Abstract Funding Acknowledgements Type of funding sources: None. Introduction The optimal lead position for right ventricle (RV) pacing is still a matter of debate. Several studies compared 2D-echocardiography left ventricle ejection fraction (LVEF) and LV global longitudinal strain (LVGLS) by speckle-tracking imaging (STI). However, these parameters present limitations, such as load dependency. Recently, myocardial work (MW) has emerged as an alternative tool for myocardial systolic function assessment. Purpose To compare LV MW and LVGLS between patients with RV outflow tract/septum pacing (Group1) and RV apical pacing (Group2). Methods Prospective single-center study of patients with permanent pacemaker (PMK) followed at our cardiac device’s outpatient clinic between july and november of 2022. Patients were divided into two groups according to RV pacing site. Moderate/severe valvular disease, LVEF<50%, segmental wall-motion abnormalities, pulmonary hypertension, cardiomyopathies, or RV dysfunction were exclusion criteria. STI-based LVGLS analysis and MW parameters were obtained (GWI:Global Work Index; GCW:Global Constructive Work; GWW:Global Wasted Work; GWE:Global Work Efficiency). RV pacing was required at the moment of imaging. A 12-lead ECG was also performed. Blood pressure (BP) was simultaneously measured. Results Our cohort comprised 30 patients in group 1 and 25 patients in group 2. The 2 groups were well-matched, except for the median time since PMK implantation, which was significantly higher in Group2 (5.3years vs 0.9years, p<0.001). The QRS was significantly narrower in Group1 (Group1:129ms±9 vs Group2:165ms±15, p<0.001). LVEF was similar in both groups (Group1:58%±7.5 vs Group2:60%±7.5, p = NS). Likewise, both systolic and diastolic BP were comparable (p = NS), but LVGLS was significantly higher in Group1 (15±3.3 vs 13±3.7, p = 0.043). Except for GWI which was also significantly higher in Group1 (1553mmHg%±581 vs 1238mmHg%±516, p = 0.040), no significant differences were found in the other parameters of MW among the groups (all p = NS). Conclusion Our results point to LVGLS being significantly lower in the group of RV apical pacing. Despite most parameters of MW didn’t differ between groups, GWI also showed significant impairment. These findings should be regarded as preliminary and further larger studies are needed to ascertain the value of this new tool in understanding the impact of pacing depolarization site on LV mechanics.

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although the perceived prognosis of patients with precapillary pulmonary hypertension (PH) is poor, the natural history of this condition is very heterogeneous. In this study we sought to identify predictors of poor outcomes which could help refine prognosis. Methods We studied consecutive patients referred to our centre from 12/2016 to 11/2018 with confirmed precapillary PH. A range of clinical, laboratory, echocardiographic and right heart catheterization (RHC) data variables were collected to assess predictors of survival. Outcome was defined as mortality from any cause. Results Of the 80 included patients, 51 (64%) were female and mean age was 60.5 ± 16.0 years. The majority of patients (45%) had pulmonary arterial hypertension (group 1) and 41% were chronic thromboembolic pulmonary hypertensive disease patients (group 4). During a median follow-up of 18.7 [IQR 12.3 – 26.7] months, 10 patients (12.5%) died. New York Heart Association (NYHA) functional class (HR 19.4 [95% CI 2.56 - 147.5], p = 0.004) was the strongest predictor of mortality, whereas higher haemoglobin (HR 0.70 [0.49 - 0.99], p= 0.047) and 6-minute walking distance (6MWD) expressed as percentage of predicted (HR 0.96 [0.93 - 0.99], p = 0.004) were associated with better survival overall. Echocardiographic parameters such as eccentricity index (HR 3.35 (95% CI 1.11 - 10.0), p = 0.031), short pulmonary acceleration time (HR 0.98 [95% CI 0.96 - 0.99], p = 0.008), the presence of moderate to severe tricuspid regurgitation (HR 6.46 [95% CI 1.67 - 25.0], p = 0.007) and pericardial effusion (HR 3.86 [95% CI 1.12 - 13.4], p = 0.033) were also associated with death. Traditional right ventricular function parameters such as fractional area change, tricuspid annular plane systolic excursion (TAPSE) and S velocity of the lateral annular tricuspid annulus did not predict mortality in these patients. Invasive pressures and pulmonary vascular resistance measured by RHC were also not associated with mortality. In multivariable analysis, NYHA functional class was the only independent predictor of mortality in patients with precapillary PH (HR 14.5 [95% CI 2.3 - 146.8], p = 0.006). Conclusion Eccentricity index, short pulmonary acceleration time, moderate to severe tricuspid regurgitation and pericardial effusion were associated with poor survival. Functional class was the strongest independent predictor of mortality in precapillary PH patients. These parameters may help stratify the risk of death in this heterogenous population.

Abstract Funding Acknowledgements Type of funding sources: None. Background Right heart catheterization (RHC) is the gold-standard method to confirm the diagnosis of Pulmonary Hypertension (PH) and to differentiate between pre- and post-capillary PH. However, RHC is an invasive and sometimes low-available procedure, which cannot be performed in all the patients with suspected PH. Clinical and echocardiographic scores have been developed to predict pre-capillary PH. We aimed to compare the performance of four of these scores in a population with suspected PH. Methods We retrospectively included consecutive patients who underwent RHC for suspected PH. If the non-invasive evaluation was clearly suggestive of left heart disease, RHC was dispensed being considered not clinically relevant. We also excluded patients with congenital heart disease. We compared the performance of four scores to predict pre-capillary PH: Score 1 (Opotowsky et al.), score 2 (Richter et al.), score 3 (Berthelot et al.) and score 4 (D’Alto et al.. Results Of the 142 included patients, 76 patients had pre-capillary PH, 42 had post-capillary PH and 24 patients did not meet invasive criteria for PH. We were able to perform the aforementioned scores in the majority of our patients (82% for score 1, 100% for score 2, 98% for score 3 and 83% for score 4). The AUC to predict pre-capillary PH using these scores were 0.74 for score 1, 0.77 for score 2, 0.82 for score 3 and 0.70 for score 4 (p = 0.37). Using the best cut-off points for each score, the score 3 correctly classified the highest percentage of patients (75.5%), with a sensitivity of 92% and a specificity of 60% to predict pre-capillary PH. Conclusion Combined clinical and echocardiographic characteristics can be used to predict pre-capillary PH with a fairly good performance. Score 3 (Berthelot et al.) was the score with the highest discrimination power. Validation of these scores in larger cohorts of patients with suspected PH are needed. Clinical and echocardiographic characteristics Interpretation Opotowsky et al. LA diameter (<32 mm: +1, >24 mm: -1), mid-systolic notch or acceleration time <80 msec (+1), E/e’>10 (-1) Score ≥ 0 has a sens. 100% and a spec. 62% for pre-capillary PH Richter et al. Age > 68 years (+1), BMI > 30 kg/m2 (+1), absence of RV enlargement (+1), LA enlargement (+1) Score >4 predicted post-capillary PH (AUC 0.78) Berthelot et al. Atrial fibrillation (+2), diabetes mellitus (+1), LA enlargement (15 ≤ LAA < 19: +1, 19 ≤ LAA < 24: +2, ≥ 19 cm2: +3), RV end-diastolic area (<27 cm2: +2), LV mass index (46 < LVMI ≤ 62: +1, 62 < LBMI ≤ 81: +2,< 81 cm2: +3) Score <5 ruled out post-capillary PH D’Alto et al E/e" ≤ 10 (+2), dilated non-collapsible IVC (+2), EI ≥ 1.2 (+1), right-to-left heart chamber dimension ratio > 1 (+1), RV forming the heart apex (+1) Score ≥ 2 has a sens. 99% and a spec. 54% for pre-capillary PH (AUC 0.85) Table 1. The clinical and echocardiographic scores evaluated in this study. AUC: area under the curve, EI: eccentricity index, IVC: inferior vena cava, LA: left atrial, LAA: left atrial area, LV: left ventricle, LVMI: left ventricle mass index, PH: pulmonary hypertension, Sens.: sensibility, Spec.: specificity, RV: right ventricle Abstract Figure.

Abstract Background Pre-infarct angina (PIA) has been shown to reduce reperfusion injury and infarct size in patients with ST-elevation myocardial infarction (STEMI) and currently represents the most efficient form of myocardial conditioning yet discovered. The role of diabetes on ischemic preconditioning remains controversial – while some pre-clinical studies suggest that diabetes blunts ischemic conditioning, clinical studies are lacking. Methods We retrospectively evaluated consecutive patients with STEMI admitted in our hospital from January 2008 to August 2018 who underwent primary angioplasty (PCI). PIA was defined as chest, arm or jaw pain during the preceding 48h before STEMI diagnosis. Peak creatine kinase and peak Troponin T levels were used as a surrogate of infarct size. Ischemic time (IT) was defined as the time between the onset of symptoms to the restoration of flow after either guidewire passage, thrombus aspiration or first balloon inflation. Results Of the 1143 included patients, 74% (n=845) were male and mean age was 62.6±13.1 years. A quarter of STEMI-patients had diabetes (25%, n=285). Almost a third of the patients (32%, n=359) had a history of angina in the preceding 48h before STEMI (PIA). The proportion of PIA was similar between diabetic and non-diabetic patients. In patients with diabetes, PIA was associated with lower creatine kinase (CK) (1144 [500–2212] vs 1715 [908–3309] U/L, p=0.0029) and Troponin T (TnT 3.30 [1.90–6.58] vs 4.88 [2.50–9.58] ng/mL, p=0.0022) despite similar IT as compared to those without PIA (328 [200–554] vs. 258 [180–530] minutes, p=0.1365). In non-diabetic patients, PIA was not significantly associated with infarct size (TnT 3.74 [2.23–7.11] vs 4.56 [2.44–7.77] ng/mL, p=0.1945; CK 1549 [910 - 2909] vs 1793 [996 - 3078] U/L, p=0.0653) even after adjustment for the increased ischemic time (240 [150–550] vs. 210 [140–405] minutes, p=0.0128) (β=−0.12, p=0.085 for CK and β=−0.11, p=0.183 for TnT). A significant interaction was observed between the existence of PIA and diabetes on peak TnT (p=0.026 for interaction) and CK (p=0.047 for interaction), which was independent of the culprit vessel and IT. During a median follow-up period of 18.0 [12.1–25.5] months, 268 (24.0%) MACE events have occurred (165 deaths, 27 strokes, 46 myocardial infarctions and 26 target vessel revascularization). PIA was associated with a significant reduction in the incidence of MACE (HR 0.66 (95% CI: 0.48–0.89)) driven by a reduction on mortality (HR 0.44 (95% CI: 0.28–0.70)). Diabetes was associated with an increased incidence of MACE (HR 1.42 (95% CI: 1.07–1.89)). No interaction was found between diabetes and PIA on their effect on MACCE events. Conclusion PIA is a strong predictor of favourable outcomes in the setting of STEMI. The effect of PIA on myocardial protection in patients with STEMI undergoing primary PCI seems to be modulated by the presence of diabetes. Distribution of Peak CK and Peak TnT Funding Acknowledgement Type of funding source: None

Abstract Background Pulmonary arterial capacitance (PAC) has emerged as one of the strongest hemodynamic predictors of adverse outcomes in a wide spectrum of cardiovascular diseases, including pulmonary hypertension in heart failure with preserved ejection fraction (HFpEF-PH). We aimed to study non-invasive surrogates for PAC using transthoracic echocardiography in this population. Methods We retrospectively evaluated consecutive patients referred to an expert tertiary care referral centre from December 2016 to November 2018. Transthoracic echocardiography (TTE) was performed within 1 year of right heart catheterization (RHC). Echo-Pac software from GE Healthcare® was used to perform echocardiographic analysis. PAC was calculated dividing right ventricular stroke volume by pulmonary arterial pulse (systolic – diastolic) pressure, measured by RHC. Results Of the 105 enrolled patients, 43 were had HFpEF-PH. Among these, 72% were female and mean age was 68.9 ± 11.2 years. Median time between TTE and RHC was 68 (IQR 34 – 191) days. Most patients were in NYHA class II (60.5%) and class III (34.9%). Fifty eight percent of the patients had history of paroxysmal or permanent atrial fibrillation. This population presented borderline parameters of right ventricle (RV) systolic dysfunction: fractional area change (FAC) 35.3 ± 9.2%, tricuspid annular plane systolic excursion (TAPSE) 18.3 ± 5.1 mm, tricuspid S’ wave 10.4 ± 2.9 and RV global longitudinal strain -15.5 ± 4.0. Regarding invasive assessment, this population presented mean pulmonary artery pressures of 38.8 ± 13.9 mmHg, pulmonary artery wedge pressure of 21.6 ± 6.4 mmHg, pulmonary vascular resistance of 3.9 ± 2.7 Wood and median PAC of 0.13 (IQR 0.09 – 0.19) ml/mmHg. The TAPSE / Pulmonary arterial systolic pressure (PASP) ratio and the Right ventricular outflow track velocity time integral (RVOT VTI) / PASP ratio were the parameters that best correlated with PAC (r = 0.69, p = 0.002 for both parameters) (table 1). These parameters were obtainable in the majority of patients (31/43). Blant-Altman analysis revealed good agreement between these measures and PAC with a mean difference of - 0.17 (CI -0.21 - -0.13) for RVOT VTI / PASP ratio and -0.23 (CI -0.28 - -0.18) for TAPSE /PASP ratio. Conclusion In a HFpEF – PH population, TAPSE / PASP and RVOT VTI / PASP are easily obtainable in most patients and significantly correlate with PAC. Abstract P1289 Figure.

Abstract Introduction Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Recently, speckle-tracking echocardiography has emerged as a new tool in the RV assessment. In this study, we aimed to study the value of global longitudinal strain in the RV evaluation of these patients. Methods We collected clinical, laboratory, echocardiographic and right heart catheterization (RHC) data from consecutive patients referred to an expert tertiary care referral centre from 12/2016 to 11/2018. Global RV systolic peak longitudinal strain (RVS) and RV free wall peak longitudinal strain (RVFWS) (mean of the basal, mid- and apical-segments) were measured by speckle-tracking technique with Echo-Pac software from GE Healthcare®. Results Of the 97 included patients, 76% were female. The mean age was 65 ± 15 years. Most patients were in NYHA class II. Median time between TTE and RHC was 70 days [IQR 34 - 184]. Group 2 PH was the most frequent aetiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7. Both strain parameters significantly correlated with other echocardiographic parameters such as TAPSE, FAC, Tricuspid S wave, RV diastolic diameter, eccentricity index (EI), systolic pulmonary artery pressure (SPAP), pulmonary acceleration time and presence of RV outflow tract notching. Strain parameters were also associated with pulmonary artery pressures and pulmonary vascular resistance (PVR) measured by RHC. Strain parameters did not correlate with PECP (p > 0.05). In multivariate analysis, RV global longitudinal strain predicted invasive mean pulmonary artery pressure and PVR independently of TAPSE and FAC (β=1.38, p < 0.001). RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02, AUC 0.72) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51, AUC 0.78). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72). Conclusion RV global and free wall longitudinal strain significantly correlate with other echocardiographic parameters of RV structure and function and with invasive pulmonary artery pressures and PVR. Abstract 555 Figure.

Abstract Introduction Noninvasive echocardiography evaluation of the right ventricle (RV) has been shown to have prognostic value in patients with pulmonary hypertension (PH). Different etiology groups might have different echocardiographic phenotypes. In this study, we aimed to study echocardiographic characterization of the different PH groups and its ability to predict pulmonary vascular disease severity. Methods We collected echocardiographic and right heart catheterization (RHC) data from 97 (75% female, age 65 ± 15 years) consecutive patients referred to an expert tertiary care referral PH centre from 12/2016 to 11/2018. Echocardiographic analysis was performed using Echo-Pac software from GE Healthcare®. Group 3 and 5 were not included in the group comparison analysis due to few patients included. Results Group 2 PH was the most frequent etiology of PH (35), followed by group 1 (26), group 4 (18), group 5 (3) and group 3 (2). The echocardiographic evaluation of this population as a whole showed borderline parameters of RV dysfunction (tricuspid annular plane systolic excursion (TAPSE) 18 ± 4 mm, fractional area change (FAC) 33 ± 10% and S’ tricuspid wave 10 ± 3 cm/sec). Mean RV global strain was -15 ± 5 and RV free wall strain was -17 ± 7. PH group 1 had a significantly lower FAC (26 ± 4%, p = 0.0025), higher eccentricity index (IE) (1.5 ± 0.1, p = 0.01), and more frequently RV outflow tract (RVOT) notching than other groups (62%, p = 0.012). Group 4 presented an intermedium echocardiographic phenotype between group 1 and 2, and showed more abnormal strain values than the other groups. Group 2 had fewer patients in sinus rhythm (atrial fibrillation in 34% of patients, p = 0.02), presented a thicker interventricular septum (11.3 ± 1.8, p = 0.014), a higher FAC (35 ± 3%, p = 0.0025), higher E mitral wave velocity (72 ± 6 cm/s, p < 0.001) and E/E’ ratio (12.7 ± 10.2, p = 0.006), and larger left (45 ± 3 cm3/m3, p < 0.01) and right atria (25 ± 2 cm2, p = 0.03). PH groups 1 and 4 had higher Pulmonary Vascular Resistance (PVR) and Pulmonary Mean Arterial Pressure (PMAP) values than group 2, which significantly correlated with echocardiographic RV function parameters as TAPSE, FAC, RV global strain and IE. In PH group 2, eccentricity index was the only predictor of PVR (β=4.1, p = 0.018). In this population, a left atria volume < 32.7 cm3/m2 (OR 4.25, CI 1.71 - 10.55) and a E/e’ ratio < 12 (OR 4.72, CI 2.05 - 10.87) predicted PECP < 15 mmHg. RV global strain > -17.1 predicted PVR > 3 wood (OR 3.46, CI 1.50 - 8.02) and PMAP > 20 mmHg (OR 4.92, CI 1.67 - 14.51). TAPSE < 18 mm predicted PVR > 3 wood (OR 7.41, CI 2.99 - 18.36, AUC 0.72). Conclusion Different PH groups present mild echocardiographic differences between them. PH group 1 presented with more echocardiographic signs of RV disfunction, and PH group 2 had higher FAC, E/E’ and larger right and left atria. RV function parameters predicted PVR in PH groups 1 and 4, and EI was the only predictor of PVR in PH group 2. Abstract P1505 Figure.

P001 - Sepsis impairs the capillary response within hypoxic capillaries and decreases erythrocyte oxygen-dependent ATP efflux