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In a small cohort of patients (58 ± 12 years) with heart failure and reduced ejection fraction (HFREF), we have analyzed myocardial mechanics in all the four principal cardiac chambers to investigate the prognostic value of left atrial (LA) remodeling. We have also studied to investigate a possible prognostic role of the biochemical markers, such as estimated glomerular filtration rate (eGFR, mL/min/1.73 m2) and N-terminal pro-brain natriuretic peptide (NT-proBNP). We used two-dimensional speckle tracking echocardiography to compute cardiac deformation in addition to measuring LA reservoir strain using two algorithms based on the type of electrocardiogram gating protocol chosen. The data have shown that not only four-chamber strain was significantly lower in HFREF compared with the controls but also LA strain predicted an adverse outcome. In addition, in the subgroup analysis, eGFR was significantly lower in patients with adverse outcome (death or cardiac transplantation). Interestingly, the contribution of the renal biomarker was as significant as NT-proBNP in this regard.

Background Older adulthood is often associated with type 2 diabetes (DM), and cardiovascular comorbidities (CVD), such as hypertension, atrial fibrillation (AF) with or without heart failure (HF). A combination of the illnesses may contribute to the decline in cerebral cognition. It is, however, not known whether there exists an association between cognitive function and cardiovascular diseases and co-existing DM in a community setting equipped with outpatient echocardiography services. Subjects and methods One hundred and thirty peri-octogenarians (79±11 years,), divided into four groups (Controls, CVD-DM, CVD+DM, and DM-CVD), matched for age, and gender, participated in the study to undergo a routine standard Doppler echocardiography, measures of which included left ventricular (LV) ejection fraction, left atrial (LA) size, pulmonary artery systolic pressure (PASP), and LV diastolic indices such as E/A-wave velocity ratio. Routine biochemistry included glomerular filtration rate and NT-proBNP, in addition to plasma glucose and HbA1c. Cognition was measured using a Mini-Mental State Examination (MMSE) score. In the CVD-DM group 14 out of 47 had AF+HF, In the CVD+DM 7 out of 24 had AF+HF (Chi sq p for trend = 0.9): i.e., a total of 30% had a combined co morbidity of DM+AF+HF. All of them had SGLT2 inhibitors alone or in combination of GLP1-RA. In the CVD group 27 out of 47 had AFIB, while in the DM+CVD group 11 of 24 had AFIB (Ci Sq p for trend=0.8) Results Mean ± SD of MMSE scores, LVEF%, PASP (mmHg), E/A ratio, and LA size (mm) in the Controls were respectively 27±3, 58±10, 22±5, and 34±9. MMSE scores did not differ. LVEF was significantly lower, and PASP higher in CVD with or without DM (all p Conclusion In this community-based cross-sectional study, cerebral cognition, as assessed by MMSE scoring, was found to be preserved in DM with or without co-existing CVD, compared with age-matched Controls. DM and CVD equally contributed to the level of cognition. Whether the newest anti hyperglycemic agents preserve cognition beyond impacting a favorable cardiac outcome is a matter to be resolved by larger, multinational trails. Routine echocardiography in primary care plays a vital role to monitor cardiac function in an increasingly older adults faced with a significant disease burden (DM+AF+HF+CAD) with risk for impaired cognition. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Novo Nordisk Figure 1

We previously reported that a high score (2 or 3 points) according to the Kumamoto criteria, a combination of high-sensitivity cardiac troponin T (hs-cTnT) ≥0.308 ng/mL, the length of QRS ≥ 120 ms in electrocardiogram, and left ventricular (LV) posterior wall thickness ≥ 13.6 mm, increases the pretest probability ofWe examined 109 consecutive patients aged ≥70 years with low scores according to the Kumamoto criteria who underwentA high RapLSI can raise the pretest probability of

In the year 1997, nearly a quarter-century ago, Nishimura and Tajik (J Am Coll Cardiol. 1997;30:8) suggested that Doppler echocardiography was the "Rosetta stone" (a metaphor for decrypting secrets of diastole) of left ventricular diastole, based solely on transmitral E/A ratio and its progression from grade I through IV, supported by cardiac catheterization, as the filling pressure started to increase to over 15 mm Hg. Ten years later, in 2007, the same Mayo group (Nagueh et al, J Am Coll Cardiology. 2008;51:679) was searching to decipher the secrets of diastole using multiple measures such as left atrial (LA) volume, E/E' ratio, pulmonary venous flow, and mitral inflow propagation velocity. This substantial leap from E/A ratio led to the more formal recommendation proposed by the American Society of Echocardiography in 2009 (Nagueh et al, J Am Soc Echocardiogr. 2009;22:107) and, as an update, in the year 2016 (Nagueh et al, J Am Soc Echocardiogr. 2016;29:277): the later version gained popularity for the simplified approach to identify diastolic dysfunction in healthy subjects as well as in those with poorly contracting left ventricle. Despite 30 years of continuous search, we are not sure if we have been able to decipher the hidden secrets of diastolic function. With this background, the Echocardiography Journal under the leadership of Dr Navin Nanda as the Editor-in-Chief has taken this initiative to publish a theme issue on left ventricular diastolic function and when this becomes dysfunctional to diminish life.

Background Three dimensional (3D) transthoracic echocardiogram (TTE) has been validated to have good agreement with cardiac magnetic resonance for the assessment of left ventricular ejection fraction (LVEF) with good interobserver reproducibility. Despite the increased use of perioperative transesophageal echocardiogram (TEE), TEE assessment of left ventricular (LV) function and volumes have never been validated against 3D TTE. Objective To evaluate whether 3D TEE measurement of LV function shows better agreement with 3DTTE, compared to 2DBiplane and X-plane TEE. Methods A total of 60 patients were included from a single large volume tertiary center, the mean age of 71.9 years, 40% were female; TTE and TEE studies were performed within one week. LV function parameters including LV EF, LV end-diastolic (LVEDV) and end systolic volumes (LVESV), stroke volumes (SV) were calculated with Qlab version 9, and 3DQ advanced software, with semi-automated endocardial contours for 3D TTE and 3D TEE. LV function parameters for 2D X-plane and Biplane TEE data sets were assessed using AGFA with manual endocardial contours. Mean differences were compared with paired, two-tail T-test, and limits of agreement were determined using the Bland-Altman analysis. Correlation between TTE and TEE values were tested using Pearson’s correlation test. Results 3D transthoracic LV EDV, ESV, SV, and EF respectively were 112± 46 ml, 57 ±32 ml, 55± 55 ml, and 51 ±11%. Comparisons and correlations between TTE and TEE for the four measures were: for EDV bias = 9.94 ml and 95% lower and upper limits of agreements being -68.7 and 88.5 ml, and r= 0.7; for ESV the bias was -0.3 ml with 95% lower and upper limits of agreements being -55 to 55 ml, and r = 0.7: for stroke volume bias= 0.2 with 95% lower and upper limits of agreements being -37 to 67 ml, and r = 0.2; for LVEF the bias was 2.7% with 95% lower and upper limits of agreements being -18.9% to 24.3%, and r= 0.7 (Fig) Conclusion Left ventricular volumetric assessments during 3D transesophageal echocardiography is not only feasible but also comparable to 3D transthoracic echocardiography obtained LV volumes and EF. Data from multicenter studies with a larger number of subjects are needed to corroborate our findings. Abstract P306 Figure. Fig. 3D LV volumes by 3D TEE vs. 3D TTE

Funding Acknowledgements EU GRANT OnBehalf MOPEAD STUDY GROUP Background Although the 2D speckle tracking software (2DSTE-SW) has been irrevocably proved to be useful for quantification of left ventricular (LV) function, the same SW has also been used successfully in a plethora of cardiac illnesses using left atrial (LA) strain and strain rate, even in the absence of a dedicated LA SW. LA peak longitudinal strain during ventricular systole (LA-Reservoir strain%; LA-Res S), and strain rate during early (LA-SRE) and late (LA-SRA) phases constitute respectively the reservoir (LA-RS%), conduit, and booster pump functions of this chamber. The role of this dynamic function has not been investigated to assess cerebral cognition in type 2 diabetes (DM). Methods We enrolled thirty-nine subjects with DM and mild LV dysfunction (76 ± 5 years, 25 F) in the EU- funded MOPEAD (Models of Patient Engagement for Alzheimer’s Disease) project. Fifteen of them underwent standard echocardiography and 2DSTE. We assessed cerebral cognition using the standard MMSE (Mini-Mental Stage Examination) score: we considered a score of less than 28 as a surrogate of mild cognitive impairment (MCI+). Besides LA-Res strain, LA-SRE, LA-SRA, LV-GLS and right ventricular free wall strain (RV-FWS) were also computed (RV-FWS). Routine biochemistry included, among other, HbA1c and NT-proBNP. Results Mean values of the 2D STE measures were LVGLS: 14± 3%, LAVI: 36± 21 ml/m2, LA -RS: 18 ±8 %, LA-SRE: 0.6± 0.3, and LA-SRA: 1.6± 0.4. RV FWS was 20± 5 %. HbA1c was 58 ± 16 mmol/mol. LVEF was 53± 7%. There was no difference in theses variable between MCI+ and those with normal cognition (MCI-). However, in the regression model, LA-Res S had the strongest association with MCI (P 0.05). Conclusion LA reservoir strain may emerge as a useful tool to explore disturbed system biology involving extracardiac organ such as the brain in older adults with type 2 diabetes, in the background of mild LV dysfunction. Abstract P1394 Figure. Fig.Regression analysis

Background Irbesartan, a long acting selective angiotensin-1 receptor inhibitor, in Marfan syndrome might reduce aortic dilatation, which is associated with dissection and rupture. We aimed to determine the effects of irbesartan on the rate of aortic dilatation in children and adults with Marfan syndrome. Methods We did a placebo-controlled, double-blind randomised trial at 22 centres in the UK. Individuals aged 6–40 years with clinically confirmed Marfan syndrome were eligible for inclusion. Study participants were all given 75 mg open label irbesartan once daily, then randomly assigned to 150 mg of irbesartan (increased to 300 mg as tolerated) or matching placebo. Aortic diameter was measured by echocardiography at baseline and then annually. All images were analysed by a core laboratory blinded to treatment allocation. The primary endpoint was the rate of aortic root dilatation. This trial is registered with ISRCTN, number ISRCTN90011794. Findings Between March 14, 2012, and May 1, 2015, 192 participants were recruited and randomly assigned to irbesartan (n=104) or placebo (n=88), and all were followed for up to 5 years. Median age at recruitment was 18 years (IQR 12–28), 99 (52%) were female, mean blood pressure was 110/65 mm Hg (SDs 16 and 12), and 108 (56%) were taking β blockers. Mean baseline aortic root diameter was 34·4 mm in the irbesartan group (SD 5·8) and placebo group (5·5). The mean rate of aortic root dilatation was 0·53 mm per year (95% CI 0·39 to 0·67) in the irbesartan group compared with 0·74 mm per year (0·60 to 0·89) in the placebo group, with a difference in means of −0·22 mm per year (−0·41 to −0·02, p=0·030). The rate of change in aortic Z score was also reduced by irbesartan (difference in means −0·10 per year, 95% CI −0·19 to −0·01, p=0·035). Irbesartan was well tolerated with no observed differences in rates of serious adverse events. Interpretation Irbesartan is associated with a reduction in the rate of aortic dilatation in children and young adults with Marfan syndrome and could reduce the incidence of aortic complications. Funding British Heart Foundation, the UK Marfan Trust, the UK Marfan Association.

Deformation imaging, particularly of left-sided heart, is fast becoming an essential tool in clinical cardiology. However, data are scant regarding the value of biventricular and bi-atrial deformation in association with comorbidities in heart failure with reduced left ventricular ejection fraction (HFREF).Forty-nine subjects (72 ± 13 years; 28 male) with HFREF and 14 age-matched controls underwent deformation imaging including LV global longitudinal strain (LVGLS%), right ventricular strain (RVS%), and left atrial reservoir strain (LARS%). Standard echo parameters included LVEF%, E/E' ratio, and pulmonary artery systolic pressure (PASP). Mean ± SD of LVEF, LVGLS%, and RVS% were 31% ± 8%, 7% ± 3%, and 17% ± 7%, respectively, and were significantly lower compared with controls (all P .0001). Over a follow-up period of 4.2 years, 24% of patients died and 48% had a composite outcome of death and heart failure hospitalization. In the logistic regression model, taking the composite of death and heart failure hospitalization as a dichotomous variable, RVS%, E/E' ratio, and PASP were the only significant univariate predictors of adverse outcome (RMultichamber deformation imaging along with renal function and PASP could best predict adverse outcome in HFREF.

Cardiovascular assessment of patients with Marfan syndrome has normally focused on the aortic root and vascular manifestations of the disease due to the high risk of aortic dissection. Although primary myocardial impairment has long been suspected in these patients, the evidence has been controversial. Advanced echocardiography and cardiovascular magnetic resonance imaging have proven to be effective, accurate, and more sensitive in the detection of subtle cardiac dysfunction. The application of these techniques to Marfan syndrome over the last 10 years has made significant progress in demonstrating the presence of primary myocardial impairment in these patients, but further work is still required to obtain confirmatory molecular, pathophysiological, and prognostic clinical data. Phenotypic expression of the disease has prognostic value, also suggesting potential effective medical therapy.