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Use of Transthoracic Echocardiography to Predict Response of Therapy in Patients with Pulmonary Hypertension
Abstracts
S258
with severe systolic dysfunction (Figure A). The mechanical mitral prosthesis functioned satisfactorily. The right coronary artery (RCA) appeared dilated (Figure B). Abnormal colour flow indicative of extensive coronary collateralisation was seen across the septum (Figure C). Computed tomography of the coronary arteries revealed an anomalous left coronary artery arising from the pulmonary artery (ALCAPA) with collateral vessels from the RCA to the left sided circulation (Figures D & E). On invasive coronary angiography, selective injection in to RCA (Figure F) showed a dilated RCA with collateral channels draining into the pulmonary artery via left coronary artery (red arrow). ALCAPA is a rare congenital anomaly. The anomalous coronary artery results in a “coronary steal syndrome” in which a left to right shunt leads to abnormal left ventricular perfusion, culminating in cardiomyopathy and mitral regurgitation. Our case highlights the importance of careful interrogation of coronary artery origins and colour Doppler signals in patients with new diagnosis of cardiomyopathy. CT coronary angiography is a useful investigation in patients suspected to have coronary anomalies.
http://dx.doi.org/10.1016/j.hlc.2016.06.598 597 Use of Isovolumetric Acceleration as an Afterload-Independent Marker of RV Dysfunction in Scleroderma L. Wright 1,∗ , N. Dwyer 2 , T. Marwick 3 1 University
of Tasmania/Baker IDI, Australia Hobart Hospital, Hobart, Australia 3 Baker IDI, Melbourne, Australia 2 Royal
Introduction: The relative contribution of primary myocardial disease vs pulmonary hypertension (PHT) to RV dysfunction (RVD) in scleroderma is difficult to elucidate. The measurement of isovolumetric acceleration (IVA) (Figure 1) may provide a relatively afterload-independent marker of RV function. We hypothesised that this would provide evidence of differential RV involvement in diffuse (DSSC) vs limited scleroderma (LSSC), independent of confounders including PHT. Methods: Complete echocardiograms were performed in 82 SSC (21 DSSC) pts, 30 of whom were on PAH Rx (DSSC n=12 (57%) vs LSSC n= 21(34%), p=0.07). IVA was measured from RV tissue Doppler as the ratio of the isovolumetric
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
velocity to acceleration time. RV and LV strain was performed using speckle tracking. Results: DSSC had worse Rodnans’ skin scores (LSSC 5.6±5.0 vs. DSSC 15.3±11.3, p<0.001), but were of similar age (p=0.06), BMI (p=0.12), HR (p=0.60) and SBP (p=0.60) to LSSC. DSSC had significantly worse IVA in DSSC (3.1±1.0 vs. 2.4±0.7, p=0.03), but no other echo markers showed significant differences. IVA was associated with SSC type (std  0.37[0.17-1.3], p=0.01), independent of age, sex, PASP, BMI, PAH therapy (std ; 0.43 CI; 0.31-1.4,p=0.002). Conclusion: The use of IVA provides an afterloadindependent marker of SSC-related heart disease.
http://dx.doi.org/10.1016/j.hlc.2016.06.599 598 Use of Transthoracic Echocardiography to Predict Response of Therapy in Patients with Pulmonary Hypertension D. Valencia 1,∗ , S. Moloi 1 , D. Korczyk 1 , G. Keir 1 , S. Wahi 1,2 , D. Erne 1 1 Princess
Alexandra Hospital, Brisbane, Australia 2 University of Queensland, Brisbane, Australia Introduction: Transthoracic echo (TTE) plays a pivotal role in the diagnosis and follow-up of patients with pulmonary arterial hypertension (PAH). Appropriately targeted PAH specific therapies can reduce morbidity and help contain costs of these therapies. The aim of the study was to assess specific echocardiographic parameters that could help predict response to therapy. Methods: Single centre, retrospective cohort of PAH patients managed by the pulmonary hypertension service between 2005 -15. All patients had a TTE and Right Heart catheterisation (RHC) at baseline and six months post treatment. 10 mmHg reduction of mean pulmonary artery pressure (mPAP) on follow up RHC was defined as a response to therapy. Guideline parameters of RA area, RV function (RVS’, TAPSE) and PVR were compared in the two groups Results: 41 (18 responders) patients were included between 2005 and 2015. RVSP RVS” TAPSE RAArea PVR (mmHg) (cm/s) (cm) (cm2) (WU)
............................................. Responders
82
10
1.9
21.4
5.01
Non responders 64
10.9
1.9
23.3
6.78
P - value
ns
ns
ns
ns
ns
Abstracts
Conclusion: Guideline echo parameters of RV function pre-treatment are not predictive of response to PAH specific therapy. Patients who responded to therapy were found to have higher pre-treatment RV pressures. Lower PVR at baseline showed a trend toward being predictive of response to treatment. http://dx.doi.org/10.1016/j.hlc.2016.06.600 599 Weekly Anonymised Sonographer Performance League Table is a Simple and Effective Communication Tool to Improve Compliance with the Recording of Non-invasive Blood Pressure at the Time of Performing an Echocardiography P. Eades ∗ , A. Kwon, A. Rainbird, G. Scalia Heart Care Partners, Queensland, Australia Introduction: HeartCare Partners introduced a comprehensive Echo quality assurance (QA) program in January 2013, and documentation of patient’s arm blood pressure (BP) was identified as an area requiring improvement at first quarterly QA meeting. Method: Documentation of BP reading was audited for every echocardiographic study performed at HeartCare Partners. The relative performance of each sonographer was communicated by comparison of their individual results to the anonymised data of all other sonographers (Figure 1). Results: Performance of BP rose from 47% of all studies performed in Q1 2013 to 84% of all studies performed in Q4 2015 (Graph 1). Cessation of weekly electronic communication with league tables from April 2014 to March 2015 saw a relapse in compliance which rapidly corrected when reinstated.
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.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
Conclusion: Quality assurance programs identify compliance weakness data. Presenting individual operators with their relative position compared to group performance in an anonymised league table form drives rapid improvement but is of benefit in maintaining long-term habits only when continued. http://dx.doi.org/10.1016/j.hlc.2016.06.601 Cardiac Technology (600–611) 600 A Comparison Between VH-IVUS and iMap Plaque Characterisation Platforms L. Frost ∗ , A. Carbone, M. Worthley, S. Worthley University of Adelaide & Royal Adelaide Hospital, Adelaide, Australia The propensity of atherosclerotic plaque to rupture is related to its histological composition. Accurate in-vivo identification of vulnerable plaque therefore allows early management strategies to be implemented to prevent future coronary events. Although VH-IVUS and iMap have been validated in in-vitro and ex-vivo human coronary arteries there has been a paucity of data published on in-vivo images compared to histology. Atherosclerotic lesions were generated in the rabbit abdominal aorta by a combination of a high cholesterol diet (0.2% supplemented) and balloon denudation of the endothelium in male New Zealand White rabbits (n=30, weight 3-3.5 kg). Intravascular imaging of the abdominal aorta was performed using both iMAP and VH-IVUS platforms. 5 m sections were cut and stained with a combined Masson’s Trichrome elastin and haematoxylin and eosin stains. A subset of aorta specimens were stained with Oil-Red-O for specific lipidic analysis. There were significant differences between all plaque components as reported by iMap and VH-IVUS. iMap analysis reported greater fibrotic areas compared to VH-IVUS (68.44 ± 7.7% vs. 27.81 ± 3.18%; p <0.0001). iMap reported greater lipidic areas compared to VH-IVUS (5.18 ± 2.44% vs. 3.25 ± 4.76%; p <0.005) however VH-IVUS reported greater necrotic areas compared to iMap (30.07 ± 6.26% vs. 16.18 ± 3.93%; p <0.0001). VH-IVUS also reported greater calcified areas compared to iMap (37.5 ± 13.18% vs. 10.18 ± 4.97%; p <0.0001). Whilst we observed systematic differences between the two platforms for the quantification of individual plaque components, iMap reported values more congruent to histological values than VH-IVUS. http://dx.doi.org/10.1016/j.hlc.2016.06.602
S258
with severe systolic dysfunction (Figure A). The mechanical mitral prosthesis functioned satisfactorily. The right coronary artery (RCA) appeared dilated (Figure B). Abnormal colour flow indicative of extensive coronary collateralisation was seen across the septum (Figure C). Computed tomography of the coronary arteries revealed an anomalous left coronary artery arising from the pulmonary artery (ALCAPA) with collateral vessels from the RCA to the left sided circulation (Figures D & E). On invasive coronary angiography, selective injection in to RCA (Figure F) showed a dilated RCA with collateral channels draining into the pulmonary artery via left coronary artery (red arrow). ALCAPA is a rare congenital anomaly. The anomalous coronary artery results in a “coronary steal syndrome” in which a left to right shunt leads to abnormal left ventricular perfusion, culminating in cardiomyopathy and mitral regurgitation. Our case highlights the importance of careful interrogation of coronary artery origins and colour Doppler signals in patients with new diagnosis of cardiomyopathy. CT coronary angiography is a useful investigation in patients suspected to have coronary anomalies.
http://dx.doi.org/10.1016/j.hlc.2016.06.598 597 Use of Isovolumetric Acceleration as an Afterload-Independent Marker of RV Dysfunction in Scleroderma L. Wright 1,∗ , N. Dwyer 2 , T. Marwick 3 1 University
of Tasmania/Baker IDI, Australia Hobart Hospital, Hobart, Australia 3 Baker IDI, Melbourne, Australia 2 Royal
Introduction: The relative contribution of primary myocardial disease vs pulmonary hypertension (PHT) to RV dysfunction (RVD) in scleroderma is difficult to elucidate. The measurement of isovolumetric acceleration (IVA) (Figure 1) may provide a relatively afterload-independent marker of RV function. We hypothesised that this would provide evidence of differential RV involvement in diffuse (DSSC) vs limited scleroderma (LSSC), independent of confounders including PHT. Methods: Complete echocardiograms were performed in 82 SSC (21 DSSC) pts, 30 of whom were on PAH Rx (DSSC n=12 (57%) vs LSSC n= 21(34%), p=0.07). IVA was measured from RV tissue Doppler as the ratio of the isovolumetric
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
velocity to acceleration time. RV and LV strain was performed using speckle tracking. Results: DSSC had worse Rodnans’ skin scores (LSSC 5.6±5.0 vs. DSSC 15.3±11.3, p<0.001), but were of similar age (p=0.06), BMI (p=0.12), HR (p=0.60) and SBP (p=0.60) to LSSC. DSSC had significantly worse IVA in DSSC (3.1±1.0 vs. 2.4±0.7, p=0.03), but no other echo markers showed significant differences. IVA was associated with SSC type (std  0.37[0.17-1.3], p=0.01), independent of age, sex, PASP, BMI, PAH therapy (std ; 0.43 CI; 0.31-1.4,p=0.002). Conclusion: The use of IVA provides an afterloadindependent marker of SSC-related heart disease.
http://dx.doi.org/10.1016/j.hlc.2016.06.599 598 Use of Transthoracic Echocardiography to Predict Response of Therapy in Patients with Pulmonary Hypertension D. Valencia 1,∗ , S. Moloi 1 , D. Korczyk 1 , G. Keir 1 , S. Wahi 1,2 , D. Erne 1 1 Princess
Alexandra Hospital, Brisbane, Australia 2 University of Queensland, Brisbane, Australia Introduction: Transthoracic echo (TTE) plays a pivotal role in the diagnosis and follow-up of patients with pulmonary arterial hypertension (PAH). Appropriately targeted PAH specific therapies can reduce morbidity and help contain costs of these therapies. The aim of the study was to assess specific echocardiographic parameters that could help predict response to therapy. Methods: Single centre, retrospective cohort of PAH patients managed by the pulmonary hypertension service between 2005 -15. All patients had a TTE and Right Heart catheterisation (RHC) at baseline and six months post treatment. 10 mmHg reduction of mean pulmonary artery pressure (mPAP) on follow up RHC was defined as a response to therapy. Guideline parameters of RA area, RV function (RVS’, TAPSE) and PVR were compared in the two groups Results: 41 (18 responders) patients were included between 2005 and 2015. RVSP RVS” TAPSE RAArea PVR (mmHg) (cm/s) (cm) (cm2) (WU)
............................................. Responders
82
10
1.9
21.4
5.01
Non responders 64
10.9
1.9
23.3
6.78
P - value
ns
ns
ns
ns
ns
Abstracts
Conclusion: Guideline echo parameters of RV function pre-treatment are not predictive of response to PAH specific therapy. Patients who responded to therapy were found to have higher pre-treatment RV pressures. Lower PVR at baseline showed a trend toward being predictive of response to treatment. http://dx.doi.org/10.1016/j.hlc.2016.06.600 599 Weekly Anonymised Sonographer Performance League Table is a Simple and Effective Communication Tool to Improve Compliance with the Recording of Non-invasive Blood Pressure at the Time of Performing an Echocardiography P. Eades ∗ , A. Kwon, A. Rainbird, G. Scalia Heart Care Partners, Queensland, Australia Introduction: HeartCare Partners introduced a comprehensive Echo quality assurance (QA) program in January 2013, and documentation of patient’s arm blood pressure (BP) was identified as an area requiring improvement at first quarterly QA meeting. Method: Documentation of BP reading was audited for every echocardiographic study performed at HeartCare Partners. The relative performance of each sonographer was communicated by comparison of their individual results to the anonymised data of all other sonographers (Figure 1). Results: Performance of BP rose from 47% of all studies performed in Q1 2013 to 84% of all studies performed in Q4 2015 (Graph 1). Cessation of weekly electronic communication with league tables from April 2014 to March 2015 saw a relapse in compliance which rapidly corrected when reinstated.
S259
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
Conclusion: Quality assurance programs identify compliance weakness data. Presenting individual operators with their relative position compared to group performance in an anonymised league table form drives rapid improvement but is of benefit in maintaining long-term habits only when continued. http://dx.doi.org/10.1016/j.hlc.2016.06.601 Cardiac Technology (600–611) 600 A Comparison Between VH-IVUS and iMap Plaque Characterisation Platforms L. Frost ∗ , A. Carbone, M. Worthley, S. Worthley University of Adelaide & Royal Adelaide Hospital, Adelaide, Australia The propensity of atherosclerotic plaque to rupture is related to its histological composition. Accurate in-vivo identification of vulnerable plaque therefore allows early management strategies to be implemented to prevent future coronary events. Although VH-IVUS and iMap have been validated in in-vitro and ex-vivo human coronary arteries there has been a paucity of data published on in-vivo images compared to histology. Atherosclerotic lesions were generated in the rabbit abdominal aorta by a combination of a high cholesterol diet (0.2% supplemented) and balloon denudation of the endothelium in male New Zealand White rabbits (n=30, weight 3-3.5 kg). Intravascular imaging of the abdominal aorta was performed using both iMAP and VH-IVUS platforms. 5 m sections were cut and stained with a combined Masson’s Trichrome elastin and haematoxylin and eosin stains. A subset of aorta specimens were stained with Oil-Red-O for specific lipidic analysis. There were significant differences between all plaque components as reported by iMap and VH-IVUS. iMap analysis reported greater fibrotic areas compared to VH-IVUS (68.44 ± 7.7% vs. 27.81 ± 3.18%; p <0.0001). iMap reported greater lipidic areas compared to VH-IVUS (5.18 ± 2.44% vs. 3.25 ± 4.76%; p <0.005) however VH-IVUS reported greater necrotic areas compared to iMap (30.07 ± 6.26% vs. 16.18 ± 3.93%; p <0.0001). VH-IVUS also reported greater calcified areas compared to iMap (37.5 ± 13.18% vs. 10.18 ± 4.97%; p <0.0001). Whilst we observed systematic differences between the two platforms for the quantification of individual plaque components, iMap reported values more congruent to histological values than VH-IVUS. http://dx.doi.org/10.1016/j.hlc.2016.06.602