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PURPOSE: Response to cardiac resynchronization therapy (CRT) is reduced in patients with high left ventricular (LV) scar burden, in particular when scar is located in the LV lateral wall or septum. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can identity scar, but is not feasible in all patients. This study investigates if myocardial metabolism by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and contractile function by echocardiographic strain are alternatives to LGE-CMR. METHODS: In a prospective multicenter study, 132 CRT candidates (91% with left bundle branch block) were studied by speckle tracking strain echocardiography, and 53 of these by FDG-PET. Regional myocardial FDG metabolism and peak systolic strain were compared to LGE-CMR as reference method. RESULTS: Reduced FDG metabolism (10% could rule out transmural scar with high sensitivity (80%) and high negative predictive value (96%). Neither FDG-PET nor strain identified septal scars (for both, AUC

AimsArrhythmic mitral valve syndrome is linked to life-threatening ventricular arrhythmias. The incidence, morphology and methods for risk stratification are not well known. This prospective study aimed to describe the incidence and the morphology of ventricular arrhythmia and propose risk stratification in patients with arrhythmic mitral valve syndrome.MethodsArrhythmic mitral valve syndrome patients were monitored for ventricular tachyarrhythmias by implantable loop recorders (ILR) and secondary preventive implantable cardioverter-defibrillators (ICD). Severe ventricular arrhythmias included ventricular fibrillation, appropriate or aborted ICD therapy, sustained ventricular tachycardia and non-sustained ventricular tachycardia with symptoms of hemodynamic instability.ResultsDuring 3.1 years of follow-up, severe ventricular arrhythmia was recorded in seven (12%) of 60 patients implanted with ILR [first event incidence rate 4% per person-year, 95% confidence interval (CI) 2–9] and in four (20%) of 20 patients with ICD (re-event incidence rate 8% per person-year, 95% CI 3–21). In the ILR group, severe ventricular arrhythmia was associated with frequent premature ventricular complexes, more non-sustained ventricular tachycardias, greater left ventricular diameter and greater posterolateral mitral annular disjunction distance (all P < 0.02).ConclusionsThe yearly incidence of ventricular arrhythmia was high in arrhythmic mitral valve syndrome patients without previous severe arrhythmias using continuous heart rhythm monitoring. The incidence was even higher in patients with secondary preventive ICD. Frequent premature ventricular complexes, non-sustained ventricular tachycardias, greater left ventricular diameter and greater posterolateral mitral annular disjunction distance were predictors of first severe arrhythmic event.

Objectives This study aimed to assess whether patients with MAD also have disjunction of the tricuspid annulus. Background Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus. Whether the disjunction extends to the right side of the heart is not known. Methods In a cohort of patients with MAD, we assessed the presence of tricuspid annulus disjunction (TAD) with the use of cardiac magnetic resonance. We explored the associations between TAD and MAD characteristics and the relationship to ventricular arrhythmias (nonsustained/sustained ventricular tachycardias and aborted cardiac arrest). Results We included 84 patients (mean age: 48 ± 16 years; 63% female). We observed TAD in 42 (50%). Patients with TAD were older (age 52 ± 16 years vs. 43 ± 15 years; p = 0.02), had greater circumferential extent of MAD (164 ± 57° vs. 115 ± 58°; p = 0.002), greater maximum longitudinal MAD distance (9.4 ± 2.9 mm vs. 6.2 ± 2.8 mm; p Conclusions We report for the first time the existence of right-sided annulus disjunction as a common finding in patients with MAD. TAD was associated with more severe left-sided annulus disjunction and mitral valve prolapse, but not with ventricular arrhythmias.

Background - Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response. Objectives - This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI. Methods - The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days. Results - We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups. Conclusions - Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703)

BACKGROUND: Cardiac resynchronization therapy (CRT) is effective in selective heart failure (HF) patients, but non-response rate remains high. Positron emission tomography (PET) may provide a better insight into the pathophysiology of left ventricular (LV) remodeling; however, its role for evaluating and selecting patients for CRT remains uncertain. PURPOSE: We investigated if regional LV glucose metabolism in combination with myocardial scar could predict response to CRT. METHODS: Consecutive CRT-eligible HF patients underwent echocardiography, cardiac magnetic resonance (CMR), and 18F-fluorodeoxyglucose (FDG) PET within 1 week before CRT implantation. Echocardiography was additionally performed 12 months after CRT and end-systolic volume reduction ≥ 15% was defined as CRT response. Septal-to-lateral wall (SLR) FDG uptake ratio was calculated from static FDG images. Late gadolinium enhancement (LGE) CMR was analyzed semi-quantitatively to define scar extent. RESULTS: We evaluated 88 patients (67 ± 10 years, 72% males). 18F-FDG SLR showed a linear correlation with volumetric reverse remodeling 12 months after CRT (r = 0.41, p = 0.0001). In non-ischemic HF patients, low FDG SLR alone predicted CRT response with sensitivity and specificity of more than 80%; however, in ischemic HF patients, specificity decreased to 46%, suggesting that in this cohort low SLR can also be caused by the presence of a septal scar. In the multivariate logistic regression model, including low FDG SLR, presence and extent of the scar in each myocardial wall, and current CRT guideline parameters, only low FDG SLR and septal scar remained associated with CRT response. Their combination could predict CRT response with sensitivity, specificity, negative, and positive predictive value of 80%, 83%, 70%, and 90%, respectively. CONCLUSIONS: FDG SLR can be used as a predictor of CRT response and combined with septal scar extent, CRT responders can be distinguished from non-responders with high diagnostic accuracy. Further studies are needed to verify whether this imaging approach can prospectively be used to optimize patient selection.

Aims Three distinct septal contraction patterns typical for left bundle branch block may be assessed using echocardiography in heart failure patients scheduled for cardiac resynchronization therapy (CRT). The aim of this study was to explore the association between these septal contraction patterns and the acute haemodynamic and electrical response to biventricular pacing (BIVP) in patients undergoing CRT implantation. Methods and results Thirty-eight CRT candidates underwent speckle tracking echocardiography prior to device implantation. The patients were divided into two groups based on whether their septal contraction pattern was indicative of dyssynchrony (premature septal contraction followed by various amount of stretch) or not (normally timed septal contraction with minimal stretch). CRT implantation was performed under invasive left ventricular (LV) pressure monitoring and we defined acute CRT response as ≥10% increase in LV dP/dtmax. End-diastolic pressure (EDP) and QRS width served as a diastolic and electrical parameter, respectively. LV dP/dtmax improved under BIVP (737 ± 177 mmHg/s vs. 838 ± 199 mmHg/s, P Conclusion Septal contraction patterns are an excellent predictor of acute CRT response. Only patients with premature septal contraction experienced acute systolic, diastolic, and electrical improvement under BIVP.

Objectives This study sought to investigate how regional left ventricular (LV) function modifies septal motion in left bundle branch block (LBBB). Background In LBBB, the interventricular septum often has marked pre-ejection shortening, followed by immediate relengthening (rebound stretch). This motion, often referred to as septal flash, is associated with positive response to cardiac resynchronization therapy (CRT). Methods In 10 anesthetized dogs, we induced LBBB by radiofrequency ablation and occluded the circumflex (CX) (n = 10) and left anterior descending (LAD) (n = 6) coronary arteries, respectively. Myocardial dimensions were measured by sonomicrometry and myocardial work by pressure-segment length analysis. In 40 heart failure patients with LBBB, including 20 with post-infarct scar and 20 with nonischemic cardiomyopathy, myocardial strain was measured by speckle-tracking echocardiography and myocardial work by pressure-strain analysis. Scar was assessed by cardiac magnetic resonance imaging with late gadolinium enhancement. Results During LBBB, each animal showed typical septal flash with pre-ejection shortening and rebound stretch, followed by reduced septal systolic shortening (p Conclusions LV lateral wall dysfunction and scar abolished septal flash and markedly improved septal function in LBBB. Therefore, function and scar in the LV lateral wall should be taken into account when septal motion is used to evaluate dyssynchrony.

Background Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus, frequently found in patients with high-risk arrhythmogenic mitral valve prolapse syndrome. It is unknown whether the annulus disjunction extends to the right side of the heart as tricuspid annulus disjunction (TAD), and whether it is associated with right ventricular electrical instability. Purpose We aimed to explore the presence of TAD, and if extended annulus disjunction was associated with ventricular arrhythmias. Methods We included patients with previously described MAD assessed by cardiac magnetic resonance imaging (CMR) in an ambispective cohort study. MAD and TAD was defined as ≥1 mm separation between the respective atrial wall-valve leaflet junction and the top of the ventricular myocardium. TAD was assessed in the lateral and inferior right ventricular free wall by means of the 4-chamber and right ventricular 2-chamber views, respectively. MAD circumference was assessed by a CMR study protocol with six left ventricular long axis views separated by 30 degrees. Mitral valve prolapse was defined as ≥2 mm superior displacement of any part of the mitral leaflets beyond the mitral annulus. Ventricular arrhythmias were defined as aborted cardiac arrest or non-sustained/sustained ventricular tachycardias recorded by electrocardiogram (ECG), stress ECG or Holter monitoring. Results We included 92 patients with MAD (62% female, age 47±16 years, 71% mitral valve prolapse). TAD was found in 48 (52%) patients, both in the lateral (n=40, 83%) and inferior (n=30, 63%) right ventricular free wall. Patients with TAD were older (age 51±16 years vs. 43±14 years, p=0.01), had greater MAD circumference (168±56° vs. 117±62°, p=0.001) and greater MAD distance (9.2±2.9 mm vs. 6.4±2.8 mm, p Conclusions TAD by CMR was highly prevalent in patients with MAD and was a marker of severe annulus disjunction and mitral valve prolapse. TAD was not associated with more ventricular arrhythmias. This novel marker warrants further research to explore the clinical implications of right-sided annulus disjunction. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Norwegian Research Council

OBJECTIVES: This study sought to investigate if contractile asymmetry between septum and left ventricular (LV) lateral wall drives heart failure development in patients with left bundle branch block (LBBB) and whether the presence of lateral wall dysfunction affects potential for recovery of LV function with cardiac resynchronization therapy (CRT). BACKGROUND: LBBB may induce or aggravate heart failure. Understanding the underlying mechanisms is important to optimize timing of CRT. METHODS: In 76 nonischemic patients with LBBB and 11 controls, we measured strain using speckle-tracking echocardiography and regional work using pressure-strain analysis. Patients with LBBB were stratified according to LV ejection fraction (EF) ≥50% (EFpreserved), 36% to 49% (EFmid), and ≤35% (EFlow). Sixty-four patients underwent CRT and were re-examined after 6 months. RESULTS: Septal work was successively reduced from controls, through EFpreserved, EFmid, and EFlow (all p

Objectives This study describes the cardiac phenotypes and markers of adverse outcome in athletes with ventricular arrhythmias with no other discernable etiology than high exercise doses. Background Little is known about phenotypes and risk markers of life-threatening arrhythmic events in athletes with ventricular arrhythmia. Methods We compared high-performance athletes who have ventricular arrhythmia with healthy controls using clinical data and cardiac imaging. None of the patients had family history of arrhythmogenic cardiomyopathy or any other discernable etiology of ventricular arrhythmia. Right (RV) and left ventricular (LV) function was assessed by echocardiographic longitudinal strain (right ventricular free wall strain longitudinal [RVFWSL] and left ventricular global longitudinal strain [LVGLS]). Mechanical dispersion was defined as the standard deviation of time to peak strain in 16 LV segments. RV ejection fraction and presence of late gadolinium enhancement was assessed by cardiac magnetic resonance. Results We included 43 athletes (45 ± 14 years of age, 16% female) with ventricular arrhythmias and 30 healthy athletes (41 ± 9 years of age, 7% female). Athletes with ventricular arrhythmias had worse RV function than healthy athletes by echocardiography (RVFWSL: −22.9 ± 4.8% vs. −26.6 ± 3.3%; p < 0.001) and by cardiac magnetic resonance (RV ejection fraction 48 ± 7% vs. 52 ± 6%; p = 0.04), and had more late gadolinium enhancement (24% vs. 3%; p = 0.03). Life-threatening arrhythmic events (aborted cardiac arrest, sustained ventricular tachycardia, or appropriate implantable cardioverter-defibrillator therapy) had occurred in 23 (53%) athletes with ventricular arrhythmias. These had impaired LV function compared to those with less severe ventricular arrhythmias (LVGLS: -17.1 ± 3.0% vs. -18.8 ± 2.0%; p = 0.04). LV mechanical dispersion was an independent marker of life-threatening events (adjusted odds ratio: 2.2 [1.1 to 4.8] by 10 ms increments; p = 0.03). Conclusions Athletes with ventricular arrhythmias had impaired RV function and more myocardial fibrosis compared to healthy athletes. Athletes with life-threatening arrhythmic events had additional LV contraction abnormalities. These phenotypes mimic arrhythmogenic cardiomyopathy and may potentially be induced by high doses of exercise in susceptible individuals.

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): The Norwegian Health Association Background Septal dysfunction is a main feature of left bundle branch block (LBBB), and increasing wall stress is a proposed mechanism of heart failure development in LBBB patients. To try to reveal the pathophysiologic pathway from dyssynchrony to heart failure, we investigated the relationship between septal and left ventricular (LV) lateral wall stress in patients with LBBB. Hypothesis Increased septal wall stress causes septal dysfunction in LBBB. Methods We included 24 LBBB-patients (65 ± 11 years, 11 males) with LV ejection fraction (EF) ranging from 18 to 67%, and 8 healthy controls (58 ± 10 years, 4 males). Wall stress was calculated at peak LV pressure (LVP) according to the law of La Place ([LVP x radius]/[wall thickness]). Wall thickness was measured using M-mode, and regional curvature was measured in mid-ventricular shortaxis from 2D echocardiographic images. We used a previously validated non-invasive method to estimate LVP from brachial blood pressure and adjusted for valvular events. Myocardial scar was ruled out by late gadolinium enhancement cardiac magnetic resonance imaging. Results Wall stress was significantly higher in septum than LV lateral wall at peak LVP (48 ± 12 vs 37 ± 11 kPa, p Conclusion Increased septal wall stress is associated with reduced systolic thickening in patients with LBBB. Septal wall thickening, in contrast to LV lateral wall thickening, was correlated to global LV function. These findings suggest that septal remodeling which could have normalized septal wall stress, was not achieved and heart failure may develop. Abstract Figure.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority Norwegian Health Association Background Scar in the left ventricular (LV) posterolateral wall is associated with poor response to cardiac resynchronization therapy (CRT). The impact of septal scar, however, has been less thoroughly investigated. As recovery of septal function seems to be an important effect of CRT, we hypothesized that CRT response depends on septal viability. Aim The aim of the present study was to investigate the association between septal scar and volumetric response to CRT, and to compare the impact of scar located in septum to scar located in the posterolateral wall. Methods 128 patients with symptomatic heart failure undergoing CRT implantation based on current guidelines (ejection fraction 30 ± 8%, QRS-width 164 ± 17 ms) were included in the study. Volumes and ejection fraction were measured by echocardiography using the biplane Simpson’s method at baseline and six months follow up. Non-response was defined as less than 15% reduction in end-systolic volume. Scar was assessed by late gadolinium enhancement cardiac magnetic resonance, and reported as percentage scar per regional myocardial volume. Numbers are given in [median ;10-90% percentile]. Results Scar was present in 62 patients (48%). Scar burden was equal in septum [0% ;0-34%] and the posterolateral wall [0% ;0-36%], p = 0.10. 31 patients (24%) did not respond to CRT. The non-responders had higher scar burden than the responders in both septum [16% ;0-57% vs 0% ;0-23%, p In univariate regression analysis both septal and posterolateral scars correlated with non-response to CRT (r = 0.51 and r = 0.33, respectively). However, combined in a multivariate model only septal scar remained a significant marker of non-response (p Septal scar ≥ 7.1% predicted non-response with a specificity of 81% and a sensitivity of 70% by receiver operating characteristic curve analyses. The area under the curve was 0.79 (95% confidence interval 0.70 – 0.89) (Figure). Conclusions Septal scar is more closely associated with volumetric non-response to CRT than posterolateral scar. Future studies should explore the correlation between regional scar burden and different functional parameters, and how they relate to CRT response. Abstract Figure. Septal scar predicts non-response to CRT

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): The Norwegian Health Association Background Left bundle branch block (LBBB) worsen prognosis in heart failure patients. LBBB may also cause heart failure in otherwise healthy individuals. The mechanical changes induced by LBBB are potential determinants of heart failure in these patients, but their relation to left ventricular (LV) systolic function is incompletely understood. Purpose This study investigates the contribution of regional contractile function to heart failure in patients with LBBB. Methods In 76 patients with LBBB and 11 healthy controls, myocardial strain was measured by speckle-tracking echocardiography and myocardial work by pressure-strain analysis. Patients with ischemic heart disease or myocardial scarring were excluded. LBBB patients were stratified by LV ejection fraction (EF) >50% (EFpreserved), 36-50% (EFmid), and ≤35% (EFlow). 62 LBBB patients subsequently underwent cardiac resynchronization therapy (CRT) implantation and was re-examined at 6 months. Results Septal work was significantly and successively reduced from controls, EFpreserved, EFmid, to EFlow (1977 ± 506, 1025 ± 342, 601 ± 494 and -41 ± 303 mmHg·%, respectively, all p 35% (NS). At six month CRT septal work was markedly increased (165 ± 485 vs 1288 ± 523 mmHg·%, p Conclusions Heart failure in LBBB patients is determined by degree of septal dysfunction. LV lateral wall function, on the other hand, is preserved in the early phase of heart failure and was only reduced in patients with severe heart failure. Further clinical studies should investigate if measuring LV lateral wall function can increase precision in patient selection for CRT. Abstract Figure.

Background Myocardial scar presence and extent, has a considerable influence on response to cardiac resynchronization therapy (CRT). Apical rocking (ApRock) and septal flash (SF) are associated with favourable outcome after CRT. Little is known however to which extent visual assessment of mechanical dyssynchrony by ApRock, SF and scar predicts CRT response. We therefore investigated, if additional scar assessment by cardiac magnetic resonance imaging (MRI) adds to the predictive value of the visual evaluation of echocardiographic images in CRT candidates. Methods A total of 201 unselected patients referred for CRT, who fulfil the contemporary guidelines for CRT implantation, were enrolled in this prospective multicentre study. Two experienced observers visually assessed echocardiographic images before CRT implantation, focussing on the presence of ApRock, SF and location and extent of scar segments of the left ventricle (LV), resulting in a CRT response prediction (i.e. Integrative Prediction). A third observer provided a consensus reading in case of disagreement. All observers were blinded to all patient information other than the ischaemic aetiology of heart failure. Independent from that, segmental myocardial scar burden was objectified by late gadolinium enhancement (LGE) cardiac MRI (LGE > 50%). CRT response was defined as ≥15% reduction in LV end-systolic volume on echocardiography, one year after device implantation. Results Overall, 69 (34%) patients had an ischaemic aetiology of heart failure. Before CRT, ApRock and SF were present in 129 (64%) and 136 (68%) patients, respectively. ApRock and SF alone predicted CRT response with an area under the curve (AUC) of 0.85 (95% CI: 0.79-0.91) and 0.84 (95% CI: 0.77-0.91) (Figure A), while the echocardiographic Integrative Prediction had an AUC of 0.90 (95% CI: 0.84-0.95), with a sensitivity of 93% and a specificity of 87% for the prediction of CRT response (Figure B) (p Conclusions An integrative visual assessment of LV function has an excellent predictive value for CRT response. Our data show, that the echocardiographic estimation of scar burden is sufficiently accurate and cannot be further improved by an additional MRI scar assessment. Abstract 160 Figure.

Funding Acknowledgements The study was supported by Center for Cardiological Innovation. Introduction Septal dysfunction is the dominant mechanism of left ventricular (LV) failure in left bundle branch block (LBBB). We hypothesize that, provided septum is viable, septal function can recover and hence LV function improve after cardiac resynchronization therapy (CRT). Purpose To determine if combined assessment of septal function and viability identifies responders to CRT. Methods In a prospective multicenter study of 200 unselected patients referred for CRT, we measured myocardial strain by speckle-tracking echocardiography and regional work by pressure-strain analysis before and 7 ± 1 months after CRT. Viability was assessed by late gadolinium enhancement cardiac magnetic resonance imaging (n = 123). CRT response was defined as ≥15% reduction in LV end-systolic volume. Results Before CRT, septal work was 258 ± 463 and LV lateral wall work 1469 ± 674 mmHg·% (p 150 ms. Conclusions The proposed combined approach with assessment of septal work and viability identified CRT responders with high precision. Abstract 561 Figure.

Background: Prompt myocardial revascularisation with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with acute ST segment elevation myocardial infarction (STEMI). However, as much as 50 % of the loss of viable myocardium may be attributed to the subsequent reperfusion injury and the associated inflammatory response. The aim of the ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction (ASSAIL-MI) trial was to evaluate the effect of interleukin-6 (IL-6) receptor inhibition on myocardial salvage in acute STEMI. Methods: The ASSAIL-MI trial was a randomised, double blind, placebo-controlled trial performed at three high-volume PCI centres in Norway. Patients admitted with STEMI within six hours of symptom onset were eligible if they had had no prior myocardial infarction. Consenting patients were randomised in a 1:1 fashion to receive a single infusion of the IL-6 receptor inhibitor tocilizumab or placebo during PCI. The primary endpoint was the myocardial salvage index as measured by cardiac magnetic resonance imaging three to seven days after randomisation. Findings: Between 16 th March 2017 and 10 th February 2020, 101 patients were randomised to tocilizumab and 98 patients were randomised to placebo. In the intention to treat analysis, the myocardial salvage index was 69 ± 19 % in patients allocated to tocilizumab and 64 ± 21 % in the placebo group (adjusted between-group difference 5.6 percentage points, 95 % confidence interval 0·0 – 11·3 percentage points, p = 0 · 04). There were 34 serious adverse events, 19 of which occurred in patients treated with tocilizumab and 15 in patients receiving placebo.Interpretation: Treatment with tocilizumab significantly improved myocardial salvage in patients presenting with acute STEMI. Funding: The South-Eastern Norway Regional Health Authority, the Central Norway Regional Health Authority, and Roche TM supported the trial. Roche™ provided the investigational medicinal products and an unrestricted grant. Trial registration number: ClinicalTrials.gov (NCT3004703). Funding Statement: The South-Eastern Norway Regional Health Authority, the Central Norway Regional Health Authority, and RocheTM supported the trial. Roche™ provided the investigational medicinal products and an unrestricted grant. Declaration of Interests: Dr Gullestad has received lecture fees from AstraZeneca, Boehringer Ingelheim, Novartis and Amgen and has been a member of local advisory board in AstraZeneca and Boehringer Ingelheim. The other authors do not have conflicts of interest pertaining to this work. Ethics Approval Statement: The trial protocol was approved by the regional ethics committee (REK Sor-Ost 2016/1223), and all participants provided written informed consent. An independent data and safety monitoring board oversaw the safety of the trial. The trial was conducted in compliance with the declaration of Helsinki and with the rules outlined in the guidelines for Good Clinical Practice.

Funding Acknowledgements The study was supported by Center for Cardiological Innovation Background Many patients referred for cardiac resynchronization therapy (CRT) do not respond to the treatment. Scar either in septum or the left ventricular (LV) lateral wall, as well as global scar burden, influence the outcome negatively. Preoperative scar assessment is therefore recommended in this patient group. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is considered reference standard for scar detection, but is not always available. Purpose To investigate the ability of advanced echocardiographic and nuclear imaging techniques to detect septal and left ventricular (LV) lateral wall scar in patients referred for CRT, compared to late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR). Methods Scar was quantified as percentage segmental LGE in 131 patients (age 66 ± 10, 66% male, QRS-width 164 ± 17ms) referred for CRT, 92% with left bundle branch block (LBBB). Longitudinal strain was assessed by speckle tracking echocardiography in 130 patients (641 septal and 630 LV lateral wall segments). Wall motion score index (WMSI) was assessed visually in all patients by an experienced operator, and graded from one to four. Glucose metabolism was assessed by 18F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) in 52 patients. Perfusion was assessed in 46 patients by either 13N-ammonia PET (n = 32) or Single Photon Emission Computed Tomography (SPECT) (n = 14). Metabolism and perfusion were reported as percentages of the segment with maximum tracer uptake. The ability of each parameter to identify scar was evaluated with receiver operating characteristic (ROC) curves with calculation of area under the curve (AUC) and 95% confidence interval (CI). AUC≥0.800 was considered reasonable agreement with LGE. Results Scar was present in 574 of total 2090 interpretable segments (79% ischemic etiology). Globally, perfusion (AUC = 0.845, 95% CI 0.777-0.914) and glucose metabolism (AUC = 0.807, 95% CI 0.758-0.855) adequately detected transmural scars, but not smaller scars (all AUC Conclusions Neither echocardiographic nor nuclear imaging techniques can replace LGE-CMR in scar assessment prior to CRT. Septum is especially challenging, explained by LBBB-induced reduction in strain, metabolism and perfusion in this region. Abstract P975 Figure. Detection of transmural septal scar

Funding Acknowledgements The study was supported by Center for Cardiological Innovation Background Myocardial scar burden (focal fibrosis) is associated with poor response to cardiac resynchronization therapy (CRT), and should preferably be detected prior to device implantation. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) is considered reference standard for scar detection, but is not available in renal failure. Diffuse fibrosis is assessed by T1 mapping CMR with or without calculation of extracellular volume fraction (ECV). The method is vulnerable to partial volume effects, thus subendocardial tissue is most often not included in mapping analyses. Whether the contrast-free native T1mapping could replace LGE in the preoperative evaluation of patients referred for CRT is unknown. Purpose To investigate if native T1 mapping and calculation of ECV can adequately detect scar in patients referred for CRT. Methods Scar was quantified as percentage segmental LGE in 45 patients (age 65 ± 10 years, 71% male, QRS-width 165 ± 17ms) referred for CRT. In total 720 segments were analyzed, and LGE≥50% was considered transmural scar. T1-mapping before and after contrast agent injection was performed in all patients. ECV was calculated based on the ratio between tissue T1 relaxation change and blood T1 relaxation change after contrast agent injection, corrected for the haematocrit level. The agreement between native T1/ECV and scar was evaluated with receiver operating characteristic (ROC) curves with calculation of area under the curve (AUC) and 95% confidence interval (CI). Results LGE was present in 255 segments, 465 segments were without LGE. Average native T1 in segments with LGE was 1028 ± 88 ms, and 1040 ± 60 ms in segments without LGE (p = 0.16). The corresponding numbers for ECV were 38.7 ± 10.9% and 30.0 ± 4.7%, p Conclusion The contrast-free CMR technique T1 mapping does not adequately detect scars in patients referred for CRT. Adding post contrast T1 measurements and calculating ECV improves accuracy, especially for transmural scars. Future studies should investigate if diffuse fibrosis could be predictive of CRT response. Abstract P1585 Figure. Detection of transmural scars

Aims Investigating the acute impact of cardiac resynchronization therapy (CRT) on regional myocardial work distribution in the left ventricle (LV) and to which extent it is related to long-term reverse remodelling. Methods and results One hundred and thirty heart failure patients, referred for CRT implantation, were recruited in our prospective multicentre study. Regional myocardial work was calculated from non-invasive segmental stress–strain loop area before and immediately after CRT. The magnitude of volumetric reverse remodelling was determined from the change in LV end-systolic volume, 11 ± 2 months after implantation. CRT caused acute redistribution of myocardial work across the LV, with an increase in septal work, and decrease in LV lateral wall work (all P Conclusion The acute redistribution of regional myocardial work between the septal and lateral wall of the LV is an important determinant of reverse remodelling after CRT implantation. Our data suggest that the treatment of the loading imbalance should, therefore, be the main aim of CRT.

Aims Left ventricular (LV) failure in left bundle branch block is caused by loss of septal function and compensatory hyperfunction of the LV lateral wall (LW) which stimulates adverse remodelling. This study investigates if septal and LW function measured as myocardial work, alone and combined with assessment of septal viability, identifies responders to cardiac resynchronization therapy (CRT). Methods and results In a prospective multicentre study of 200 CRT recipients, myocardial work was measured by pressure-strain analysis and viability by cardiac magnetic resonance (CMR) imaging (n = 125). CRT response was defined as ≥15% reduction in LV end-systolic volume after 6 months. Before CRT, septal work was markedly lower than LW work (P Conclusion Assessment of myocardial work and septal viability identified CRT responders with high accuracy.

Background Assessment of qualitative or subjective image quality in radiology is traditionally performed using a fixed-point scale even though reproducibility has proved challenging. Objective Image quality of 3-T coronary magnetic resonance (MR) angiography was evaluated using three scoring methods, hypothesizing that a continuous scoring scale like visual analogue scale would improve the assessment. Materials and methods Adolescents corrected for transposition of the great arteries with arterial switch operation, ages 9–15 years (n=12), and healthy, age-matched controls (n=12), were examined with 3-D steady-state free precession magnetic resonance imaging. Image quality of the coronary artery origin was evaluated by using a fixed-point scale (1–4), visual analogue scale of 10 cm and a visual analogue scale with reference points (figurative visual analogue scale). Satisfactory image quality was set to a fixed-point scale 3=visual analogue scale/figurative visual analogue scale 6.6 cm. Statistical analysis was performed using Cohen kappa coefficient and agreement index. Results The mean interobserver scores for the fixed-point scale, visual analogue scale and figurative visual analogue scale were, respectively, in the left main stem 2.8, 5.7, 7.0; left anterior descending artery 2.8, 4.7, 6.6; circumflex artery 2.5, 4.5, 6.2, and right coronary artery 3.2, 6.3, 7.7. Scoring with a fixed-point scale gave an intraobserver κ of 0.52–0.77 while interobserver κ was lacking. For visual analogue scale and figurative visual analogue scale, intraobserver agreement indices were, respectively, 0.08–0.58 and 0.43–0.71 and interobserver agreement indices were up to 0.5 and 0.65, respectively. Conclusion Qualitative image quality evaluation with coronary 3-D steady-state free precession MR angiography, using a visual analogue scale with reference points, had better reproducibility compared to a fixed-point scale and visual analogue scale. Image quality, being a continuum, may be better determined by this method.

Objectives To present nine patients with an abnormal widened bony Eustachian tube running anteriorly in the skull base through the sphenoid bone. Methods Patients with a particular anomaly in the bony Eustachian tube incidentally found on CT examinations were registered consecutively over a period of four years. Results Nine patients had the anomaly, eight unilaterally and one bilaterally. All our patients had additional anomalies involving the outer, middle, and/or inner ear. Conclusion The consequences of this anomaly remain unknown, but the presence of the widened, bony ET should increase the awareness for complex temporal bone deformities and vice versa. Level of Evidence 4.

Aims A difficult cardiac resynchronization therapy (CRT) implantation scenario emerges when no lateral pacing option exists. The aim of this study was to explore the effect of biventricular pacing (BIVP) on vectorcardiographic parameters in patients with a non-lateral left ventricular (LV) lead position. We hypothesized that perimeter and area reduction for both the QRS complex and T-wave would predict acute CRT response. Methods and results Twenty-six patients (14 ischaemic) with a mean age of 63 ± 10 years and standard CRT indication underwent device implantation with continuous LV pressure registration. The LV lead was placed in either an anterior or apical position. Biventricular pacing was performed at a rate 10% above intrinsic rhythm with acute CRT response defined as LV ΔdP/dtmax >10%. Using this criterion 12 patients were identified as acute CRT responders (responders: 16.7 ± 4.8% vs. non-responders: 1.9 ± 5.3%, P

IntroductionInterleukin-6 (IL-6) may be involved in ischaemia-reperfusion injury and myocardial remodelling after myocardial infarction (MI). We have recently shown that IL-6 inhibition by tocilizumab attenuates systemic inflammation and troponin T-release in patients with acute non-ST elevation MI (NSTEMI). Experimental studies suggest that IL-6 inhibition can limit infarct size through anti-inflammatory mechanisms, but this has not been tested in clinical studies. With the ASSessing the effect of Anti-IL-6 treatment in MI (ASSAIL-MI) trial, we aim to examine whether a single administration of the IL-6 receptor antagonist tocilizumab can increase myocardial salvage in patients with acute ST-elevation MI (STEMI).Methods and analysisThe ASSAIL-MI trial is a randomised, double blind, placebo-controlled trial, conducted at three high-volume percutaneous coronary intervention (PCI) centres in Norway. 200 patients with first-time STEMI presenting within 6 hours of the onset of chest pain will be randomised to receive tocilizumab or matching placebo prior to PCI. The patients are followed-up for 6 months. The primary endpoint is the myocardial salvage index measured by cardiac MRI (CMR) 3–7 days after the intervention. Secondary endpoints include final infarct size measured by CMR and plasma markers of myocardial necrosis. Efficacy and safety assessments during follow-up include blood sampling, echocardiography and CMR.Ethics and disseminationBased on previous experience the study is considered feasible and safe. If tocilizumab increases myocardial salvage, further endpoint-driven multicentre trials may be initiated. The ASSAIL-MI trial has the potential to change clinical practice in patients with STEMI.RegistrationClinicaltrials.gov, identifier NCT03004703.

Background Myocardial scar is frequently present in patients with heart failure and left bundle branch block (LBBB), and associated with reduced response to cardiac resynchronization therapy (CRT). Furthermore, LBBB may be associated with markedly reduced strain, work, metabolism and perfusion in septum, even without septal ischemia. Therefore, it may be challenging to identify scar by functional imaging methods. Purpose To investigate the ability of advanced echocardiographic and nuclear imaging techniques to detect septal and left ventricular (LV) lateral wall scar in patients referred for CRT, compared to late gadolinium enhancement (LGE) cardiac magnetic resonance. Methods Scar was quantified as percentage LGE in five septal and five LV lateral wall segments of 131 patients (age 66±10, 66% male, QRS-width 164±17ms) referred for CRT, 92% with LBBB. Longitudinal strain was assessed by speckle tracking echocardiography in 130 patients (652 septal and 631 LV lateral wall segments). Myocardial work was calculated by LV pressure-strain analysis. Systolic shortening defined positive work, while systolic lengthening defined negative work. Glucose metabolism was assessed by 18F-fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) in 52 patients (260 septal and 260 LV lateral wall segments). Perfusion was assessed in 46 patients (230 septal and 230 LV lateral wall segments) by either 13N-ammonia PET (n=32) or Single Photon Emission Computed Tomography (SPECT) (n=14). Metabolism and perfusion were reported as percentages of the segment with maximum tracer uptake. We evaluated parameter relationship to scar with Spearman correlation (rs) and regression analysis. Results LGE was present in 198 septal (30%) and 136 LV lateral wall (21%) segments. In a multivariate regression model with negative work, metabolism, perfusion and peak strain, only the first three parameters showed a significant association with LGE percent in septum (p In the LV lateral wall, however, negative work did not shown a significant association with percentage LGE in univariate regression analysis (p=0.109). In a multivariate regression model positive work, metabolism and perfusion correlated with percentage LGE (p=0.049, p=0.008 and p Two representative patients Conclusions Septal negative work correlates inversely with septal scar in patients referred for CRT. This finding is probably linked to LBBB, and may be explained by increased stiffness of scar tissue. Myocardial work, but not peak strain, reflects scar in the LV lateral wall. Future studies should explore the assessment of scar in the complete LV and how this relates to CRT response.

Background In patients with dilated cardiomyopathy and left bundle branch block (LBBB), different regions of the left ventricle (LV) have been shown to perform different amounts of work. In this study, we investigate the acute impact of cardiac resynchronization therapy (CRT) on regional LV work distribution and its relation to long-term reverse-remodelling. Methods We recruited 130 heart failure patients, referred for CRT. Regional myocardial work was calculated from non-invasive echocardiographic segmental stress-strain-loop-area before and immediately after CRT. The magnitude of volumetric reverse-remodelling was determined from the change in LV end-systolic volume (ESV), 11±2 months after implantation. Characteristics of patients with the lowest and highest quartile of LV ESV reverse remodelling (ΔLV ESV −48%) were compared. Results Before CRT, myocardial work showed significant differences among the walls of the LV (Figure 1A). CRT caused an acute re-distribution of myocardial work, on average with most increase in the septum and most decrease laterally (all walls p Figure 1 Conclusions The acute re-distribution of regional myocardial work between the septal and lateral wall of the left ventricle is the main determinant of long term reverse-remodelling after CRT-implantation. Our data suggest that modification of regional loading is the mode of action of CRT treatment.

Introduction Cardiac resynchronization therapy (CRT) has evolved as an important treatment in patients with symptomatic heart failure, reduced left ventricular (LV) ejection fraction and wide QRS. However, as one third of patients do not benefit from the therapy, there is need for better selection criteria. Previous studies have shown an association between recovery of septal function and response to CRT. Purpose To test the hypothesis that septal dysfunction in the absence of scar predicts response to CRT. Methods In 121 patients undergoing CRT implantation according to current European Society of Cardiology guidelines, we performed speckle-tracking echocardiography and estimated LV pressure non-invasively based on a method recently innovated in our lab. Pressure-strain analysis was used to calculate myocardial work. Septal dysfunction with asymmetric LV workload was calculated as the difference between LV lateral wall and septal work. Late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) was performed to assess septal scar. CRT response was defined as ≥15% reduction of LV end systolic volume by echocardiography at 6 months follow-up. Results Eighty-eight patients (73%) responded to CRT at 6 months follow-up. Multivariate logistic regression analysis including lateral-to-septal work difference, septal scar, QRS duration and QRS morphology found that only lateral-to-septal work difference and septal scar were significant predictors of CRT response (both p Conclusions A multimodality approach with strain echocardiography and LGE-CMR was able to detect CRT responders with high accuracy, also in the subset of patients with intermediate QRS duration. A dysfunctional but viable septum appears to be an ideal target for CRT.

Background Strain is a more sensitive and precise parameter than ejection fraction (EF) for detection and characterization of subclinical left ventricular (LV) dysfunction and remodeling. Similar relationship is expected for right ventricle (RV); however RV functional parameters are less validated. Feature tracking strain analysis based on standard cardiac magnetic resonance (CMR) cine imaging is available for both ventricles. We experience a large slice-to-slice variation for RV global circumferential strain (GCS), possibly making the parameter vulnerable to minute position changes. Purpose To evaluate slice-to-slice differences in RV GCS for identification of the least variation region in a patient group without regional RV disease, in order to achieve a robust method for measurement. Hypothesis The slice-to-slice difference in peak GCS is lower in the mid-ventricular part of the RV than in the basal and apical parts. Methods 50 patients 6–72 months after pulmonary embolism without other major cardiopulmonary disease were included; mean age 60 years (range: 18–75 years); 68% men. Standard 2D cine CMR was obtained in longitudinal planes and in 10–12 consecutive 10 mm short axis planes for complete coverage of the RV. RV free wall and the inner contour of the septum were manually segmented on every end-diastolic and end-systolic slice from the pulmonary valve to the apex for feature tracking strain analysis. Peak RV GCS for every short axis slice and GCS difference (absolute percentage points) between adjacent slices were calculated. RV EF and peak RV GLS from the 4-chamber image were measured for correlation to RV GCS. Wilcoxon signed rank test and Pearson correlation were performed. Confidence intervals of means are based on 1000 bootstrap samples. Results RV EF was 46.6% (95% CI: 44.3; 48.8), RV peak GLS was −17.6% (95% CI: −18.6; −16.6). RV mid-ventricular GCS was −10.9% (95% CI: −12.0; −9.9). RV peak GCS slice-to-slice difference was 6.8 absolute percentage points (95% CI: 6.0; 7.6) in the basal part, 2.7 (95% CI: 2.4; 3.0) in the mid-ventricular part and 4.6 (95% CI: 3.9; 5.3) apically. Difference was significantly lower in mid-ventricular (p RV EF correlated to RV peak GLS (r: −0.397, p=0.004) and mid-ventricular peak GCS (r: −0.356, p=0.01) but not to basal or apical peak GCS. RV peak GLS correlated to basal and mid-ventricular peak GCS (r: 0.313, p=0.03 and r: 0.301, p=0.03 respectively) but not to apical peak GCS. Figure 1 shows slice-to-slice difference (expressed in absolute percentage points) in right ventricular peak GCS. Conclusion Slice-to-slice difference in RV peak GCS was significantly lower in the mid-ventricular region. Large differences in the basal and apical parts indicate that measurements largely depend on slice positioning.

Aims Regional myocardial work may be assessed by pressure–strain analysis using a non-invasive estimate of left ventricular pressure (LVP). Strain by speckle tracking echocardiography (STE) is not always accessible due to poor image quality. This study investigated the estimation of regional myocardial work from strain by feature tracking (FT) cardiac magnetic resonance (CMR) and non-invasive LVP. Methods and results Thirty-seven heart failure patients with reduced ejection fraction, left bundle branch block (LBBB), and no myocardial scar were compared to nine controls without LBBB. Circumferential strain was measured by FT-CMR in a mid-ventricular short-axis cine view, and longitudinal strain by STE. Segmental work was calculated by pressure–strain analysis. Twenty-five patients underwent 18F-fluorodeoxyglucose (FDG) positron emission tomography. Segmental values were reported as percentages of the segment with maximum myocardial FDG uptake. In LBBB patients, net CMR-derived work was 51 ± 537 (mean ± standard deviation) in septum vs. 1978 ± 1084 mmHg·% in the left ventricular (LV) lateral wall (P Conclusion FT-CMR in combination with non-invasive LVP demonstrated markedly reduced work in septum compared to the LV lateral wall in patients with LBBB. Work distribution correlated with STE-derived work and energy demand as reflected in FDG uptake. These results suggest that FT-CMR in combination with non-invasive LVP is a relevant clinical tool to measure regional myocardial work.

Objectives It has long been known that cochlear implantation may cause loss of residual hearing and vestibular function. Different insertion depths may cause varying degrees of intracochlear trauma in the apical region of the cochlea. The present study investigated the correlation between the insertion depth and postoperative loss of residual hearing and vestibular function. Design Thirty-nine adults underwent unilateral cochlear implantation. One group received a Med-El +Flex electrode array (24 mm; n = 4), 1 group received a Med-El +Flex electrode array (28 mm; n = 18), and 1 group received a Med-El +Flex electrode array (31.5 mm; n = 17). Residual hearing, cervical vestibular-evoked myogenic potentials, videonystagmography, and subjective visual vertical/horizontal were explored before and after surgery. The electrode insertion depth and scalar position were examined with high-resolution rotational tomography after implantation in 29 subjects. Results There was no observed relationship between the angular insertion depth (405° to 708°) and loss of low-frequency pure-tone average. Frequency-specific analysis revealed a weak relationship between the angular insertion depth and loss of hearing at 250 Hz (R= 0.20; p = 0.02). There was no statistically significant difference in the residual hearing and vestibular function between the +Flex and the +Flex electrode array. Eight percent of the cases had vertigo after surgery. The electrode arrays were positioned inside the scala tympani and not scala vestibuli in all subjects. In 18% of the cases, the +Flex electrode array was not fully inserted. Conclusions The final outcome in residual hearing correlates very weakly with the angular insertion depth for depths above 405°. Postoperative loss of vestibular function did not correlate with the angular insertion depth or age at implantation. The surgical protocol used in this study seems to minimize the risk of postoperative vertigo symptoms.

This study sought to investigate how regional left ventricular (LV) function modifies septal motion in left bundle branch block (LBBB).In LBBB, the interventricular septum often has marked pre-ejection shortening, followed by immediate relengthening (rebound stretch). This motion, often referred to as septal flash, is associated with positive response to cardiac resynchronization therapy (CRT).In 10 anesthetized dogs, we induced LBBB by radiofrequency ablation and occluded the circumflex (CX) (n = 10) and left anterior descending (LAD) (n = 6) coronary arteries, respectively. Myocardial dimensions were measured by sonomicrometry and myocardial work by pressure-segment length analysis. In 40 heart failure patients with LBBB, including 20 with post-infarct scar and 20 with nonischemic cardiomyopathy, myocardial strain was measured by speckle-tracking echocardiography and myocardial work by pressure-strain analysis. Scar was assessed by cardiac magnetic resonance imaging with late gadolinium enhancement.During LBBB, each animal showed typical septal flash with pre-ejection shortening and rebound stretch, followed by reduced septal systolic shortening (p 0.01). CX occlusion caused LV lateral wall dysfunction and abolished septal flash due to loss of rebound stretch (p 0.0001). Furthermore, CX occlusion restored septal systolic shortening to a similar level as before induction of LBBB and substantially improved septal work (p 0.001). LAD occlusion, however, accentuated septal flash by increasing rebound stretch (p 0.05). Consistent with the experimental findings, septal flash was absent in patients with LV lateral wall scar due to lack of rebound stretch (p 0.001), and septal systolic shortening and septal work far exceeded values in nonischemic cardiomyopathy (p 0.0001). Septal flash was present in most patients with anteroseptal scar.LV lateral wall dysfunction and scar abolished septal flash and markedly improved septal function in LBBB. Therefore, function and scar in the LV lateral wall should be taken into account when septal motion is used to evaluate dyssynchrony.

Purpose Balloon dilation of the Eustachian tube is a treatment option for obstructive Eustachian tube dysfunction. The desired balloon position is in the cartilaginous portion. However, the balloon catheter may slide into the bony portion without the surgeon's knowledge. Knowing the length of the cartilaginous portion may improve catheter positioning, but there is no published research on measuring this portion selectively or on whether the length has an impact on development of disease or treatment outcome. To evaluate whether a measurement obtained from CT images is valuable and accurate, to standardize the manner of which the length is measured, and to compare our radiologic measurements to procedural findings, we designed a combined study. Further, we tested the length's influence on development of disease and treatment outcome. Methods Anatomical end points of the cartilaginous part of the Eustachian tube were unambiguously defined. The length was retrospectively measured bilaterally in 29 CT examinations by two radiologists, and repeated by one after two weeks. New reformats and measurements were made after 18 months for 10 of the patients. Prospectively 10 patients were included in a study where the length measured on CT was compared to per-procedural measurements based on catheter insertion depth to isthmus. Various parameters including length and treatment outcome were measured in 69 patients and 34 controls. Results Correlation was adequate to excellent in all comparisons. The length of the cartilaginous Eustachian tube did not predict treatment outcome or disease development. The lengths were significantly shorter in females. Conclusion Measuring the cartilaginous portion of the Eustachian tube on CT images is precise and reproducible, and reflects the length measured intraoperatively. However, it does not seem have a prognostic value.

Myocardial scar burden is an important prognostic factor after myocardial infarction. This cohort study compared assessment of left ventricle scar burden between pathological Q waves on electrocardiography (ECG), Selvester multiparametric ECG scoring system for scar burden, and global longitudinal strain (GLS) by speckle-tracking echocardiography 6 months after myocardial infarction. The scar burden was defined by late gadolinium enhancement cardiac magnetic resonance as fraction of total left ventricle tissue. ECG measures were presence of pathologic Q waves and Selvester scores. GLS was the average of peak strain from 16 left ventricle segments. In 34 patients aged 58 ± 10 years (mean ± SD), the scar burden was 19% (9, 26) (median [quartiles]) and 79% had scar burden >5%. Patients with scar burden >5% more frequently had pathologic Q waves (63% vs 14%) and had worse Selvester scores (5 [3, 7] vs 0 [0, 1]) and worse GLS (−16.6 ± 2.4% vs −19.9 ± 1.1%). Pathologic Q waves, Selvester scores, ejection fraction, and GLS related to scar burden in univariable analyses. Sensitivity and specificity for detecting scar burden >5% was 63% and 86% (pathologic Q waves), 89% and 86% (Selvester score), 81% and 86% (ejection fraction), 89% and 86% (GLS), and 96% and 71% (combination of Q waves, Selvester score, and GLS). In conclusion, Selvester score and GLS related to scars 6 months after myocardial infarction, and pathologic Q waves were only weakly associated with scar and GLS was associated with scar independently of ECG markers.

To evaluate the effect of the intracochlear electrode position on the residual hearing and VNG- and cVEMP responses.Prospective pilot study.Thirteen adult patients who underwent unilateral cochlear implant surgery were examined with high-resolution rotational tomography after cochlear implantation. All subjects were also tested with VNG, and 12 of the subjects were tested with cVEMP and audiometry before and after surgery.We found that although the electrode was originally planned to be positioned inside the scala tympani, only 8 of 13 had full insertion into the scala tympani. Loss of cVEMP response occurred to the same extent in the group with full scala tympani positioning and the group with scala vestibuli involvement. There was a non-significant difference in the loss of caloric response and residual hearing between the two groups. Interscalar dislocation of the electrode inside the cochlea was observed in two patients. A higher loss of residual hearing could be seen in the group with electrode dislocation between the scalae.Our findings indicate that intracochlear electrode dislocation is a possible cause to loss of residual hearing during cochlear implantation but cannot be the sole cause of postoperative vestibular loss.

BackgroundPatient-specific left ventricular (LV) lead optimisation strategies with immediate feedback on cardiac resynchronisation therapy (CRT) effectiveness are needed. The purpose of this study was to compare contractility surrogates derived from biventricular lead motion analysis to the peak positive time derivative of LV pressure (dP/dtmax) in patients undergoing CRT implantation.MethodsTwenty-seven patients underwent CRT implantation with continuous haemodynamic monitoring. The right ventricular (RV) lead was placed in apex and a quadripolar LV lead was placed laterally. Biplane fluoroscopy cine films facilitated construction of three-dimensional RV–LV interlead distance waveforms at baseline and under biventricular pacing (BIVP) from which the following contractility surrogates were derived; fractional shortening (FS), time to peak systolic contraction and peak shortening of the interlead distance (negative slope). Acute haemodynamic CRT response was defined as LV ∆dP/dtmax ≥ 10 %.ResultsWe observed a mean increase in dP/dtmax under BIVP (899±205 mm Hg/s vs 777±180 mm Hg/s, pmax, 18 patients were classified as acute CRT responders and nine as non-responders (23.3%±10.6% vs 1.9±5.3%, pConclusionThe baseline RV–LV interlead distance was associated with echocardiographic LV dimensions. In CRT recipients, contractility surrogates derived from the RV–LV interlead distance waveform could not discriminate between acute haemodynamic responders and non-responders.