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Introduction: It is estimated that 15% of patients with AS have concomitant cardiac amyloidosis (CA). Left ventricular (LV) longitudinal strain (LS) pattern with relative apical sparing (RELAPS>1), shown as bright red in the apical segments on the polar map, has been strongly associated with CA. Its presence and its significance in AS is yet to be determined. Purpose(s): To determine the prevalence of the RELAPS>1 pattern in patients with severe AS with and without concomitant CA, and to analyze the echocardiographic phenotype associated with this strain pattern and its prognostic value. Method(s): Patients with severe symptomatic AS undergoing TAVI were prospectively and consecutively included between Jan-19 and Dec-20. Pre-procedure, a complete echocardiogram was performed that included deformation parameters using Speckle-Tracking. Strain derived Indices accepted for CA screening were calculated: RELAPS: Relative apical LS (average apical LS/average basal+mid LS);SAB: (apical-septal/basal-septal LS);EFSR: (LVEF/GLS). After TAVI, a 99Tc-PYP scintigraphy and a proteinogram were performed to screen for CA. Result(s): 324 patients were included. The mean age was 81 yo, 52% women. Strain analysis could be performed in 243 patients due to acoustic window and covid19 pandemic restrictions. Among those, 111 (46%) presented relative apical sparing (RELAPS>1). There were no differences in clinical characteristics between patients with RELAPS <1 and >1: Similar age, sex, cardiovascular risk factors and funcional class, renal function or NT-proBNP. Among patients with RELAPS>1 there was more frecuently CA with uptake grade 2 and 3 on scintigraphy (15% vs. 4.5%, P=0.006) (Figure 1). RELAPS>1 group showed greater LV hypertrophic remodeling: Thicker myocardial wall with smaller ventricular cavity, especially concentric hypertrophy;LVEF and GLS was similar, however, MAPSE and myocardial contraction fraction (MCF) were worse in RELAPS >1 group, and EFSR was significantly higher (4.2 vs 3.9, p=0.002). RELAPS >1 group had smaller aortic valve area (AVA: 0.6 vs 0.7 cm2, p=0.045), but similar transvalvular gradients due to lower stroke volume. It had larger atria and less left atrial (LA) fractional emptying, as well as higher prevalence of atrial fibrillation (AF: 41% vs 27%, p=0.03). Right ventricle (RV) size were similar, however, RV function was worse in RELAPS >1 group (TAPSE: 19 vs 21 mm, p=0.003;free Wall LS: -24 vs -27%, p=0.008). There was no difference in all-cause mortality at 1 year of follow-up between groups (6.4% vs. 6.3%, p=1). Figure 2 represents the morphological characteristics according to the LS phenotype. Conclusion(s): In severe AS, RELAPS >1 is present in almost half of the patients. It is associated with worse cardiac remodeling, as well as higher prevalence of AF. However, it wasn't associated with higher mortality at 1 year. 1 in 7 patients with AS and RELAPS >1 have concomitant ATTR CA grade 2/3.
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Background: Post COVID19 condition occurs in individuals with a history of probable or confirmed SARS Cov2 infection, usually 3 months from the onset of COVID19 with symptoms that last for up to at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction, but also arterial hypertension (AH) and generally have an impact on everyday function. Aim: COVID 19 pneumonia initiates new onset AH and aggravates the structural and functional myocardium remodeling in the long term after hospitalization. Methods: The study population /initially questioned 1500 patients for symptoms after acute COVID 19 pneumonia / included 220 patients without history of any disease, mean age of 45 ± 12 years, male 145 (43 ± 10 years) female 75 (52 ± 14 years). The global longitudinal strain (GLS) was extracted for left ventricle (LV) and right ventricle(RV) and AMBP analysis, mean arterial pressure (MAP)and heart rate HR were performed at baseline /30-40 days after acute infection/ 3rd and 12th months follow up. CMR was performed at 3rd (3mFU) and 12th months (12mFU) also to confirm our resulst. Results: From initial population /1500 pts/ self-reported symptoms at 12mFU are 1265 (84.6 %) and 235 /15.4 %) are symptom free at 12mFU. At 3mFU HR and MAP increased significantly / from 75 ± 6 beats /min to 88 ± 12 beats/ min, 109 ± 15 mmHg to 118 ± 19mmHg. Sys BP increased slightly at 3mFU /128 ± 14, p = 0.6/ and continue at 12mFU / 129 ± 12, p = 0.7/. Diastolic BP increased significantly at 12mFU /86 ± 12.3 to 91 ± 10.0, p > 0.01/ and AH presence at 3mFU in 143 (65%)up to 161(73%) at 12mFU. Symptoms of heart failure with preserved EF were found at 3mFU in 91 pts (41%) and in 99 pts (45%) at 12mFU. Echocardiography showed predominantly decrease of the load on the right heart at 3mFU and 12mFU (RV FAC % p < 0.019, TAPSE p < 0.05, RVOT VTI p < 0.01). LV function showd increased EDD, ESD, EDV, ESV, and decreased EF and GLS at 3mFU and slightly improvement at 12mFU. Despite normal EF, GLS / 18.5 %, p < 0.01) and segmental LS in all apical and mid anteroseptal, inferoseptal and basal anteroseptal and inferoseptal levels (16% to 18%, p < 0.01) and RV (22.3% to 24%) at 12mFU shown diminished and still preserved values. Conclusion: New onset AH is one of major symptoms after COVID 19 and remains at 12mFU. Despite of satisfactory improvement of conventional parameters for LV and RV function, GLS indicate worsening of the LV systolic function.
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Introduction. During SARS-CoV-2 pandemic there was a surge in number of patients requiring ICU admission, monitoring devices, mechanical ventilation and prone positioning. In such conditions, proper hemodynamic assessment resulted challenging, whilst the need to evaluate right ventricle (RV) performance and pulmonary resistances in prone position ventilation was impellent. Aim. We explored the feasibility of a novel approach to assess both hemodynamics and cardiac function by trans-thoracic echocardiography (TTE) during mechanical ventilation before and after prone positioning. Materials and Methods. TTE was performed in eight patients before and 1 hour after prone positioning (TTEp), alongside standard hemodynamic monitoring. In order to obtain enough physical space to position the TTE-probe, we deflated the lower-thoracic section of the air-mattress, and placed the probe between the mattress surface and the thorax of the patient. Both apical-4-chambers and apical-5-chambers views were obtained. Results. We observed an overall improvement in the RV function parameters after pronation, although not statistically significant. In one case, prone position showed a reduction in TAPSE by 43% and an increase in PAPs by 9%, compared to the supine values. The same case showed a negative outcome. Conclusions. Despite trans-esophageal echocardiography remains the gold standard in patients in prone position, limited availability and the need for skilled sonographers limit its feasibility during pandemics. Though, TTEp guarantees resource-saving and time-effectiveness since multiple information can be drawn even on a single view.
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Introduction: Point-of-Care Ultrasound (PoCUS) can rapidly diagnose presence and severity of COVID-19 disease and associated pathologies.1 PoCUS identifies life-threatening complications at the bedside, with the potential to reduce the need for out-of-department transfers for imaging, alongside associated radiation exposure and spread of infection.2 Use of PoCUS by doctors in the intensive care unit (ICU) is becoming increasingly widespread. However, uptake by ICU nurses is poor despite evidence to suggest comparable accuracy in acquiring and reporting PoCUS scans, and the potential benefit to patients as a result of an increased workforce of competent PoCUS clinicians.3-5 Objective: To report findings in critically ill COVID-19 patients identified through nurse-led cardiac and 6-point lung PoCUS. Method: This case series was part of the national service evaluation led by the Intensive Care Society, SAM, FUSIC, and FAMUS. Conduct was approved by the departmental lead for critical care ultrasound. An ICU nurse trained in Focused Intensive Care Echocardiography (FICE) and Focused Ultrasound in Intensive Care (FUSIC) performed cardiac and 6-point lung PoCUS scans on ICU patients with confirmed COVID-19 disease during the recovery phase. Severity of disease was scored between 0-3 (Table 1) in each lung region (upper anterior;mid-anterior;posterolateral) and a total score calculated (0-18). PoCUS scans were only performed on patients identified by the treating ICU consultant. Correlations between PoCUS findings and patient demographics, key clinical data, physiological parameters, and 30-day outcome were analysed using Pearson's coefficient. Descriptive statistics analysis (mean;standard deviation/ mode;interquartile range) were used to describe data. Results: A cardiac and 6-point lung PoCUS scan was performed on 15 patients. Fourteen (93%) scans were performed to answer lung-specific clinical questions including assessment of ventilation strategy (ventilation mode;PEEP level) in 5 (33%) patients, extravascular lung water assessment in 9 (60%), and lung assessment prior to tracheostomy decannulation in 1 (7%). Moderate to severe COVID-19 was apparent in all lung fields with severity scores from 6 to 14 (Figure 1). Left ventricular (LV) function was normal in 13 (87%) patients, 2 (13%) demonstrated signs of a dilated right ventricle (RV), and 1 (6%) had impaired LV and RV function (Figure 2). Ten scans identified pathologies that contributed to a change in clinical management immediately following the scan (Figure 3). Interventions included: (1) change in fluid management (increased fluid removal on renal filtration, new furosemide prescription) 4 (27%) patients) and a level 2 echo assessment due to identification of new cardiac pathologies (3 (20%) patients). Five patients had no change in care. We identified a moderate positive correlation between lung severity score and APACHE II (Pearson's coefficient: 0.69;p value <0.01). Weak correlation was found between lung severity score and white cell count, SOFA score, and PaO2/ FiO2. There was no difference in 30-day outcome in patients with a higher lung severity score or abnormal cardiac scan. Conclusion: Cardiac and lung PoCUS is a vital tool in the assessment of COVID-19 disease. The addition of ICU nurses to the growing workforce of PoCUS competent clinicians increases availability of real-time imaging.
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INTRODUCTION It is well known that COVID-19 affects the cardiovascular system by exacerbating heart failure in patients with preexisting conditions and troponin elevation in critically ill patients. The insight into the cardiovascular involvement and sequelae in those with no preexisting conditions is poor. We performed a systematic and comprehensive echocardiographic evaluation of patients hospitalized with COVID-19. The aim of the study was to analyze cardiac performance in subjects with no prior history of structural heart disease in relation to inflammatory markers and clinical outcome. The study is a part of CRACoV project, with prospective design and an assumed 12-month follow-up. Following data are preliminary results of baseline examinations. MATERIAL AND METHODS The study included 106 patients hospitalized with diagnosed COVID-19 infection (age 56.7 ± 12,8 years;39 women). Patients with prior heart failure, known structural heart disease, acute coronary syndrome, acute stroke or acute vascular episode as well as chronic kidney disease, chronic inflammatory or neoplasmatic disease were excluded from the study. In all participants standard clinical assessment and laboratory tests including C-reactive protein (CRP), interleukin 6 (IL-6), cardiac troponin I, N-terminal pro-brain natriuretic peptide (NT-pro-BNP) were performed. Severity of the disease was classified according to World Health Organization criteria. An extended echocardiographic image acquisition protocol was performed in all subjects within 72-hours from admission. All analyses, including left ventricle (LV) longitudinal deformation (GLS), were performed off-line. RESULTS COVID-19 had severe course in 58 subjects, 4 patients in critical condition died during hospitalization. High-flow oxygen therapy was required in 17 subjects. LV systolic function was preserved in all subjects (mean 62.3 ± 5.2%;GLS -19.9 ± ± 6.4;CO 5.51 ± 1.47 l/min). Averaged E/Eè was 6.97 ± 1.80. Right ventricle (RV) was enlarged in 6 patients, in all RV function was preserved (TAPSE 24.6 ± 3.74 mm, RV S' 15.6 ± 3.03 mm). In one patient RV thrombus was detected. Pericardial effusion was present in 8 patients. Elevated NT-pro-BNP (>300 pg/ml) was detected in 34 patients and elevated troponin in 3 subjects. NT-pro-BNP significantly correlated with CRP (r = 0.24;P <0.01);IL-6 (r = 0.28;P <0.01) and negatively with LV GLS (r = -0.27;P = 0.01). In multiple regression the risk of high-flow oxygen therapy was related with male gender (b = -0.30;P = 0.04), CRP (b = 0.50;P <0.005), NT-pro-BNP (b = -0.28;P = 0.04) and RV diameter (b = 0.33;P = 0.02). CONCLUSIONS In subjects with COVID-19 and normal LV systolic function, elevation of NT-pro-BNP is frequent and reflects haemodynamic stress related with acute inflammatory disease. NT-pro-BNP significantly associates with the risk of severe course of COVID-19. RV diameter is independently related with worse prognosis in COVID-19.
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INTRODUCTION Coronavirus disease-2019 (COVID-19) is an emerging disease with a wide spread, multiorgan involvement beyond pulmonary manifestations and unknown cardiovascular (CV) consequences. Therefore our aim was to assess the myocardial injury in patients recovered from COVID-19 in cardiovascular magnetic resonance (CMR). MATERIAL AND METHODS This was a multicenter, prospective study involving 5 Polish CMR labs with a high and long-standing experience in CV diseases. All the consecutive patients recovered from COVID-19 (confirmed in reverse transcription polymerase chain reaction [RT-PCR] test) and scheduled for CMR due to cardiac symptoms and a clinical suspicion of myocarditis were enrolled into the study. Patients with a history of previous cardiac injury were excluded from the study. All the patients underwent a contrast-enhanced CMR with conventional myocarditis protocol, including a late gadolinium enhancement (LGE). RESULTS The study group included 250 patients (age 45 ± 12 years old;53% females) with hypertension (24%), diabetes (6%), obesity (67%) and chronic pulmonary disease (6%) sent for cardiac imaging. The main single indications were: a suspicion of myocarditis (42%) or unexplained fatigue (22%) or arrhythmia (12%). Sixty patients had at least moderate COVID-19 requiring hospitalization and the CMR was performed up to 6 months after the disease with the majority of cases performed within 3 months (76%). The left ventricle (LV) function was normal in 91,5% (mean ejection fraction [EF] 62 ± 14%) with a moderate or severe dysfunction in 17 and 4 pts. The right ventricle (RV) function was normal in 85% (mean EF 56.2 ± 8%) with a borderline dysfunction (EF 45-50%) in 17 patients and dysfunction in 20 patients. The enlargement of ventricles (indexed to body surface area) was found in 19 (LV) and 7 (RV) cases. The pericardial effusion was found in 29 pts (11%) and active pericarditis in 21 cases (8%). Finally, active myocarditis and/or edema was noticed in 28 (11%) individuals and myocarditis-like LGE as a post-myocarditis injury in LV myocardium was found in 129 patients (51%). However, 79% of patients showed LGE limited to four or less segments and great majority of the injured segments (92%) revealed only a mild range of LGE (<25% of segment). There was a trend and a weak association between the time of recovery and number of injured segments (r = 0.1;P = 0.05) and no association between the number of injured segments and age (P = ns). CONCLUSIONS Half of the patients recovered from COVID-19 were found to have a myocarditis-like LGE injury in LV, mostly with limited myocardial extent and preserved systolic function. Every fifth of them revealed signs of active inflammation within perior myocardium. The long-term clinical consequences of our findings are unknown.