiography accuracy for detecting viability inchronic left ventricular dysfunction undergoing myocardial revascularization

DR. Aleixo1; JM. Tsutsui1; LAM. Cesar1; JA. Ramires1; W. Mathias-Jr11Heart Institute (InCor) - University of Sao Paulo Medical School, Sao Paulo, Brazil

Background: Real-time perfusion echocardiography (RTPE) is an emerging modalityfor assessing myocardial perfusion and allows noninvasive quantification of regionalmyocardial blood flow. The aim of this study was to evaluate the accuracy of RTPEfor predicting myocardial viability and improvement in quality of life after coronaryrevascularization.Methods: Twenty four patients with coronary artery disease and ventricular dysfunction(ejection fraction ,40%) underwent RTPE and answered Minnesota Quality ofLife Questionnaire before and after coronary artery bypass grafting (CABG).RTPE was performed using continuous PESDA or Definity intravenous infusionwith power modulation image. Viability was defined as presence of homogeneousopacification in at least one myocardial segment in the resting on revascularizedterritory, according coronary distribution. All revascularized territories were analyzed.Results: Hibernating myocardium (regional recovery after CABG) was observed in 77%of RTPE viable territories and in 44% of non-viable (p=0.03). Sensitivity, specificity, pre-dictive positive and negative values of RTPE for detecting viability were 74%, 60%, 77%and 56%, respectively. Quality of life score improved from 36.4 (29.1–43.6) to 18.1(12.8–23.4; p=0.001). However, there was no statistical correlation with RTPE.Conclusion: RTPE provides good accuracy for detecting hibernating myocardium inpatients with coronary artery disease and ventricular dysfunction. Nevertheless, itcouldn’t predict the quality of life improvement after CABG.

182Impact of spontaneous reperfusion on infarct size and microvascular damageafter primary PCI

S. Funaro1; E. Canali2; A. Mattatelli2; D. Berardi2; M. Madonna2; A. Porfidia3; L. Galiuto3;L. Agati21Catholic University of the Sacred Heart, Campobasso, Italy; 2Sapienza University ofRome, Rome, Italy; 3Catholic University of the Sacred Heart, Rome, Italy

Purpose: Previous studies demonstrated that patients with ST-elevation myocardialinfarction (STEMI) undergoing percutaneous intervention (PCI) take advantage of aspontaneous reperfusion of infarct-related artery (IRA) on initial angiography in termsof angiographic and clinical results. So, we evaluated in a group of STEMI patientsundergoing primary PCI the weight of spontaneous IRA reperfusion before angiogra-phy on infarct size (IS) and microvascular damage (MD) extension.Methods: 103 out of 110 STEMI patients enrolled in AMICI (acute myocardial infarctioncontrast imaging) multicenter study represented our study population. Clinical charac-teristics were collected and CK peak, early % ST-segment reduction, Blush and TIMIgrade were evaluated before and after PCI. IS was measured by using conventionalechocardiography as a percent of dysfunctional LV segments (WMA%), MD wasassessed by using contrast echocardiography as a percent of myocardial contrastdefect length (CDL%). Ejection fraction (LVEF%) was also assessed. According toTIMI flow grade before PCI, patients were divided in two groups: Group A : TIMI flow2–3 (spontaneous reflow), Group B: TIMI flow: 0–1.Results: 35 patients entered in group A, and 68 in group B.There were no significant differences between groups as for time to reperfusion andrisk factors except for family history of coronary diseases and hypercholesterolemiawhich were higher in group B (37% vs 9% p¼0.002 and 45% vs 28% p¼0.046 respect-ively). The percentage of female gender was higher in group A (26% vs 10% p 0.042).Furthermore, clinical indexes of reperfusion as % ST segment reduction, and peak CK

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did not differ between groups (56+35 vs 46 + 51 p 0.564 and 2345 + 2000 vs 2400+ 1900 p¼ 0.895 respectively). Finally TIMI grade after PCI was good in both groups(2.7+0.41 vs 2.7 + 0.46 p¼ 0.83). On day 1 after PCI, CDL% and WMA% were sig-nificantly lower and LVEF% slightly higher in patients with spontaneous reflow (11+15 vs 21+16% p¼0.018, 28+21 vs 42+17% p¼0.006 and 49+7 vs 46+9%p¼0.178 respectively). On multivariable analysis for prediction of spontaneousreflow, family history and female gender were independently associated with spon-taneous reflow before PCI (OR¼7.3; 95%IC ¼1.9–28 p¼0.04 and OR¼3.996%IC¼1–13 p¼ 0.28 respectively).Conclusion: In STEMI patients spontaneous reestablishment of flow pre primary PCIis more frequent in female gender and in patients without family history of CADand with lower incidence of hypercholesterolemia. Such spontaneous reflow isassociated with smaller microvascular damage and infarct size and better LV systolicfunction.

183Improvement of microvascular flow and myocardial function after reopening ofchronic coronary occlusion. Early results of recanalization of chronic coronaryocclusion and recovery of dysfunction

S. Barchetta1; AM. Leone1; E. Fedele1; A. Porfidia1; AR. De Caterina1; AG. Rebuzzi1;F. Crea1; L. Galiuto1

1Catholic University of the Sacred Heart, Rome, Italy

Purpose: the utility of reopening a chronic coronary occlusion (CCO) is under debate.We postulate that recanalization of CCO is associated with improved microvascularflow and myocardial function.Methods: we analyzed the first 13 patients that completed the follow up out of the26 patients initially enrolled in the trial. Patients were included in the trial if they hadcoronary occlusion that dated between 3 days and 12 months. All patients underwentmyocardial contrast echocardiography (MCE) before reopening of CCO and after 9 þ3months of follow-up. The length of perfusion defect was measured in 3 apical viewsaveraged and expressed as % left ventricle (LV). Wall motion score index (WMSI) , con-trast score index (CSI), LV volumes and ejection fraction were calculated.Results: at follow-up, a significant reduction of perfusion defect (9.5 + 12 % vs 1.4 +4.7 %, p ¼ 0.005), improvement of CSI (1.4 + 0.3 vs 1.1 + 0.2, p ¼ 0.001), improve-ment of WMSI (1.5 + 0.4 vs 1.2 + 0.2, p ¼ 0.0004) and increase of ejection fraction(50.8 + 7.9% vs 58.2 + 6.2%, p ¼ 0.0001) were observed in the absence of LV dilata-tion (end diastolic volume 111.1 + 20.7 ml vs 100.6 + 17.6 ml, p ¼ 0.005 ; end-systolic volume 55.6 + 20 ml vs 42.8 + 13.2 ml, p ¼ 0.001).Conclusions: preliminary results of the study demonstrate that reopening of chroniccoronary occlusion is associated with improved microvascular flow, regional andglobal myocardial function and with preserved LV volumes.

184Detection of restenosis using Dobutamine stress myocardial contrastechocardiography after coronary angioplasty

M. Olszowska1; M. Kostkiewicz1; P. Podolec1; W. Tracz1

1Jagiellonian University, Krakow, Poland

Background: Dobutamine stress echocardiography (DSE) detects coronary stenosisby inducing ischaemia and subsequently wall motion abnormalities. Myocardial per-fusion can be assessed at real time, when using a low mechanical index and harmonicimaging, following intravenous injection of contrast agent.The study aimed to determine whether myocardial contrast echocardiography (MCE)may be used in detecting restenosis during DSE after coronary angioplasty.Methods: The study group consisted of 71 patients (pts), (41 M; 30 F) who underwentcoronary angioplasty (PCI) due to coronary artery disease (CAD). All pts underwentDSE. Dobutamine was infused in incremental doses of 5 to 40mg/kg/min. Bolus injec-tion of intravenous Optison was administered at rest and during peak dobutaminestress test. Wall motion score index (WMSI) and segmental perfusion were estimatedat real time before and 10-14 days after PCI using low MI (0.3) after 0.3 ml bolus injec-tion of intravenous Optison. MCE was scored semiquantitatively as: 1 - homogenouscontrast enhancement, 0.5 - patchy contrast enhancement, 0 - no contrast. Thefollow-up period was 6.05+0.45 months. DSE with contrast agent and coronary angio-graphy was repeated in pts with suspected restenosis.Results: The analysis of the mean WMSI was 1.27+0.19 at rest and 1.4+0.18 at peakand decreased to 1.2+0.16 at rest and 1.29+0.4 at peak (p,0.001) after PCI. 68 pts afterPCI had no segments with induced perfusion defect at peak dose of dobutamine, 3 ptshad segments with induced perfusion defect but it was smaller. In the follow-up period20 pts were suspected to perform restenosis. The sensitivity, the specificity, and the accu-racy of DSM with MCE in detecting perfusion defect due to restenosis after coronaryangioplasty (confirmed angiographically) was 88%, 77% and 85%, respectively.Conclusions: MCE during DSE revealed substantial potential for identifying angiogra-phically restenosis after coronary angioplasty.

185Description of new image processing tools improving echo contrast detectionfor ECHOPIV method

M. Lugiez1; D. Coisne2; M. Menard1; S. Dubois1; C. Cuvier3; V. Deplano3; L. Christiaens2

1L3I University, La Rochelle, France; 2CHU de Poitiers - Hopital de la Miletrie, Poitiers,France; 3Irphee CNRS, Marseille, France

Echo Particular velocity imaging (ECHOPIV) is a promising tool detectingflow patternsin cardiovascular structures. Optical flow method implemented forcontrast movementdetection usually gave semi-quantitative information. Wethought to improve pre treat-ment and image processing in order to obtain morereliably results. Validation of ourimage processing approach was done usingtwo pulsatiles in vitro modelssimulatingvascular laminar flow and intra ventricular complex flow and usingoptical PIV asreference.Method: In order to determine the particle displacement we have to applydifferenttreatment on the image sequences to recover suitable images formovement detection.First: we remove the noise through soft wavelet thresholding method. Thesequence isdecomposed in approximation and details coefficient for a givingscale, thus very smalldetails (mostly representative of noise) are avoiding,and then the image isreconstructed.Second: we decompose images into two components, first one holdinggeometry, thestructure of images and second one representative of texture, theparticles in our case.This is very convenient to estimate the movement sinceour sequence isn’t disturbed byquite chaotic particle mixture movement andproblem induced by plane transfer of par-ticles between two consecutive frames.Since we got the regularized component, theoptical flow could be estimatethrough partial derivative equation method.We use a multi-scale implementation, the movement is first estimate onlow-resolutionversion of the sequence to catch the global motion, then themovement is estimate atthe upper resolution refine by previous results. Thismethod is iteratively applied till toreach the original resolution.Image 1 show the velocity field and the shear stress profile obtained inthe vascularmodel

186Bioeffects of the ultrasound contraste in normal and abnormal situations of themicrocirculation: an experimental study

A. Camarozano1; F. Cyrino2; E. Bouskela2; AG. Siqueira-Filho1; K. Camarozano3;R. Noe1

1Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil; 2UniversidadeEstadual do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil; 3Fundaca ABC, SaoPaulo,Brazil

Purpose: Adhesion of microspheres to leukocytes in inflammatory tissues has beendiscussed and the effect of ultrasound in this context as well. However, little isknown about the behavior of microspheres in capillaries under disease conditions.The evaluation of circulatory effects of these agents may explain their effect on themyocardium.Aim: To investigate microvascular and hemodynamic behavior of microspheres (con-trast for ultrasound-US) in the following groups of hamsters: control,ischemia-reperfusion, type-2 diabetes, diabetes with ischemia and sepse.Method: An experimental study of the microcirculation, using the cheek pouchpreparation, in 90 male hamsters was performed. Animals were divided intogroups according to disease induction: GI=ischemia/reperfusion; GD=diabetes;GDI=diabetes with ischemia/reperfusion and GS=sepse, in relation to GC (controlgroup). We analyzed the inflammatory response in the microcirculation (AL=adheredleukocytes, RL=rolling leukocytes), VD=vein diameter and DA=arteriolar diameterand the hemodynamic pattern such as arterial blood pressure (BP), heart rate (HR)and rheology according blood flow (BF), at the baseline and after 15, 30, 45 and60min after microsphere administration. During the procedure we administered Definity(a lipid coated microsphere containing perfluoropropane gas) or placebo (salinesolution).ANOVA and Mann-Whitney tests were used for comparisons, with a significance levelset at 5%.Results: There was no difference in AL, RL, VD and AD with or without microspheres indifferent groups. There was also no difference in BP and HR before and after Definity(NS) and BF was subjectively worse in GS. Number of AL and RL was higher in GDIand GS in relation GC (p,0,05).Conclusion: Inflammatory and hemodynamic responses in the microcirculationshowed no alteration with this contrast agent. The inflammatory response seemed tobe pronounced in GDI and GS, independent of microsphere use. These findingshelp us to establish the safety level when using contrast for ultrasound.

echopiv for euroecho.

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187Myocardial contrast echocardiography is superior to single photon emissioncomputed tomography for the detection of hibernating myocardium

RK. Chelliah1; M. Hickman1; L. Burden1; R. Senior11Northwick Park Hospital, Harrow, United Kingdom

Background: Single photon Emission Computed Tomography (SPECT) is widely usedfor the assessment of hibernating myocardium (HM) in patients with ischemic cardio-myopathy. Myocardial Contrast Echcardiography (MCE) is a relatively new techniquewhich can assess myocardial perfusion at the bedside. We hypothesised that MCE,due to it’s better spatial and temporal resolution compared to SPECT, will be superiorto SPECT for the detection of HM.Method: Accordingly 32 patients with symptomatic ischemic cardiomyopathy (meanleft ventricular ejection fraction= 30% þ/- 9%) underwent simultaneous rest and vaso-dilator SPECT and MCE. Of these, 23 patients underwent coronary revascularisation.These patients were then assessed 3 months after revascularisation, for recovery ofleft ventricular function, which is the definition of hibernating myocardium.Results: Of the 214 dysfunctional LV segments, 156 (73%) segments demonstratedHM in 23 patients of which 16 (70%) showed significant improvement of LV function(defined as 30% improvement of wall motion score index at follow up). Logisticregression analysis using both qualitative and quantitative MCE and SPECT showedthat qualitative and quantitative MCE were the independent predictors for the detectionof HM( p value=0.03 for qualitative MCE and p=0.000 for quantitative MCE ). Further-more, using clinical LV function data, SPECT and MCE for predicting recovery of LVfunction, MCE was the only independent predictor(p value=0.02). Of the 32 patients,significantly more reversible defects (p,0.0001) were identified by MCE(267 seg-ments) compared to SPECT( 98 segments) and significantly more reversible defects( p, 0.0001) by MCE (54%) predicted recovery of function compared to SPECT (20%).Conclusion: MCE was superior to SPECT for the assessment of HM in ischemiccardiomopathy.

188Influence of gender on the extent of myocardial viability after primary coronaryangioplasty

E. Canali1; A. Mattatelli1; D. Berardi1; S. Funaro2; M. Madonna3; L. Galiuto2; L. Agati11Sapienza University of Rome, Rome, Italy; 2Catholic University of the Sacred Heart,Campobasso, Italy; 3IRCCS San Raffaele Hospital, Rome, Italy

Purpose: Few studies have been addressed about sex distinctions in the amount ofjeopardized myocardium that is salvaged by mechanical reperfusion in patients withacute myocardial infarction (AMI). The aim of our study was to evaluate possiblegender-related differences in tissue viability after ST elevation myocardial infarction(STEMI). Myocardial contrast echocardiography (MCE) was used to assess residualtissue perfusion within the infarct area after successful coronary reperfusion.Methods: We studied 110 consecutive patients who underwent successful primary cor-onary angioplasty within 6 h of onset of STEMI. Two-dimensional echocardiographywas performed within 24 hours of coronary recanalization and microvascular perfusionwas assessed by real-time MCE on 7+2 days after AMI by using a quantitative analysissoftware. Contrast defect length (CDL%) was measured to assess microvascular integ-rity on endocardial border. Myocardial viability index was obtained by summing per-fused but dysfunctioning segments divided by all dysfunctional segments andexpressed as percentage.Results: Of the 110 patients received primary PCI, 28 patients were females (26%) and82 (74%) were males. Women were significantly older (62 þ 10 years vs. men age 58 þ10, p=0.101) and had a longer time to reperfusion (8.6 þ 7.1 hours vs 4.5 þ 4.2 hoursin men, p=0.011). Contrast defect length was larger in men than women (20 þ 7.2 % vs11 þ 7.0 %, respectively, p=0.009) suggesting the presence of a bigger microvasculardamage. Myocardial viability index was higher in women than in men (56 þ 37 % vs33 þ 22 %, respectively, p= 0.016). Multiple linear regression analysis was used toassess the independent impact of gender on myocardial viability. After adjustmentfor other variables, female gender (p=0.006), younger age (p=0.019), anterior infarc-tion (p=0.003), shorter time to reperfusion (p=0.018), small contrast defect length(p=0.002) and the use of glycoprotein IIb/IIIa inhibitors (p=0.004) were identified asindependent factors associated with a higher myocardial viability.Conclusions: In successfully reperfused STEMI population, myocardial viability asdetected by MCE is gender-dependent also after adjusting for other baseline andrisk factors. A different response to antiaggregating drugs, a higher tolerance tohypoxic setting and the activation of estrogen receptors against intracellular calciumloading could probably be involved in this favorable women behavior. Despite alonger time to reperfusion and a lower respect of recent STEMI guidelines, tissue via-bility after coronary reperfusion was higher in women.

ECHOCARDIOGRAPHIC EVALUATION OF THE RIGHT HEART

189Right heart function evolution immediately and one month after successfulballoon mitral valvuloplasty: a tissue Doppler imaging study

S. Adavane1; S. Santhosh2; S. Karthikeyan2; S. Ederhy1; S. Rajagopal2; N. Haddour1;J. Balachander2; A. Cohen1

1AP-HP - Hopital St Antoine, Paris, France; 2Jawaharlal institute of post graduate medicaleducation and research, Pondicherry, India

Background: The course of right ventricular function abnormalities in patients withrheumatic mitral stenosis (MS) treated with balloon mitral valvuloplasty (BMV) is notclearly defined.Purpose: The study aimed to assess the evolution of systolic, diastolic and global func-tion of the right ventricle (RV) immediately and one month after BMV using a standardDoppler echocardiographic approach combined with tissue Doppler imaging (TDI).Methods: Thirty three consecutive patients (70% female, age 31+ 8 years old; range19 to 45) with moderate to severe MS (mitral valve area MVA � 1.5cm2) in sinus rhythmwho underwent successful BMV (i.e. a 50% increase in MVA and/or a decrease in leftatrial pressure to less than 18 mmHg without mechanical complications) were prospec-tively included. Echocardiographic parameters of RV function were performed beforeBMV, 24 to 48 hours after BMV and one month after BMV and included pulsed waveTDI (S velocity, E/Ea, Ea/Aa, E/A, isovolumic relaxation time (IVRT), Tei index, tricuspidannular plane systolic excursion (TAPSE), RV fractional area change (RVFAC), and pul-monary vascular resistance (PVR). The control group included 14 healthy subjects(64% female, 32+ 5 years old; range 23 to 45).Results: MVA by planimetry increased from 0.88+0.15 to 1.55+0.26 then 1.66+0.28cm2 at one month (p,0.0001) and mitral valve mean gradient (MVG) fell from16+6 to 6+2 then 7+2 mmHg (p,0.0001) after BMV. The right atrium (RA)-RVpressure gradient decreased from 57+25 to 42+13 then 40+12 mmHg(p,0.0001) and PVR fell from 2.53+0.92 to 1.86+0.43 then 1.85+0.37 Wood units(p,0.0001). There was no significant change with regard to TDI S velocity, RVFACand Tei index, the last one remaining significantly higher than controls. There was a sig-nificant increase of TAPSE (p¼0.01 immediately after BMV; p,0.001 at one month)which was significantly correlated to the decrease in PVR, RV-RA pressure gradient,the immediate decrease in MVG, and the increase in MVA at one month. There wasa significant improvement in E, Ea, E/A, Ea/Aa immediately and one month afterBMV which was correlated to the decrease in right heart pressures but IVRT remainedprolonged compared to controls. This improvement occurred only in patients withMVA.1.5 cm2 after BMV.Conclusion: In patients with MVA.1.5 cm2 after BMV, successful BMV results in a sig-nificant improvement of RV systolic function assessed by TAPSE, of diastolic functionassessed by E, Ea, E/A, Ea/Aa while Tei index and IVRT remained significantly higherthan controls immediately and one month after BMV.

190Isovolumic myocardial acceleration, new index of right ventricular function afterpercutaneous mitral valvuloplasty

E. Khalifa1

1Dar Al Fouad Hospital, Giza, Egypt

Objectives: In mitral stenosis, Right ventricular (RV) function may be affected either byrheumatic process or due to pulmonary vascular alterations. The aim of this study wasto determin if isovolumic myocardial acceleration (IVA) measured by tissue Dopplerimaging (DTI) of tricuspid annulus could be used in detection of RV function immedi-ately after percutaneous mitral valvuloplasty (PMV)Patients and methods: The current study enrolled 80 patients with chronic rheumaticmitral stenosis in sinus rhythm. Conventional echocardiographic parameters, mitralvalve area (MVA), transmitral diastolic gradient, pulmonary artery pressure (PAP), RVfractional shortening (RVFS%), tricuspid annular plane systolic excursion (TAPSE). TDI-derived systolic velocities of tricuspid annulus, isovolumic myocardial acceleration(IVA), peak myocardial velocity during isovolumic contraction (IVV), peak systolic vel-ocity during ejection period (Sm) and RV Tei index were calculated to all patientsbefor and after (one day ) PMVResults: TAPSE, RVFS% and Sm were relatively higher following PMV but did notattain statistical significance.TDI-derived IVA, IVV index were found to be significantly increased after PMV from1.71þ0.54 m/s2 to 3.27þ0.22 m/s2 , and from 0.11þ0.04 cm/s to 0.14þ0.06 cm/srespectivly with (P,0.001) for all. RV Tei index significantlly deceased from0.49þ0.025 to 0.31þ0.21 (P, 0.01). Significant negative correlation could be estab-lished between IVA and PAP (before and after PMV) (r = 20.61, r=20.58 respectively),Tei index (r = 20.72) and mean transmitral diastolic gradient (r = 20.74), whereas sig-nificant positive correlation was established between IVA and MVA (r = 0.68) withp,0.0001 for all correlations.Conclusion :TDI- derived IVA can be used as reliable, non invasive parameter to detectearly improvement of RV function following PMV

191The role of interventricular interaction for the functional recovery of the RV afterpulmonary endarterectomy

S. Giusca1; V. Dambrauskaite1; J. D’hooge1; P. Claus1; L. Herbots1; F. Rademakers1;M. Delcroix1; JU. Voigt11Catholic University of Leuven (KULeuven), Leuven, Belgium

Aims: The impact of LV on RV function is not fully understood. In this study, we inves-tigated the changes of regional RV free wall and septal function compared to changesin invasive and non-invasive measures of RV and LV performance in patients withchronic thromboembolic pulmonary hypertension (CTEPH) who undergo pulmonaryendarterectomy (PEA).Methods: 16 pts(60+15) with CTEPH underwent echocardiography before(PREOP), 1week (1W) and 1, 3 and 6months (1M, 3M, 6M) after PEA. Wedetermined RV and LV end diastolic area (EDA) and volume (EDV) and ratio of

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

192How does the reference system of echocardiographic measurements influencethe assessment of acute changes in RV Function? A study in patients whounderwent pulmonary endarterectomy

S. Giusca1; V. Dambrauskaite1; J. D’hooge1; P. Claus1; L. Herbots1; F. Rademakers1;M. Delcroix1; JU. Voigt11Catholic University of Leuven (KULeuven), Leuven, Belgium

Aims: In the clinical routine, a variety of echocardiographic parameters are used toassess right ventricular (RV) function. We sought to compare the ability of different con-ventional and tissue Doppler derived echocardiographic parameters to reflect acute RVfunction changes in patients with chronic thromboembolic pulmonary hypertension(CTEPH) who underwent pulmonary endarterectomy (PEA).Methods: 16 patients with CTEPH (60+15) underwent echocardiography andright heart catheterization before and within 1 week after PEA. Tricuspid annularplane systolic excursion (TAPSE) and longitudinal systolic velocity of the tricuspidring (Vt) were measured as parameters dependent on the transducer as reference.RV fractional area change (RVFAC), RV Tei index, and Strain in the interventricularseptum (Sivs) and RV free wall (Srfw) were measured as independent parameters.Results were compared to pulmonary vascular resistance (PVR), mean pulmonaryartery pressure (mPAP) and cardiac index (CI) as obtained from right heartcatheterization.Results: Hemodynamics improved significantly after PEA (PVR: 976+432 vs.276+143 dyne*sec/cm5, mPAP 44+9 vs 32+12 mmHg and CI 1.6+0.5 vs.3.2+0.6 l/min, all p,0.001. This was mirrord by Sivs (217.5+3.5% vs. 221+5%,p¼0.04), Tei index (0.59+0.16 vs. 0.39+0.13, p,0.001) and RVFAC (29.4+6% vs.36.5+7%, p¼0.02). Srfw did not change. In contrast, TAPSE (14.5+4.5mm vs.8.5+2.7mm , p,0.001) and Vt (9.3+3cm/s vs. 6.9+2.3 cm/s, p¼0.04) decreased,indicating a worsening of function. Changes in mPAP correlated well with changes inSivr (r¼20.81, p¼0.001) and RVFAC (r¼20.7, p¼0.02); changes in PVR and CI cor-related with the changes in Tei index (r¼0.65, p¼0.01, and r¼20.6, p¼0.03). In con-trast, TAPSE and Vt did not correlate to hemodynamic data.Conclusions: Parameters which are measured vs. the transducer (TAPSE, Vt) donot accurately reflect postoperative changes in RV function due to operationinduced changes in overall heart motion. Parameters without external referencesystem (S, Tei, RVFAC) are superior and should be preferred for pre-/post-operativecomparisons.

193TAPSE values and body size: an echocardiographic study in normal infants andchildren

I. Nunez-Gil1; MD. Rubio2; L. Deiros2; C. Blanco2; L. Garcia-Guereta2; C. Labrandero2;A. Barrios2; F. Gutierrez-Larraya2

1Hospital Clinico San Carlos, Madrid, Spain; 2Hospital Universitario La Paz, Madrid,Spain

Purpose: Detailed data on normal echocardiographic values are vital since importantdecisions concerning management often rely on these findings. TAPSE (Tricuspidannular plane systolic excursion) measurements correlate nicely with right ventricularfunction and its values are well established in adults. However, normalized data in

children are lacking. Our aim was to implement normal TAPSE values regarding thesize of the body from birth to childhood.Methods: We prospectively included 248 normal neonates, infants and children (51.2%male). The patients were referred to office mainly for asymptomatic murmur. Subjectswith any other condition were excluded. Complete echocardiographic studies wereperformed and reported as normal in all cases. The weight and height of eachpatient were recorded at the same time.Results: The mean age was 4.11 years (range 0.01-18), the mean height 95.9 cm (range46–171) and the mean weight was 18.1kg (range 2.3–76.5). Mean TAPSE was17.3+4.1cm. There was no significant difference in TAPSE values between gender.Regression curvilinear adjustment models were tested for TAPSE, showing incrementalvalues regarding age, height, weight, body mass index and body surface. Figure 1depicts a scatterplot including TAPSE measures related to body surface (logarithmicregression model). Body surface displayed the closest positive correlation with TAPSEvalues (r-coefficient¼0.82) while cardiac frequency a negative relationship (r=-0.72).Conclusions: Normal TAPSE values depends on age, being most closely correlatedwith body surface area. We provide these adjusted data. This information can be pre-sented as Z-score nomograms, and be useful in the real-life practice.

194Bosentan reduces right-to-left ventricular diastolic delay in patients withchronic thromboembolic pulmonary hypertension

HACM. Bruin De-Bon1; M. Hardziyenka2; S. Surie1; P. Bresser1; RBA. Van Den Brink1;HL. Tan1; BJ. Bouma1

1Academic medical center, Amsterdam, Netherlands; 2Interuniversity CardiologyInstitute of the Netherlands (ICIN), Utrecht, Netherlands

Aim: To assess effects of bosentan treatment on diastolic interventricular synchronicityin patients with chronic thromboembolic pulmonary hypertension (CTEPH).Methods and Results: Eighteen patients with CTEPH (mean age 56+17 years, 7women) treated for 16 weeks with bosentan underwent transthoracic echocardiogra-phy and 6-minute walking test (6MWT) at baseline and after treatment. Tricuspidannulus plane systolic excursion (TAPSE), right ventricular (RV) peak systolic velocityof tricuspid annulus (RV Sm), systolic pulmonary artery pressure were estimatedusing tricuspid regurgitation jet velocity (sPAP), and RV and left ventricular (LV) myocar-dial contraction duration (MCD) (time interval between onset of QRS and onset of earlydiastolic filling velocity E0 of each ventricle) of basal segments were obtained and ana-lyzed off-line. RV-to-LV diastolic delay was calculated by subtraction of LV MCD from RVMCD. Paired Student0s t-test was applied for comparisons.After 16 weeks of bosentan treatment, RV-to-LV diastolic delay and sPAP decreased,while 6MWT increased significantly compared to baseline (Table).Conclusion: Bosentan treatment reduces RV-to-LV diastolic delay in CTEPH patients.

195How much precise is tricuspidal annular plane systolic excursion in assessingright ventricle systolic function? A comparison with the gold-standard cardiacmagnetic resonance.

O. Catalano1; G. Moro1; M. Mussida1; S. Antonaci1; M. Frascaroli1; M. Baldi1; F. Cobelli11Foundation Salvatore Maugeri, I.R.C.C.S., Pavia, Italy

Right ventricle (RV) contractility predicts prognosis and is a functional determinant inmany congenital and acquired heart diseases. Thanks to an inherent simplicity, tricus-pidal annular plane systolic excursion (TAPSE) is the most frequently used parameter

Preop 1week 1month 3months 6months

RVEDA (cm2) 27.5+6 22.2+4* 21.1+4* 20.5+4* 17.8+3*LVEDV (ml) 51+11 69+11* 74+13* 70+16* 72+17*LV/RVEDD 0.65+0.1 1.1+0.2* 1.1+0.2* 1.1+0.2* 1.2+0.1*LVEF (%) 64+6 65+7* 65+5* 65+6* 64+4*RVFAC (%) 29.5+6 36.5+7* 42.5+5* 44.8+9* 43.2+7*Sfws(%) 213+6 214.8+4 218.8+4* 223.9+5* 227+4*Sivs(%) 217.5+4 221.1+5* 221.4+3* 221.8+3* 221.9+3*

*p,0.05.

Figure 1.

Table 1 Effects of bosentan treatment

Baseline After bosentan P value

6MWT, m 456+121 494+121 0.001heart rate, bpm 82+14 81+11 0.82RV-to-LV diastolic delay, ms 63+24 36+19 ,0.001RV MCD, ms 439+52 423+43 0.075LV MCD, ms 376+47 387+36 0.33sPAP, mmHg 76+21 71+23 0.043TAPSE, cm 1.8+0.4 1.9+0.5 0.30RV Sm, cm/s 11.1+2.4 10.9+2.5 0.43

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in clinical practice. Aim of the study was to compare TAPSE with the gold-standard RVejection fraction (EF) at cardiac magnetic resonance (CMR). Methods and results. Weperformed a retrospective study by retrieving, from our hospital data-base, all consecu-tive patients (pts) who underwent, from 1st September 2005 to 31 August 2007, a CMRstudy with RVEF and TAPSE calculation and (within 1 week) an Echo evaluation includ-ing TAPSE assessment. We selected 190 pts: 153/37 m/f, 61+15 years, BSA1.81+0.18 m2, RR interval 928+175 msec and SBP/DBP 128+23/76+12 mmHg.At linear regression analysis Echo TAPSE and CMR TAPSE were significantly butweakly correlated with CMR RVEF (r¼0.35, R2¼0.12, p,0.000, and r¼0.42,R2¼0.18, p,0.000, respectively). We used a CMR RVEF cut-off value of 40%, the95th percentile inferior limit of a normal population tested in our laboratory, to definea reduced or normal RV contractility. Receiver operator characteristic (ROC) curvesshowed that Echo TAPSE values , 15 mm are sufficiently specific (specificity 81%)to assess a reduced RVEF, and values � 19 mm (specificity 79%) to identify a pre-served RVEF. TAPSE performance was overall modest in predicting RVEF (areaunder the curve ¼ 71%). Conclusions. TAPSE is a simple and useful echocardio-graphic method for a first step assessment of RV contractility. However, uncertaintyabout RV funcion remains in case of intermediate values of TAPSE. Moreover,TAPSE can not be considered the method of choice whenever a precise assessmentof RV contractility is required.

196Pulmonary transit of agitated contrast during exercise is associated withreduced pulmonary vascular resistance and augmentation of right ventricularfunction

A. La Gerche1; AT. Burns2; DJ. Mooney2; H. Heidbuchel3; AI. Macisaac2; DL. Prior21The University of Melbourne, Melbourne, Australia; 2St. Vincent’s Health, Melbourne,Australia; 3Catholic University of Leuven (KULeuven), Leuven, Belgium

Background: Factors modulating exercise induced increases in pulmonary arterypressure are incompletely understood. It has been hypothesized that the pulmonarytransit of agitated contrast (PTAC) on echocardiography indicates recruitment oflarger vessels and possible RV afterload reduction.Methods: 54 subjects (40 athletes, 14 untrained) performed maximal exercise on asemi-supine bicycle. Repeated 1–2ml agitated colloid boluses were administered intra-venously. Arterial blood gases and B-type natriuretic peptide (BNP) were obtained atbaseline and peak exercise. Continuous echocardiographic measures of pulmonaryartery pressures (PASP), resistance (PVR), cardiac output (CO), RV and LV myocardialvelocities in systole (RVSm, LVSm), isovolumic contraction (RV IVA), LV preload (E/e0)and invasive mean arterial blood pressure (BPmean) were obtained. PTAC was semi-quantitatively graded by the presence of ,20 or .20 bubbles in the left ventricle (LV) atmaximal exercise.Results: The presence of .20 bubbles divided the cohort into 2 equal groups low(n¼27) and high (n¼27) PTAC. High PTAC was associated with lower peak PASP andPVR compared with low PTAC. This resulted in improved measures of systolic RV func-tion and a smaller increase in BNP - see Table. There were no differences in measures ofLV preload (E/e0 7.5+1.6 vs 7.3+1.0, p¼0.6 for high vs low), BPmean (121+10 vs122+10mmHg, p¼0.5) or LV Sm (13.4+3.2 vs 12.3+2.5cm/sec, p¼0.2) suggestingthat the BNP increase was due to the RV loading differences. There was no differencein pO2 decrease (8.2+14 vs 9.0+14,p¼0.8) suggesting that if large vessel recruitmentexplains this phenomenon, it does not cause significant shunting.Conclusion: Greater degrees of PTAC are associated with a reduction in exerciseinduced PASP and PVR which results in improved RV function and lower BNP. Thisphysiological variant may be an important modulating factor in pulmonary vascularpathology.

197TAPSE as a predictor of the right heart failure in patients with pulmonaryhypertension

OA. Polikina1; VV. Vikentyev1

1Moscow State University of Medicine and Dentistry, Moscow, Russian Federation

Recently tricuspid annular plane systolic excursion (TAPSE) has become a well-knownsensitive indicator describing functional state of the right ventricle in patients with car-diovascular and pulmonary diseases.Aim of the study was to assess the predicting value of TAPSE in patients with chronicobstructive pulmonary disease (COPD) and pulmonary hypertension (PH) presentingno clinical signs of right heart failure.Methods: 89 patients of 46–77 years with COPD and PH were examined (64% males)and underwent 1 year follow-up. Baseline and follow-up echocardiography was per-formed including M- and B-mode right ventricle (RV) measurements, Doppler Echocar-diography with RV systolic pressure calculation. TAPSE was assessed using M-mode.Results: in patients who within the follow-up period developed clinical manifestationsof the right heart failure (RHF), the mean TAPSE at baseline was 9.5 þ/2 0.17 mm. Insubset of subjects whose TAPSE at baseline was less then 15 mm, 66.7% (40 people)developed clinical RHF. In group with TAPSE less then 10 mm, 90% presented clinicallysignificant RHF. We found that TAPSE was significantly negatively related to systolic RVpressure and subjects’ age.Conclusion: TAPSE can be regarded as simple and reliable indicator showing thepossibility of RHF development in patients with COPD and PH.

198Mid-term echocardiographic follow-up of the patients with chronicthromboembolic pulmonary hypertension after pulmonarythromboendarterectomy

T. Palecek1; D. Ambroz1; P. Jansa1; J. Lindner1; K. Taborska1; M. Vitovec1; P. Polacek1;A. Linhart11Charles University in Prague, 1st Faculty of Med., Prague, Czech Republic

Background and aim of the study: Pulmonary thromboendarterctomy (PEA) is amethod of choice for treatment of symptomatic patients with chronic thromboembolicpulmonary hypertension (CTEPH). Short-term studies have repeatedly demonstratedsignificant improvement in morphological and functional parameters of right (RV)and left (LV) ventricle. The aim of our study was to evaluate the mid-term changes inechocardiographic parameters obtained from patients with CTEPH who underwentPEA.Methods: The study group consisted of 50 patients (53+13 years) with CTEPH, inwhom echocardiography was performed before, 1 month and 12 months after PEA.The investigated parameters comprised pulmonary artery systolic pressure (PASP),right ventricular end-diastolic diameter (RV EDD), area (RV EDA) and fractional areachange (RV FAC)); left ventricular end-diastolic diameter (LV EDD), end-diastolicvolume (LV EDV), eccentricity index (LV EI) and ejection fraction (LV EF).Results: The results are summarized in Table 1.Conclusions: The profound decline in pulmonary artery pressure occurs early afterPEA and is accompanied by significant decrease in RV size and improvement of itssystolic function. Corresponding increase in LV size and normalization of its shapemay be also detected early after PEA. These favorable hemodynamic, morphologicaland functional changes of pulmonary circulation and both ventricles persist or evenimprove in mid-term one-year follow-up after PEA.

199Right ventricle performance assessed by TDI in olympic-level athletes

W. Krol1; W. Braksator1; M. Kuch1; B. Chybowska1; A. Mamacarz1; H. Krysztofiak2;M. Dluzniewski21Warsaw Medical University, Warsaw, Poland; 2Centre of Sport Medicine, Warsaw,Poland

The influence of exercise on heart is widely discussed topic especially when left ventri-cle is considered, however much less attention is given to right ventricle (RV). It isknown that enlargement of right ventricle with tricuspid valve regurgitation (TVR) andmoderately increased TVR gradient (TVRG), which are known signs of RV overloadin general population are sometimes observed in athletes, especially in those

ROC curves: RV function by TAPSE.

Table 1 Pulmonary and RV measures with exercise

Measures at peak exercise Low PTAC (n ¼ 27) High PTAC (n ¼ 27) p value

PASP (mmHg) 62.4+ 13.5 52.3+ 9.8 0.003PVR ¼ PASP/(HR � RVOT VTI) 0.018+ .003 0.014+ .003 ,0.001RVSm (cm/s) 18.9+ 2.9 21.5+ 4.5 ,0.001RV IVA (cm/s2) 5.1+ 1.9 6.9+ 2.7 0.002Increase in BNP (pg/ml) 16.0+ 13.6 9.4+ 10.5 0.048

Table 1.

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participating in sports requiring intensive mixed (dynamic and static) exertion such ascycling or rowing (group IIIC according to 36th Bethesda Conference). Available dateconcerning right ventricle assessment was based on varied or endurance (IIIA)athletes.Methods: We examined 36 members (30 men, 6 women) of Polish Olympic Team -25rowers, 5 mountain cyclist, 6 ice skaters aged 25,5yrs in average. A single TTE was per-formed. Beside standard measurements systolic (S0), early (E0) and atrial (A0) diastolicvelocities of tricuspid annulus were assessed using TDI. To decrease the bias ofpreload dependent parameters and increase quality of image measurements were per-formed during deep expiration. Values were taken as a average of 3 consequentmeasurements. Student test T was used to assess statistic differences in subgroupswith or without RV dilation (above 3cm) or elevated TVRG (above 30mmHg).Results: All measured in TDI velocities were within normal values for young, healthyindividuals (see tab.), no abnormal patterns or inverted E/A ratio were observed.There were no statistically significant differences in annular velocities between athleteswith or without RV enlargement. However, one with elevated TVRG( which was presentin 11% of examined) was related to lower S0 annular velocities- 11cm/s vs. 15,4cm/s(p¼0,002).Conclusion: 1. In athletes with extreme mixed exercise load right heart annular vel-ocities are normal- even in individuals with enlarged right ventricle and elevated TVRG.2. Enlargement of RV and moderately increased TVRG seems to be another sign of ath-lete’s heart syndrome.3. Elevated (.30mmHg) TVRG is related to lower TV annulus systolic velocities.

200Early detection of subclinical right ventricular changes in elite rowers usingautomated functional imaging and measurement of isovolumic acceleration

G. King1; EMM. Ho1; K. Bennett1; I. Almuntaser1; RT. Murphy1; AS. Brown1

1St. James’s Hospital, Dublin, Ireland

Introduction: Participationin high-intensity training for endurance sports may predis-pose the athlete to mild subclinical changes of right ventricular (RV) injury.Aim: To assess changes to the right ventricle as a consequence of high-intensity train-ing by measuring global longitudinal strain and isovolumic acceleration(IVA).Methods: 18 male elite rowers were compared with an age- and gender-matchedgroup of 17 controls. Two-dimensional speckle tracking-based automated functionalimaging was used to measure RV longitudinal strain and pulsed-wave tissue Dopplerat the lateral tricuspid annulus was used to measure IVA. RV diameter, RV wall thick-ness, and pulmonary arterial pressure (PAP) were also measured. Independentt-tests were used to compare RV longitudinal strain, RV diameter, RV thickness, andPAP. The Mann-Whitney Utest was used to compare IVA between the two groups.Results: In rowers, the mean RV diameter was significantly increased compared withcontrols (34.0+ 6.77 vs 22.5+ 6.92; p,0.0001). The mean RV longitudinal strain waslower in rowers compared with controls (20.11+ 2.81 vs 25.38+ 2.57;p,0.001). Themean IVA was significantly greater in rowers compared to controls (2.02+ 0.60 vs1.48+ 0.30; p=0.002). The mean RV wall thickness was no different between rowersand controls (0.422+ 0.10 vs 0.359+0.11, p=0.063). The mean PAP was alsosimilar in both groups (23.29 mmHg+ 6.04vs 21.12 mmHg+ 4.4, p=0.8).Conclusions: Our study demonstrates that subclinical changes in the right ventricle asa consequence of high-intensity training, manifest as an increase in RV size, and areduction in peak global longitudinal strain and an increase in isovolumic acceleration.

201Stress Doppler echocardiography: the estimation of pulmonary artery systolicpressure at peak and within early recovery phase

M. Vitovec1; T. Palecek1; P. Jansa1; D. Ambroz1; A. Linhart11General University Hospital, Prague 2, Czech Republic

Background: Stress Doppler echocardiography represents a promising tool for theevaluation of exercise-induced increase of pulmonary artery systolic pressure (PASP)in subjects with borderline PASP values at rest. However, the estimation of PASP atpeak exercise might be technically difficult.Aim of our study: To compare the values of PASP obtained at peak exercise with thosemeasured within the first minute of recovery phase.Methods: 44 subjects (55+11 years, 24 females) with borderline Doppler-estimatedvalues of PASP at rest and without inferior vena cava dilatation underwent stress echo-cardiography on a variable-load supine bicycle-ergometer. PASP was estimated frompeak tricuspid regurgitant jet velocity (þ5mmHg) as an estimate of right atrialpressure). PASP was measured at peak exercise and at the end of first minute of recov-ery phase.Results: In the whole study group, PASP at rest was 33+6 mmHg, at peak exercise58+10 mmHg and 47+9 mmHg at the first minute of recovery phase (all p .0.05).Using current recommended cut-off values for exercise-induced PASP (50mmHg forpeak exercise and 40mmHg for immediate recovery phase), stress-induced pulmonary

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

202The influence of mitral balloon valvuloplasty on short and long term rightventricular function: evaluation by tissue Doppler imaging

H. Karapinar1; Z. Kaya2; H. Kaya2; OB. Esen3; M. Akcakoyun2; G. Acar2; AM. Esen2;C. Kirma2

1Van High Speciality Education and Research Hospital, Van, Turkey; 2Kartal KosuyoluHeart Education and Research Hospital, Istanbul, Turkey; 3Istanbul Memorial Hospital,Istanbul, Turkey

Introduction: We aimed to evaluate the effect of mitral balloon valvuloplasty (MBV) onright ventricular systolic and diastolic functions at early (24 hours) and long term (6months) period.Methods: Twenty-seven consecutive patients who were successfully treated with MBVwere included in the study. All of the patients underwent transthoracic echocardio-graphic (TTE) examination that also included right ventricular tissue Doppler evaluation(TDI) 24 hours before the planned MBV. TDI evaluation included measurement of sys-tolic (S’, indicate right ventricular systolic function), early (E’) and late diastolic (A’, indi-cate right atrial systolic function) wave velocities from the lateral tricuspid annulus. E’wave velocity and E’/A’ ratio were chosen to be markers of right ventricular diastolicfunction. The same TTE evaluation was performed at 24 hours and 6 months afterthe procedure. MBV was done by the Inoue technique under TTE guidance. Theresults are expressed as mean+standard deviation, and compared by pairedsample t-test.Results: In the early phase, all of the patients displayed significant increase in rightventricular S’ and A’ wave velocities (9.52+1.85 vs 10.92+1.2 cm/s, p¼0.012;210.44+2.64 vs 211.73+2.05 cm/s, p¼0.029; respectively). And, there was no sig-nificant change in E’ wave velocity and E’/A’ ratio (p¼NS). In the late phase, S’ wavevelocity was similar to the one obtained at 24 hours and was significantly higher thanthe preprocedural velocity (10.69+1.72 vs 9.52+1.85 cm/s, p¼0.023). However, A’wave velocity decreased and did not sustain the significance of increase it showed24 hours after the procedure (210.74+2.63 vs 210.44+2.64 cm/s, p¼NS). Finally,E’ wave velocity increase just reach significant level in the late phase (29.21+1.81vs 27.85+1.54 cm/s, p¼0.046).Conclusion: The systolic right ventricular function started to improve early after MBVand this improvement was sustained in the late phase. Although the improvement inthe diastolic right ventricular function in the early phase was not significant, theimprovement reached statistical significance in the late phase.

203Evaluation of right ventricular hemodynamic by two-dimensional strain inpatients with chronic pulmonary thrombus embolism

K. Takada1; K. Sugimoto2; A. Yamada1; H. Inuzuka2; M. Kato2; S. Ito2; M. Iwase1;Y. Ozaki11Fujita Health University School of Medicine, Toyoake, Japan; 2Fujita Health UniversityHospital, Toyoake, Japan

Background: Assessment of right ventricular (RV) function is important as RV dysfunc-tion is associated with worse clinical outcomes. However, this could be problematicbecause standard methods of evaluating RV function are limited due to its poorlydefined geometry. Recent studies demonstrated that RV myocardial strain could accu-rately quantify RV function in patients with pulmonary hypertension (PH).Purpose: The purpose of this study was to examine the correlation of RV strain withinvasive pulmonary hemodynamic and RV function in patients with chronic pulmonarythrombus embolism (CTPE).Subjects: Forty five patients with CPTE (mean age: 57.1þ14.2 years) underwent two-dimenional (2D) echocardiography and 2D speckle-tracking strain evaluation of RVregional contractility. Patients additionally underwent right-heart cardiac catheteriza-tion. PH was defined as mean pulmonary artery pressure (mPAP) .25mmHg at rest.Study subjects were divided into 2 groups based on mPAP as below:Group 1 (n=25): mPAP .25mmHg (mean age: 58.8þ12.0 years)Group 2 (n=20): mPAP,25mmHg (mean age: 56.3þ16.0 years)Methods: All patients underwent transthoracic echocardiography to obtain longitudinalstrain with placement of two regions of interest in the basal and middle ventricular seg-ments of RV free wall. Right atrial pressure, pulmonary artery pressure, mPAP, pulmon-ary wedge pressure, cardiac index were measured by right-heart catheterization.Results: RV peak strain (RV-PS) was significantly higher in Group 1 than in Group 2(-16.1+ 4.7% versus -29.7+ 6.9%, p , 0.01, respectively). RV-PS showed a significantcorrelation with mPAP (r=0.804, p,0.001). Receiver operating characteristic analysisrevealed that a cut-off value of RV-PS at -18% could detect mPAP.25mmHg with sen-sitivity 91%and the specificity 86% (area of under the curve 0.953, p,0.001)Conclusion: RV strain could assess not only RV regional and global function but alsoRV hemodynamics in patients with CPTE.

Table 1. TV annulus velocities.

Examined group (n¼36) SD Healthy, young controls n¼55 (Erol et al.) SD

E0 (cm/s) 15,8 2,6 16,6 4,7A0 (cm/s) 10,6 3,4 10,9 2,2S0 (cm/s) 14,9 3 14,5 2

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204Right ventricular dysfunction evaluate by echocardiography in spontaneouslyhypertensive rats after sinoartic denervation

RA. Sirvente1; LE. Souza1; RN. Fuente1; B. Rodrigues1; ICM. Silva1; C. Mady1;MC. Irigoyen1; VMC. Salemi11Instituto de Cardiologia da Faculdade de Medicina da Universidade de SaPaulo, SaoPaulo, Brazil

Purpose: Assessment of right heart hemodynamics in patients with heart failure is ofgreat clinical importance for both diagnostic purpose and prognostication. Duringthe development of hypertension, sympathetic hyperactivity commonly seems to berelated to left ventricular dysfunction and baro and chemo reflexes impairment.However, right ventricle (RV) function has not been evaluated specially regarding theassociation of hypertension and baroreflex dysfunction. In this issue, the aim of thisstudy was to evaluate the role of chemo and baroreflex dysfunction induced by sinoaor-tic denervation (SAD) on RV performance of spontaneously hypertensive rats (SHR), aswell as the impact of this alteration on cardiac function.Methods: The animals were divided into 4 groups: normotensive rats (CTR, n¼5); SHR(n¼5); SAD (n¼7); and SADþSHR (n¼7). SAD was induced in 2 months old SHR andWistar rats (normotensive). After 10 weeks of SAD induction the animals were sub-mitted to echocardiographic examination for assessment of RV function, that includedflow velocity pattern in the right ventricular outflow tract to evaluate the accelerationtime (AT) and right ventricular ejection time (RVET). RV end-diastolic pressure(RVEDP) was invasively measured by right heart catheterization.Results: The groups SAD, SHR and SADþSHR showed a decrease AT (32+1.35,32+1.22 and 26+1.48msec, respectively) when compared with control (41+2.16msec., p�0.05). Either AT or AT/RVET were decreased while RVEDP was increasedin SAD, SHR and SADþSHR group when compared to CTR group (5.9+0.59,6.7+0.15 and 8.1+1.02 vs 3+0.39 mmHg, respectively). SADþSHR group pre-sented the greater RVEDP and the shorter AT compared to all groups (p, 0.05).A very strong correlation was found between AT and APT/RVET with RVEDP(r¼ 20.8723; p�0.05; r¼20.7373, p�0.05, respectively).Conclusions: These data suggest that the reflex dysfunction induced by SAD in SHRmay lead to an additional impairment on RV function, and also the development of pul-monary hypertension.

2052D-echocardiography of the right ventricle in athlete’s heart and hearts ofnormal size compared to magnetic resonance imaging: which measurementsshould be applied in athletes?

J. Scharhag1; T. Thuenenkoetter2; A. Urhausen2; G. Schneider3; W. Kindermann4

1University Outpatient Clinic, Centre for Sports Medicine, Potsdam, Germany; 2Centre ofSports Medicine, Luxembourg, Luxembourg; 3University Clinic of Radiology, Homburg,Germany; 4Institute for Sports and Preventive Medicine, University of Saarland,Saarbruecken, Germany

Purpose: Pathologic hypertrophy and cardiomyopathy of the right ventricle (RV) havebeen shown to be related to ventricular arrhythmias and sudden cardiac death in ath-letes. However, it is unclear which 2 dimensional (2D) echocardiographic measure-ments reflect RV dimensions in athlete’s heart (AH) correctly. Therefore, the studyaimed to compare 2D-echocardiography of the RV in AH and hearts of normal sizeto magnetic resonance imaging (MRI), and, thereby, derive recommendations for RVechocardiography in athletes.Methods: 23 healthy male endurance athletes with AH (A; age: 28+ 4yrs; heart volume:14.1+ 1.0 ml/kg; VO2max: 68+ 6 ml/min/kg) and 26 healthy untrained males (C; age:26+ 4yrs; heart volume: 11.0+ 0.9 ml/kg; VO2max: 43+ 6 ml/min/kg) matched forbody dimensions were examined by transthoracic 2D-echocardiography. EnddiastolicRV free wall thicknesses (T1,T5,T9) and diameters (m-mode enddiastolic diameter[RV-EDD]; longitudinal [RV-LAX], sagittal, outflow-tract and tricuspid valve anulus diam-eters) were determined in recommended parasternal and 4-chamber views. RV enddias-tolic volume (RV-EDV) and mass (RVM) were determined by MRI.Results: Significant correlations between echocardiographic and MRI measurementswere found for RV-EDV and RV-EDD (r¼0.49; p=0.001) as well as RV-LAX (r¼0.38;p¼0.01), and RVM and T5 (r¼0.52; p¼0.01). For RV echocardiography, mild signifi-cant differences between A and C were documented for RV-EDD (medians [quartiles]:A:26mm [24/29mm]; C:22mm [21/27mm]; p¼0.04; measurable in 49/49 subjects), andin the parasternal short axis view for T5 (A:6.0mm [5.4/7.8mm]; C:5.0mm [4.5/5.2mm];p¼0.04; measurable in 22/49).Conclusion: 2-dimensional RV echocardiographic measurements offer only a limitedpotential to reflect true RV dimensions. Only RV-EDD may differentiate betweennormal hearts and exercise related RV adaptations in AH, and is the only recommend-able parameter to be measured in athletes routinely. In unclear cases additionalmethods should be used to examine the RV in athletes.

206assessment of myocardial strain may disclose right ventricular dysfunction inpatients with intestinal carcinoid disease

LG. Sahakyan1; KH. Haugaa2; DS. Bergestuen3; E. Thiis-Evensen3; T. Edvardsen2

1Yerevan State Medical University, Armenia/ Dept. of Cardiology, RikshospitaletUniversity Hospital, Oslo, Norway; 2Dept. of Cardiology, Rikshospitalet UniversityHospital and University of Oslo, Oslo, Norway; 3Dept. of Medicine, RikshospitaletUniversity Hospital, Oslo, Norway

Purpose: Cardiac fibrosis is an important complication of carcinoid disease leadingtypically to right-sided valvular dysfunction and heart failure. Current echocardio-graphic evaluation of right ventricular (RV) function in patients with carcinoid heartdisease (CaHD) is limited and may be difficult due to its poorly defined geometry.CaHD is defined as the presence of at least mild right-sided valvular regurgitation orstenosis most often in the form of tricuspid regurgitation (TR). We hypothesized thatassessment of myocardial strain by echocardiography may be useful for evaluationof early RV dysfunction in patients with CaHD.Methods: We studied 89 patients with carcinoids (mean age 61+12; 47 females) and20 healthy individuals (mean age 55+15; 7 females). Peak systolic strains were aver-aged from 3 myocardial segments in the RV free wall. We compared RV free wall strainsin the patient group to the corresponding strains in the control group. Patients weredivided into two groups according to the presence or absence of TR.Results: Average RV strain was reduced in the patient group compared to the controlgroup ( 20.6+5.0% vs 28.6+5.3%,p,0.001). Of the patients, 38 had mild or greaterTR. There was no difference in RV function between the patients with and without TR(221.2+4.5% vs 219.9+5.4%,ns), indicating early subclinical RV dysfunction evenin carcinoid patients currently not fulfilling the criteria for CaHD.Conclusions: RV function assessed by myocardial strain was lower in patients withintestinal carcinoid disease irrespective of valvular involvement compared to controls.These findings may indicate early RV involvement even in patients without right-sidedvalvular dysfunction. Myocardial strain may therefore disclose RV dysfunction inpatients with intestinal carcinoid disease.

207Tricuspid annular displacement predicts brain natriuretic peptide levels inchronic pulmonary hypertension

T. Hugues1; S. Bun1; G. Latcu1; F. Lemoigne2; JP. Rinaldi1; N. Saoudi1; P. Gibelin2

1The Princess Grace Hospital Centre, Monaco, Monaco; 2CHU de Nice - HopitalPasteur, Nice, France

TAD based on a tissue tracking algorithm is a new sample technique that is ultrasoundbeam angle-independend for automated detection of tricuspid annular displacement.Purpose: We evaluated right atrial (RA) contractility and right ventricular (RV) systolicfunction (as assessed by TAD) in adults with pulmonary arterial hypertension (PAH)and correlated it with serum brain natriuretic peptide levels (BNP).Methods: Seventeen patients (pts) with PAH underwent a standard and pulsed Dopplertissue transthoracic echocardiography. TAD Late diastolic myocardial velocity Aa of RV(RV Aa) was regarded as the parameter of RA contractility and RV E/Ea as an index of RApressure. BNP levels were measured within 24 hours of echocardiographic examination.Results: Among the 17 PAH pts, 9 were male with mean age of 63,5 þ/- 13, mean BNPlevel 590,4 þ/- 515,3 pg/mL, mean RV Aa was 13,2 þ/- 3,9 cm/s and mean Sa 9,7 þ/-2,2 cm/s. BNP level was negatively correlated with TAD (r2= 0,57; p= 0,0005) and posi-tively with RA pressure (r2= 0,39; p= 0,007), RA area (r2= 0,39; p= 0,007) and heartrate (r2= 0,65; p= 0,0005). A value of TAD . 14 mm predicted BNP level , 90 pg/mL(Se= 100%, Sp= 66,7 %, PPV= 93,3% , NPV= 100%) and TAD , 10 mm predictedBNP level . 150 pg/mL (PPV= 100%; NPV = 40%). In pts with BNP, 90 pg/mL,TR E/A and DT was respectively 0,6 þ/- 0,1 cm/s and 220 þ/- 28,3 ms. So therewas impaired diastolic function. When BNP was . 90 pg/mL, RV E/Ea was 7,5 þ/-2,9 in favour of an increase of RA pressure.Conclusion: We have demonstrated that BNP level was good correlated to TAD. So webelieve that TAD represents a interesting tool for evaluating RV function

reduced RV strain in a patient

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208Incidence of pulmonary hypertension in patients with Sarcoidosis in Greece

E. Gialafos1; K. Aggeli1; G. Rousakis1; A. Kalianos1; G. Siasos1; G. Marinos1; A. Rapti1;C. Stefanadis1

1University of Athens, Athens, Greece

Introduction: Pulmonary hypertension (PH) is a life threatening complication of Sarcoi-dosis and the presence of PH adversely affects the survival of these patients. Aim ofthis study was the investigation of the frequency of PH and the possible associationof PH with clinical parameters of the disease in greek patients.Methods: A retrospective analysis was performed on 113 patients with biopsy provenSarcoidosis. The patients were evaluated for PH by detailed cardiac ultrasound includ-ing Doppler echocardiography. All patients underwent lung function test and high res-olution computed tomography (HRCT) was used to evaluate the stage of the disease.PH was defined as estimated systolic pulmonary artery pressure (PASP) � 40 mmHg.The frequency of PH was evaluated, and clinical parameters were compared betweenpatients with PH and those without.Results: Among 113 patients, 11 patients (9,7%) had PH. These patients had reducedvalues of PFT indices (FVC¼78+24 %, TLC¼69+14, DLCO¼61+15) implying moreadvanced staging than the patients without PH. Also, the PH-patients showed diastolicdysfunction of right and left ventricle assessed by E/A wave ,1 detected in tricuspidand mitral valve. Multivariate analysis showed that stage of the disease and the pres-ence of reduced DLCO reduction(,60% of the predicted ) were independent predic-tors for the presence of PH.Conclussion: The incidence Pulmonary Hypertension in greek patients with Sarcoido-sis was 9,7% estimated echocardiographically. The stage of the disease and the DLCOreduction were independent predictors for the presence of PH in this setting of patients.

209Predictive echocardiographic parameters of pulmonary hypertension in sicklecell disease : results from Etendard study ( French prospective multicenterstudy )

S. Lahmam Bennani1; J. Inamo2; F. Parent3; L. Hajji4; O. De Sauniere1; MS. Slama1;G. Simonneau3

1Service de Cardiologie, Hopital Antoine Beclere, Clamart, France; 2Service decardiologie, Hopital de Fort de France, Martinique, Fort de France, France; 3Service dePneumologie, Hopital Antoine Beclere, clamart, France; 4Service de Cardiologie,Hopital Henri Mondor, Creteil, France

Pulmonary hypertension (PH) is defined at right-heart catheterisation (RHC) by amPAP � 25 mmHg. PH recognized complication of chronic hemolytic anemias andparticularly of sickle cell disease (SCD). Different studies showed a high prevalenceof PH in SCD, if estimated by a tricuspid regurgitation jet velocity (TRV) � 2.5m/s onDoppler echocardiography (around 30%).The aim of this prospective multicenter study was to evaluate the prevalence of PH, andto determinate predictive echocardiographic parameters of PH in 385 consecutiveadult patients with stable SCD, recruited from 4 SCD referral centers. All patients hadechocardiography and RHC when TRV was � 2.5m/s.Of the 385 patients, 96 had a TRV � 2.5m/s on echocardiography (25%). RHC wasperformed and showed no PH in 72/96 patients (false positive ofechocardiography¼75%). Post-capillary PH (defined by a mPAP � 25 mmHg andPCWP .15 mmHg) was seen in 13/96 patients, a hyperkinetic state with mPAP � 25mmHg and high cardiac output but normal pulmonary vascular resistance (PVR,160 dyn.sec.cm25) in 5/96, and precapillary pulmonary arterial hypertension (PAH)(defined by mPAP � 25 mmHg, PCWP � 15 mmHg and PVR � 160 dyn.sec.cm25) inonly 6/96 patients (mean mPAP ¼29+5 mmHg).In these patients, at univariate analysis, the following echocardiographic variables weresignificantly associated with PH : Left auricular diameter in M-mode (p,0,0001), longi-tudinal right auricular diameter in 4 chambers view (p¼0,004), mitral peak early dias-tolic velocity at TDI (Ea) (p¼0,0002), and mitral E/Ea ratio (p¼0,02).PH confirmed by RHC is rare among SCD patients, with a prevalence of 24/385 (6%).PAH was present in only 6 patients (1.6%). In this population, using a TRV � 2.5m/s onDoppler echocardiography, alone, is inapropriate to diagnose PH. The association withothers echocardiographic parameters seems to be interesting to identify patients whomust have a RHC to confirm and classify PH in SCD patients.

210Relationship between mechanical and volumetric properties of right ventricle: Astudy on healthy subjects using modern echocardiography and cardiacmagnetic resonance imaging

SK. Saha1; A. Patel2; A. Kiotsekoglou3; SC. Govind4; J. Nowak5; LA. Brodin6; A. Younis3;AS. Gopal21Sundsvall Hospital, Sundsvall, Sweden; 2Saint Francis Hospital, New York, UnitedStates of America; 3St George’s University of London, London, United Kingdom;4VIVUS-BMJ Heart Center, Bangalore, India; 5Karolinska University Hospital, Stockholm,Sweden; 6Royal Technical University, Stockholm, Sweden

Purpose: Newer markers of mechanical functions (velocity, displacement, and strain:all being age and gender dependent), that have been well studied and validated toassess left ventricular (LV) pathophysiology, have not been tested in the right ventricle(RV). We propose that advanced echocardiographic modalities in combination withcardiac magnetic resonance imaging (CMR) may provide a better understanding of

right ventricular (RV) physiology that is challenging given the complex geometry ofthe RV designed for synchronized mechanical and volumetric functions, as in LV. Sub-jects and Methods: 59 normal subjects (60+12 years, 30 men) underwent standardDoppler (St2D), 3D, 4D echocardiography (SONOS 5500), and CMR (1.5 T Siemens)for estimation of RV ejection fraction (EF). 2D images of 42 subjects were feasible forfurther analyses using the 2D cardiac performance imaging, CPA, (TomTec ImageArena 4.0) for estimation of RV EF (2DEF), longitudinal and radial velocity, displace-ment, and strain (S%). Pearson’s correlation coefficients with two-tailed t tests were per-formed to study the relationship between mechanical and volumetric properties of theRV. Results: CPA data revealed significant difference of 2DEF (%) between individuals,70 and . 70 years of age (58+ 7 vs. 52+ 9; p,0.05). The mean values of longitudi-nal and radial data did not differ (10+3 vs. 9+2 and 7+2 vs. 6+2 respectively forlongitudinal and radial velocities, cm/s; 37+ 12 vs. 33+13 and 47+20 vs. 35+25respectively for longitudinal and radial strain%, all p. 0.05). Correlations test revealedstrongest association between CMR EF and 3DEF (r= 0, 8; p = 0.000) and modest butsignificant associations between 2DEF vs. 3D and CMR EF (all r = 0,4; p= 0.007) aswell as between CMR EF vs. longitudinal strain (r= 0,4; p= 0.007). Significant inter-relationship also existed among all the CPA variables while St2D had a significantrelationship with radial strain (r = 0,4; p= 0.007). 4D EF did not have any correlationwith any other variables. CMR EF (%) was lower in females (48+8 vs. 58+7;p,0.001). Conclusions: CPA in combination with 3D and/or MR may provide betterinsight into RV physiology. Though any single modality may not be suitable to studycomplex RV functions, CPA with its simultaneous generation of mechanical and volu-metric data maybe suitable for routine use in a busy practice. Further evaluation ofthe soft ware with far greater number of subjects is however needed. Age andgender considerations are also required for proper assessment of RV functional status.

211Dyssynchrony can be a reason for false positive myocardial SPECT results instable angina patients

JS. Cho1; HJ. Youn1; EJ. Cho1; HD. Kim1; HJ. Yoon1; SW. Jin1; HO. Jung1; HK. Jeon1

1The Catholic University of Korea College of Medicine, Seoul, Korea, Republic of

Purpose: Thallium single photon emission computed tomography (SPECT) has beenknown as its high incidence of false positive result, even though quantitative perfusionSPECT scans have advantage in differentiating attenuation artifacts from true perfusiondefects. Dyssynchrony is one of the causes of false positive result of SPECT and bynormal QRS duration, dyssynchrony cannot be excluded. The incidence of dyssyn-chrony in normal left ventricular (LV) function is reported upto 30%. We aimed thisstudy to evaluate the dyssynchrony might be a reason for false positive results of myo-cardial SPECT in stable angina patients.Methods: 30 patients with clinically diagnosed stable angina and positive myocardialSPECT results who underwent coronary angiogram were included. These patientswere divided into two groups (group I, patients with positive SPECT results andnormal coronary angiography (n¼16, mean age¼69.4+5.8 years, 8 males), group IIpatients with positive SEPCT results and significant coronary lesion in coronary angio-graphy (n¼14, mean age¼71.1+4.3 years, 7 males). We examined conventionalechocardiographic parameters and dyssynchrony index including septal to posteriorwall motion delay on parasternal long axis view, both inter-ventricular and intra-ventricular electromechanical delay, septal to lateral delay on apical 4 chambes view, and maximal difference in time to peak velocities between any two of twelve LV seg-ments (Ts-12) on apical 4 chambes view, 2 chambes view and long axis view.Results: There were no significant differences in conventional echocardiograpic par-ameters (LV dimension, volume, ejection fraction and E/E0) between two groups. Theinter-ventricular (15.4+12.6 vs. 17.3+12. msec, P¼0.784) and intra-ventricular(115.1+20.7 vs. 106.5+27.1msec, P¼0.409) electromechanical delay was not signifi-cantly different. (Time delay between anterior and inferior wall was no significantlydifferent (basal segment : 60.0+50.8 vs. 66.9+49.5, P¼0.827, mid segment ;77.0+58.9 vs. 73.3+51.1msec, P¼0.911). But the basal segment time delaybetween lateral and septal wall peak systolic velocity were significantly delayed ingroup I (76.9+43.3 vs. 28.8+27.1 P¼0.013).Conclusions: In patients with stable angina, dyssynchrony of left ventricle might be thereason for false positive SPECT results in patients with stable angina. MyocardialSPECT examination with dyssynchrony index measurement might be good tool forscreen possible normal coronary angiographic results.

212Mid-term evolution of patients with severe pulmonary hypertension receivingvasodilating therapy. Study of clinical, biological and echocardiographyparameters

C. Ginghina1; RO. Jurcut1; IM. Coman1; I. Ghiorghiu1; D. Iorgoveanu1; O. Andrei1;S. Vasile1; OR. Savu1

1Institute of Cardiovascular Diseases "Prof. Dr. CC Iliescu", Bucharest, Romania

Purpose: Pulmonary hypertension (PHT) is a severe disease with poor prognosis. Theaim of the study was to assess the evolution of clinical, biological, and echocardiogra-phy parameters during modern vasodilating therapy.Methods: Eighteen pts with PHT (30.8+10.8y, 4 men) receiving specific vasodilatingtherapy (sildenafil and/or bosentan) were enrolled: grA, 8 pts with arterial idiopathicPHT; grB, 10 pts with Eisenmenger syndrome. All pts underwent evaluation of clinical(6-minute walk distance, 6MWD), biological (BNP) and echocardiography parameters(conventional and 2-dimensional strain imaging, 2DSI) at baseline, after 3 and 6

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

213Right ventricular function before and after conversion of atrial fibrillation tosinus rhythm

L. Lenartowska1; M. Stopyra-Poczatek1; J. Kowal1; A. Kaczmarzyk-Radka1; J. Lewczuk1

1Wojewodzki Szpital Specjalistyczny, Dpt. of Cardiology, Wroclaw, Poland

Left ventricular (LV) function were widely studied during atrial fibrillation (AF). The aim ofthis study was to determinate right ventricle (RV) function before and after conversion ofAF to sinus rhythm (SR).Materials and method: We studied 68 patients (32 women, 56,5+11,2 years) with AF(duration of AF 4,2+1,6 weeks). Echocardiographic examination with 2D, PW, CW,Color and TDI were performed. We studied RV function parameters as TAPSE (tricus-pid annulus systolic excursion), FAC (fractional area changing), TDI of lateral tricuspidannulus (peak systolic velocity S‘t, peak early diastolic velocity E‘t and peak late dias-tolic velocity A‘t).All patients were examinated before, 1 day after and 3 months after conversion to SR.Results: Before cardioversion TAPSE was significantly lower comparing to healthysubjects (18,1+1,9mm), no difference 1 day after conversion to SR, but significantlyimproved after 3 months (p.0.05). FAC was normal at baseline and no differenceduring two next examinations. TDI parameters as S‘t was significantly lower in AF(10,7+2,4cm/s) and 1 day after cardioversion, but after 3 months significantlyincreased (16,3+2,2cm/s, p.0.05). E‘t was examined 24 hours after conversion toSR and after 3 months, we didn‘t found difference. A‘t after successful cardioversionsignificantly increased after 3 months (17,3+3,2cm/s, p.0.05).Conclusions: 1. Right ventricular function is reduced during atrial fibrillation.2. The parameters of right ventricular function improved after successful conversion tosinus rhythm.3. Recovery of right ventricular function is not immediately after cardioversion.

214New echocardiographic prognostic factors of mortality in pulmonary arterialhypertension

G. Brierre1; N. Souletie1; B. Degano1; L. Tetu1; V. Bongard1; D. Carrie1

1CHU de Toulouse - Hopital de Rangueil, Toulouse, France

Purpose: Right cardiac function conditions the prognosis of pulmonary artery hyper-tension (PAH). The clinician needs objective parameters for evaluating right ventricularfunction in order to assess the gravity of the disease as early as possible and so adaptthe treatment. The present role of transthoracic echocardiography is generally limitedto screening for PAH.The aim of our study was to seek new echocardiographic prognostic factors of mor-tality in PAH which would give this investigation an important place in the managementof this disease.Methods: We prospectively included, between June 2005 and February 2008, 79 patientsof groups 1, 3, 4 and 5 of the Venice classification. At inclusion patients underwent rightcardiac catheterization, transthoracic echocardiography and a 6-minute walking test.Results: Distribution according to the NYHA functional classification was class I 1.3%,class II 29%, class III 57% and class IV 12.7%. The 6-minute walking distance was 300m [210–375] (median [interquartile interval]), cardiac index 2.38 L.min21.m22 [2.03–2.87] and pulmonary vascular resistance 8.4 WU [5.6–11.4]. During follow-up (12months [5–21]), 16 patients died of their pulmonary disease. The incidence rate ofdeath was 18 for 100 person-years (one-year survival rate 82%).In univariate analysis, 7 echocardiographic parameters were associated with mortality,of which 4 have never previously been reported in PAH: mean pulmonary arterial

pressure (PAP) � 49 mmHg (relative risk (RR) of death 3.94 [95% CI 1.34–11.5, p ¼0.012]); diastolic PAP � 29 mmHg (RR 4.97 [95% CI 1.58–15.6, p ¼ 0.006]); abnormalend-diastolic septal curvature (RR 5.33 [95% CI 1.21–23.5, p ¼ 0.027]); inferior venacava diameter � 20 mm with respiratory variation of diameter , 50% (RR 3.39 [95%CI 1.23–9.35, p ¼ 0.018]). The 3 other echocardiographic parameters found in ourstudy and already described in the literature were the Tei index, presence of pericardialeffusion and tricuspid annular plane systolic excursion (TAPSE). After adjustment forNYHA class IV, these parameters remained significant.Conclusion: Transthoracic echocardiography, because of the prognostic factors ofmortality it reveals at the initial investigation, must have its place in therapeutic decisionmaking and so its role should not be restricted to screening for PAH.

215Impact of right ventricle dysfunction assessed with tissue Dopplerechocardiography on exercise capacity in patients after inferior myocardialinfarction treated invasively

K. Smarz1; B. Zaborska1; T. Jaxa-Chamiec1; P. Maciejewski1; A. Budaj11Postgraduate Medical School, Warsaw, Poland

Background: Right ventricular (RV) involvement in patients (pts) with inferior myocar-dial infarction (MI) occurs in 30-50% of cases. In pts with chronic heart failure RV dys-function causes worsening of exercise capacity (EC). RV systolic myocardial velocity(SmRV) was shown to be an indicator of RV systolic function. Data on influence ofRV function on EC in pts with MI are scarce.Aim: To assess EC in the group with RV dysfunction complicating inferior MI in com-parison to the group without RV dysfunction.Methods: Pts with first inferior STEMI treated by primary percutaneous coronary inter-vention (pPCI) were prospectively assessed. ECHO was performed post pPCI within 48hours from the onset of symptoms (early) and on the day of cardiopulmonary exercisetest (CPET) (late). RV dysfunction was defined as SmRV ,12 cm/s in pulse wave tissueDoppler echocardiography (TDE). CPET was done on day 14þ/210. VO2 peak (ml/kg/min) and percent of predicted VO2max values (%) were assessed as EC parameters.None of the pts had exercise limiting factors other than dyspnoe and/or fatigue.Results: Pts with inferior MI (n=61, 75% male, mean age 60þ/210) were enrolled.Patients were divided into three groups: the group without RV dysfunction (n=34,76% male, mean age 59þ/212), the group with RV dysfunction in the first 48 hrs(n=27, 74% male, mean age 61þ/28) and the group with RV dysfunction on theday of CPET (n=17, 71% male, mean age 62þ/29). Comparison of EC parametersis shown in the table.Conclusion: In patients after acute inferior MI early and late RV dysfunction has a sig-nificant impact on exercise capacity estimated with cardiopulmonary stress test.

216Enhanced pressure increase in the pulmonary artery after peak flow assessedusing Doppler echocardiography identifies patients with elevated pulmonaryvascular resistance

F. Lindgren1; B. Rundqvist1; S. Petersson1; N. Selimovic1; O. Bech-Hanssen1

1Institute of Medicine at Sahlgrenska Academy, Gothenburg, Sweden

Purpose: It is important to distinguish patients with pulmonary hypertension (PH) due toincreased pulmonary vascular resistance (PVR) from those due to increased pulmonarycapillary wedge pressure (PCWP), as it effects both treatment and prognosis. Dopplerechocardiography (DE) can estimate the pulmonary artery (PA) systolic and mean press-ures (PASP, PAMP) as well as the PVR (DE-PVR). Low peripheral resistance and a smallpressure increase (PI) after peak flow in the PA, characterize the normal pulmonary cir-culation. In the present study we hypothesized that the level of PI after peak velocityidentifies patients with increased PVR. The aim of the study was to evaluate the diagnos-tic accuracy of DE-PVR and the PI to identify patients with increased PVR (PVR.3WU).Methods: DE and right heart catheterization (Swan-Ganz catheters, thermodilution forcardiac output, CO) were performed within 24 hours at 106 occasions in 96 patients.The investigations were divided into a testing sample (n¼53) and a validationsample (n¼53). The tricuspid regurgitation velocity was used to estimate PASP, dias-tolic (PADP) pressures and the pressure at the time of peak velocity (PAVP). Thetime intervals from QRS to the pulmonary valve opening (PADP) and the peak velocityin the PA using pulsed Doppler were superimposed on the tricuspid velocity envelope.Right atrial pressure and CO were assessed using standard DE methods. TheDE-PCWP was estimated as 9, 15 or 20 mmHg by combining mitral and pulmonaryvenous flow data. The PI was calculated as PASP-PAVP, PAMP as PADPþ0.33 (PASP-PADP) and PVR as PAMP-PCWP/CO.Results: The proportion of patients with catheter PASP.40 mmHg, PVR.3 WU) andPCWP.12 mmHg were 77%, 70% and 46% respectively. The receiver operator charac-teristic curves in the testing sample for DE-PVR/PI to detect increased PVR had an areaunder the curve (95% CI) of 0.83 (0.70–0.96)/0.95 (0.89–1.0). The Table shows the

Baseline 3 months 6 months

6MWD (m) 304+141 405+131* 600+170#

BNP (ng/ml) 462.2+479.1 306.7+327.4 232.4+174.2Systolic pulmonary pressure (mmHg) 94+21 100+16 109+21Mean pulmonary pressure (mmHg) 51+7 53+7 52+4RV end-diastolic diameter (mm) 45+11 48+10 44+9RV fractional area change (%) 25+9 27+9 25+9TAPSE (mm) 16.0+4.5 16.2+3.6 17.0+4.1Global RV performance index 0.79+0.25 0.80+0.29 0.71+0.15Cardiac output (l/min) 4.4+1.4 4.6+2.1 4.0+2.1RV basal systolic VEL (cm/s) 7.5+2.2 7.6+4.2 7.6+2.9RV basal peak systolic S (%) 216.6+8.0 217.2+9.3 219.7+12.4RV basal postsystolic S index (%) 25.0+21.1 20.7+16.2 25.5+20.5

Posthoc analysis: *p¼0.04 vs baseline; #p,0.01 vs baseline and vs 3 months.

Table 1 Comparison of EC parameters

SmRV�12cm/s

SmRV,12cm/s first48 hrs

SmRV,12 cm/s day ofCPET

VO2 peak (ml/kg/min) 21+ 6.2*# 18.5+ 5.2* 17.5+ 5.6#VO2 peak /VO2 maxpredicted (%)

72+ 21 63+ 12.8 61+ 13.3

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

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sensitivity, specificity, positive (PVþ) and negative predictive (PV2) values in the vali-dation sample.Conclusion: In the present study we found that the novel DE parameter PI identifiedpatients with increased PVR with a diagnostic accuracy superior to DE-PVR.

217Prognostic value of right ventricular function in ischemic dilatedmyocardiopathy

SGC. Gamaza1; P. Cabeza1; FJ. Camacho1; E. Diaz1; A. Gutierrez1; J. Gallego1;M. Sancho1; R. Vazquez1

1Puerta del Mar Hospital, Cadiz, Spain

Purpose: The aim of this study was to determine the prognostic value of the right ven-tricular function estimated by transthoracic echocardiogram in patients with ischemicdilated cardiomyopathy.Methods: We studied those patients who went to our Echocardiography Laboratory inour center between January and December of 2007, and they were diagnosed asdilated cardiomyopathy with severe left ventricular dysfunction (left ventricular ejectionfraction less than 35%), and severe lesions in the coronariography. All of these patientsunderwent traditional echocardiography, and meditions of the right ventricular function(Tricuspid Annular Plane Systolic Excursion -TAPSE- and S wave of the tricuspidannular by Tissue Doppler). We recorded their demographic, risk factors and echocar-diographic values. It was defined as primary objective MACE (combined end-point ofdeath, acute heart failure hospital readmissions or heart transplantation).Results: We studied 38 patients with ischemic dilated myocardiopathy, with 12.86months of mean follow-up. The MACE was present in 46.4% of the patients (28.6% car-diovascular deaths). These MACE were more frequent in the right ventricular dysfunc-tion group (31.3% vs 66.7%, p,0.05), due to a more frequent hospital readmissions inthis group. We found statistical significant differences in TAPSE value (15.08+4.11 vs18.8+5.17) between the two groups. There were not significant differences in cardio-vascular risk factors, atrial fibrillation, functional class, left ventricular ejection fraction.Conclusions: We found a significant higher proportion of acute heart failure readmis-sions and cardiovascular events, in ischemic dilated myocardiopathy with right ventri-cular dysfunction, independent of associated factors.

218The prognostic importance of right ventricular dysfunction in patients withmoderate ischemic mitral regurgitation and left ventricular dysfunctionqualified to cardiosurgery treatment

R. Piatkowski1; J. Kochanowski1; P. Scislo1; M. Grabowski1; M. Marchel1; D. Kosior1;G. Opolski11Medical University of Warsaw, 1st Department of Cardiology, Warsaw, Poland

Purpose: Right ventricular (RV) function assessed after myocardial infarction (MI) havebeen identified as an important prognostic factors for mortality and/or development ofheart failure (HF). The purpose of this study was to evaluate the use of RV function aspredictor of mortality and hospitalizations due to exacerbation of HF in patients (pts)with ischemic mitral regurgitation (IMR) qualified for cardiosurgical treatment - coronaryartery by-pass grafting alone (CABGa) or CABG with mitral reconstruction (CABGmr).Materials and methods: We prospectively analyzed 100 pts (M 56, 64+8 years) withmoderate IMR, 3-24 weeks after MI. Effective regurgitation orifice (ERO) was used forquantitative IMR assessment (moderate �10-20 mm2). All the pts were qualified forCABG (multiple vessel coronary disease, ejection fraction (EF) 44+9%, wall motionscore index (WMSI) 1.57+0.3). The patients were referred for CABGa (gr.1; n=74)or CABGmr (gr.2; n=26) based on clinical assessment, 2D and 3D echo at rest andexercise. Tricuspid annular plane systolic excursion (TAPSE) was acquired to evaluateRV function (measured with M-mode imaging in the 4-chamber view). RV function wasrelated to clinical outcome (median follow-up: 12 months).Results: During the follow-up period of 12 months, 5 deaths (5 %) and 8 hospitaliz-ations (8%) due to exacerbation of HF occurred. With use of the following cut-offpoints of TAPSE � 12 mm (group I), and TAPSE .12 mm (group 2)—an associationwas found between the lower TAPSE and increased mortality. In group 1 (n ¼52pts), 5 pts (21%) died and 6 pts was hospitalized due to HF (11.5%); in group 2 (n¼48), no patient died and 2 pts was hospitalized (4%). There was a significant differ-ence (p¼0.02) in clinical outcomes between group I and II. ROC analysis identifiedTAPSE �12 mm as predictive cut-off for prediction adverse clinical outcome in allstudy group: (death: sensitivity 80%, specificity 76%, area under curve [AUC]=0.807;death and HF hospitalizations: sensitivity 69%, specificity 79%; AUC ¼0.767).Conclusion: TAPSE is simple and useful quantitative measurement of RV systolic per-formance and have a predictive value in pts with moderate IMR reffered for cardiosur-gery treatment.

219The interventricular septal curvature in echocardiography : a new approach forscreening and prognostic assessment in pulmonary arterial hypertension

N. Souletie1; G. Brierre1; B. Degano1; L. Tetu1; V. Bongard1; D. Carrie1

1CHU de Toulouse - Hopital de Rangueil, Toulouse, France

Purpose: Pulmonary arterial hypertension (PAH) is a rare and serious disease, charac-terized by increased pulmonary resistance leading to right heart failure and death.Transthoracic echocardiography has its place in screening and surveillance of PAH.The normal interventricular septal curvature (SC) is convex towards the right ventriclein systole and in diastole. It is considered abnormal if it is flattened or convextowards the left ventricle in parasternal short-axis views through the base of theheart, in two-dimensional mode.We aimed to study the relation between an abnormal SC and pulmonary pressuremeasurements, in the absence of systemic arterial hypertension.Methods: Seventy-nine patients with PAH were prospectively included between June2005 and February 2008. All patients underwent transthoracic echocardiography withdirect measurement of systolic and diastolic pulmonary artery pressure, indirectmeasurement by calculation of mean pulmonary artery pressure and visual assess-ment of the interventricular septal curvature (normal or abnormal).Results: During the median follow-up of 12 months (interquartile interval:5–21 months),16 patients died of their pulmonary disease (mortality rate 18 for 100 person-years).An abnormal end-diastolic septal curvature was significantly associated with highermortality (relative risk of death 5.33 [95% CI 1.21–23.5; p ¼ 0.027]).Conclusions: The appearance of the interventricular SC, normal or abnormal, and itstime period (systolic, diastolic, or systolic and diastolic) provides semi-quantitativeinformation on the presence and severity of PAH. Abnormal end-diastolic SC is afactor of poor prognosis of the disease.

HEART FAILURE

220Longitudinal global strain by speckle tracking is an independent predictor ofoutcome in heart failure patients with impaired left ventricular function

J. Nahum1; C. Dussault1; A. Bensaid1; L. Macron1; P. Gueret1; P. Lim1

1AP-HP - Hopital Henri Mondor, Creteil, France

Objective: To assess the predictive value of peak global longitudinal strain(1) and 1

rate by speckle tracking to predict outcome in heart failure (HF)patients.Methods: The study included 112 consecutive patients admitted for HF (64+13years,81% male, 52% ischemia) with reduced left ventricular ejection fraction(LVEF,50%,mean ¼31+10%, range 10-49]. Longitudinal global-1 and 1 rate by speckletrackingwere curves computed from apical views and compared to the occurrenceof majorcardiac events (death, heart transplantation, and recurrent HF).Results: On the whole, peak systoliclongitudinal global-1 and 1 rate averaged 28+3% [range 23 to-18] and 20.34+0.20s-1 [range 21.6 to 20.1], respectively. Dur-ingthe follow up period (208+149 days), major cardiac adverse events occurredin40 (36%) patients (11 death, 23 recurrent HF and 4 heart transplantation).Univariableanalysis using Cox model shown that global-1, 1 rate, LVEF, tricuspid annular planesystolic excursion, NYHAclass and BNP level were associated with cardiac adverseevent. However, only global-1(OR1.2, p¼0.025) and BNP level (OR1.3, p¼0.024)were predictive of outcome bymultivariable analysis.Conclusion: Inpatients admitted for heart failure with impaired LVEF, peak global strainbyspeckle tracking appears to be the only echocardiography predictor ofadverseoutcome.

221Correlation between longitudinal systolic function and ejection fraction of theleft ventricle assesed with bimode and tissue doppler echocardiography inpatients with reduced ejection fraction

I. Daskalov1

1MMA, Sofia, Bulgaria

Aims: The aim of the study was to asses the relationship between longitudinal systolicfunction of the left ventricle, quantitative analyzed with tissue Doppler and

Cut-off Sensitivity Specificity PVþ PV2

DE-PVR 5 WU 92 62 82 80PI 5 mmHg 94 81 88 85

Table 1 SC according to pulmonary pressures

Normal systolicand diastolic SCN¼14

Abnormal systolicor diastolic SCN¼20

Abnormal systolicand diastolic SCN¼45

P-value*

Age 63.7 (1) 52.5 60.6 0.05065.9 [54.4–76.1] (2) 46.8 [41.1–67.2] 63.4 [48.8–74.9]

SAP 138 122 124 0.096135 [122–150] 126 [117–130] 124 [110–140]

DAP 78 76 78 0.71681 [71–85] 80 [68–80] 80 [68–87]

sPAP 65 79 91 ,0.000164 [54–70] 73 [67–84] 86 [77–102]

dPAP 17 26 29 ,0.000118 [15–19] 22 [20–28] 28 [24–33]

mPAP 33 44 49 ,0.000133 [29–35] 41 [35–50] 48 [42–52]

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

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echocardiographycally estimated ejection fraction in patients with reduced left ventricu-lar systolic function.Design: prospective, one-year study.Patients: Forty patients aged from twenty to eighty-nine years were successfullyenrolled in the study. All participants were with reduced left ventricular ejection fraction.Methods: The quantitative analysis of the left ventricular longitudinal systolic functionwas assessed according to the average peak mitral annular descent velocity in twoconsecutive regimens: PW and colour M-mode tissue Doppler echocardiography.The average peak systolic velocity was calculated for every regimen separately, as asum of velocities divided to a sum of used positions. The echocardiograms wereobtained from six mitral annular sites.Results: The average peak mitral annular descent velocity from color coded M modetissue Doppler showed strong correlation with left ventricular ejection fraction (r¼0,798; p,0.0001). The similar results but with lower coefficient of correlationshowed average peak mitral annular descent velocity from PW tissue Doppler andleft ventricular ejection fraction (r ¼0,275; p¼0,002). Peak mitral annular descent vel-ocity from the septal corner of the mitral ring in apical 4-chamber view correlatedmost closely with TTE estimated ejection fraction.Conclusion: The data collected from our study provide high diagnostic accuracyespecially when ejection fraction is difficult to assess. We recommend using averagepeak mitral annular descent velocity from color coded M mode as a quantitativeindex of a global systolic function of the left ventricle. Peak mitral annular descent vel-ocity average � 2,64 sm/sec from color coded M mode tissue Doppler had a sensitivityof 97 percent for an ejection fraction �25 percent and specificity of 60 percent to rejectejection fraction � 25 percent for the same velocity. We recommend using followedequation: EF ¼7,1þ8 X average Peak mitral annular descent velocity (color Mmodetissue Doppler). These data are valid for patients with reduced ejection fraction.

222Prognostic value of E/(EaxSa) ratio in patients with left ventricular dysfunction

C. Mornos1; D. Cozma1; A. Ionac1; L. Petrescu1; SI. Dragulescu1

1Institute of Cardiovascular Diseases, Timisoara, Romania

Background: The E/(Ea�Sa) ratio (where E=peak early diastolic transmitral velocity,Ea=peak early mitral annular diastolic velocity and Sa=peak systolic velocity ofmitral annulus) has been shown to reflect left ventricular (LV) filling pressure.Purpose: to investigate whether E/(Ea�Sa) could be a predictor of cardiac events inpatients with LV dysfunction.Methods: We screened 145 consecutive patients with LV dysfunction in sinus rhythmreferred for left heart catheterization at our institution in 2006. Patients with inadequateechocardiographic images, paced rhythm, mitral stenosis, mitral prosthesis, significantprimary or organic mitral regurgitation, severe mitral annular calcification, pericardialdisease, acute coronary syndrome or coronary artery by-pass within 72 hours wereexcluded. Only 110 patients were eligible. In these patients conventional echocardio-graphy and Tissue Doppler Imaging were performed. E/(Ea�Sa) was calculated; theaverage of the velocities from the septal and lateral site of the mitral annulus wasused. Mean age was 62+13 years, 70 patients (63.6%) had coronary artery disease,and LV ejection fraction was 40+14%. The primary study end point was cardiacevents such as rehospitalization due to congestive heart failure and mortality.Results: During 32+7 months of follow-up, cardiac events occurred in 86 patients.Mean E/(Ea�Sa) was 2.4+1.3 in those patients, while it was 1.17+0.5 in the rest(p=0.001). The optimal E/(Ea�Sa) cut-off was 1.23 to predict cardiac events (83%

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

223Global and regional myocardial function is depressed during therapeutichypothermia

V. Kerans1; H. Skulstad1; A. Espinoza1; PS. Halvorsen1; T. Edvardsen1; JF. Bugge1

1Oslo University Hospital, Oslo, Norway

Purpose: Moderate hypothermia is widely used as neuroprotective treatment aftercardiac arrest. These patients may have reduced myocardial function due to ischemicdamage, but hypothermia itself may also influence on myocardial performance. Theeffects of moderate hypothermia on myocardial function were explored in this exper-imental animal study.Methods: Eight anesthetized pigs were studied in an open chest model. Amicromanometer-tipped catheter were positioned in the left ventricle (LV) to measurepeak LV pressure (LVP) and LV end-systolic pressure (LVEDP) and calculate thepressure time derivative (dP/dt). Cardiac output (CO) was measured by thermodilutiontechnique from a catheter in the pulmonary artery and systemic vascular resistance(SVR) was estimated. Echocardiography was performed to measure global LV functionas ejection fraction (LVEF) by the biplane Simpson method. In addition, regional myo-cardial function was measured in the LV mid segments of septum and lateral wall (SW,LW) by strain Doppler echocardiography. Negative strain expresses regional systolicshortening. Moderate hypothermia was performed by intravascular cooling. In orderto obtain equal conditions during all measurements, right atrial pacing were performedat a fixed frequency of 100 beats per minute for five minutes during normothermia(388C) and hypothermia (338C) prior to hemodynamic measurements and echocardio-graphy . Values are given as mean+SD.Results: Hypothermia reduced spontaneous heart rate in all pigs (87+11 to 75+14min-1, p,0.05). At a paced frequency of 100 beats/min CO decreased from5.0+0.7 to 3.7+0.6 l/min (p,0.05). LVP were reduced from 86+5 to 64+7 mmHg(p,0.05) and dP/dt from 1500+504 to 1034+387 (p,0.05). LVEF decreased from58+6 to 51+4% (p,0.05). Regional myocardial function was reduced in both theseptal and lateral wall, as strain changed from -30.9+7.1 to 17.4+5.0% (p,0.05)and from 229.6+8.7 to 218.4+4.5% (p,0.05), respectively. Preload measured asLVEDP and afterload assessed as SVR remained unchanged from normothermia tohypothermia (9+3 vs 8+3 mmHg and 882+144 vs 904+ 123 dyn.s.cm-5 (n.s.)).Conclusion: Moderate hypothermia caused reduced global and regional LV function.As loading parameters were unchanged and dP/dt was reduced, hypothermia seemsto have a direct negative effect on myocardial contractility. These findings should betaken into considerations when LV function is assessed in patients with therapeutichypothermia following cardiac arrest.

224Left ventricular systolic dysfunction is associated with advanced chronickidney disease but improved after maintenance hemodialysis

YW. Liu1; CT. Su2; WC. Tsai1; CS. Yang3; MT. Yang3; JH. Chen1

1National Cheng Kung University Hospital, Tainan, Taiwan; 2National Taiwan UniversityHospital, Yun-Lin Branch, Yun-Lin, Taiwan; 3Catholic Fu-An Hospital, Yun-Lin, Taiwan

Purpose: The aim of the study was to illustrate the heart function of different CKDstages and the influence of maintenance hemodialysis (HD) on cardiac functionsassessed by left ventricular (LV) deformation.Methods: We included 113 chronic renal failure patients and cataloged to 3 subgroups(16 with early-stage CKD, stage 1 or 2; 37 with advanced-stage CKD, stage 3 or 4 or 5;60 with end-stage renal disease (ESRD) undergoing regular HD, thrice per week, morethan 3 months) and 56 patients without renal failure as controls. The conventional par-ameters, tissure Doppler imaging and 2D strain imaging were acquired.Results: Among all study subjects, no difference in age, and the prevalence of conco-mitant diseases was revealed. LV ejection fraction (EF), and S0 were similar among the4 groups. Compared with the controls, radial strain was decreased in all CKD groups(early-stage: 40+ 15%, advanced-stage: 39+ 21%, ESRD: 37+ 21%, controls: 56+23%, p,0.001). Importantly, compared with the controls and early-stage CKD group(global longitudinal strain (GSl): 219+ 5 %, circumferential strain (Sc): 222+ 6%),LV systolic function was deteriorated in advanced-stage CKD group (GSl: 215+ 5%, Sc: 217+ 6%, p,0.001), but improved in ESRD group undergoing regular HD

Table 1 Comparison of echocardiographic results

Controls(n¼56)

Early stageCKD (n¼16)

Advanced-stageCKD (n¼37)

ESRD (n¼60) ANOVA pvalue

LVEDVI(mL/m2)

66.3+ 15.8 78.8+ 15.0 77.4+ 33.6 77.9+ 27.4 0.231

LVEF (%) 67.8+ 13.9 65.4+ 9.9 65.4+ 15.1 63.7+ 9.0 0.368GSl (%) 218.7+ 5.7 218.6+ 4.2 215.0+ 4.5 218.7+ 3.9 0.001Sc (%) 222.0+ 5.5 220.6+ 6.6 217.3+ 6.2 219.9+ 5.9 0.007Sr (%) 55.7+ 23.3 40.1+ 14.5 38.9+ 21.4 36.8+ 20.1 , 0.001E/E0 10.3+ 3.5 10.3+ 1.8 15.6+ 6.9 17.5+ 9.6 , 0.001

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(GSl: 219+ 4 %, Sc: 220+ 6%). The LV filling pressure (E/E0) was significantlyincreased in regular HD group (18+ 10 vs. 10+ 2, p,0.001).Conclusion: LVEF and S0 are failed to demonstrate the LV systolic dysfunction in CKDgroups. LV contractile dysfunction can be documented by decreased myocardial defor-mation, including longitudinal, circumferential, and radial strain, in patients withadvanced-stage CKD, but actually improve, except radial strain, in ESRD patients onmaintenance hemodialyis. However, persistent LV diastolic dysfunction can bedetected in the ESRD group even undergoing regular HD.

225clinical characteristic and prognosis of patients with acute congestive heartfailure with preserved left ventricular systolic function in Jeju Island of SouthKorea

S-J. Joo1; S-Y. Hyun1; D-G. Kang1; S-Y. Kim1; K-S. Kim1

1Jeju National University Hospital, Jeju, Korea, Republic of

Objectives: Recent evidences showed that left ventricular (LV) systolic function ispreserved in the half of patients with acute congestive heart failure (AHF) in thewestern countries. They have the different clinical characteristics, but a similar long-term mortality compared with those with decreased LV systolic function. Koreanpatients with AHF may show a different pattern. We investigated the clinical character-istics and prognosis of AHF with preserved LV systolic function in Jeju Island ofSouth Korea.Methods: From Jan 1st 2005 to Dec 31st 2007, 144 patients with AHF admitted to ourhospital. Echocardiographic studies were performed in 138 patients, and LVEF �50%was used to define AHF with preserved LVSF. Patients with valvular heart diseases, con-genital heart diseases or thyroid heart diseases were excluded (n=25). Final 113patients were grouped as I (LVEF �50%) and II (LVEF ,50%).Results: 37 patients (41%) had LVEF �50%. They were older (79.2+9.7 vs.72.4+14.1 years, p=0.004) and female-dominant (73% vs. 47%, p=0.004). Theunderlying causes were significantly different (p,0.001); hypertensive heartdisease (41%), ischemic heart disease (43%), and others (16%) in group I, and hyper-tensive heart disease (23%), ischemic heart disease (50%), dilated cardiomyopathy(26%) and others (1%) in group II. Atrial fibrillation at the admission was found in51% of group I and 42% of group II (p=0.57). Echocardiographic data of group Ishowed smaller LV end-diastolic dimension (4.63+0.64 vs. 5.69+0.74 cm,p,0.001) and LV end-systolic dimension (2.85+0.61 vs. 4.63+0.75 cm, p,0.001).LVEF was 66.4+9.0% in group I and 34.5+10.2% in group II. Patients withsinus rhythm of group I had lower E/A ratio (0.81+0.36 vs. 1.47+0.87, p,0.001)and E/E’ ratio (16.6+4.7 vs. 24.3+9.9, p,0.001). Patients of group II had more restric-tive LV filling patterns (64% vs. 27%, p=0.017). In-hospital mortality was not signifi-cantly different between group 1 (3%) and group 2 (7%). Kaplan-Meier survivalanalysis showed the same one-year mortality rate (19.3% in group I vs. 20.4% ingroup II)Conclusions: LV systolic function was preserved in 41% of Korean patients with AHF.They showed the different clinical characteristics from those with decreased LV systolicfunction, but one-year mortality rate was not different.

226Value of brain natriuretic peptide levels for risk stratification and monitoring ofbeta-blocker therapy in chronic heart failure with preserved or deterioratedsystolic function

LR. Tumasyan1; KG. Adamyan1

1Institute of Cardiology, Yerevan, Armenia

The aim of study was to assess the value of BNP level in the risk stratification andassociation between changes in levels of peptide and modification of prognosis inpatients (pts) with III NYHA class chronic heart failure (CHF) in relation to preserved(PEF) or reduced ejection fraction (REF).Methods: 88 pts (age 61.5+1.2) with PEF and 98 pts (age 58.7+0.9) with REF insinus rhythm were randomly assigned to groups receiving (45 and 51 pts) and non-receiving (43 and 47 pts) carvedilol (C, up to 50 mg) in addition to ACE inhibitors,aldosterone antagonists and diuretics. Plasma levels of BNP (pg/ml) were assessedat baseline and 12 months of treatment.Results: During mean follow-up of 15+1.2 months from cardiac causes died total 43(23.1%) pts, 19 (21.6%) pts with PEF and 24 (24.5%) pts with REF. Mean plasma levelsof BNP were significantly higher in pts with REF than in pts with PEF (874+112 vs.372+55 pg/ml, p,0.001). All pts with adverse outcomes had higher levels of BNP(935+152 vs. 257+80 pg/ml). In addition, the probability of death was predicted byplasma levels of BNP (p,0.001) in groups with REF (986+116 vs. 471+75 pg/ml)or PEF (528+120 vs. 281+75 pg/ml). The distribution of pts with PEF in groupsaccording to baseline BNP levels (BNP,450 and BNP�450) and REF (BNP,600and BNP�600) allowed to identify patients with low (11.2%) and high risk (38.7%) ofone-year mortality from cardiac causes (p,0.01). Plasma baseline levels of BNPwere not significantly differs in pts with PEF and REF receiving and non-receiving C,however, long-term treatment with C has resulted to higher incidence of decreasingof BNP �50% (73% and 81%) compared to pts non-treated by C (28% and 23%,p,0.01). Among patients with a �50% reduction of baseline BNP value, the numberof pts with events was significantly lower compared to pts with a ,30% BNP reduction(relative risk [RR] 0.35, p,0.01). In the groups of pts with REF and PEF, divided accord-ing to cut off value of BNP, one-year mortality rates were 6.5% and 21%, 6.7% and 25%

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

227The prognosis in diastolic heart failure is better than in systolic heart failure inthe elderly

M. Denes1; M. Lengyel11Hungarian Institute of Cardiology, Budapest, Hungary

In population based studies on heart failure (HF) with normal ejection fraction (HFNEF)diastolic dysfunction (DD) has not been evaluated. The better or similar outcome ofHFNEF compared to systolic HF (SHF) is still controversial. In this prospective studywe aimed to assess the three-month and the long-term survival rate of patients withtrue diastolic HF (DHF).Patients: 73 consecutive, hospitalized patients with DHF (24 males, mean age:72.2+11.2 yrs) were compared with 84 patients with SHF (46 males, mean age:73.3+11.6 yrs).Methods: NYHA functional class was assessed. E and A velocities, and decelerationtime (DT) of the mitral inflow pattern, and the systolic (S) and diastolic (D) velocitiesof the pulmonary venous flow were measured by Doppler-echocardiography. The myo-cardial Ea velocity was obtained by tissue Doppler imaging (TDI) at the lateral mitralannulus. The E/A, E/Ea and S/D ratios were calculated. Elevated filling pressure(EFP) was defined as DT,150 ms, or E/Ea �7 and/or S/D ,1. DHF was defined asclinical symptoms (NYHA II-IV) or signs of HF, preserved EF (.50%) and EFP. SHFwas defined as clinical symptoms (NYHA II-IV) or signs of HF and EF�50%. Three-month and long-term (median: 352 days) follow-ups was obtained. All-cause mortality,cardiovascular (CV) mortality, and hospitalization for HF were estimated by the Kaplan-Meier method and compared by the log-rank test.Results: The EF was lower in SHF than in DHF (27.6+7.0% vs 60.1+10.7%;p,0.001). There was no difference between DHF and SHF in age (72.2+11.2 vs73.3+11.6 yrs, p=0.93), but the female gender was more frequent in DHF (49/73 vs38/84; chi-square: 7.6, p=0.006). Patients with DHF had less severe NYHA class(2.6+0.8 vs 3.0+0.9 p=0.007). DHF had a better rate of all-cause mortality both inthe three-month (9.5% vs 21.4%, p,0.05) and in the long-term follow-up (21.9% vs42.8%; p,0.005), and also in the long term follow-up of CV mortality (9.5% vs29.8%; p,0.001), but the difference in the three-month CV mortality was nor significant(6.8% vs 15.5%; p=0.09). Five patients were readmitted for SHF in contrast to no read-mission for DHF (3.5% vs 0%; p,0.05), but the hospitalization rate for HF did not differduring the long-term follow-up (13.7% vs 20.2%).Conclusions: In patients hospitalized for DHF had a better short-and long-term survivalrate compared to SHF, which might be associated with lower NYHA functional class inour elderly population.

228Pulmonary sonography in patients with Diastolic Heart Failure

M. Tsverava1; D. Tsverava1

1Tbilisi Medical Academy, Tbilisi, Georgia, Republic of

Background: About 35% of patients with heart failure (HF) have preserved systolicfunction. Pulmonary congestion and Oedema is useful marker of Diastolic HeartFailure (DHF). The aim of this study was to determine the place of chest sonographyin diagnosis of DHF.Methods: We studied 245 patients with II-IV NYHA class HF. 176 Patients have SystolicHeart Failure (SHF) (I gr), 68 patient - DHF (II gr) and 105 patients Left Ventricular Dias-tolic Dysfunction but without signs of HF (control, III gr). All patients undergone stan-dard EchoCG examination. Sonographic evaluation of a lung was done in horizontalor vertical positions of patient, from 10 points of thoracic wall which corresponded tothe projection of lower, middle and upper lobes of a right lung and upper and lowerlobes of left lung.Results: In patients with HF we significantly often found the one of the sorts of rever-beration phenomenon - “Comet tail Phenomenon” (CTPh). CTPh was registered in97.7% 91.3% and 40.0% of patients in I, II and III gr respectively (the differencebetween control an HF groups was significant). The count of points from where theCTPh was registered was 8.8 in SHF group, 6.8 in DHF gr. and 0.7 in control gr. TheCTPh was registered from 3 or more points of thoracic wall in 96.02% of patients inI gr, 81.16% - in II gr and only 4,76% in III gr. In HF groups CTPh was prominent, pro-tracted and multiple while in the control group it was single and short lasting, like light-ening. There was good correlation between the count of CTPh registration points fromthe thoracic wall and the heart failure NYHA class (r=0.56), left ventricular systolic(r=0.40) and diastolic (r=0.32) diameters and negative correlation with EF% (r=-0,42).Conclusion: Thoracic US is sensitive and accurate method for evaluation pulmonarycongestion in patients Diastolic Heart Failure. The US sign of pulmonary congestionin HF is a “Comet tail phenomenon”, which is protracted, prominent, multiple and regis-tered from larger area of thoracic wall (3 points or more).

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229Resting cardiac function in patients with heart failure and normal ejectionfraction

GWK. Yip1; Q. Zhang2; JM. Xie1; YJ. Liang1; YM. Liu1; YY. Lam1; CM. Yu2

1Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, ChineseUniversity of HK, Hong Kong, Hong Kong SAR, People’s Republic of China; 2Institute ofVascular Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR,People’s Republic of China

Purpose: Previous studies suggest presence of normal torsion and circumferentialstrain in heart failure with normal ejection fraction (HFNEF) but lower longitudinaland radial strain compared with the control subject. We examined the myocardialdeformations in a larger cohort with HFNEF.Methods: Two-dimensional speckled echocardiography was performed in 113(age:74+12) HFNEF patients with ejection fraction .50%, 176 (age:67+13) patientswith HF and reduced ejection fraction (HFREF) and 60 (age:53+9) normal controlsubjects.Results: Torsion (HFREF: 8.2+5.38, HFNEF: 16.2+7.18, control: 21.4+5.18, p,0.001),global circumferential strain (HFREF: 9.5+3.3, HFNEF: 20.7+5.0, control: 26.4+3.6,p,0.001), global longitudinal and radial strains were significantly lower in both heartfailure groups than in controls, and were depressed to a larger extent in HFREF patientsthan in those with HFNEF (both p,0.001) after age adjustment. (Table 1)Conclusions: There appears to be a continuum of systolic function between normal,HFNEF, and HFREF. Isolated diastolic dysfunction in HFNEF is uncommon.

230Myocardial reserve estimation in patients with and without heart failure signs

A. Bobrov1; N. Hyshova2

1Military Medical Academy, Saint Petersburg, Russian Federation; 2Almazov Heart,Blood and Endocrinology Centre, Saint Petersburg, Russian Federation

Background: In healthy men the exercise leads to increasing of cardiac output (CO),decreasing isovolumic relaxation time (IVRT) right up to the maximal heart rate (HR).Decreasing of CO and increasing of IVRT during HR growth identifies the decompen-sation (or reserve) of the heart contractility and relaxation.Objective: To evaluate myocardial reserve during the stress test in men with andwithout systolic and diastolic dysfunction.Methods: We enrolled 398 cardiologist patients (males, age 52.4+1.2 years, withoutsigns of heart failure) referred for the exercise stress-echo. CO and IVRT were calcu-lated on the heart rate 70, 80 . . . 140 bpm. Cardiac frequency at which CO or IVRTcstarts its ascending limb called critical HR.Results: 118 patients had normal echo at the rest. 44 (37%) of them had monophasiclimb of CO and IVRT dynamics, 74 (63%) had biphasic dynamics of CO and IVRT. 280patients had systolic or diastolic dysfunction at the rest. 59 (21%) of them had mono-phasic limb of CO and IVRT dynamics, 221 (79%) had biphasic dynamics of CO and

IVRT. Groups with biphasic dynamics of CO and IVRT were analyzed. Values of criticalHR are presented in the table.Conclusions: Estimation of CO and IVRT can access patient’s myocardial reserve andseverity of heart failure. Minimal myocardial reserve observed in patients with com-bined dysfunction, restrictive type of diastolic dysfunction, 2-nd functional class ofheart failure.

231How to identify latent systolic dysfunction and post operative risk in patientswith mitral incompetence and normal ejection fraction?

GEDN. El-Kilany1

1Chest Diseases Hospital , Cardiology Department, Kuwait, Kuwait

Purpose: To study the significance of impaired positive peak rate of left ventricular (LV)pressure development (MR þdp/dt) and global systolic strain (GLPSS) values inpatients presented with significant mitral incompetence (MR) in coronary arterydisease (CAD) and early dilated cardiomyopathy (DCM) with normal ejection fraction(EF).Methods: A description of LV contractile behavior requires measurement of the abilityof the ventricle to develop force (pressure) and to shorten. Hence, performance of theventricle as a pump assessed in the present study by measuring the pressure devel-oped by the ventricle (Left ventricular þdP/dt is estimated from MR jet as the rate ofpressure rise from 1 to 3 m/sec) and shortening assessed by GLPSS (this Dopplertechnology allowed measurement of LV systolic strain for the entire length of LV myo-cardium). GLPSS and MR þdp/dt were calculated in 30 consecutive patients (meanage was 55+12 years) characterized by echocardiographic evidence of moderateor severe MR (in CAD and DCM patients) and normal EF (mean LV Ejection Fractionof 50.9+ 5.9 %) and compared with those obtained in 35 consecutive controls (age54.7+11.4 years) with normal echocardiographic study of the heart.Results: The mean values of MR þdp/dt and GLPSS averaged from the 3 apical views(Fig.1), differed significantly in DCM and CAD patients ( characterized by significant MRwith normal EF) compared with control group, ( MRþ dp/dt¼ 733+ 170 mmhg/s andGLPSS - 13+ 1.3 % ) versus (1420+ 210 mmhg/s and 219 .5+ 3.3 %) for patientsversus control, respectively, p,0.001. A depressed values of MRþdp/dt were highly cor-related with GLPSS values in patients with CAD and DCM ,r ¼ 0.78. The combined useof 2D Strain(,213%) and MR dp/dt(, 900mmhg/s) in the presence of MR (grade II ormore) had 89% sensitivity and 92% specificity for detection of patients at risk of post-operative major cardiac events after MR and coronary artery bypass surgery (Fig.2).Conclusion: latent LV systolic dysfunction could be defined noninvasively bydepressed peak MRþdP/dt and GLPSS in the echocardiography laboratories.

232The stroke volume in heart failure with normal ejection fraction is determined bythe end-diastolic volume

DH. Maciver11Musgrove Park Hospital, Taunton, United Kingdom

Purpose: The function of the left ventricle is to deliver an adequate stroke volume (SV)& cardiac output to the tissues. Heart failure with a normal ejection fraction (HFNEF) isstrongly associated with significant concentric left ventricular hypertrophy (cLVH) andthere is robust echocardiographic evidence of important regional contractile dysfunc-tion (reduced long-axis displacement & systolic tissue Doppler velocities and abnormalradial, longitudinal and circumferential strain) in HFNEF. Mathematical modelling hasshown that reduced long-axis shortening with cLVH results in augmented myocardialthickening, a normal ejection fraction but a reduced SV. The SV is usually normal inheart failure and so the changes in end-diastolic volume (EDV) necessary to achievea normal SV were assessed.Methods: Three-dimensional mathematical modelling of left ventricular contraction.Input variables were LVH and long-axis myocardial shortening. Circumferential shorten-ing & SV were constant. Output variables were EDV and ejection fraction.Results: The model demonstrates a reciprocal relationship between EF & EDV so thatthe end-diastolic volume (EDV) is predicted to be high in heart failure with a reducedejection fraction but the EDV is normal in presence of the combination of reduced myo-cardial shortening & left ventricular hypertrophy. This simulates the findings in HFNEF.Conclusions: The relatively normal EDV in HFNEF can be explained by the combi-nation of reduced myocardial shortening and cLVH. It is suggested that feedbackmechanisms normalise SV in both heart failure with reduced ejection fraction &HFNEF and would explain the echocardiographic findings in heart failure.

Table 1

Control HFNEF HFREF HFNEF vsHFREF

Age (range) 53+9 (35–74) 74+12 (34–95)§

67+13 (30–94)§ ,0.001

Male (%) 51.7 36.3 69.3D ,0.001SBP (mmHg) 123+12 158+31§ 130+25 ,0.001DBP (mmHg) 75+8 78+19 74+16 NSLVEF (%) 68.4+4.4 62.7+7.5§ 31.6+8.9§ ,0.001NYHA class(I/II/III/IV) – (10/30/44/16) (9/21/46/24) NSCAD (%) – 31.5 48.5 ,0.01Hypertension (%) – 63.1 54.5 NSDiabetes Mellitus (%) – 45.0 36.4 NSHyperlipidemia (%) – 13.5 13.0 NSGlobal circ-S (%)* 26.4+3.6 20.7+5.0§ 9.5+3.3§ ,0.001Global rad-S (%)* 44.3+10.2 32.9+10.7‡ 18.0+9.7§ ,0.001Global longitudinal-S(%)*

21.0+2.5 16.0+3.8§ 9.6+3.6§ ,0.001

Torsional-S (degree)*

21.4+5.1 16.2+7.1§ 8.2+5.3§ ,0.001

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

Critical HR (M+m)

Critical HR and type of echo dysfunctionNormal Echo, (n¼74) 125,0+2,5Mono dysfunction (systolic or diastolic), (n¼149) 111+0,9Combined dysfunction (systolic and diastolic), (n¼131) 107,3+1,2Critical HR and type of dyastolic dysfunctionClassic type of dyastolic dysfunction (n¼123) 112,2+1,2Pseudonormal type of dyastolic dysfunction (n¼69) 102,3+1,8Restrictive type of dyastolic dysfunction (n¼9) 96,3+2,5Critical HR and heart failure (NYHA)Without HF (n¼16) 117,1+1,91-st functional class of HF (n¼134) 112,4+1,42-nd functional class of HF (n¼204) 107,3+1,1

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233The unravelling of reduced left ventricular longitudinal systolic deformation bytwo-dimensional speckle tracking in outpatients with normal ejection fraction

SC. Govind1; A. Kiotsekoglou2; AJ. Camm2; A. Younis2; JC. Moggridge2; H. Basappa1;SS. Ramesh1; SK. Saha3

1VIVUS-BMJ Heart Center, Bangalore, India; 2St George0s University of London, London,United Kingdom; 3Sundsvall Hospital, Sundsvall, Sweden

Purpose: In everyday clinical practice, the most commonly used measurement of leftventricular (LV) systolic function is ejection fraction (EF). However, LV performance maynot be accurately assessed by conventional measurements. Therefore, our aim was toinvestigate LV systolic function in an outpatient setting using two-dimensional speckletracking (2DST) which constitutes a modern, validated and accurate method of asses-sing myocardial function.Methods and Results: Echocardiographic studies from 57 outpatients (mean age of53+12 years, 20 women) with a variety of clinical diagnoses such as coronary heartdisease, hypertension, diabetes mellitus, stroke and thyroid and kidney abnormalitieswere retrospectively analysed using 2DST. The images were acquired from parasternallong- and short axis views as well as from apical 4-, 3-, and 2-chamber acousticwindows. LV EF was calculated using the Simpson0s biplane method. LV imagessampled at appropriate frame rates were post-processed using the 2DST software.Longitudinal parameters such as global peak systolic strain rate and end-systolicstrain along with regional peak systolic velocities and displacements were obtainedfrom the apical images. In addition to that, global circumferential strain rate atsystole were also calculated taking the average of six short-axis LV segments. Patientswere divided into 2 groups according to their EF values (EF ,54% and EF�55%).2DST systolic parameters were significantly reduced in patients with abnormal EF(p�0.003) as it was expected. In order to identify any possible LV systolic functionalabnormalities within the patient group with normal EF, a longitudinal strain value of16% was selected as a cut-off point. 2DST systolic longitudinal parameters werefound to be significantly decreased in 13 out of 27 outpatients (p�0.008) whilst the cir-cumferential strain values showed no differences. Interclass correlation co-efficientdemonstrated that age has a negative association with LV longitudinal systolic function(p�0.03). However, gender showed no effect. Statistical analysis showed that the sen-sitivity and specificity of 2DST is 81% and 68%, respectively.Conclusions: Our findings suggest the 2DSTcan provide more accurate, sensitive andspecific assessment of myocardial systolic function in patients with normal LV EF eval-uated by conventional echocardiography. As experience improves, this techniqueshould be increasingly incorporated in the monitoring of myocardial function in an out-patient setting.

PACING AND DYSSYNCHRONY

234Differences in left ventricular contraction synchronicity between left bundlebranch block and right ventricular pacing

Ji-Hyun JH. Kim1; MK. Seo1; HK. Kim1; YJ. Kim1; GY. Cho1; DW. Sohn1

1Seoul National University, Seoul, Korea, Republic of

Background: Tissue velocity imaging has been used to calculate left ventricular dys-synchrony index(LVdys) in most previous works; however, recent PROSPECT trialrevealed its disadvantages. We aimed to evaluate differences in LVdys betweenacute RV pacing and LBBB pts using 2D speckle tracking-derived radial strain.Methods and Results: Total 34 subjects were enrolled with good echoCG images(normal for GrI, LBBB pts for GrII, and pts with acute RV pacing for GrIII). On top ofmeasure of conventional parameters, LVdys and max difference of time to peakstrain were obtained. Results were shown in Tables and Figures in detail. On multi-variate logistic regression analysis with 130msec as a cutoff value for LVdys, LV end-diastolic volume(LVEDV) and S0 emerged as independent determinants for LVdys(Figure A and B).Conclusions: Despite similar degree of QRS duration and ECG morphology, a higherproportion of LBBB patients had LVdys. LV preload and contractility were independentdeterminants for LVdys presence.

235Differences of left ventricular dyssynchrony between high septal pacing andapical pacing in patient with normal left ventricular systolic function

H. Yoshikawa1; M. Suzuki1; T. Otsuka1; T. Tsuchida1; T. Osaki1; N. Tezuka1; M. Noro1;K. Sugi11Toho Univesity ohashi Medical Center, Tokyo, Japan

Background: Permanent right ventricular apical pacing results in development of heartfailure due to ventricular mechanical dyssynchrony. The purpose of this study was todefine the differences of left ventricular dyssynchrony between high septal pacingand apical pacing by tissue Doppler imaging (TDI) and 2-dimensionnal (2D) speckle-tracking echocardiography (STE).Methods: Sixty patients undergoing newly implantation of permanent pacemakerwith normal left ventricular systolic function were enrolled in this study. Patients weredivided into two groups of high septal pacing group (n¼36), and conventional rightapical pacing group (n¼24). Patients characteristics in high septal pacing group wasas follows; mean age was 72.9+13.9, left ventricular diastolic diameter: 47.4+5.6mm, ejection fraction: 68.2+6.7%. Patients characteristics in apical pacing groupwas as follows; mean age was 75.4+11.3, left ventricular diastolic diameter:45.2+5.3 mm, ejection fraction: 72.2+5.2%. Patients with left ventricular systolic dys-function, myocardial infarction or valvular disorders were excluded in the study. Leftventricular dyssynchrony was measured using TDI and 2D-STE. Systolic velocitycurves by TDI obtained at basal -septal, basal-lateral, mid-septal and mid-lateral ofleft ventricle at 4-chamber view. The time difference (TD) between the earliest-and latest-activated segments obtained from each systolic velocity curve byTDI were defined as TD-TDI. The traced endocardium by 2D-STE is automaticallydivided into 6 standard segments: septal, anteroseptal, anterior, lateral, posterior,and inferior. Time difference obtained by systolic strain curves by 2D-STEwere defined as follows; TD-RS: radial strain, TD-CS: circumferential strain, TD-LS:longitudinal strain.Results: TD-TDI in high septal pacing group was significantly shorter than apicalpacing group (20.0+24.3 msec vs 59.7+43.0 msec , p ,0.0001). TD-RS in highseptal pacing group was also significantly shorter than apical pacing group(13.5+19.9 msec vs 45.8+24.6 msec, p ,0.0001). TD-LS by 3 and 4-chamber viewwere significantly shorter in septal pacing group (3-chamber view : 34.3+17.9 msecvs 68.4+32.7 msec, p¼0.031; 4-chamber view: 42.7+22.0 msec vs 66.6+26.8msec, p¼0.001). No significant difference was observed in TD-CS between twogroups.Conclusion: Left ventricular dyssynchrony was smaller in patient with high septalpacing. Measurement of time difference by radial and longitudinal strain using2D-STE is useful to detect the differences of left ventricular mechanical dyssynchronyin patients with permanent pacemaker implantation as well as TDI.

236Impact of interventricular septal pacing in ventricular stimulation andinterventricular mechanical asyncrony

A. Charalampopoulos1; A. Marinakos1; S. Marinakos1; A. Katranis1; D. Syrseloudis2;N. Raikos1; A. Katsaros1; D. Chrissos1

1Cardiology Department, General Panarkadian Hospital, Tripoli, Greece; 2HippokrationGeneral Hospital of Athens, Athens, Greece

Purpose: Pacing through the right ventricular (RV) apex, even when atrioventricularsequential activation is maintained, affects left ventricular(LV) contractility resulting inparadoxical septal motion and interventricular mechanical asynchrony. The aim ofour study is to determine whether septal pacing affects to a lesser extend the electro-mechanical performance of the left ventricle.Methods: Fifty – one patients with a permanent pacemaker were examined anddivided into two groups (I and II). Group I consisted of 27 patients (mean age 78+7 years) having the pacemaker wire implanted at the apex of the RV, while group II con-sisted of 24 patients (mean age 77+ 7 years) being paced through the interventricularseptum (IVS). Using Doppler echocardiography we measured the time interval (in milli-seconds) from the beginning of the QRS complex till the onset of left ventricular outflowtract flow velocity (Q-LVOTFV) , from the apical four-chambers view and the time inter-val from the beginning of the QRS complex till the onset of right ventricular outflow tractflow velocity (Q- RVOTFV) from the parasternal short-axis view. The difference betweenthese two intervals [(Q-RVOTFV) - (Q-LVOTFV)] (interventricular asynchrony timing,IAT) was measured in all patients of both groups. The statistical analysis was madeby Mann-Whitney test.Results: In all group I patients (27/27, 100%) stimulation of the RV preceded the one ofthe LV, IAT was 42,19+ 15,4 msec and a paradoxical septal motion was observed in 2Dechocardiography. On the contrary, in 16/ 24 patients of group II (66,6%) the RV wasstimulated earlier than the LV , in 3/ 24 patients (12,5 %) the stimulation of both ventri-cles was simultaneous and in 5/24 patients (20,8%) LV preceded RV. IAT in this group

Table 1 Multiple logistic regression analysis

Independent determinants b Wald P value R2 value

LV end-diastolic volume 0.027 4.2 0.04 0.65S’ 275.46 6.2 0.01

Multivariate logistic regression analysis for determining independent determinants of the pres-ence of LVdys.

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

237Left ventricular dyssynchrony induced by right ventricular apical pacingcorrelates with the decrease in left ventricular ejection fraction and bothimprove by pacing from RV septal sites

H. Alhous1; G. Small1; A. Hannah1; G. Hillis2; P. Broadhurst11Aberdeen Royal Infirmary, Aberdeen, United Kingdom; 2The George Institute forInternational Health, Sydney, Australia

IntroductionRight ventricular apical (RVA) pacing may induce Left Ventricular (LV) mechanical dys-synchrony with deleterious effects on LV function. Lead placement in the RV mid interventricular septum (RV mIVS) or RV outflow tract (RVOT) may reduce LV dyssynchronyand improve LV performance. There are, however, few data on assessing the effects ofalternate RV pacing sites on LV function and LV synchrony.Methods: Twenty two patients [16 (73%) male, mean age 73 years] with standard indi-cations for PPM underwent temporary dual chamber pacing. The RV lead was placedsequentially at the RVA, RV mIVS and RVOT in random order. Detailed echocardio-graphic studies were performed at baseline (AAI pacing) and at each RV lead position.LV Ejection Fraction (LVEF) was calculated using Biplane Simpson’s rule. Intra-ventricular dyssynchrony was assessed by the calculation of the standard deviationof the time-to-peak systolic velocity in the 12- (6-basal and 6-mid) LV walls segments(the ’dyssynchrony index’: Ts-SD). Continuous data are expressed as median valuesand compared using the Wilcoxon signed ranks test. Correlation coefficient betweenTs-SD and LVEF was calculated using Spearman’s rho linear correlation and its signifi-cance levelResults: RVA pacing significantly decreased LVEF compared to baseline (Table 1). RVseptal pacing at either RVOT or RV mIVS resulted in significant improvement in LVEFcompared to RVA pacing (Table-1). Ts-SD was significantly increased by RVA pacingcompared to baseline but this was significantly improved by RV septal pacing com-pared to RVA pacing (Table-1). There was a significant negative correlation (r¼0.36,p¼0.006), between Ts-SD and LVEF at all RV pacing sites combined.Table-1Conclusions: RVA pacing results in an acute reduction in LV systolic function which isunaffected by RV septal and outflow tract pacing. The mechanism for this may be dueto a greater degree of pacing-induced LV dyssynchrony

238Pacing-induced electromechanical ventricular dyssynchrony does notinfluence right ventricular function

MC. Pereira Nunes1; CDG. Abreu1; ALP. Ribeiro1; CMV. Freire2; MOC. Rocha1;RCP. Reis3; MM. Barbosa2

1Postgraduate Course of Tropical Medicine, School of Medicine, Federal University ofMinas Gerais, Belo Horizonte, Brazil; 2ECOCENTER, Hospital Socor, Belo Horizonte,MG, Brazil, Belo Horizonte, Brazil; 3Federal University of Minas Gerais, Belo Horizonte,Brazil

Background: Asynchronous electrical activation induced by right ventricular (RV)apical pacing can cause various abnormalities in left ventricular (LV) function.However, the effect of ventricular pacing on RV function has not been well described,This study evaluated RV systolic function in patients undergoing long-term RV apicalpacing.Methods: An echocardiogram was performed at follow-up (mean intervals frompacemaker implantation, 89.7+ 80.5 months, range 1 to 371 days) in 85 patients.Twenty- four healthy controls (mean age: 42+ 12 years, 12 males) were alsostudied. Conventional echocardiography and tissue Doppler imaging (TDI) wereused to analyze RV function. Strain imaging measurements included peak systolicstrain and strain rate at the basal RV free wall. LV function and ventricular dyssynchronyby TDI were assessed. All recordings were performed by one investigator and intraob-server variability was assessed.Results: Percentage of ventricular pacing was 96+ 4% and QRS duration was 139+14 ms. All patients were in NYHA functional class I or II and no patient had significant LV

dysfunction (EF= 52+ 8%). RV peak systolic tissue velocity was 12+ 2.6 cm/s; RVfractional area change 56+ 11%, and RV index of myocardial performance 0.34+0.14. Echocardiographic parameters of RV function were similar between patientsand controls (strain: 22.8+ 5.8% vs 22.1+ 5.6%; strain rate: 1.47+0.91 s-1 vs1.42+ 0.39 s-1). Mean interventricular delay was 41.7+ 19 ms, indicating interventri-cular dyssynchrony. Significant LV dyssynchrony (septal-to-lateral delay � 65ms) wasfound in 31 patients (36%). Intraobserver variability for strain and strain rate was2.4% and 18.3%, respectively.Conclusion: RV apical pacing does not seem to affect RV systolic function, even in thepresence of electromechanical dyssynchrony. Although cardiac resynchronizationtherapy had beneficial effects on RV function, RV response to pacing-induced dyssyn-chrony remains unclear.

239Evaluation of left ventricular dyssynchrony by velocity vector imaging insubjects with normal QRS duration. Comparison with color coded tissueDoppler imaging

B. Purushottam1; AC. Parameswaran1; A. Amanullah1

1Albert Einstein Medical Center, Philadelpha, United States of America

Purpose: Data on echo criteria for dyssynchrony in patients with left ventricular dys-function are abundant; data on the normal variations in healthy subjects are scarce.Knowledge of the normal variations will serve as a reference when studying the dis-eased heart. Unlike color-coded tissue doppler imaging (TDI), velocity vectorimaging (VVI) is angle independent and can assess longitudinal, circumferential andradial velocities and strain.Methods: We studied two groups of patients. One group consisted of 135 subjectswith normal left ventricular ejection fraction (EF), no clinical evidence of heart failure,QRS duration ,120ms and no history of myocardial infarction. Using the VVI tech-nique, time to peak longitudinal, radial and circumferential velocities and strain werecalculated. The second group consisted of 35 patients in whom we compared thetime to peak longitudinal velocities by TDI and VVI.Results: 1) Dyssynchrony among healthy subjects: The final cohort consisted of 100patients. 52% were male, mean age 60+17 years, mean QRS duration 86+12 msand EF was 61+5%. Among normal subjects, 17% had septal to lateral (S-L) walllongitudinal delay .75 ms, 63% of subjects had S-L wall radial delay .75 ms and25% had a circumferential opposing wall delay .100 ms. Those with circumferentialopposing wall delay of .100ms had an EF lower than those with ,100 ms delay(57+5 % vs. 62+5 %, p ,0.05).2) Comparison of VVI with TDI: The second cohort consisted of a final 33 patients. 62%were male, mean age 63+16 years, mean QRS duration 76+40 ms and 22% had anEF,55%. Among those patients whose TDI could be analyzed, everyone with S-L walldelay .65 ms also had a delay .75 ms by VVI.Conclusions: There is significant variation in time to peak velocities among healthysubjects. Using published criteria for dyssynchrony, a significant number of healthysubjects will be labeled as having dyssynchrony. Those with circumferential dyssyn-chrony have lower EFs, which highlights the contribution of left ventricular twisttowards LV function. VVI is an attractive alternative to TDI for assessing mechanical dys-synchrony and can be used when adequate TDI tracings cannot be obtained.

240Triplane tissue Doppler echocardiography and radionuclide angiocardiographyin the assessment of ventricular asynchrony in patients with heart failure

A. Vitarelli1; P. Franciosa1; R. Massa1; D. Battaglia1; F. Caranci1; L. Capotosto1;M. Cortes Morichetti2; S. Rosanio3

1Sapienza University, Rome, Italy; 2Kremlin-Bicetre Universite Paris-Sud, Paris, France;3University of Texas, Galveston, United States of America

Purpose: Several parameters have recently been proposed to assess mechanical dys-synchrony both by tissue Doppler / strain Doppler imaging (TDI/SRI) and radionuclideangioscintigraphy (RNA). It is unknown whether large differences exist between TDIand RNA to evaluate inter- and intra-ventricular dyssynchrony and whether theresults are interchangeable.Methods: Thirty-four patients with dilated cardiomyopathy (NYHA class II or greater),left bundle branch block (QRS �120ms), and LV ejection fraction �35% werestudied with triplane TDI echocardiography (Vivid 9 ultrasound system, GE, Horten,Norway) and RNA before and after biventricular pacing (BP). Intraventricular dyssyn-chrony was determined as the difference between the longest and shortest electrome-chanical coupling times in the basal septal, lateral, and posterior LV segments.Interventricular dyssynchrony was determined as the difference between electrome-chanical coupling times in the basal lateral RV segment and the most delayed LVsegment. On line continuous LV volume changings were recorded using RNA and inter-ventricular delay and basal-apical contraction were obtained.Results: At six months follow-up after BV implantation, patients functional statusimproved by one NYHA class or more and LVEF improved overall from 20.4+6.5%to 29.5+11.1%. Interventricular dyssynchrony by triplane TDI was reduced from75.7+29 ms to 32.6+20.9 ms (p,0.005) and intraventricular dyssynchrony from79+24.7 ms to 28.3+12.8 ms (p,0.001). Interventricular dyssynchrony by RNAwas reduced from 77+28 ms to 13.7+25.3 ms (p,0.001) and apicobasal intraventri-cular dyssynchrony from 68.6+26.4 ms to 17.1+19.2 ms (p,0.001). Triplane TDI andRNA parameters had optimal predictive accuracy of the effects of BP on LV function

Table 1

AAImedian

RVA median (pvalues*)

RV mIVS median (pvalues‡)

RVOT median (pvalues‡)

LVEF (%) 54 46 (p¼0.005*) 51 (0.007‡) 54 (0.01‡)Ts-SD(ms)

18 39 (p¼0.001*) 18 (p¼0.01‡) 15 (p¼0.001‡)

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

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

241Comparison Of dyssynchrony between patients with depressed left ventricularejection fraction and those with normal left ventricular ejection fraction usingvelocity vector imaging

B. Purushottam1; AC. Parameswaran1; A. Amanullah1

1Albert Einstein Medical Center, Philadelpha, United States of America

Purpose: Identifying the type of intra left ventricular dyssynchrony which is more preva-lent among heart failure patients when compared to patients with normal left ventricular(LV) ejection fraction (EF) can potentially serve as a warning sign of systolic dysfunc-tion. The aim of the study was to compare time to peak longitudinal, circumferential,radial velocities and strain and their opposing wall delays in patients with depressedLVEF (,55%) with those patients with a normal LVEF (�55%) in a group of patientswith QRS duration ,120ms using Velocity Vector Imaging (VVI).Methods: 110 consecutive patients with a QRS duration ,120ms and with no historyof myocardial infarction who had their echocardiograms analyzed with the VVI tech-nique were included in the study. Peak longitudinal, circumferential and radial velocitiesand strain and the time taken to achieve their peak velocities (TTP) and strain wereassessed by VVI from the basal septal, basal lateral, basal inferior and basal anteriorwalls in the apical view and all the walls in the short axis view at the level of the papillarymuscles. Opposing wall TTP delay and time to peak strain delay along with maximumdelay were also calculated.Results: The final cohort consisted of 100 patients. 51% were males, mean age 60+18 years and mean EF 58+ 11%. We found that patients with a depressed LVEF hadan increased opposing wall TTP circumferential delay (95.58+ 67.08 ms, p¼0.03)between the anterolateral and inferoseptal walls when compared to those with anormal LVEF (46.55+ 58.04 ms). There were also lower circumferential velocities inall the basal walls of the left ventricle in the group of patients with a depressed LVEF.Conclusion: Using the VVI technique we found that there was no significant differ-ences in the longitudinal and radial dyssynchrony between patients with depressedLVEF and those with a normal LVEF who have a QRS duration ,120ms. However,there was significantly increased circumferential dyssynchrony between the anterolat-eral and inferoseptal walls and lower circumferential peak velocities in patients with adepressed LVEF. This may lead to impaired circumferential twist contributing to left ven-tricular systolic dysfunction.

242Multi-segmental assessment of left ventricular mechanical dyssynchronyreveals better sensitivity than global doppler hemodynamics in congestiveheart failure

Q. Zhang1; RJ. Van Bommel2; JYS. Chan3; V. Delgado2; YJ. Liang3; MJ. Schalij2; JJ. Bax2; CM. Yu4

1Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, HongKong, Hong Kong SAR, People’s Republic of China; 2Department of Cardiology, LeidenUniversity Medical Centre, Leiden, Netherlands; 3Cardiology, Dept of Medicine &Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, HongKong SAR, People’s Republic of China; 4Institute of Vascular Medicine, The ChineseUniversity of Hong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China

Background: Eletromechanical dyssynchrony exists in congestive heart failure (HF)where a number of echocardiographic parameters have been suggested for assess-ment and hence prediction of responses after cardiac resynchronization therapy.However, there is no large study that provides side-by-side comparison of multiple dys-synchrony parameters in the same HF population.Methods: 445 HF patients with NYHA class II-IV and ejection fraction �35% wererecruited from 2 cardiac centers, in whom 236 had wide (.120ms) and 209 patientshad narrow (�120ms) QRS complexes. Doppler methods included left ventricular pre-ejection interval (LPEI), ratio of filling time to R-R interval (FT-RR), late lateral wall con-traction (LLWC) and interventricular delay (IVMD). Tissue Doppler imaging (TDI)measured the maximal difference of time to peak systolic velocity in 4 basal segments(Ts-4b) and standard deviation among 12 segments (Ts-SD). 2D speckle tracking cal-culated the anteroseptal-to-posterior delay in radial strain (Trs-AS-P).Results: By using TDI or speckle tracking parameters, the prevalence of dyssynchronyis similar between wide and narrow QRS groups, except for Ts-SD while is more

prevalent in wide QRS group (Table). However, most of the Doppler methods resultedin a significantly lower prevalence of dyssynchrony in the narrow QRS group. Overall,Doppler parameters gave rise a lower prevalence of dyssynchrony than TDI andspeckle tracking method.Conclusions: Multi-segmental approach by TDI and speckle tracking appears todetect mechanical dyssynchrony more readily than Doppler methods which reflectglobal hemodynamics or only compare one segment, in particular in patients withnarrow QRS.

243Defining left ventricle synchrony by 2D speckle tracking imaging in hearttransplant recipients

H. Saleh1; HR. Villarraga1; Y. Yu1; S. Kushwaha1; F. Miller1; P. Pellikka1

1Mayo Clinic, Rochester, Minnesota, United States of America

Objective: Noninvasive imaging has an important role in the evaluation of myocardialfunction in heart transplant recipients. Measurement of strain and strain rate hasemerged as a sensitive modality to evaluate cardiac function. We sought to assessleft ventricular longitudinal and circumferential synchrony by 2D speckle tracking echo-cardiography (STE) expressed as the time to peak systolic strain(TTPS) and time topeak systolic strain rate ( TTPSR) in the transplanted heart.Methods: We studied retrospectively 40 heart recipients, including 29 males, 12+3months after transplantation. Subjects with abnormal ejection fraction (LVEF ,55%),severe rejection, severe valvular disease, or coronary artery disease were excluded.A control group was comprised of 82 healthy individuals; 31 males, with a lowpretest probability of CAD and a negative stress echocardiogram. At the time of theassessment, all subjects were in sinus rhythm without cardiac pacing. Echocardiogra-phy Imaging was performed using a standardized protocol. Three beat cineloop clipsfrom the parasternal short axis and apical 4, 3 and 2 chamber views were exported andanalyzed offline with dedicated software (Syngo Velocity Vector Imaging, SiemensMedical Solutions, Malvern, PA).Results: characteristics of patients vs. controls included age 52+12 vs 59+14,p =.013, HR 90+16 vs72+13, p,.0001, PR Interval 157+21 vs. 163+27, p=.34,QRS duration 107+20 vs. 90+11, p,.0001, BMI 26+5 vs. 27+5, p= .33, LVEF65+4vs 63+4, p =.014, LVMI 95+21 vs. 89+21p=.13, respectively.Synchrony findings for patients and controls are:circumferential TTPS 329+43 vs.371+46 p, 0.0001, circumferential TTPSR 177+37 vs.196+45 p=0.0446,longitudi-nal TTPS 344+34 vs.401+36 p,0.0001, longitudinal TTPSR 171+28 207+29p,0.0001. After adjusting for LVEF, HR and global TTP, longitudinal TTPS and SRwere better differentiators between groups. AUC were 0.87 and 0.81, respectively.Conclusion: LV synchrony in cardiac allograft recipients is lower when compared tothat of controls and was a good differentiator between the 2 groups after adjustingfor other variables. Differences between groups were greatest for longitudinal TTPSand SR. LV synchrony response in other subsets of patients with HTX requiresfurther research.

244Real-time 3-dimensional echocardiography reveals early signs of global leftventricular dyssynchrony in high-risk patients with type II diabetes and nocoronary artery disease.

E. De Marco1; F. Loperfido1; G. Savino1; F. Gabrielli1; R. Natali1; E. Bock1; L. Bonomo1;F. Crea1

1Catholic University of the Sacred Heart, Rome, Italy

Background: Preclinical left ventricular (LV) dysfunction is common in type II diabetesmellitus, as revealed by tissue Doppler imaging (TDI) and derived techniques. Real-time 3-dimensional echocardiography (RT-3DE) quantitatively assesses LV global dys-synchrony by measuring the systolic dyssynchrony index (SDI). No data exist on thevalue of SDI for detecting preclinical LV dysfunction in diabetic pts.Purpose: We sought to determine if preclinical LV dysfunction, i.e. early signs of global(longitudinal, radial, or circumferential) LV dyssynchrony at RT-3DE, is more frequent inhigh-risk patients with type II diabetes than in those without.Methods: We examined 22 consecutive asymptomatic high-risk pts (Framingham riskscore . 20%). In all patients, the presence of ischemic heart disease was carefullyexcluded by both stress testing and evidence of no coronary artery lumen reductionat 64-slices computed tomography (CT). The Agatston coronary artery calcium(CAC) score was obtained. Echocardiographic studies were performed using a ie33Philips system. Longitudinal LV dyssynchrony was measured by TDI as theseptal-to-lateral peak systolic velocities delay (SLD). Global LV dyssynchrony wasmeasured by RT-3DE as SDI (derived off-line as the time dispersion to minimumregional volume apart from 16 LV segments time-volume curves), using a dedicatedsoftware (Q-LAB).Results: All pts were in sinus rhythm; their mean age was 59+ 16 yrs; there were 12men and 10 women; the QRS length was , 120 msec in all. LV ejection fraction was61+ 16%. A total of 10 pts (40%) had compensated type II diabetes (HbA1c 5.9 þ1.2%). Diabetic and non diabetic patients were similar with regard to age (56+ 11vs 60+ 17 years), gender (60% vs 58% males), HDL (35+ 5 vs 34+ 6 mg/dl) andLDL cholesterol (142+ 15 vs 138+ 16 mg/dl), BP (130/75 vs 128/78 mmHg), andsmoking status (60% vs 58% ). There was a trend for higher CT CAC score in diabeticpts (69+102 vs 14+23 HU, p=0.06). Pts with and without type II diabetes had similarTDI SLD (43+ 38 vs 61+ 39 msec; p = 0.3). In contrast, RT-3DE SDI was significantlyhigher in diabetic pts (7.2%+ 7.6 vs 2.2%+ 2.7%; p , 0.02).

Parameters Whole group Wide QRS Narrow QRS

LPEI�140ms 28% 41% 12%*FT-RR�40% 21% 32% 8%*IVMD�40ms 26% 41% 10%*LLWC 24% 25% 24%Ts-4b�65ms 60% 59% 61%Ts-SD�33ms 59% 63% 54%§Trs-AS-P�130ms 42% 47% 36%

*p, 0.001, §p,0.05 vs Wide QRS.

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

245Left ventricular mechanical asynchrony in diabetic patients

M. Przewlocka-Kosmala1; M. Cielecka1; H. Szczepanik-Osadnik1; W. Kosmala1

1Wroclaw Medical University, Wroclaw, Poland

Systolic and diastolic left ventricular mechanical asynchrony (LVMA), which might con-tribute to LV contraction and relaxation impairment, has been demonstrated in heartfailure, coronary heart disease and hypertension (HT). Less in known about thisabnormality in diabetes mellitus (DM). Aim: To assess systolic and diastolic LVMA inDM patients with asymptomatic myocardial dysfunction.Material and methods: 98 patients with DM aged 59+12, 58 of them with coexistingHT, and without coronary heart disease were enrolled in the study. 44 healthy age-matched persons served as controls. Widening of QRS complexes in ECG was theexclusion criterion. Echo study with tissue Doppler imaging included the analysis ofmean peak systolic velocity (S mean) and mean peak early diastolic velocity (Emean), being the averaged values from the 6 basal segments of LV, which served asestimates of global myocardial function. The measure of systolic and diastolic LVMAwas the maximal difference in TS and in TE between any two of 12 mid and basal seg-ments, where TS and TE were the time from the beginning of QRS complex in ECG topeak systolic velocity and to peak early diastolic velocity in tissue velocity curve,respectively.Results: Systolic and diastolic LVMA as indicated by higher values of TS and TE differ-ences was demonstrated in both groups of DM patients, being however moreadvanced in subjects with coexisting HT. The independent predictors were for systolicLVMA: LV mass index (b¼0.23,p,0.001), diastolic blood pressure (b¼0.19,p,0.01)and S mean (b¼-0.38,p,0.001), and for diastolic LVMA: LV mass index(b¼0.15,p,0.04), diastolic blood pressure (b¼0.27,p,0.001) and E mean(b¼-0.32,p,0.001).Conclusions: In patients with DM (1) systolic and diastolic LVMA is a part of myocar-dial affection by the disease and is closely related to LV function impairment; (2) coex-istence of HT potentiates both systolic and diastolic LVMA which parallels LV functionalabnormalities.

PULMONARY DISEASES

246Left ventricular response to increased pressure afterload in the right ventricle -comparison between pulmonary hypertension and pulmonary valve stenosis

RO. Jurcut1; E. Floares2; D. Iorgoveanu2; R. Ticulescu2; BA. Popescu1; I. Ghiorghiu2;IM. Coman2; C. Ginghina2

1‘Carol Davila‘ University of Medicine and Pharmacy, Bucharest, Romania; 2Institute ofCardiovascular Diseases ”Prof. Dr. CC Iliescu”, Bucharest, Romania

Purpose: Ventricular interdependence is a known cardiac pathophysiological process.Anatomical remodeling of the right ventricle (RV) as a response to increased pressureafterload leads to geometrical changes in the left ventricle (LV). LV function remains avery important prognostic predictor in this setting. We compared LV function par-ameters in patients with pulmonary stenosis (PS) versus patients with arterial pulmon-ary hypertension (PH) using echocardiography.Methods: We included 36 age- and gender-matched patients (pts): group A (10 pts,mean age 32.0+18.3y) with valvular PS; group B (13 pts, 39.1+15.8) with arterialPH; group C (13 normal subjects, 38.1+14.7y). All pts had standard

echocardiography with measurements of LV dimensions, systolic function parameters,eccentricity index, LV myocardial performance index (LV-MPI), Doppler myocardial iso-volumic relaxation time (DM-IVRT).Results: RV systolic pressure was 81+41 mmHg in GrA, 96+38 mmHg in GrB(p¼0.37 vs GrA), 22+4 mmHg in GrC (p,0.01 vs GrA and B). LV function parametersare presented in the Table.Conclusions: Our results suggest that LV geometry changes resulted from RVpressure overload, with RV dilation, are associated with LV diastolic dysfunction onlyin patients with arterial PH, and not in those with pulmonary valve stenosis.

247Right ventricular function in patients with idiopathic pulmonary hypertension

G. Nasr11Suez Canal University, Ismailia, Egypt

Background and Aim: In patients with idiopathic pulmonary hypertension (IPAH), itsprogression and survival are related to the capability of the right ventricle to accommo-date chronically elevated pulmonary artery pressure. So the aim of this study was toassess right ventricular function in these patients.Methods: A descriptive, cross-sectional, hospital based clinical trial enrolling 15 patients(5males and 10 females) diagnosed as having idiopathic pulmonary arterial hypertension.All patients underwent a complete transthoracic echocardiographic study including stan-dard two-dimensional echocardiographic evaluation (2D-ECHO) of RV size and function.In addition, right ventricular end-diastolic and end-systolic areas were measured from theapical 4-chamber view to calculate right ventricular fractional area change. EccentricityIndex using the mid-ventricular short axis image at the level of the papillary muscles inboth systole and diastole and right ventricular Myocardial Performance Index were calcu-lated as well . (Total isovolumic ejection time index¼ IRT þ ICT/ET). ).Results: Most of parameters of right ventricular dysfunction were altered with a P ,

.00001. This was higher in females than males. Among the patients only 10 had abnor-mal RV systolic function measured by fractional area change and Eccentricity Index.The combined myocardial performance unmasked the presence of right ventriculardysfunction in 13of them. There was associated right ventricular dysfunction withincreasing right ventricular systolic pressure P , .00001Conclusion: A comprehensive echocardiographic assessment of RV function allows atool for risk stratification of patients with IPAH. RV Tei Index is a real addition.

248Impact of right ventricle function in mortality in patients with pulmonary arterialhypertension

P. Loureiro1; R. Placido1; A. Nunes Diogo1; S. Martins1; J. Marques1; S. Ribeiro1;A. Almeida1; M. Lopes1

1Hospital Santa Maria, Lisbon, Portugal

Introduction: Pulmonary arterial hypertension (PHA) defines a group of diseasesassociated with a high mortality and mobility. In spite of recent advances in geneticsand biological PAH determinants, the pathogenesis of the majority forms of PAHremains unclear. The mortality rate associated to this pathology remains high and prog-nostic variables are not well established despite the recent therapeutics.Objectives: This study aimed to assess the mortality rate and the impact of clinical vari-ables and echocardiographic parameters on the prognosis of patients (pts) with PAH.Methods: We conducted a retrospective study of pts with PAH included consecutivelyin a Pulmonary Hypertension Ambulatory Clinic, in the period of 2002 to 2008.Theselected endpoint was mortality. The prognostic significance of the following variableswere analyzed: a) age, gender, BMI, NYHA class, cardiac rhythm; b) Echocardiogra-phy: left ventricle (LV) diastolic dimension and wall thickness, right ventricle (RV) dias-tolic dimension, pulmonary artery systolic pressure (PASP), maximal velocity oftricuspid regurgitation (Vmax), mitral E and A velocity, tricuspid annular plane systolicexcursion (TAPSE), RV maximal longitudinal strain.Results: 36 pts were included, 24 women (66.7%), 64+13 years-old, BMI28.91+6.78kg/m2. Twenty pts (55.55%) were in class III/IV NYHA. Mortality was 28%at a follow-up period of 23,9þ/-20,3 months (0,3 a 79). Considering the two groups,with and without mortality, only TAPSE and RV longitudinal strain showed values signifi-cantly lower in the mortality group, with p,0.001 and p=0.013, respectively.Conclusion: The present study shows a high mortality rate associated with PAH in afollow-up period less than 7 years. The analysis of risk variables shows that only theRV function indexes, TAPSE and RV maximal longitudinal strain, were associatedwith a high mortality. These findings suggest a significant impact of RV function inthe prognosis of PAH.

249Left ventricular global dysfunction is related to pulmonary artery pressure inpatient with chronic obstructive pulmonary disease

Elzbieta E. Suchon1; W. Tracz1; A. Prokop1; P. Nalepa1; P. Podolec1

1John Paul II Hospital, Krakow, Poland

Background and aim: Several studies have shown that patients with right ventriclepressure overload often have impaired diastolic left ventricle function. The studyaimed to evaluate the effects of chronic obstructive pulmonary disease (COPD) onthe global left ventricle function (measured on the basis of myocardial performanceindex - MPI) and its relation to the pulmonary artery pressure.

Table 1 Results

DM DMþHT Controls

TSdifference [ms] 78+26* 99+27*# 50+24TEdifference [ms] 60+15* 77+17*# 44+10S mean [cm/s] 6.6+1.0* 5.7+0.9*# 7.4+0.6E mean [cm/s] 6.9+1.1* 5.1+1.0*# 8.5+1.4

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

Parameters Group A Pulmonaryvalve stenosis N=10

Group B Pulmonaryhypertension N=13

Group CControls N=13

PANOVA

RV end-diastolicdiameter (mm)

31+6 47+9* 29+6 ,0.001

LV Eccentricityindex

1.4+0.2* 1.6+0.4* 1.0+0.4 ,0.001

LV ejection fraction(%)

64+6 58+15 65+5 NS

LV mitral E/A ratio 1.3+0.3 1.0+0.4* 1.4+0.3 0.04LV E/E’ ratio 4.7+2.1 10.3+4.5*,# 7.2+3.6 0.003LV DM-IVRT (ms) 70+7 108+36* 66+25 0.002LV-MPI 0.41+0.14 0.57+0.20*,# 0.44+0.12 0.01

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

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Material and methods: Fifty patients mean age of: 60.9+ 8.5, range: 55 - 78 yearswith COPD without any additional cardiac diseases and 30 age and sex matchedhealthy subjects were enrolled into the study. All patients underwent pulmonary func-tion tests and transthoracic echocardiography. The LVMPI was calculated as (a2b)/b, were a is the interval between the cessation and onset of mitral inflow, and b isthe ejection time.Results: Our results are presented in the Table 1. LVMPI was significantly higher inCOPD patients in comparison to the controls (0.54+ 0.1 vs 0.32+ 0.07; p , 0.001).There was a significant negative correlation between LVMPI and forced expiratoryvolume in 1 second expressed as the % of the predicted value - FEV1% (r = - 0.45;p,0.01). Moreover we found a significant and strong correlation between LVMPI andRVSP (r = 0.7; p,0.001).Conclusion. The global LV function is impaired in COPD patients despite of preservedleft ventricular ejection fraction and it is related to the increase in the pulmonary arterypressure.

250Non-invasive assessment of murine pulmonary arterial pressure: validation andapplication to models of pulmonary hypertension

B. Kurtz1; H. Thibault1; M. Raher1; RS. Shaik1; A. Waxman1; G. Derumeaux2; K. Bloch1;M. Scherrer-Crosbie1

1Massachusetts General Hospital, Boston, United States of America; 2Universite ClaudeBernard, Lyon, France

Background: Genetically modified mice offer the unique opportunity to gain insightsinto the pathophysiology of pulmonary arterial hypertension (PAH). In mice, rightheart catheterization is the only available technique to measure right ventricular systolicpressure (RVSP). However, it is a terminal procedure and does not allow serialfollow-up. Our objective was to validate a non-invasive technique to assess RVSP inmice.Methods: Right ventricle catheterization and echocardiography were simultaneouslyperformed in mice with pulmonary hypertension induced acutely by infusion of athromboxane analogue, U-46619 or chronically by lung-specific over-expression ofinterleukin 6 (IL-6). Pulmonary acceleration time (PAT) and ejection time (ET) weremeasured in the parasternal short axis view by pulsed-wave Doppler of pulmonaryartery flow.Results: Infusion of U-46619 acutely increased RVSP, shortened PAT, and decreasedPAT/ET. The pulmonary flow pattern changed from symmetric at baseline to asym-metric at higher RVSPs. In mice with chronic PAH and wild-type mice, the PAT corre-lated linearly with RVSP (r2=20.67; p,0.0001), as did PAT/ET (r2=20.76,p,0.0001). Sensitivity and specificity for detecting high RVSP (.32 mmHg) were100% (7/7) and 86% (6/7), respectively, for both indexes (cutoff values: PAT ,21 msand PAT/ET ,39%). Intra-observer and inter-observer variability of PAT and PAT/ETwere less than 6%.Conclusions: Right ventricular systolic pressure can be estimated noninvasively inmice. Echocardiography allows the monitoring of acute changes of RVSP and thedetection of pulmonary hypertension. This technique enables the follow-up of PAHevolution easily and repeatedly in mice.

251Ultrasound lung comets in systemic sclerosis: a chest sonography hallmark ofpulmonary interstitial fibrosis

L. Gargani1; M. Doveri2; L. D’errico3; MC. Scali4; S. Mondillo4; S. Bombardieri2;D. Caramella3; E. Picano1

1CNR Istituto di Fisiologia Clinica, Pisa, Italy; 2Rheumatology Division, University of Pisa,Pisa, Italy; 3University of Pisa, Department of Diagnostica & Interventional Radiology,Pisa, Italy; 4Policlinico Santa Maria Alle Scotte, Siena, Italy

Background: Pulmonary interstitial fibrosis is present in over 70% of patients with sys-temic sclerosis (SSc) and is a significant determinant of outcome in these patients.High resolution computed tomography (HRCT) of the chest is the current undisputedgold standard to assess pulmonary fibrosis. Ultrasound lung comets (ULC) are arecently described sign of interstitial lung fibrosis, detectable with chest sonography.Aim: To assess the correlation between ULC and HRCT to evaluate pulmonary fibrosisin SSc patients.Methods: We enrolled 33 consecutive SSc patients (age 54+ 13 years, 30 females) inthe Rheumatology Clinic of an University. In all, we independently assessed ULC andchest HRCT within 1 week. ULC score was obtained by summing the number of ULCon anterior and posterior chest. Pulmonary fibrosis by HRCT was quantified with a pre-viously described 30-point Warrick score. Results: Presence of ULC (defined as a totalnumber . 10) was observed in 17 (51%) SSc patients. Mean ULC score was 37+50,higher in the diffuse than in the limited form (73+ 66 vs. 21+ 35, p,.05). A significantpositive linear correlation was found between ULC and Warrick score (r ¼ .72,p , .001).Conclusions: ULC are often found in SSc, are more frequent in the diffuse than thelimited form, and are reasonably well correlated with HRCT-derived assessment oflung fibrosis. They represent a simple, bedside, radiation-free hallmark of pulmonaryfibrosis, of potential diagnostic and prognostic value.

252Echocardiographic assessment of right ventricular and right atrial functions inpatients with pulmonary hypertension of different etiologies and severities

O. Ciftci1; N. Ozer1; E. Atalar1; K. Ovunc1; S. Aksoyek1; F. Ozmen1; S. Kes1; H. Ozkutlu1

1Hacettepe University, Faculty of Medicine, Department of Cardiology, Ankara, Turkey

Purpose: Pulmonary hypertension (PHT) is a chronic disorder characterized by achronic increase in afterload of right ventricle, which may lead to progressive rightheart dysfunction and death. Left heart diseases, collagen tissue diseases, andchronic obstructive lung diseases are common clinical secondary causes of PHT.Our objective was to assess right heart functions in PHT as well as to study the differ-ences in right heart functions in varying PHT etiologies and severities.Methods: A total of 83 patients with PHT and 49 controls were enrolled. The PHT etiol-ogy was a left heart disease in 39 patients, a connective tissue disorder in 23, and arespiratory disease in the remaining 21. Two-dimensional echocardiographic, conven-tional Doppler echocardiographic, and tissue Doppler echocardiographic examin-ations with myocardial velocity profiles and strain/strain rate imaging wereperformed, by which right ventricular and right atrial functions were evaluated. Further-more, patients with mild, moderate, and severe PHT and patients with different pulmon-ary hypertension etiologies were compared with each other.Results: In PHT a right ventricular systolic dysfunction is detected by TAPSE (16,2(+5,0) vs 20,7 (+2,7); p,0,001), tricuspid lateral annulus systolic myocardial velocity(Sm) (12,8 (4,6-27,2) vs 16,4 (10,7-22,2); p,0,001), right ventricular lateral wall basalsegment strain (16,6 (7,4- 38,2) vs 20,6 (6,3-55,0); p,0,01), and interventricular

Table 1.

COPD group (n=50) Controls (n=30) p

Age (years) 60.9+ 8.5 61.1+ 7.9 NSFEV1 (% of predicted) 40+ 9.5 98+ 4.9 ,0.001RVSP (mmHg) 40.2+ 12.3 21.3+ 2.9 ,0.001LVMPI 0.54+ 0.1 0.32+ 0.07 ,0.001LV diameter (mm) 48.9+ 6.9 50.1+ 8.1 NSLV EF (%) 61.2+ 6.5 63+ 4.1 NS

Correlation between RVSP and PAT.

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

CARDIAC RESYNCHRONISATION THERAPY

253Left ventricular torsion is reduced during left ventricular pacing after anexperimental acute anterior myocardial infarction

A. Kaladaridou1; D. Bramos1; E. Skaltsiotes1; D. Takos1; C. Pamboucas1; G. Kottes1;A. Antoniou1; ST. Toumanidis1

1Dpt. of Clinical Therapeutics, “Alexandra” Hospital, Athens, Greece

Purpose: A significant number of patients with ischemic cardiac failure are character-ized as non-responders to biventricular pacing (P). Previous studies have shown thepivotal role of torsion on LV contractility. The purpose of this study is to examine theeffect of different LV pacing modes and sites on LV torsion after an experimentalacute anterior myocardial infarction.Methods: In 5 healthy pigs atrio-ventricular or ventricular epicardial P at LV apex orlateral wall was performed before and 30 min post LAD ligation, in a random order.Totally, 80 P were performed. LV torsion was calculated by measuring LV basal andapical rotation from basal and apical short-axis epicardial planes with speckle trackingtechnique using EchoPAC platform. LV torsion in sinus rhythm post LAD ligation wascompared to LVtorsion in every P mode and site. Moreover, comparative evaluationof LVtorsion between the different P modes and sites was performed.Results: LV ejection fraction post LAD ligation reduced significantly (32+8% vs53+8%, p,0.01). LV torsion reduced significantly in every P mode and site (atrio-ventricular 5.42+3.55, p,0.001 and ventricular 4.22+3.34, p,0.05 apical P, as wellas atrio-ventricular 4.20+2.29, p,0.05 and ventricular P 3.53+3.43, p,0.04 of thelateral wall) in comparison to sinus rhythm, post LAD ligation (8.09+4.57). None ofthe P mode or site revealed any superiority.Conclusions: LV pacing exerts adverse effect on LV torsion after an acute anteriormyocardial infarction experimentally. Further clinical studies are indicated to evaluatethe role of LV torsion in LV contractility under pacing, in patients with cardiac failure.

254Correlation between cardiac morphological and functional indices,myocardialdyssynchrony and intraventricular conduction in patients with congestive heartfailure of various ethiology.

Maria M. Trukshina1; M. Sitnikova1; D. Lebedev1; E. Shlyakhto1

1Federal Center of Heart, Blood and Endocrinology n.a.V.A.Almazov,, St.Petersburg,Russian Federation

Purpose: To evaluate the distribution of various types of left ventricular dyssynchronywith ECG abnormalities and indices of left ventricular (LV) function in patients with con-gestive heart failure (CHF) II-IV class.Methods: Inclusion criteria: CHF II-IV class, LVEF�35%, optimal medical treatment.Exclusion criteria: significant valvular disease, acute coronary syndrome. 26 patientswere screened, 84% men, 58,0+13,4 y.o.; 76% had coronary artery disease (CAD),24%-dilated cardiomyopathy (DM). All patients were examined with electrocardiogram,echocardiography (Echo). Echo with Tissue Doppler Imading (TDI) was assessedusing Vivid 7 Dimension Ultrasound System (GE Vingmed Ultrasounds A/S, Norway)for evaluation of interventricular (IVD) and intraventricular (INVD) dyssynchrony. IVDwas assessed as difference between aortic and pulmonary preejection time (cut-offIVD .40ms); INVD was assessed using time-to-peak systolic velocities (Ts-12) in 12segments (middle and basal) of LV (cut-off: Ts-12 . 100 ms) and Ts-12 standard devi-ation (SD-Ts, cut-off: SD-Ts.32). In the presence of IVD or INVD dyssynchrony wasconsidered to be isolated, in the presence of both IVD and INVD dyssynchrony wasconsidered to be mixed.Results: According to QRS duration patients were divided into 2 groups, first group(53%) include patients with QRS,120ms (100,0+7,5ms), second group (47%) -with QRS �120ms (150,0+24,7ms) and complete left bundle branch block (LBBB).Groups were compared by CHF class (3,0+0,6), LV EDD (73,5+7,5mm and75,0+8,8mm), LV ESD (60,5+5,8mm and 65,0+8,4mm), LV EF (27,0+6,9% and28,5+5,4%), degree of mitral regurgitation (2,0+0,7). Among patients withQRS,120ms CAD, DM, atrial fibrillation (AF), isolated IVD or isolated INVD occurredequally; 30% of patients with AF had no dyssynchrony . In DM INVD and mixed dyssyn-chrony were common. In the narrow QRS group IVD was 27,0+24,2ms (2–93ms),INVD - Ts-12 95, 0+40, 0ms (42–200ms), SD-Ts 235, 9+18,6 (13–45). Group withQRS�120ms had more isolated INVD and mixed dyssynchrony (especially in CAD

and AF), less frequently occured isolated IVD 237, 0+32,1ms (8–119), higher thanin group one. Ts-12- 105,0+54,7ms (30–250ms) and SD-Ts-39,0+23,7 (11-103)were higher than among patients with QRS,120ms.Conclusions: Duration of QRS doesn’t correlate with the size of LV chambers, severityof mitral regurgitation and LV EF in patients with CHF. In narrow QRS isolated types ofdyssynchrony are often. Patients with wide QRS and LBBB usually have intraventricularand mixed dyssynchrony, of Ts-12 and SD-Ts are significantly higher.

255Differential prevalence of left ventricular dyssynchrony between acutedecompensated heart failure and chronic stable heart failure revealed by tissueDoppler imaging

Q. Zhang1; APW. Lee2; YT. Liu2; GWK. Yip2; YJ. Liang2; RJ. Li2; JM. Xie2; CM. Yu3

1Li Ka Shing Institute of Health Sciences, Chinese University of HK, Hong Kong, HongKong SAR, People’s Republic of China; 2Cardiology, Dept of Medicine & Therapeutics,Prince of Wales Hospital, Chinese University of HK, Hong Kong, Hong Kong SAR,People’s Republic of China; 3Institute of Vascular Medicine, The Chinese University ofHong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China

Background: Left ventricular (LV) dyssynchrony has been recognized as an importantcomponent of cardiac dysfunction which contributes to progressive deterioration ofheart failure (HF), in particular in patients with wide QRS complexes. However, itremains unclear whether LV dyssynchrony is also related to the development ofacute decompensated HF.Methods: 100 patients with systolic HF (LV ejection fraction ,50%) were enrolled inwhom 50 patients were hospitalized for acute exacerbation of HF and 50 patientshad chronic stable HF without HF hospitalization during the past 6 months. The 2groups were matched for age, gender, ejection fraction and QRS duration (Table). LVsystolic dyssynchrony was assessed by tissue Doppler imaging using the standarddeviation (Ts-SD) and maximal difference (Ts-Diff) of the time to peak systolic velocityamong the 12 segments.Results: Despite similar LV ejection fraction and QRS duration, patients with acuteexacerbation of HF had significantly prolonged Ts-SD and Ts-Diff than those withchronic stable HF. By using Ts-SD�33ms or Ts-Diff�100ms as a cutoff, the prevalenceof systolic dyssynchrony was much higher in the acute HF group (Table).Conclusions: LV systolic dyssynchrony detected by tissue Doppler imaging is moreprevalent in patients with acute decompensated HF. This implicates that changes inmechanical dyssynchrony may predispose to HF exacerbation and hospitalization,which might warrant further studies.

256Arrhythmias and sudden death in patients with advanced heart failure and highgrade of asynchrony

W. Brzozowski1; A. Tomaszewski1; A. Wysokinski11Medical University, Lublin, Poland

Heart failure (HF) patients who have complex conduction disturbances and the highgrade of intra- and interventricualr asynchrony are prone to a variety of arrhythmias.Most of them are asymptomatic, however they have prognostic significance and some-times provide to cardiac arrest (CA)or suden cardiac death (SCD).The aim of this study was to evaluate symptomatic and asymptomatic arrhtythmias inpatients with advanced HF and conduction disturbances followed by high grade ofcontraction asynchrony.Group of 88 patients (76 men, 12 women; mean age 60,8+ 12,2 y, EF ,= 40 %) weresubjected to 1–year follow-up with 48 hours Holter monitoring every three months

Table 1 Comparison btw Acute & Chronic stable HF

Parameters Acute HF Chronic HF P value

Age, year 67+14 68+15 .659Gender/Male, n (%) 36 (72%) 36 (72%) 1.000LV ejection fraction, % 32.5+9.2 32.4+8.5 .971QRS duration, ms 125+31 124+31 .836QRS group/wide, n (%) 28 (56%) 29 (58%) .843Ts-SD, ms 45.7+15.6 34.0+18.7 .001Systolic dyssynchrony by Ts-SD, n (%) 42 (84%) 24 (48%) ,0.001Ts-Diff, ms 135+44 92+48 ,0.001Systolic dyssynchrony by Ts-Diff, n (%) 40 (80%) 22 (44%) ,0.001

Table 1 Arrhythmias and SCD in HF patients (% of

chronic atrial fibrillation 11,38proxysmal atrial fibrillation/flagellation 47,73spraventricular tachycardia 15,91vetricular tachycardia (VT) 44,32vntricular fibrillation (VF) 27,27CA (VT or VF) 29,55

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(Diagnostic Monitoring, Premier IV, ver. 3.3).All documented data of arryhthmias andSCD were collected and analyzed.During 1-year follow-up 14 patients died (16 % of group; 4 patients died suddenly–recurrent VT/VF).Conclusions:1.Patients with HF and conduction disturbances followed by high grade of contractionasynchrony commonly died suddenly.2.The incidence of ventricular arrhythmias is as common as the incidence of supraven-tricular ones in investigated group of patients3.Serious arrhythmias are frequently asymptomatic and require longer periods ofHolter monitoring

257Are there any echocardiographic predictors for appropriate therapies by thedefibrillator in patients with an implanted cardiac resynchronization therapy -defibrillator device?

Ana Teresa AT. Timoteo1; A. Galrinho1; LM. Branco1; MM. Oliveira1; M. Nogueira Silva1;J. Feliciano1; A. Leal1; RC. Ferreira1

1Hospital Santa Marta, Lisbon, Portugal

The significant risk of sudden arrhythmic death (SD) in patients (P) with congestiveheart failure and electro-mechanical ventricular dessyncrony has contributed for theincrease in cardiac-ressynchronization therapy (CRT) combined with cardioverter-defibrillator (D).Objectives: To evaluate in P submitted to CRT-D what are the echocardiographic vari-ables that could predict the occurrence of appropriate therapies (AT) for ventriculartachydysrithmia. Methods: We evaluated 38 consecutive P (60+ 12 years 63%males) with echocardiographic evaluation before and 6 months after CRT-D implan-tation. We identified P with AT in a mean follow-up of 471+ 323 days (median 425days). A standard echocadiographic study with tissue Doppler imaging (TDI) included,was performed. Responders were defined as P with improvement in NYHA class �1 inthe first six months, and reverse remodelling as a decrease in left ventricularend-systolic volume �15% and/or an increase in left ventricular ejection fraction(LVEF) �25%.Results: The responders0 rate was 74%, and reverse remodelling rate was 55%. In 21%of P there were AT. These P presented with higher end-diastolic left ventricular internaldiameter (LVID) before implantation (86+ 8 vs. 76+ 11 mm, p¼0.03) and at 6 months(81+ 8 vs. 72+14 mm, p¼0.08), increased end-systolic LVID (66+ 14 vs. 56+ 14mm, p¼ 0.03) and lower LVEF (24+ 6 vs. 34+ 14%, p¼ 0.08) in the evaluation at 6months. In the group with AT, responder rate was lower (38 vs. 83%, p¼0.03),without significant differences for reverse remodelling (60 vs. 38%, p¼0.426) and forthe other variables. By univariate analysis, predictors for AT were end-diastolic LVID(OR 1.12, 95% CI 1.01–1.23) and end-systolic LVID (OR 1.08, 95% CI 1.0–1.18).Age, gender, ischemic etiology, use of anti-arrythmic drugs, reverse remodelling andTDI of mitral annulus could not predict AT. In multivariate logistic regression analysis,only end-diastolic LVID before implantation showed a trend for prediction of AT (OR1.31, 95% CI 0.96 – 1.78, p¼0.08).Conclusions: In P submitted to CRT-D, episodes of ventricular tachydysrithmia canoccur independently of the echocardiographic response, with end-diastolic LVIDbefore implantation showed some trend to predict AT in medium-term. These resultsreinforce the importance of combined devices with the capacity forcardioversion-defibrillation.

258Resynchronization versus remodeling dependent responders to biventricularpacing for congestive heart failure

Andrada A. Labecka1; T. Chwyczko1; M. Sterlinski1; B. Firek1; A. Maciag1; A. Kraska1;I. Kowalik1; H. Szwed1

1Institute of Cardiology, Warsaw, Poland

Purpose: The aim of the study was to evaluate whether the left ventricle resynchroniza-tion by biventricular pacing in heart failure was related to an improvement of the exer-cise capacity independently of the left ventricle reverse remodeling in long-termobservation.Methods: We enrolled 44 patients who had a standard indication for cardiac resyn-chronization therapy (CRT) and who were able to perform an exercise test prior toimplantation. Peak oxygen consumption (VO2 max) during cardiopulmonary exercisetesting and echocardiographic parameters were measured prior to CRT and at least3 months after the implantation. Responders to CRT were defined by an increase inVO2 max by minimum 2ml/kg/min. Left ventricle (LV) reverse remodeling wasdefined by a reduction of the end-systolic volume (ESV) by minimum 15%. LV resyn-chronization was assessed by the reduction of the mechanical pre-ejection period(MPEP), defined as the period from the onset of the mitral regurgitation flow signaland the onset of the aortic flow signal.Results: As confirmed by the exercise testing 56,8% patients positively responded toCRT; 45,4% patients had reverse LV remodeling and in 61,3% patients MPEP wasreduced. The increase in VO2 max significantly correlated with the LV reverse remodel-ing (r=0,4164, p=0,0049), but not with the MPEP reduction for the whole group ofpatients. Two subgroups of patients were distinguished: 19 patients (43,2%) withVO2 increase dependent on resynchronization (MPEP reduction) and 25 patients(56,8%) with VO2 increase dependent on remodeling (ESV reduction). For the “resyn-chronization dependent" subgroup there was an excellent (R2=0,84, p,0,0001) linear

dependence of the VO2 max increase and MPEP reduction [VO2 max increa-se=0,08x(MPEP reduction)þ4,7;], independently to the relative ESV reduction in multi-factorial analysis (p=ns). For the “remodeling dependent" subgroup, there was nocorrelation of VO2 increase with the retiming of the cardiac cycle, but significant corre-lation with the LV remodeling (p=0,036). There was significantly more responders inthe “resynchronization dependent" than in the “remodeling dependent" subgroup(84% vs 36% p=0,0038) and the degree of response was higher, VO2 increase5,04 vs 1,89 ml/kg/min (p=0,0041).Conclusion: The response to CRT is heterogeneous. For almost half of the patients LVresynchronization is the mechanism which mainly predicts response to CRT, indepen-dently of the remodeling. The resynchronization sensitive patients have a higher rateand a higher degree of response.

259Right ventricular pacing changes left ventricle radial contraction pattern inpatients with congestive heart failure and baseline intraventriculardyssynchrony.

Alexandra Ioana A I. Vasile1; D. Constantinescu1; C. Iorgulescu1; D. Zamfir1;N. Dumitrescu1; M. Dorobantu1; R. Vatasescu1

1Emergency Hospital of Bucharest, Bucharest, Romania

Background: Baseline mechanical intraventricular dyssynchrony showed only a weakcorrelation with response to CRT in patients with congestive heart falure (CHF) andwide QRS. Currently the effects of right ventricular (RV) pacing during CRT on quantityand pattern of the intraventricular dyssynchrony are not explored.Objective: To evaluate the effects of RV pacing on intraventricular dyssynchrony andon the location of the maximum LV delay area in CHF patients and wide QRS.Methods: Speckle tracking radial strain was performed in 20 consecutive CHF patientswith left bundle branch block (LBBB) one week after implantation of a biventricularpace-maker (9 ischemic etiology, 61+10 years, 9 women, NYHA class 3.2+ 0.4, LVejection fraction 21+5%). All patients were in sinus rhythm with a normal PR intervaland they have significant baseline mechanical intraventricular dyssynchrony (timedifference in peak septal wall-to-posterior wall strain �130 ms on speckle trackingradial strain). RV lead was placed in the interventricular septum by mapping (aimingfor the narrowest QRS with as normal as possible axis). Maximum LV delay area wasdefined in sinus rhythm (ODO mode) and in RV pacing (DDD with short AV delay)as the segment with the latest systolic peak from the 6 regional colorcoded time-straincurves.Results: RV septal pacing did not changed significantly the quantity of intraventriculardyssynchrony (330+103 ms vs. 344+61msec during sinus rhythm, p¼NS). However,the location of the maximum delay area shifted in 17 out of 20 patients. Baselinemaximum delay area was located on the lateral wall in 11 patients (55%), on the inferiorwall in 4 patients (20%) and on the infero-lateral wall in 5 patients (25%). During RVpacing maximum delay area was located on the infero-lateral wall in 15 patients(75%) and on the inferior wall in 5 patients (20%).Conclusions: RV septal pacing maintains significant intraventricular dyssynchrony andchanges the location of maximum LV delay area. This might explain the weak corre-lation of baseline mechanical intraventricular dyssynchrony assesed during intrinsicrhythm and the response to CRT.

260An assessment of the effect of different sonographers on the reproducibility oftissue Doppler imaging dyssynchrony analysis

RP. Beynon1; RA. Argyle1; KA. Pearce1; NC. Davidson1; SG. Ray1

1University Hospital of South Manchester, Manchester, United Kingdom

Purpose: Tissue Doppler imaging (TDI) is in widespread use for the selection ofpatients for cardiac resynchronisation therapy (CRT). The reproducibility of TDI timeto peak systolic contraction (Ts) has been quoted in most trials, but all have concen-trated on the ability of analysers to repeat measurements on a pre scanned image.The impact of the sonographer on reproducibility has been poorly studied in previoustrials yet this is as important as the reproducibililty of analysis for the technique to berobust. This study set out to investigate the effect of different sonographers on thereproducibility of TDI data.Methods: 20 normal subjects were recruited. All subjects had a QRS duration of , 110msec. TDI images were obtained by two highly experienced sonographers using aVIVID 7 machine. Images were optimised independantly by both sonographers fordepth, sector width and gain. Time to peak systolic contraction (Ts) was calculatedfrom the onset of the QRS complex in 6 basal and 6 mid LV segments. Ts 4S wasthe maximal difference in Ts in the basal septal, lateral, anterior and inferior segments.TS SD was taken as the standard deviation of the Ts in all 12 segments. All 40 sets ofimages were analysed twice off line using ECHOPAC software by the same operatorallowing the impact of intersonographer reproducibility to be compared with the analy-ser’s own intraobserver reproducibility. Coefficients of variation were calculated for allcomparisons.

Table 1 Results

Ts Ts 4S TS SD

Intersonographer 14% 30% 41%Intraobserver 9% 15% 17%

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Conclusion: Intraobserver reproducibility of Ts was found to be in keeping with pre-vious studies. Reproducibility however significantly worsened when images from differ-ent sonographers were assessed. This study is likely to be a conservative estimate of‘real world’ reproducibility as all subjects were taken from a normal population where Tsmeasurements are typically easier than in patients with dilated ventricles. The results ofthis study suggest that the impact of the sonographer requires further investigation infuture trials.

261Right atrial size and deformation predict echocardiographic response tocardiac resynchronization therapy in patients with dilated cardiomyopathy

Antonello A. D’andrea1; P. Caso2; R. Scarafile1; L. Riegler1; G. Salerno1; R. Cocchia1;R. Gravino1; R. Calabro’11Chair of Cardiology - Second University of Naples, Naples Italy, Italy; 2OspedaleVincenzo Monaldi, Naples, Italy

Background: Right atrial (RA) enlargement has been depicted as a significant inde-pendent predictor of unfavorable outcome in patients with pulmonary hypertension.Aim of the study: To detect by standard echo and by two-dimensional strain (2DSE)RA morphology and function in patients with dilated cardiomyopathy (DCM), and toassess if RA measurements may predict response to cardiac resynchronizationtherapy (CRT).Methods: The study population included 130 patients (54.4 plus or minus 10.2 years)with either idiopathic (70 patients) or ischemic (60 patients) DCM selected for CRT, and60 healthy controls. All the patients underwent at baseline clinical examination, stan-dard Doppler echo and non-Doppler two-dimensional RA Strain by Vivid 7 ultrasoundsystem (General Electrics - Horton - Norway). After 6 months from CRT, DCM patientswere considered as echocardiografic responders to CRT if left ventricular end-systolicvolume decreased by 15%.Results: All the DCM patients were in NYHA class III before CRT implantation. Themean LVEF was 29.2+5.5%. Six months after CRT, 94 patients (72.8 %) were inNYHA functional class I-II. The patients were subdivided into echocardiographicresponders (n ¼ 85; 66.1 %) and non responders (n ¼ 45; 33.9 %) to CRT. Left ventricu-lar and right ventricular dimension and function were not significantly different betweenthe two groups. Conversely, tricuspid regurgitation velocity (p,0.01), inferior venacava diameter (p,0.01) and both RA area index (19.7+5.5 cm/m2 in non respondersvs. 13.2+4.4 cm/m2 in responders; p,0.001) and myocardial deformation of RAlateral wall (22.3+10.2 % in non responders vs. 40.2+8.9 % in responders;p,0.001) were significantly different between the two groups. By ROC curve analysis,a RA area index . 16 cm/m2 showed a sensitivity and a specificity respectively of80.7% and 88.8% (p,0.0001) to predict negative response to CRT. By multivariableanalysis, RA area index (OR: 3.1; 95% CI: 2.1–3.9; p,0.001) and ischemic aetiologyof DCM (OR: 1.3; 95% CI: 1.1–1.9; p,0.01) were powerful independent determinantsof response to CRT.Conclusions: This study evaluated for the first time RA size and reservoir function inpatients with DCM. RA enlargement was an excellent independent predictor ofresponse to CRT.

262Radial strain delay using speckle tracking echocardiography to predictresponse to cardiac resynchronization therapy: going beyond segmental timingalone

Fakhar FZ. Khan1; MS. Virdee2; D. O’halloran1; PA. Read1; SP. Fynn2; DP. Dutka1

1Addenbrooke’s Hospital, Cambridge, United Kingdom; 2Papworth Hospital,Cambridge, United Kingdom

Introduction: In the selection of patients for cardiac resynchronization therapy (CRT),echocardiographic dyssynchrony parameters based upon the timing of regional con-traction alone are limited by being inherently independent of consideration of under-lying myocardial contractility. We hypothesised that patient selection to predict CRTresponse would be enhanced using a strain-based parameter based not only on thetiming of myocardial segmental motion, but also on the amplitude of contraction, apotential measure of contractile reserve. We assessed a novel radial strain delayindex to predict response to CRT.Methods: Radial 2D strain speckle tracking analysis was performed in 35 patients withheart failure scheduled for CRT (age 65 þ/2 8 years, 21 males, QRS 151 þ/2 12ms,NYHA III/IV 32/3, EF 22 þ/2 7%). Radial strain-delay (RSD) was calculated as the sumof the difference in peak radial strain and strain at aortic valve closure in the 12 nonapical segments. All patients underwent CRT and response to treatment was definedas a .15% reduction from baseline in LV end systolic volume (LVESV) at 3 months.The predictive value of the RSD to predict CRT response was compared to previouslyreported dyssynchrony measures including the standard deviation (SD) of time to peakmyocardial longitudinal velocity of 12 segments (Ts SD12), the anteroseptal-posteriorwall radial strain delay (AS-P delay) and the SD of time to peak radial strain of 12 seg-ments (Rs-SD12).Results: Echocardiographic response to CRT was seen in 21/35 patients. Significantdifferences were seen between responders and non responders in the RSD (89 þ/242 vs 28 þ/2 13%, p,0.01), AS-P delay (249 þ/2 152 vs 91 þ/2 83ms) and theRs-SD12 (140 þ/2 59 vs 73 þ/2 49ms). There was no difference in the Ts SD12between responders and non responders. The RSD had the best correlation withLVESV reduction (r¼0.64, p,0.001) and using an optimal cut off of 41%(AUC¼0.92), the RSD was able to predict response to CRT with a sensitivity of 91%

and specificity of 92%. This was much higher than for the AS-P (cut off 130ms,AUC¼0.81, sensitivity 73%, specificity 71%) and Rs -SD12 (cut off 90ms, AUC¼0.79,sensitivity 75% specificity 75%).Conclusion: A radial strain delay parameter based on both the timing and amplitude ofsegmental strain has a stronger predictive value in determining CRT response com-pared to parameters based on segmental timing alone.

263Is left ventricular end-systolic volume the best echocardiographic indicator ofclinical response to cardiac resynchronization therapy?

A. Zaroui1; Patricia P. Reant1; P. Ritter1; A. Deplagne1; A. Mignot1; P. Bordachar1;R. Roudaut1; S. Lafitte1

1Hopital Cardiologique Haut-Leveque, Bordeaux, France

Background: Common definition of response to cardiac resynchronization therapy(CRT) for severe refractory heart failure is based on NYHA class improvement. Left ven-tricular (LV) end-systolic volume improvement �15% has been used in some studies todefine echocardiographic LV reverse remodeling after CRT.Objectives: To analyze evolution of echocardiographic parameters and their associ-ation to clinical response after CRT.Materials and Methods: Ninety-six patients have been investigated before and 6months after implantation of a CRT device with conventional indication according toESC guidelines. Echocardiographies including measurements of LV dimensions, andcontraction by 2-dimensional strain were performed at baseline and at 6 months.Response to CRT was clinically defined by an improvement of NYHA class tograde � II at 6 months.Results: Seventy-four (76%) patients were clinically defined as responders to CRT at 6months. Reduction of LV end-systolic volume �15% was observed in 63 patients (65%)and, in univariate analysis, was associated in 80% of the case with clinical response(p,0.05, OR 1.5 [CI 0.9-2.4]). Global longitudinal strain was improved from29.7+2.7% to 211.2+2.2% in clinical responders (p,0.01) versus 28.2+2.9% to28.1+4.9% (p ns) in non responders and, �15% relative improvement of this par-ameter was associated in 95% of the cases with clinical response to CRT at 6months (p,0.001, OR 6.4 [CI 1.5-26.2]). Moreover, 87% of the patients without degra-dation of global longitudinal strain at six months were clinically improved (p,0.04, OR3.2 [CI 1.4-7.2]).Conclusion: In this study, we observed that global longitudinal strain improvement�15% was better associated to clinical response after CRT than LV end-systolicvolume reduction.

264Ideal dyssynchrony parameters for predicting the response to cardiacresynchronization therapy in the canine model of pacing-induced heart failure

YS. Wang1; X. Gong1; YG. Su1; Xianhong XH. Shu1

1Zhongshan Hospital of Fudan University, Shanghai, China, People’s Republic of

Background: Tissue Doppler imaging (TDI), real-time three-dimensional echocardio-graphy (RT3DE) and speckle tracking strain imaging (STSI) are methods for theassessment of left ventricular (LV) dyssynchrony. In this study we used dogswith rapid ventriucular pacing-induced heart failure to evaluate which methodcan detect the mechanical dyssynchrony in the canine model and to investigatewhich parameter is the best to predict the response to cardiac resynchronizationtherapy (CRT).Methods: Twelve adult beagle dogs were randomly divided into three groups. Eight ofthem underwent right ventricular pacing to induce heart failure (Group A&B). Whentheir LVEF decreased below 35%, dogs in Group A received CRT and meanwhiledogs in Group B were given no therapy except termination of rapid ventricularpacing. The other 4 dogs were used as sham controls without connection to thepacemakers (Group C). Right ventricle was paced at 260 beats/min in Group A&B.TDI, RT3DE and STSI were performed in conscious animals at baseline, 3 weeksafter pacing, 4 weeks after CRT in Group A, 4 weeks after deactivation of thepacemakers in Group B and 7 weeks after surgery in Group C. The systolic dyssyn-chrony parameter derived from TDI was the standard deviation of time to maximumsystolic velocity of the 12 LV segments (Ts-12SD). As for the dyssynchrony indexderived from RT3DE, we used the standard deviation of time to minimum regionalvolume of the 16 LV segments (Tmsv-16SD). STSI dyssynchrony indexes includedstandard deviation of time from onset of QRS to peak radial strain (Trs-6SD) andpeak circumferential strain (Tcs-6SD) of the 6 middle LV segments. LV ejection fraction(LVEF), end diastolic volume (LVEDV) and end-systolic volume (LVESV) weremeasured by RT3DE.Results: In Group A&B, rapid RV pacing worsened LVEF, enlarged LVESV and dyssyn-chronized LV segments. Although in Group B LVEF partially returned to baseline andLVESV reduced obviously, LVEDV remained persistently enlarged up to a 4-weekrecovery period. After 4 weeks of CRT, LVEDV reduced dramatically from37.35+9.53ml to 28.95+3.98ml with the improvement of LVEF and LVESV inGroup A. Defined as a 15% decrease of LVEDV for predicting the response to CRT,preliminary receiver-operator curve analysis showed good sensitivity and specificityof to detect dyssynchrony with heart failure. Conclusions RT3DE and STSI can effec-tively detect left ventricular dyssynchrony in rapid ventricular pacing-induced heartfailure canines. Tmsv-16SD and Trs-6SD are the best parameters to predict responseto CRT.

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265Effects of chronic right ventricular pacing on left ventricular cardiomechanics inpatients with complete heart block

Kai Thorsten KT. Laser1; P. Hauffe1; B. Hansky1; D. Kececioglu1

1Heart and Diabetes Center North Rhine-Westphalia, Ruhr University of Bochum, BadOeynhausen, Germany

Purpose: We assessed the clinical and cardiomechanical effects of right ventricularpacemaker (PM) therapy on our PM-dependent patients.Methods: 55 patients (25m, 5m.-29y., median 14y., 49 DDD, 2 biventricular) with con-genital and postoperative complete AV-block were ex-amined by echocardiography.They were compared with 45 age, sex and BSA matched healthy children. 3D-Echo(Tomtec) and speckle tracking (2D Strain, GE) were used to assess volumetric data,Strain and timing values that were normalized to heart rate .Results: Duration of PM stimulation was 7.5+5 years, 5 patients were classified �NYHA 3. QRS duration was 140.1+41 ms in patients vs 66.5+14 ms in controls.Mean EF was 53.2+10% (3 pts , 40%, SDI 16 was .10 in 8 pts). We calculateddecreased peak systolic longitudinal (PSS) and global radial (GRS) strain values, seg-mental timing was shorter in the patients compared to controls (data below). Patientshad decreased maximal torsion (7.2+5.28 vs 10.3+5.58, p,0,05) and less time differ-ence between apical and basal rotation (5.5+26.3% vs 18.2+15.3%, p,0,05). Con-clusions: Clinically chronic RV-stimulation is tolerated well in our patients. 3D-Echoand speckle tracking are interesting tools to assess changes of three dimensional LVmechanics. To estimate their value in the individual follow-up further investigationsare needed.

266Differences in dyssynchrony assessment based on time-to-peak velocity,displacement, strain and strain rate: why are they different?

A. Yoshida1; S. Nakatani2; M. Amaki1; J. Tanaka3; H. Kanzaki1; M. Kitakaze1

1National Cardiovascular Center, Suita, Osaka, Japan; 2Osaka University GraduateSchool of Medicine, Osaka, Japan; 3Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan

Purpose: Although various echocardiographic parameters have been used to predictthe effectiveness of cardiac resynchronization therapy (CRT), results of assessed dys-synchrony are often contradictory. We hypothesized that these parameters might beaffected by regional contraction irrespective of the true mechanical delay leading tosuch contradiction.Methods: We obtained left ventricular short-axis images at the mid level in 30 patientswith dilated cardiomyopathy (DCM), 22 with ischemic cardiomyopathy (ICM) and 30normal controls using Vivid 7 (GE). We set a region of interest on the posteriorsubendocardium and measured the time from QRS onset to peak velocity, peakdisplacement, peak strain and strain rate. Posterior wall thickening was measuredusing M-mode echocardiography.Results: Time-to-peak velocity was significantly longer in DCM and ICM than controls(250+62 vs. 197+51 vs. 166+28 ms, p,0.001, p,0.05 vs controls) whereas time-to-peak displacement and time-to-peak strain showed no differences among the threegroups. Time-to-peak velocity showed significant correlations with wall thickening(DCM: r¼0.49 p,0.01, ICM: r¼0.59 p,0.01, Total: r¼0.53 p,0.001). However,time-to-peak displacement, peak strain and strain rate did not correlate with wallthickening.

Conclusions: Some methods to assess timing of regional motion were affectedby myocardial contraction and others not. This discrepancy may at least partly explainwhy CRT indication evaluated by various parameters is contradictory. We shoulddevise a parameter that reflects true mechanical dyssynchrony for CRT indication.

267Analysis of the temporal delay in myocardial deformation throughout thecardiac cycle: utility for selecting candidates to cardiac resynchronizationtherapy

Etelvino E. Silva1; V. Delgado1; D. Tamborero1; B. Vidal1; JM. Tolosana1; LL. Mont1;J. Brugada1; M. Sitges1

1Hospital Clinico Universidad de Barcelona, Barcelona, Spain

Background: Analysis of myocardial strains based on 2D echocardiography has beenproposed to assess left ventricular (LV) mechanical dyssynchrony by measuring timedifferences in peak systolic strains from opposing LV walls. Peak systolic strain may bedifficult to identify. Our aim was to evaluate 1) LV dyssynchrony by assessing theoverlap among the strain traces of the LV walls throughout the cardiac cycle and curvesand 2) its usefulness to identify responders to Cardiac Resynchronization Therapy (CRT)Methods and Results: 50 patients with heart failure and LV systolic dysfunction under-gone CRT. 2D echocardiographic images were acquired at baseline and at 6 monthsfollow-up. Myocardial radial strain (RS) and circumferential strain (CS) were analyzedwith a commercially available software. Strain curves were postprocessed with a math-ematical script. Quantification of LV asynchrony was expressed as an index of temporaloverlap from the analyzed traces. Responders to CRT were defined by a reduction�15% of the end-systolic LV at 6 moths follow up. Responders to CRT had higher LVasynchrony based on both RS and CS analysis. A cut off above 7% overlap for RS(area under the curve 0.76) and above 8.5% for CS (are under the curve 0.68) identifiedresponders to CRT (Figure )Conclusions: Quantifying the temporal superposition of LV wall deformations with acomputed algorithm allows measurement of LV intraventricular asynchrony throughoutthe cardiac cycle. The derived index is useful to identify responders to CRT.

268Impact of functional mitral regurgitation on left ventricular reverse remodelingafter cardiac resynchronization therapy

YJ. Liang1; Q. Zhang2; JWH. Fung1; JYS. Chan1; GWK. Yip1; Q. Shang1; CM. Yu3

1Cardiology, Dept of Medicine & Therapeutics, Prince of Wales Hospital, ChineseUniversity of HK, Hong Kong, Hong Kong SAR, People’s Republic of China; 2Li Ka ShingInstitute of Health Sciences, The Chinese University of Hong Kong, Hong Kong, HongKong SAR, People’s Republic of China; 3Institute of Vascular Medicine, The ChineseUniversity of Hong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China

Purpose: To examine whether the presence of pre-pacing functional mitral regurgita-tion (MR) and its improvement would affect the extent of left ventricular (LV) reverseremodeling after cardiac resynchronization therapy (CRT); and compare the relativecontribution of early- and late-systolic MR.Methods: This study enrolled 83 patients, of whom 48 had more than mild MR and 35showed no MR at baseline. MR volume was computed by the continuity equationbased on Doppler flow. Instantaneous MR flow rate was measured by proximal flowconvergence method at early and late systolic phases. Echocardiography was per-formed at baseline and 3 months for changes in MR and LV reverse remodeling.Results: At 3 months, there was reduction in total MR volume (38+20 vs. 33+21ml)with decrease in both early- (71+52 vs. 60+51ml/s) and late-systolic (49+46 vs.42+46ml/s) MR flow rate (all p,0.05). The improvement in total MR volume of�11% was associated with LV reverse remodeling (defined as reduction of LV end-systolic volume �15%) with a sensitivity of 90% and a specificity of 80% (AUC: 0.85,p,0.001), which was also significant in multivariate analysis. The corresponding sen-sitivity, specificity and AUC were 95%, 84% and 0.88 for reduction in early-systolic MRand 75%, 54% and 0.74 respectively for late-systolic MR. The extent of reverse remo-deling was greatest in patients with improvement in total MR (-29.8+12.0%), intermedi-ate in those with mild or no MR at baseline (218.6+16.6%) and was the least in thosewithout improvement in total MR (25.5+8.6%, p,0.01 among groups).Conclusions: Improvement of functional MR contributes to LV reverse remodelingresponse after CRT, in which reduction of early-systolic MR is a more powerful com-ponent than late-systolic MR.

269Persistence of secondary mitral regurgitation and response to cardiacresynchronization therapy

Fernando F. Cabrera Bueno1; MJ. Molina Mora1; J. Fernandez Pastor1;JL. Pena Hernandez1; J. Alzueta1; A. Barrera1; E. De Teresa1

1Hospital Universitario Virgen de la Victoria, Malaga, Spain

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Background: Cardiac resynchronization therapy (CRT) improves survival and qualityof life of patients with advanced heart failure. Although a significant improvement inmitral regurgitation has been reported in these patients, its presence has also beenassociated with a worse response to CRT.Methods: 76 patients (28.9% women, 63+11 years) with dilated myocardiopathy inadvanced stages of heart failure were included on this study. The presence of signifi-cant mitral regurgitation (SMR), defined by a regurgitant orifice area (ROA)�0.20cm2, was assessed at baseline and its evolution six months after undergoing CRT.On follow-up, the potential role of persistence of SMR on clinical (death or readmissiondue to heart failure), echocardiographic response (reverse remodelling) and majorarrhythmic events was studied.Results: Of the 76 patients, 32 (42.1%) had SMR. At follow-up six months after CRT,SMR had disappeared in 11 of the 32 patients (34.3%). The only independent predic-tive factor of persistence of SMR after CRT was the pre-implant ROA, with an OR of 1.25(95% CI, 1.031–1.575; p¼0.025). Additionally, seven (9.21%) patients without SMRprior to the implant developed it during the six-month follow-up. The presence ofSMR after CRT was associated with higher rates of clinical events (46.4 vs. 18.7%,p¼0.011), less reverse remodelling (28.5% vs. 83.3%, p,0.001), and a greater inci-dence of arrhythmic events (35.7 vs. 14.5 %, p¼0.034).Conclusions: CRT can reduce moderate or severe baseline mitral regurgitation downto a non-significant grade in one third of patients. However, persistence of SMR wasassociated with a worse clinical evolution, less reverse remodelling and a greater inci-dence of arrhythmic events.

270Speckle tracking echocardiography reliably identifies the optimal site for leftventricular lead placement in patients undergoing cardiac resynchronizationtherapy

Fakhar FZ. Khan1; MS. Virdee2; D. O’halloran1; PA. Read1; SP. Fynn2; DP. Dutka1

1Addenbrooke’s Hospital, Cambridge, United Kingdom; 2Papworth Hospital,Cambridge, United Kingdom

Introduction: In patients undergoing cardiac resynchronization therapy (CRT), left ven-tricular (LV) lead placement to the latest site of activation improves LV reverse remodel-ing and mortality whereas pacing areas of myocardial scar has detrimental effects.Speckle tracking echocardiography offers assessment of the timing and extent of seg-mental myocardial deformation. We hypothesised that assessments of the strain ampli-tude of the paced LV segment in addition to segmental timing determined by speckletracking echocardiography would enhance the selection of the optimal site for lead pla-cement compared to pacing the latest site alone.Methods: Radial 2D strain speckle tracking analysis was performed in 38 patients withheart failure scheduled for CRT (age 65 þ/2 8 years, 24 males, QRS 152 þ/2 14ms,NYHA III/IV 35/3, EF 23 þ/2 7%). All patients underwent CRT and the position of the LVlead was determined post implant from biplane fluoroscopy and the paced segmentdetermined. For the paced segment in each patient we determined the radial strainamplitude as well as the extent of segmental delay expressed as the ratio of the time(from QRS onset) to peak strain divided by the time to peak strain of the earliestsegment (late/early – L/E ratio). Response to treatment was defined as a .15%reduction from baseline in LV end systolic volume (LVESV) at 3 months.Results: Echocardiographic response to CRT was seen in 23/38 patients. Lead place-ment to delayed segments with a late/early ratio .1.5 predicted response to CRT with asensitivity of 91% and specificity of 81% (AUC 0.89). The late/early ratio of the pacedsegment correlated well with the extent of LVESV at 3 months (r¼0.51, p,0.001).When the amplitude of the paced segment was additionally considered to the late/early ratio, using a cut off of 10% the sensitivity of predicting response to CRTincreased to 100% and the specificity increased to 85%.

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

271A comparison of the reproducibility of tissue Doppler imaging betweenresearch and clinical departments

RP. Beynon1; RA. Argyle1; N. Abidin1; J. Fallon1; KA. Pearce1;R. Aghamohammadzadeh1; SG. Ray1; NC. Davidson1

1University Hospital of South Manchester, Manchester, United Kingdom

Purpose: Since the publication of the PROSPECT trial, the role for tissue Dopplerimaging (TDI) in cardiac resynchronisation therapy (CRT) has been called into ques-tion. A striking finding of the PROSPECT trial was the inter-centre coefficient of variationof 33.7%. Trials have characteristically been performed by highly trained researchersperforming high volumes of studies. We compared the reproducility of TDI measuresbetween our research and clinical departments in an attempt to assess if TDI couldbe transfered to main stream clinical practice.Methods: 10 patients with heart failure referred for dyssynchrony assessment under-went TDI 12 segment echocardiographic assessment using a VIVID 7 system.Images were analysed independently by four operators off line for time to peak systoliccontraction. Two operators were already exposed to high volumes of TDI analysis aspart of their MD research program (Research 1 and Research 2). The other two oper-ators were highly experienced sonographers who had previously used TDI regularly asa clinical tool (Clinical 1 and Clinical 2).Results: 120 segments were analysed by all the operators. Coefficients of variationwere calculated for all 120 TDI segments. The standard deviation of the 12 segmentswas calculated during each study to give the ’Yu index’.Conclusion: The reproducibility of TDI measurements was significantly better in ourresearch group compared to our clinical group. This is likely to be due to the greaterprior exposure to TDI amongst the research operators. Our results are in keepingwith the PROSPECT trial and suggest that TDI is a useful research tool but its transferto the clinical setting may be more difficult than previously assumed.

272Absence of left ventricular apical rocking and atrial-ventricular dyssynchronypredicts non-response to cardiac resynchronization therapy

Francois F. Tournoux1; D. Mccarty2; A. Chen-Tournoux2; RC. Chan3; R. Manzke3;JP. Singh2; MH. Picard2; AE. Weyman2

1Lariboisiere Hospital (AP-HP), Paris, France; 2Massachusetts General Hospital, Boston,United States of America; 3Philips Research North America, Boston, United States ofAmerica

Background: Current non-invasive imaging techniques attempt to identify patientswho may respond to cardiac resynchronization therapy (CRT). However, becauseresponse to CRT is dependent upon several factors, it may be clinically moreuseful to identify patients for whom CRT would not be beneficial even underoptimal conditions, thus avoiding unnecessary device implantation. Since mechanicaldyssynchrony may affect both filling and ejection of the left ventricle (LV), we devel-oped a composite echocardiographic index looking at 1) atrial-ventricular dyssyn-chrony (AV-DYS) and 2) intraventricular dyssynchrony and tested its the negativepredictive value.Methods: Subjects with standard indications for CRT underwent echo before andduring the month following device implantation. AV-DYS was defined as a percentageof LV filling time over the cardiac cycle. Intraventricular dyssynchrony produces acharacteristic rocking of the LV apex, which indicates unopposed contraction of onewall due to delayed activation of the opposite wall. LV apical rocking was evaluatedusing displacement curves from tissue Doppler velocity recordings of the septal andlateral walls, and was quantified as the percentage of the cardiac cycle over whichthe displacement curves showed discordant behavior. CRT responder status was deter-mined based on the early hemodynamic response to CRT, with responders defined ashaving an intra-individual percentage change of .25% in the Doppler-derived LV dP/dtover baseline. Optimal cut-points for which LV apical rocking and AV dyssynchronypredicted response status were determined using ROC analysis.Results: 40 consecutive patients (66+14 years, LV ejection fraction 27+6%, QRS dur-ation 168+25 ms) were included. Optimal cut-points were 31% for LV apical rockingand 39% for AV-DYS. The combination of both parameters (presence of either apicalrocking.31% or AV-DYS�39%) had a sensitivity of 95%, specificity of 80%, positivepredictive value of 83%, and, most importantly, a negative predictive value of 94%for CRT response.

Table 1 Results

Time to Peak TDI Yu Index

Research1 / Research2 6.7% 14.8%Clinical1 / Clinical2 15.3% 40.4%Research1 / Clinical1 12.3% 21.8%Research1 / Clinical2 8.7% 26.2%Research2 / Clinical1 12.7% 26.1%Research2 / Clinical2 10.9% 19.0%

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

273Inter-ventricular delay at peak exercise in heart failure patients selected forcardiac resynchronisation therapy is independently correlated with leftventricular remodeling at three months

N. Piriou1; S. Abbey1; JP. Gueffet1; JN. Trochu1

1L’Institut du Thorax-CHU Nantes-Hopital G. et R. Laeunnec, Nantes, France

Purpose: Cardiac resynchronisation therapy (CRT) improves survival and reverses leftventricle (LV) remodeling in heart failure (HF) patients presenting with severe LV systo-lic dysfunction and prolonged QRS interval. However, one third remain non-respondersto CRT. We assessed whether exercise inter-ventricular dyssynchrony could be a rel-evant index for the prediction of response to CRT.Methods: Eighteen HF patients performed exercise echocardiography before deviceimplantation. Inter-ventricular mechanical delay (IVMD) was recorded at rest andpeak exercise. We determined correlations between IVMD at exercise and mitral regur-gitation assessed by the effective regurgitant orifice area (ERO), and right ventricular(RV) longitudinal systolic function assessed by peak tricuspid annulus S wave velocityin tissue doppler imaging. We looked for correlations between those parameters andthe degree of LV reverse remodeling at three months follow-up, assessed by the per-centage of change in LV end-sytolic volume (%DESV) and absolute value of changein ejection fraction (DLVEF).Results: Exercise-induced changes in IVMD only significantly correlated with RV longi-tudinal systolic function (r = - 0.602; p = 0.01) at peak exercise. In a multivariate analy-sis by multiple linear regression (table 1), IVMD at peak exercise was independentlycorrelated with %DESV and DLVEF at follow-up. Peak exercise ERO was independentlycorrelated with %DESV.Conclusion: In HF patients, IVMD at peak exercise before device implantation seemsto be a relevant independent predictor of mid-term LV remodeling after CRT. Its relationwith RV longitudinal systolic function during exercise could provide a pathophysiologi-cal explanation.

274Clinical outcome after cardiac resynchronization therapy is related to septaldeformation pattern characteristics on baseline echocardiography

Geert GE. Leenders1; BWL. De Boeck1; AJ. Teske1; M. Meine1; MD. Bogaard1;MJ. Cramer1; FW. Prinzen2; PA. Doevendans1

1University Medical Center Utrecht, Utrecht, Netherlands; 2University of Maastricht,Maastricht, Netherlands

Purpose: To assess whether clinical outcome after cardiac resynchronization therapy(CRT) can be predicted by septal deformation pattern characteristics at baseline andwhether these characteristics are related to treatment effects.Methods: Before and 6 months after CRT echocardiographic studies and plasmaBNP measurements were performed. Septal longitudinal deformation wasdetermined at baseline using speckle tracking echocardiography. Systolic reboundstretch (SRSsept; all stretch after initial shortening in the septum) was determinedand septal deformation pattern (DPsept) was categorized into three characteristictypes (double peak, early single peak and late single peak during systole) . A com-bined clinical endpoint of death or cardiac transplantation was recorded in allpatients.

Results: One-hundred-and-one patients (age 65+11, 69 men, 18 NYHA IV, QRS173+23) scheduled for CRT were included. Mean follow-up was 16+9 months. Thecombined end-point was reached in 23 patients. SRSsept, DPsept, interventricularmechanical delay (IVMD) and NYHA class were independent predictors of the com-bined endpoint (all p,0.05). Baseline SRSsept, DPsept and IVMD correlated withreverse remodeling (all r.0.5, p,0.001) and neurohormonal response (r¼0.439,p,0.001; r¼0.286, p,0.001 and r¼0.493, p¼0.008 respectively) at 6 monthsfollow-up whereas NYHA class was only mildly correlated with reverse remodeling(r¼ 20.271 p¼0.015).Conclusions: Septal deformation pattern characteristics predict prognosis aftercardiac resynchronization therapy and are related to treatment effects.

275A new ECG criterion of intraventricular dyssynchrony is superior to currentcriteria in cardiac resynchronization therapy outcome prediction

Andras A. Vereckei1; V. Kutyifa2; L. Geller2; M. Kiss1; G. Szenasi3; E. Zima2; I. Karadi1;B. Merkely2

13rd Department of Internal Medicine, Semmelweis University School of Medicine,Budapest, Hungary; 2Semmelweis University Cardiology Centre, Budapest, Hungary;3EGIS Pharmaceutical Works PLC, Budapest, Hungary

Purpose: Current traditional and imaging criteria used to predict the functionalimprovement with cardiac resynchronization therapy (CRT) are suboptimal. Changesin QRS duration, the only ECG criterion used in patient selection for CRT, show poorcorrelation with the post CRT hemodynamic improvement. Intraventricular dyssyn-chrony is always associated with a prolonged total endocardial activation time. Wehypothesized that the greater is the prolongation of endocardial activation time, themore effective CRT will be. Methods: A new ECG criterion (NC) considered as a surro-gate marker of total left ventricular (LV) endocardial activation time was devised. To esti-mate the LV endocardial activation time, the difference between the intrinsicoiddeflections (ID) in leads V6 and V3 reflecting the electrical potentials of the left ventri-cular apex, lateral wall and left side of the ventricular septum respectively was calcu-lated and divided by QRS duration: (V6ID-V3ID)/QRS duration (in %). The NC wasdetermined from ECGs recorded prior to biventricular pacemaker implantation inpatients selected for CRT based on traditional criteria (TC) and arbitrarily if its valuewas .25% responder (R) diagnosis, if its value was �25% non-responder (NR) diag-nosis was made. The first author retrospectively analyzed ECGs from 126 patients withknown CRT outcome, blinded to the patients’ clinical response to CRT. Results: Duringfollow up 35/126(28%) patients were NR, thus using the TC correct diagnosis wasestablished in the remaining 91/126(72%) R patients. Applying the NCþTC togetherthe correct diagnosis was made in significantly (p,0.001) more [101/126(80%)]cases. Using NCþTC together R diagnosis was made in 91/126(72%) patients, its sen-sitivity, specificity, (þ) and (2) predictive values were 86,66,87 and 64% respectively,which were better than those recently reported for the best echocardiographic intraven-tricular dyssynchrony criteria, although no head-to-head comparison was made in thisstudy, and the (þ) predictive value was superior to that of TC alone (87% vs. 72%;p,0.01). Conclusions: NCþTC together proved to be superior to TC alone in predic-tion of CRToutcome, have better sensitivity, specificity and predictive values than thoserecently reported for the best echocardiographic intraventricular dyssynchrony criteriaand renders possible a new, very simple and more accurate patient selection strategyfor CRT to be outlined in the presentation.

276Reverse remodeling provoked by cardiac contractility modulation versuscardiac resynchronization therapy in patients with advanced congestive heartfailure

Q. Zhang1; JYS. Chan2; JWH. Fung2; GWK. Yip2; YJ. Liang2; AKY. Chan2; CM. Yu3

1Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, HongKong, Hong Kong SAR, People’s Republic of China; 2Cardiology, Dept of Medicine &Therapeutics, Prince of Wales Hospital, Chinese University of HK, Hong Kong, HongKong SAR, People’s Republic of China; 3Institute of Vascular Medicine, The ChineseUniversity of Hong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China

Background: Cardiac Contractility Modulation (CCM) is a new form of device therapyfor advanced heart failure with normal QRS duration and therefore not a current indi-cation for cardiac resynchronization therapy (CRT). Left ventricular (LV) reverse remo-deling response has been reported in patients receiving either device therapy, so it isinteresting to compare between CCM and CRT.Methods: Four groups of patients (n¼30 in each) were included in this study. They allhad NYHA class III or IV heart failure with LV ejection fraction (EF) ,35% despiteoptimal medical therapy before device implantation. Group 1: QRS,120ms receivedCCM; Group 2: QRS,120ms received CRT; Group 3: QRS 120-150ms receivedCRT; Group 4: QRS.150ms with typical LBBB received CRT. The CRT groups werematched with the CCM group in age, gender and etiology (Table). Echocardiographywas performed at baseline and 3 months.Results: Baseline ejection fraction was comparable. Significant LV reverse remodelingwas observed in all the 4 groups with reduction in LV end-systolic volume (LVESV) andgain in LVEF. However, LV reverse remodeling was the greatest in Group 4 but similar inthe other 3 groups. By using an increase in LVEF of � 5%, the responder rate was thehighest in Group 4, but was not different among the other 3 groups.

Table 1

Exercise echo measurements Univariate analysis Multivariate analysis

%DESV

IVMD at peak exercise r = 0.447 : p = 0.07 b = 0.466 ; p=0.01ERO at peak exercise r = 0.756 ; p , 0.001 b = 0.808 ; p, 0.001Peak exercise tricuspid annular Swave velocity

r = -0.495 ; p= 0.05 b = 0.175 ; p =0.39

D LVEF IVMD at peak exercise r = -0.535 ; p = 0.02 b = -0.496 ; p=0.03ERO at peak exercise r = -0.544 ; p = 0.02 b = -0.311 ; p=0.23Peak exercise tricuspid annular Swave velocity

r = 0.498 ; p = 0.04 b = 0.082 ; p =0.75

Correlations between exercise echo measurements and LV remodeling.

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

277Prediction of response to cardiac resynchronization therapy: comparisonbetween tissue doppler imaging and real-time three-dimensionalechocardiography

Sebastiaan S. Kleijn1; J. Van Dijk1; CC. De Cock1; CP. Allaart1; AC. Van Rossum1;O. Kamp1

1VU University Medical Center, Amsterdam, Netherlands

Purpose: Recently, we have shown that there are marked differences in presence ofmechanical dyssynchrony by tissue Doppler imaging (TDI) and real-time three-dimensional echocardiography (RT3DE) in patients with a wide range of LV ejectionfractions (EF) and different etiologies of cardiomyopathy when current cutoff valuesare applied, making interchangeability of these techniques uncertain. To ascertainwhich technique is superior, we performed a direct comparison of TDI- and RT3DE-derived mechanical dyssynchrony to predict response to cardiac resynchronizationtherapy (CRT).Methods: A total of 27 patients underwent CRT after assessment of baseline mechan-ical dyssynchrony by TDI and RT3DE. Mechanical dyssynchrony was measured withTDI using the standard deviation of time to peak systolic tissue velocity of 12 LV myo-cardial segments. With RT3DE, the standard deviation of time from QRS onset tominimal volume of 16 LV subvolumes was assessed. Before CRT implantation and at6-month follow-up, echocardiographic assessment of LV volumes and EF was per-formed and the clinical status including New York Heart Association functional class,6-minute walking distance, and Minnesota quality-of-life score was assessed.Response was defined as a reduction of �15% in LV end-systolic volume after CRT.Results: Seventeen patients (63%) experienced a reduction of �15% in LV end-systolicvolume and were classified as responders. All baseline characteristics were similarbetween responders and nonresponders, except for mechanical dyssynchronyassessed by RT3DE, which was significantly higher in responders compared with non-responders (10.0+ 2.8% versus 6.3+ 2.3, P¼0.001). ROC curve analysis demon-strated an optimal cutoff value for SDI by RT3DE of 6.7%, yielding a sensitivity of88% with a specificity of 70% to predict response to CRT. Applying previouslydefined cutoff values for both techniques, a sensitivity of 88% and a specificity of60% were derived from the RT3DE cutoff value of 6.4%. In comparison, a cutoffvalue of 32ms for SDI by TDI yielded a sensitivity of 59% with a specificity of 50% topredict response to CRT.Conclusions: Assessment of mechanical dyssynchrony by RT3DE might be an appro-priate alternative to TDI for accurate prediction of response to CRT.

278Echocardiographically-guided AV and VV optimisation of LVOT VTI improvesechocardiographic parameters of dyssynchrony following cardiacresynchronisation therapy in heart failure

Michael John M J. Daly1; K. Morrison1; K. Ashfield1; R. Kirkpatrick1; LJ. Dixon1

1Regional Medical Cardiology Centre, Royal Victoria Hospital, Belfast, United Kingdom

Purpose: Cardiac resynchronisation therapy (CRT) is a recognised treatment optionfor a select group of patients with heart failure, i.e. those with New York Heart Associ-ation (NYHA) class III-IV symptoms despite optimal pharmacological therapy, left ven-tricular ejection fraction � 35% and either a QRS �150ms or a QRS 120-149ms withechocardiographic evidence of mechanical dyssynchrony. Despite these selection cri-teria to identify those patients most likely to benefit from device implantation, �30% do

not obtain significant clinical benefit from therapy and are termed ’non-responders’. AVand VV optimisation of LVOT VTI may improve parameters of mechanical dyssynchronyon echocardiography, which may translate to subjective clinical improvement andresponse to therapy in this group of patients.Methods: We studied the acute effect of echocardiographically-guided AV and VVoptimisation of LVOT VTI in a group of 16 patients (age 71.5+ 8.4, 69% male) withsymptomatic heart failure (NYHA class 3.5+ 0.5; NT-proBNP 2570.4+ 421.2 ng/L(Normal range , 222 ng/L)) who had not obtained significant clinical response follow-ing CRT. Results are expressed as mean+ standard deviation. Echocardiographic par-ameters of dyssynchrony were recorded pre- and immediately post-optimisation.Tissue doppler of the basal, septal, lateral and anterior walls were also recorded,with time from QRS onset to maximal systolic velocity calculated.Results: AV and VV optimisation resulted in significant improvement in cardiac output,as assessed by LVOT VTI which improved from 76.3+ 12.1 cm/s pre-optimisation to114.3+ 13.4 cm/s immediately post-optimisation (p,0.005). Interventricular dyssyn-chrony improved significantly: aortic pre-ejection time reduced from 140.8+ 17.6 msto 126.5+ 26.4 ms (p=0.05) and interventricular mechanical delay reduced from46.6+ 10.2 ms to 12.0+ 6.8 ms (p,0.0005). Intraventricular dyssynchrony alsoimproved significantly: septal to posterior wall delay reduced from 159.7+ 88.1 msto 94.6+ 84.3 ms (p,0.05). Tissue doppler of the septal and lateral walls showed sig-nificant reduction in opposing wall delay from 96.0+ 56.5 ms to 55.3+ 42.7 ms(p=0.03).Conclusion: Echocardiographically-guided AV and VV optimisation of LVOT VTI in agroup of CRT non-responders, results in significant improvement in the parametersof both inter- and intraventricular dyssynchrony as assessed by echocardiography.Further studies are underway to determine whether these improvements are main-tained with time, and whether they correspond to improvement in NYHA functionalclass, quality of life and clinical outcome.

279Echo guided VV and AV delay programming: impact on response to cardiacresynchronization therapy

Hanaa H. Mohamed Fereig Hamed1; AM. Hamdy1; A. Abdel-Aziz2; MA. Nabih3;RM. Hamdy1

1Al-Azhar University, Cairo, Egypt; 2CCU-Cairo University, Cairo, Egypt; 3Ain ShamsUniversity, Cairo, Egypt

Background: Echo-Doppler is an effective method allowing immediate evaluation ofcardiac efficacy in response to changing the interventricular (VV) and atrioventricular(AV) delays after cardiac resynchronization therapy (CRT). This work aimed at studyingthe impact of echo-guided programming of VV delay (simultaneous versus sequential)or programming of VV delay followed by AV delay on the response to CRT.Patients and Methods: 34 heart failure patients treated with CRT were evaluated withecho-Doppler & tissue Doppler parameters at different settings of VV delays rangingfrom 0 to 50 msec (simultaneous versus sequential VV delays) followed by different set-tings of AV delay programming ranging from 80 to 150 msec. Echo-Doppler measuresincluded ejection fraction (EF), mitral and aortic velocity time integrals (M-VTI & Ao-VTIrespectively). Tissue Doppler Dyssynchrony index (Ts-SD) was calculated as the stan-dard deviation of times to peak systolic velocities (Ts) at 6 LV basal segments. We com-pared the effects of simultaneous versus sequential VV delays with LV pre-activation onthese parameters without changing the preset AV delay. The effect of programming AVdelay after optimizing the VV delay was further evaluated.Results: Both EF and Ao-VTI significantly decreased with simultaneous biventricularpacing compared to the basic preset VV and AV delays. The EF, M-VTI and Ao-VTIwere significantly higher and TS-SD was significantly lower at sequential VV delaywith LV pre-activation compared to either basic preset VV & AV delays or simultaneousVV activation & preset AV delay (table I). The EF and M-VTI significantly increased(p,0.001 & p,0.005 respectively) and TS-SD significantly decreased (p,0.005)with further programming of AV delay after VV optimization compared to only optimiz-ing VV delay.Conclusion: Sequential ventricular pacing with LV pre-activation is more beneficialthan simultaneous biventricular pacing. Echo guided optimization of both VV and AVdelays has a good impact on cardiac function post CRT

280Echocardiographic effects of changing atrioventricular delay in cardiacresynchronization therapy based on Tissue Tracking.

Nana N. Valeur1; T. Fritz-Hansen1; N. Risum1; R. Mogelvang1; PE. Bloch-Thomsen1;P. Sogaard1

1University Hospital, Gentofte, Denmark

Aim: To study echocardiographic parameters as surrogates for hemodynamic effectsof different AV-delay in cardiac resynchronization therapy (CRT).

Table 1 Comparisons between the 4 study groups

Group 1CCMQRS ,120

Group 2 CRTQRS ,120

Group 3 CRTQRS 120-150

Group 4 CRTQRS .150

Age, years 60+11 58+12 66+9 65+12Gender, male/female

24/6 24/6 19/11 23/7

Etiology,ischemic/non-

15/15 16/14 17/13 13/17

LVEDV,baseline, cm3

160+41 171+44 194+89 210+78*

LVESV,baseline, cm3

115+35 127+40 148+76 163+71*

LVEF,baseline, %

28.4+6.2 27.0+6.7 24.9+7.1 23.7+8.3

Change inLVESV, %

211+12 215+18 213+20 232+20†§D

Change inLVEF, %

4.7+4.0 6.2+5.5 6.0+7.3 10.9+7.9*D

Responderrate, %

53 57 53 77*D

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

Table I

EF M-VTI Ao-VTI TS-SD

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

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

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

281Short term effect of AV optimization

Anita A. Sadeghpour1; L. Zahedi1; M. Haghjoo1; M. Esmaeilzadeh1; M. Parsaei11Rajaei Cardiovascular Medical and Research Center, Tehran, Iran (Islamic Republic of)

Purpose: The clinical syndrome of heart failure (HF) remains of leading cause ofcardiac morbidity and mortality.The coming years will see a continues growth in device based therapy for HF that iseffective in reducing HF morbidity and mortality. Cardiac resynchronization therapy(CRT) is an established adjunctive treatment for patients with systolic heart failureand ventricular dyssynchrony. The majority of recipients response to CRT with improve-ment in quality of life, New York Heart functional class, 6-min walk test and ventricularfunction.The goal of atrioventricular (AV) delay optimization are to improve left ventricular (LV)filling and timing of contraction and to minimize MR.The aim of our study was to evalu-ate the results of early AV optimization(AVO) by using echocardiography on symptomsand systolic function and compare it with another group without early optimization.Methods: 58 patients, 19 women, mean age+SD=57+12.9 years (range 18 to 80years) which were suitable for CRT implantation were enrolled. After CRT theydivided into two groups, one group had early AVO ( the day after CRT implantation)by echocardiography and in the other group AVO was not done. Ultimately, bothgroups were evaluated 3 months later.Results: Optimization performed in 32(55.2%) patients and 28 were responders.Responders were more in optimization groups [19(59.4%) compared to 9(34.6%);p=0.06]. Functional class and 6 min walk test was improved in AV optimizedgroup(p = 0.008). Stroke volume by using LVOT VTI also increased significantly (P:0.000) although other objectives parameters include EF, LVESV, LVEDV, TissueDoppler dyssynchrony indices, improved with CRT, but there was no significant differ-ence between two groups.Conclusion: Our findings suggest that the short term effect of CRT that is more promi-nent with AV optimization is mostly on functional class and patient well being. Early AVoptimization has no significant effect on LV reverse remodeling in first 3 months afterCRT, so we suggest AV optimization only in nonresponder patients.TT-LV differences according to AV-delay.

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