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USEFULNESS OF PREOPERATIVE LEFT VENTRICULAR VOLUMETRIC MEASUREMENTS TO PREDICT LEFT VENTRICULAR REMODELING AFTER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE AORTIC REGURGITATION
S150
p¼0.04). After adjustment for MR severity (ERO), LV forward ejection fraction, indexed left atrial volume, VO2 max, and peak exercise SPAP >60 mmHg, a DSPAP>15 mmHg during first stage of exercise was an independent predictor of cardiovascular events (HR: 4.95, p¼0.004). CONCLUSION: Asymptomatic patients with MR presenting a rise in SPAP at low level of exercise have increased risk of cardiac events. The increase in SPAP early during exercise stress test may be useful to identify patients who may benefit from early surgery.
147 QUALITY OF TRANSTHORACIC ECHOCARDIOGRAM IMPACTS VALUE IN RULING OUT NATIVE VALVE ENDOCARDITIS: A SINGLE CANADIAN CENTER EXPERIENCE K Connolly, K Levitt, H Abdel-Qadir, G Ong, C Chow, K Connelly Toronto, Ontario BACKGROUND:
Detection of infective endocarditis (IE) remains a diagnostic challenge. Current guidelines recommend initial evaluation with transthoracic echocardiogram (TTE) with subsequent transesophageal echocardiogram (TEE) if the pretest probability of IE is intermediate or high. The low reported sensitivity of TTE for detection of IE is based on studies using less advanced echo techniques than are available today, and do not take into account TTE quality. More recent evidence suggests that image quality of TTE may greatly impact the negative predictive value (NPV) of TTE for ruling out native valve vegetations. A good quality TTE may be sufficient to rule out IE in the absence of high risk clinical features. METHODS: Echocardiograms from sequential patients with both a TTE and TEE ordered to assess for IE between January 2010 and December 2012 were examined. Data from the echocardiograms was extracted including whether the study was noted to be technically difficult by the echocardiographer and whether there was a new vegetation seen. Clinical data was obtained by chart review. RESULTS: Data was collected from 148 unique patients with both a TTE and TEE. Of these, 126 patients had a
Canadian Journal of Cardiology Volume 32 2016
negative TTE for vegetation, 15 were positive and 7 were indeterminate. Vegetation on TEE was found in 10% (13/ 126) of those with negative TTE and 14% (1/7) with an indeterminate TTE. All (15/15) with a positive TTE went on to have a positive TEE. The overall NPV of TTE without factoring in test quality was 89% (82-92%). Among the negative TTEs, 44% (56/126) were deemed technically difficult studies (TDS); 12.5% of these (7/56) subsequently had positive TEEs. Of the 70 technically adequate TTEs, 8.5% (6/70) had positive TEEs (p¼ NS). When patients with prosthetic valves were excluded from analysis, only 2% (1/50) with technically adequate echoes had subsequent positive TEEs (p ¼ 0.008). The technically adequate TTEs without prosthetic valves had a NPV of 91% (79-96) for ruling out IE. CONCLUSION: The negative predictive value of a good quality TTE in ruling out native valve IE has recently been demonstrated, and is further supported by this data. When the quality of study is taken into account, rate of false negative TTEs decreases substantially. Further study is required and increased standardization of quality ratings of TTE is needed before this approach can be routinely used.
148 USEFULNESS OF PREOPERATIVE LEFT VENTRICULAR VOLUMETRIC MEASUREMENTS TO PREDICT LEFT VENTRICULAR REMODELING AFTER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE AORTIC REGURGITATION G Ong, A Harrington, J Lu, B Al-Amro, RJ Chisholm, C Chow, H Leong-Poi, M Peterson, KA Connelly Toronto, Ontario BACKGROUND:
Left ventricular ejection fraction (LVEF) and end-systolic dimension are important parameters to consider prior to aortic valve surgery for patients with severe aortic regurgitation (AR). Although both low LVEF and large LV dimensions are associated with increased late mortality, more data are needed to determine threshold values of LV shape measurements for surgery. It is unclear whether LV dilatation would be better assessed by volumetric measurements than linear dimensions. We hypothesize that that in patients with severe AR, LV volumes as assessed by the biplane method of discs will be a more sensitive indicator of postoperative LV remodeling than linear dimensions. METHODS: This is a retrospective study of patients with AR who had echocardiograms done at the St. Michael’s Hospital between January 1 2009 and January 1 2016. Early postoperative echocardiograms were excluded. The left ventricular end-diastolic and end-systolic indexed diameters (LVEDDI, LVESDI) and volumes (LVEDVI, LVESVI) using the biplane method of discs were obtained. Univariate analysis was performed. Variables with p<0.05 were included in multiple linear regression analysis to assess the predictors of postoperative LV remodelling, as defined by reduction (10%) in LVESVI.
Abstracts
S151
RESULTS:
Sixty-two patients (5214 years) underwent AVR for severe AR had preoperative and postoperative echocardiograms (median time to postoperative echocardiogram 43 days). The LVEDDI measured 3.20.5 cm/m2 and LVESDI 2.30.6 cm/m2. The LVEDVI was 13250 ml/m2 and LVESVI was 6237 ml/m2. The end-diastolic sphericity index (LV minor to major axis ratio), measured 0.650.07 and the end-systolic sphericity index, 0.550.09. The LVEF was 53%10%. Seventy-four percent of patients met LVESVI remodelling criteria. Multivariate analysis demonstrated that preoperative LV end-diastolic diameter, LVEDVI, LVESVI and LVEF were predictors of LV remodeling (all p<0.01). Thirteen (23%) patients had a severely dilated LV end-diastolic diameter but up to 38 patients (67%) had severely dilated LVEDVI as measured by the method of discs. Therefore, 27 (44%) patients were reclassified as having a severely dilated end-diastolic LV by volumetric measurements over dimensions. Similarly, 9 (16%) patients had severely dilated LV end-systolic diameter but 34 (60%) patients had severely dilated LVESVI. Twenty-five (40%) patients were reclassified as having a severely dilated end-systolic LV by volumetric measurements over dimensions. CONCLUSION: In patients undergoing AVR for isolated severe AR, the LV volumetric measurements by the method of discs are more accurate to classify the LV dilatation associated with severe AR. Pre-operative LVEDVI, LVESVI, LVEF and LV end-diastolic diameter were the best predictors of post-operative LV remodeling. Classification of severity LV dimensions according to linear and volumetric dimensions n=62 n % LV end-diastolic diameter ≥ 6.5 cm
13 23
LVEDV Ind ≥ 100/80 ml/m2
38 67
Reclassification of LV size as being severely dilated based on volumetric measurement
27 44
LV end-systolic diameter ≥ 5 cm
9 16
LVESV Ind ≥ 45/40 ml/m2
34 60
Reclassification of LV size as being severely dilated based on volumetric measurement
25 40
Cardiac evaluation of patients with anorexia nervosa generally involves routine ECG and transthoracic echocardiography. Little is known on the role of cardiac magnetic resonance imaging (CMR) for the noninvasive characterization of cardiac abnormalities in this patient cohort. The objective of this study is to characterize baseline CMR findings in adolescent patients who have been diagnosed with severe anorexia nervosa. METHODS/RESULTS: This is a cross sectional study evaluating the use of CMR in patients with anorexia nervosa. All patients met the DSM V anorexia nervosa diagnostic criteria with a body mass index of < 18.5 kg/m2 at the time of diagnosis. We used a CMR protocol assessing cardiac anatomy, functional assessment including flow, and myocardial delayed enhancement at a single tertiary center. We analyzed 16 female patients with an average age of 17 years (range 13-22 years). The average body mass index (BMI) was 20 kg/m2 (range 17-26 kg/m2). The average LVEF was 55.3% (range 46.1-60.2%) and RVEF was 51.4% (range 41.2-61.4%). The average LV stroke volume was 39 mL (range 34.8-46.3 mL) and average RV stroke volume was 35.7 mL (range 22.1-49.2 mL; Table 1). There was no delayed enhancement, suggestive of myocardial fibrosis, in any of the patients. CONCLUSION: There were significant changes in stroke volumes and ejection fraction in the left and right ventricles in patients with severe anorexia nervosa as compared to published literature controls. In contrast to previous studies, there was no evidence of myocardial fibrosis in these patients. Some of our patients are partly treated for AN. Further research is needed to determine if these significant changes in cardiac parameters are progressive or if they are potentially reversible with treatment. Table 1: CMR findings in a population with anorexia nervosa compared to reference values Parameter
Adult reference values Study population Mean+/(females) Mean+/STD(range), N= 16 STD(range)
p value
LV end diastolic volume/BSA
71.4 ± 6.6 (61.4-86.2)
78 ± 8.7 (61-95)
0.0007
LV end systolic volume/BSA
32.5 ± 5.0 (24.8-46.6)
26 ± 4.7 (17-35)
0.0001
LV stroke volume/BSA
39.0 ± 2.8 (34.8-46.3)
52 ± 6.2 (40-64)
< 0.0001
LV ejection fraction 55.3 ± 4.2 (46.1-60.2)
67 ± 4.6 (58-76)
< 0.0001
LV mass/BSA
45.5 ± 4.3 (39.0-54.3)
62 ± 7.5 (47-77)
< 0.0001
RV end diastolic volume/BSA
69.9 ± 9.7 (53.7-85.3)
78 ± 9 (60-96)
0.0045
K Chu, I Buffo, M Lane, L Ludwig, D Jassal, DI Schantz
RV end systolic volume/BSA
32.2 ± 5.5 (26.0-44.3)
28 ± 7 (14-42)
0.008
Winnipeg, Manitoba
RV stroke volume/BSA
35.7 ± 7.5 (22.1-49.2)
50 ± 6 (38-62)
< 0.0001
BACKGROUND:
RV ejection 51.4 ± 6.3 (41.2-61.4) 64 ± 6 (52-76) fraction Abbr: BSA: body surface area, LV: left ventricular, RV: right ventricular
149 A PILOT STUDY TO ASSESS CARDIAC ABNORMALITIES IN SEVERE ANOREXIA NERVOSA PATIENTS USING CARDIAC MAGNETIC RESONANCE IMAGING
Anorexia nervosa (AN) is associated with numerous cardiac abnormalities including bradyarrythmias, decreased myocardial mass and function, and pericardial effusions. This patient population has an increased mortality rate in comparison to other psychiatric illnesses.
Manitoba Medical Services Foundation
p¼0.04). After adjustment for MR severity (ERO), LV forward ejection fraction, indexed left atrial volume, VO2 max, and peak exercise SPAP >60 mmHg, a DSPAP>15 mmHg during first stage of exercise was an independent predictor of cardiovascular events (HR: 4.95, p¼0.004). CONCLUSION: Asymptomatic patients with MR presenting a rise in SPAP at low level of exercise have increased risk of cardiac events. The increase in SPAP early during exercise stress test may be useful to identify patients who may benefit from early surgery.
147 QUALITY OF TRANSTHORACIC ECHOCARDIOGRAM IMPACTS VALUE IN RULING OUT NATIVE VALVE ENDOCARDITIS: A SINGLE CANADIAN CENTER EXPERIENCE K Connolly, K Levitt, H Abdel-Qadir, G Ong, C Chow, K Connelly Toronto, Ontario BACKGROUND:
Detection of infective endocarditis (IE) remains a diagnostic challenge. Current guidelines recommend initial evaluation with transthoracic echocardiogram (TTE) with subsequent transesophageal echocardiogram (TEE) if the pretest probability of IE is intermediate or high. The low reported sensitivity of TTE for detection of IE is based on studies using less advanced echo techniques than are available today, and do not take into account TTE quality. More recent evidence suggests that image quality of TTE may greatly impact the negative predictive value (NPV) of TTE for ruling out native valve vegetations. A good quality TTE may be sufficient to rule out IE in the absence of high risk clinical features. METHODS: Echocardiograms from sequential patients with both a TTE and TEE ordered to assess for IE between January 2010 and December 2012 were examined. Data from the echocardiograms was extracted including whether the study was noted to be technically difficult by the echocardiographer and whether there was a new vegetation seen. Clinical data was obtained by chart review. RESULTS: Data was collected from 148 unique patients with both a TTE and TEE. Of these, 126 patients had a
Canadian Journal of Cardiology Volume 32 2016
negative TTE for vegetation, 15 were positive and 7 were indeterminate. Vegetation on TEE was found in 10% (13/ 126) of those with negative TTE and 14% (1/7) with an indeterminate TTE. All (15/15) with a positive TTE went on to have a positive TEE. The overall NPV of TTE without factoring in test quality was 89% (82-92%). Among the negative TTEs, 44% (56/126) were deemed technically difficult studies (TDS); 12.5% of these (7/56) subsequently had positive TEEs. Of the 70 technically adequate TTEs, 8.5% (6/70) had positive TEEs (p¼ NS). When patients with prosthetic valves were excluded from analysis, only 2% (1/50) with technically adequate echoes had subsequent positive TEEs (p ¼ 0.008). The technically adequate TTEs without prosthetic valves had a NPV of 91% (79-96) for ruling out IE. CONCLUSION: The negative predictive value of a good quality TTE in ruling out native valve IE has recently been demonstrated, and is further supported by this data. When the quality of study is taken into account, rate of false negative TTEs decreases substantially. Further study is required and increased standardization of quality ratings of TTE is needed before this approach can be routinely used.
148 USEFULNESS OF PREOPERATIVE LEFT VENTRICULAR VOLUMETRIC MEASUREMENTS TO PREDICT LEFT VENTRICULAR REMODELING AFTER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE AORTIC REGURGITATION G Ong, A Harrington, J Lu, B Al-Amro, RJ Chisholm, C Chow, H Leong-Poi, M Peterson, KA Connelly Toronto, Ontario BACKGROUND:
Left ventricular ejection fraction (LVEF) and end-systolic dimension are important parameters to consider prior to aortic valve surgery for patients with severe aortic regurgitation (AR). Although both low LVEF and large LV dimensions are associated with increased late mortality, more data are needed to determine threshold values of LV shape measurements for surgery. It is unclear whether LV dilatation would be better assessed by volumetric measurements than linear dimensions. We hypothesize that that in patients with severe AR, LV volumes as assessed by the biplane method of discs will be a more sensitive indicator of postoperative LV remodeling than linear dimensions. METHODS: This is a retrospective study of patients with AR who had echocardiograms done at the St. Michael’s Hospital between January 1 2009 and January 1 2016. Early postoperative echocardiograms were excluded. The left ventricular end-diastolic and end-systolic indexed diameters (LVEDDI, LVESDI) and volumes (LVEDVI, LVESVI) using the biplane method of discs were obtained. Univariate analysis was performed. Variables with p<0.05 were included in multiple linear regression analysis to assess the predictors of postoperative LV remodelling, as defined by reduction (10%) in LVESVI.
Abstracts
S151
RESULTS:
Sixty-two patients (5214 years) underwent AVR for severe AR had preoperative and postoperative echocardiograms (median time to postoperative echocardiogram 43 days). The LVEDDI measured 3.20.5 cm/m2 and LVESDI 2.30.6 cm/m2. The LVEDVI was 13250 ml/m2 and LVESVI was 6237 ml/m2. The end-diastolic sphericity index (LV minor to major axis ratio), measured 0.650.07 and the end-systolic sphericity index, 0.550.09. The LVEF was 53%10%. Seventy-four percent of patients met LVESVI remodelling criteria. Multivariate analysis demonstrated that preoperative LV end-diastolic diameter, LVEDVI, LVESVI and LVEF were predictors of LV remodeling (all p<0.01). Thirteen (23%) patients had a severely dilated LV end-diastolic diameter but up to 38 patients (67%) had severely dilated LVEDVI as measured by the method of discs. Therefore, 27 (44%) patients were reclassified as having a severely dilated end-diastolic LV by volumetric measurements over dimensions. Similarly, 9 (16%) patients had severely dilated LV end-systolic diameter but 34 (60%) patients had severely dilated LVESVI. Twenty-five (40%) patients were reclassified as having a severely dilated end-systolic LV by volumetric measurements over dimensions. CONCLUSION: In patients undergoing AVR for isolated severe AR, the LV volumetric measurements by the method of discs are more accurate to classify the LV dilatation associated with severe AR. Pre-operative LVEDVI, LVESVI, LVEF and LV end-diastolic diameter were the best predictors of post-operative LV remodeling. Classification of severity LV dimensions according to linear and volumetric dimensions n=62 n % LV end-diastolic diameter ≥ 6.5 cm
13 23
LVEDV Ind ≥ 100/80 ml/m2
38 67
Reclassification of LV size as being severely dilated based on volumetric measurement
27 44
LV end-systolic diameter ≥ 5 cm
9 16
LVESV Ind ≥ 45/40 ml/m2
34 60
Reclassification of LV size as being severely dilated based on volumetric measurement
25 40
Cardiac evaluation of patients with anorexia nervosa generally involves routine ECG and transthoracic echocardiography. Little is known on the role of cardiac magnetic resonance imaging (CMR) for the noninvasive characterization of cardiac abnormalities in this patient cohort. The objective of this study is to characterize baseline CMR findings in adolescent patients who have been diagnosed with severe anorexia nervosa. METHODS/RESULTS: This is a cross sectional study evaluating the use of CMR in patients with anorexia nervosa. All patients met the DSM V anorexia nervosa diagnostic criteria with a body mass index of < 18.5 kg/m2 at the time of diagnosis. We used a CMR protocol assessing cardiac anatomy, functional assessment including flow, and myocardial delayed enhancement at a single tertiary center. We analyzed 16 female patients with an average age of 17 years (range 13-22 years). The average body mass index (BMI) was 20 kg/m2 (range 17-26 kg/m2). The average LVEF was 55.3% (range 46.1-60.2%) and RVEF was 51.4% (range 41.2-61.4%). The average LV stroke volume was 39 mL (range 34.8-46.3 mL) and average RV stroke volume was 35.7 mL (range 22.1-49.2 mL; Table 1). There was no delayed enhancement, suggestive of myocardial fibrosis, in any of the patients. CONCLUSION: There were significant changes in stroke volumes and ejection fraction in the left and right ventricles in patients with severe anorexia nervosa as compared to published literature controls. In contrast to previous studies, there was no evidence of myocardial fibrosis in these patients. Some of our patients are partly treated for AN. Further research is needed to determine if these significant changes in cardiac parameters are progressive or if they are potentially reversible with treatment. Table 1: CMR findings in a population with anorexia nervosa compared to reference values Parameter
Adult reference values Study population Mean+/(females) Mean+/STD(range), N= 16 STD(range)
p value
LV end diastolic volume/BSA
71.4 ± 6.6 (61.4-86.2)
78 ± 8.7 (61-95)
0.0007
LV end systolic volume/BSA
32.5 ± 5.0 (24.8-46.6)
26 ± 4.7 (17-35)
0.0001
LV stroke volume/BSA
39.0 ± 2.8 (34.8-46.3)
52 ± 6.2 (40-64)
< 0.0001
LV ejection fraction 55.3 ± 4.2 (46.1-60.2)
67 ± 4.6 (58-76)
< 0.0001
LV mass/BSA
45.5 ± 4.3 (39.0-54.3)
62 ± 7.5 (47-77)
< 0.0001
RV end diastolic volume/BSA
69.9 ± 9.7 (53.7-85.3)
78 ± 9 (60-96)
0.0045
K Chu, I Buffo, M Lane, L Ludwig, D Jassal, DI Schantz
RV end systolic volume/BSA
32.2 ± 5.5 (26.0-44.3)
28 ± 7 (14-42)
0.008
Winnipeg, Manitoba
RV stroke volume/BSA
35.7 ± 7.5 (22.1-49.2)
50 ± 6 (38-62)
< 0.0001
BACKGROUND:
RV ejection 51.4 ± 6.3 (41.2-61.4) 64 ± 6 (52-76) fraction Abbr: BSA: body surface area, LV: left ventricular, RV: right ventricular
149 A PILOT STUDY TO ASSESS CARDIAC ABNORMALITIES IN SEVERE ANOREXIA NERVOSA PATIENTS USING CARDIAC MAGNETIC RESONANCE IMAGING
Anorexia nervosa (AN) is associated with numerous cardiac abnormalities including bradyarrythmias, decreased myocardial mass and function, and pericardial effusions. This patient population has an increased mortality rate in comparison to other psychiatric illnesses.
Manitoba Medical Services Foundation