Sep 6, 2018

ESC Congress 2018, Monday 27th of August



Projects at the Center focusing on work efficiency and diastolic function were strongly represented on Monday. Several abstracts were showcased, including;
"Septal rebound stretch is a tug of war between septum and left ventricular lateral wall"
"Septal flash and rebound stretch are different entities"
"Cardiac resynchronization therapy - Always right for the right ventricle?"

Professor Otto Smiseth, MD, PhD, and leader of the work package focusing on these topics held a talk titled "Imaging the dyssynchrony. Where are we?". Center director of cardiology research Kristina Haugaa, MD, PhD chaired the session "Cardiomyopathies: Diagnosis and outcome". Haugaa is also one of the authors behind "The effect of age on quality of life in patients with cardiac implantable electronic devices. The results of an EHRA Scientific Initiatives Committee multinational survey in Italian patients." The aim of this study was to evaluate age-related attitudes, worries, psychological effects, and met or unmet needs in an Italian population after a CIEDs implantation. CIEDs (cardiac implantable electronic devices) are important therapeutic options to oppose the effects of bradyarrhythmias or to improve prognosis of patients with heart failure (HF).

Copyright: Margareth Ribe / OUH
Posted by: Anonymous


Monday 27th of August



Fumagalli S, Haugaa KH, Potpara TS, Pieragnoli P, Ricciardi G, Rasero L, Solimene F,  Mascia G, Mascioli G, Zuo G, Lenarczyk R, Dagres N
The effect of age on quality of life in patients with cardiac implantable electronic devices. The results of an EHRA Scientific Initiatives Committee multinational survey in Italian patients.

Background: Cardiac implantable electronic devices (CIEDs) are important therapeutic options to oppose the effects of bradyarrhythmias or to improve prognosis of patients with heart failure (HF). Aim of this study was to evaluate age-related attitudes, worries, psychological effects, and met or unmet needs in an Italian population after a CIEDs implantation.

Methods: Patients with CIEDs attending their periodical medical evaluation at the Electrophysiology Laboratories received a questionnaire specifically conceived by the EHRA Scientific Initiatives Committee as a part of a multicentre, multinational snapshot survey. Seven countries participated to the study, and a total of 1644 replies were collected. Of these, 437 (26%) were from Italy, which was the second country for number of participants. Present results refer to the Italian population only. CIEDs were stratified into devices to treat bradycardia (pacemaker - PM) or HF (cardiac resynchronization therapy - CRT; implantable cardiac defibrillators - ICD; CRT with defibrillator - CRT-D).

Results: The use of CIEDs was more common at advanced age (≤50: 3.2%; 51–75: 37.8%; >75 years: 59.0%). Men were implanted more frequently than women (62.5 vs. 37.5%), especially with defibrillators (men – PM: 57.9%; CRT: 57.1%; ICD: 75.3%; CRT-D: 75.0%; p=0.023). Older patients needed less information about CIEDs than younger ones (≤50: 35.7%; 51–75: 40.6%; >75 years: 50.0%; p=0.048), who would prefer to have more psychological support (p=0.043) and to be better informed about CIEDs-related consequences on physical (p=0.016) and sexual (p=0.027) activities, and on driving limitations (p=0.016). When compared to older subjects, younger individuals with CIEDs experienced more difficulties, especially in their professional activity and private life (≤50: 50.0%; 51–75: 29.7%; >75 years: 22.1%; p=0.011), and more worries, especially fear of abnormal functioning or a shock (≤50: 78.6%; 51–75: 29.7%; >75 years: 26.7%; p=0.009). Younger patients more often felt that their normal daily life was limited by the device (≤50: 7.1%; 51–75: 11.6%; >75 years: 1.6%; p=0.001); on the contrary, health related quality of life (HRQL) more often improved in elderly subjects (≤50: 42.9%; 51–75: 53.7%; >75 years: 68.6%; p<0.001). The degree of information about what to do with CIEDs when the end of life is approaching is scant, with no age-related differences (≤50: 75.0%; 51–75: 66.7%; >75 years: 73.6%; p=0.294). Only 8.6% of subjects aged 51–75 years (no one in the other groups) affirmed they would prefer their ICD was inactive at the end of life.

Conclusions: HRQL after CIEDs implantation improves more frequently in older patients, who are the majority of those receiving a device. The psychological burden of CIEDs is more frequently perceived at younger ages. End of life issues are seldom discussed.

Copyright: John Aalen / OUH


Aalen J, Remme EW, Krogh MR, Andersen OS, Masuda K, Odland HH, Opdahl A,
Smiseth OA
Septal rebound stretch is a tug of war between septum and left ventricular lateral wall.

Introduction: The echocardiographic hallmark of left bundle branch block (LBBB) is abnormal motion of the interventricular septum. This includes marked preejection shortening and subsequent paradoxical systolic lengthening named rebound stretch. Since septal rebound stretch was suggested as predictor of response to cardiac resynchronization therapy (CRT) it is important to determine its mechanism and modifiers.

Purpose: To test the hypothesis that presence and extent of septal rebound stretch in LBBB is determined by the relative contractility in the septum and left ventricular (LV) lateral wall.

Methods: In 10 anaesthetized dogs we induced LBBB by radiofrequency ablation. The circumflex coronary (CX) artery was temporarily occluded (n=10) to reduce LV lateral wall contractility and the left anterior descending (LAD) artery was temporarily occluded (n=6) to reduce septal contractility. Septal and LV lateral wall segment lengths were measured by sonomicrometry before and during occlusions.

Results: Induction of LBBB caused the characteristic septal contraction pattern with preejection shortening, rebound stretch and reduced septal systolic shortening in all animals. CX occlusion reduced LV lateral wall systolic shortening from 5.0±1.2 (mean±SD) to 0.5±1.0 mm (p<0.01). This was followed by loss of septal rebound stretch from 1.4±0.6 to 0.2±0.2 mm (p<0.01) (figure) and increased septal systolic shortening from 2.1±1.4 to 4.2±1.3 mm (p<0.01).

LAD occlusion, on the other hand, caused an increase in septal rebound stretch to 2.7±1.2 mm (p<0.05 vs. no ischaemia) and a reduction in septal systolic shortening to 0.3±1.5 mm (p<0.05 vs. no ischaemia) (figure).

Conclusions: Septal ischaemia aggravated septal dysfunction in LBBB by increasing rebound stretch, whereas LV lateral wall ischaemia normalized septal contraction pattern by abolishing rebound stretch. These results imply that abnormal septal motion in LBBB reflects a tug of war between septum and LV lateral wall. This interaction should be taken into account when using abnormal septal motion to identify responders to CRT.



Copyright: Margareth Ribe / OUH


Larsen CK,  Aalen J, Storsten P, Sirnes PA, Gjesdal O, Kongsgaard E, Hisdal J, Smiseth OA,  Hopp E
Septal flash and rebound stretch are different entities.

Background: Septal flash and rebound stretch are two commonly observed echocardiographic features of left bundle branch block (LBBB). Both predict response to cardiac resynchronization therapy (CRT), and have been thought to reflect the same phenomenon. Recent mathematical simulation studies, however, have indicated that they may have different underlying mechanisms.

Purpose: We aimed to investigate if septal flash and rebound stretch would appear to be different in LBBB-patients with normal and reduced ejection fraction (EF), respectively.

Methods: LBBB-patients with preserved EF (n=11) and reduced EF (n=16) underwent full echocardiographic examination. All were non-ischemic. EF was calculated by the biplane Simpson's method. Septal flash was determined visually by M-mode in the parasternal short axis view as an abnormal early systolic left-right motion of the interventricular septum. Rebound stretch was defined as a stretch during early systole following pre-ejection shortening in the septum, and was measured by strain from speckle-tracking echocardiography.

Results: EF was 56±6 and 31±5% (p<0.001) in the two groups, respectively. Septal flash was present in all patients. However, only 4 of the 11 patients with preserved EF showed rebound stretch, while 12 of the 16 patients with reduced EF did (figure). The amplitude of the stretch was also significantly lower in the group with preserved EF compared to the group with reduced EF (0.2±0.2% and 2.9±3.2%, p=0.009).

Conclusions: Septal flash was evident in all LBBB-patients, independent of LV function. Rebound stretch, however, was associated with reduced LVEF. These findings support previous findings from a mathematical simulation model that septal flash and rebound stretch are different entities, although they are both features of LBBB. Future studies should investigate if rebound stretch could improve current CRT-selection criteria.

Figure: Two representative patients




Copyright: Margareth Ribe / OUH

Storsten P, Aalen J, Boe E, Remme EW, Larsen CK, Gjesdal O, Andersen OS, Kongsgaard E,  Duchenne J, Voigt JU, Smiseth OA, Skulstad H
Cardiac resynchronization therapy - Always right for the right ventricle?

Background: Right ventricular (RV) function influences prognosis in recipients of cardiac resynchronization therapy (CRT). However, direct impact of left bundle branch block (LBBB) and CRT on RV function is not well understood.

Purpose: To study the immediate response of CRT on RV function in LBBB.

Methods: 14 patients with LBBB and non-ischaemic cardiomyopathy (QRS 169±17ms) were studied shortly before and during CRT. RV longitudinal strain was measured by speckle tracking echocardiography. Global RV free wall systolic strain (GLS) was calculated. In 10 anaesthetized dogs we measured RV dimensions by sonomicrometry and pressure by micromanometer and induced LBBB by RF ablation. RV work was calculated from RV pressure-dimension loops.

Results: In patients, LBBB was associated with an abnormal and distinctive early-systolic contraction pattern in the RV free wall, with a steep initial shortening followed by a small plateau before it continued to contract (arrow in left panel of Figure). The abnormal RV free wall shortening coincided with pre-ejection shortening in the septum. This early systolic RV shortening was markedly attenuated by CRT (p<0.05). However, RV free wall GLS was unchanged (Figure, right panel). Similar RV free wall contraction pattern as in patients, were observed in the dog model during LBBB. However, with CRT there was a marked increase in RV free wall work from 23±14 to 36±15mm*mmHg (p<0.01).

Conclusions: Patients with LBBB had an abnormal RV contraction pattern occurring in early systole, which was reduced by CRT. The animal model showed that CRT increased workload on the RV free wall despite no improvement in total strain. Therefore, in hearts with intact RV function the RV free wall may compensate well during CRT, whereas hearts with a failing RV may not tolerate the increased workload and may respond poorly to CRT.

Representative patient and mean data



Storsten P, Boe E, Aalen J, Remme EW, Gjesdal O, Andersen ØS, Kongsgaard E, Smiseth OA, Skulstad H
Left ventricular free wall pacing causes excessive work load in septum and right ventricular free wall-a mirror image of left bundle branch block.

Background: Previous studies have shown that ventricular pacing causes non-uniform distribution of work in the left ventricle (LV). This is a potentially deleterious effect since excessive segmental load may be a stimulus to remodelling and may contribute to progression of heart failure.

Purpose: To determine effect of LV free wall pacing on distribution of work within the LV and between the LV and right ventricular (RV) free wall.

Methods: In 16 anaesthetized dogs, LV and RV pressures and dimensions by sonomicrometry were used to assess work as area of ventricular pressure-dimension loops. Longitudinal segment lengths were used for regional work and diameters for LV and RV short axis work. Two different activation patterns were studied, induction of LBBB by RF ablation (n=10) and pacing of the LV lateral wall (n=6) to study early activation from the septum and the LV lateral wall, respectively.

Results: Induction of LBBB caused reduction of RV free wall work from 36±15 to 23±14mm*mmHg (p<0.01) and reduction in septal work from 96±52 to 16±61mm*mmHg (p<0.01.) There was a simultaneous increase in work in the LV lateral wall from 118±89 to 194±111mm*mmHg (p<0.01). Therefore, LBBB caused a shift in workload from the early activated septum and RV free wall to the late activated LV lateral wall (Figure 1). During LV lateral wall pacing there was an opposite shift, with reduction of work in the early activated LV lateral wall from 47±39 to -6±22mm*mmHg (p<0.05), and increase of work in the late activated RV free wall from 27±18 to 36±18mm*mmHg (p<0.05) and in septum from 72±32 to 141±41mm*mmHg (p<0.05).

Conclusion: Single lead LV lateral wall pacing shifted ventricular work from the LV lateral wall to septum and RV free wall. This was opposite to effect of inducing LBBB. These results suggest that care should be exerted when placing pacing leads in the left ventricle since work load can become excessive in late activated myocardium in both ventricles. These principles should be explored in clinical studies in patients who receive LV pacing during cardiac resynchronization therapy.


Jensen M, Faber L, Liebregts M, Januska J, Krejci J, Bartel T, Cooper RM, Drabowski M,  Hansen PR, Almaas VM, Seggewiss H, Horstkotte D, Berg JT, Bundgaard H, Veselka J
Clinical significance of impaired cardiac conduction after alcohol septal ablation

Objective: Impairment of cardiac conduction and need for pacemaker (PM) after alcohol septal ablation (ASA) in patients with obstructive hypertrophic cardiomyopathy (HCM) has been of major concern.

Methods: We analysed the impact of bundle branch block (BBB) and PM after ASA on symptoms and survival in 1416 HCM patients.

Results: Before ASA 58 (4%) patients had a PM and 64 (5%) patients had an implantable cardioverter defibrillator (ICD). At latest follow-up (5.0±4.0 years) after ASA, 118 (8%) patients had an ICD and 229 (16%) patients had a PM. In patients without implantable device before ASA 13% had a PM and 5% had an ICD implanted following ASA. New onset BBB was present in 44% (right BBB in 31%) of patients without previous BBB. At latest follow-up, we found no associations between BBB and New York Heart Association (NYHA) class 3–4 (OR 0.98, CI 0.63 - 1.51, p=0.91) (see Table) or Canadian Cardiovascular Society (CCS) class 3–4 (OR 1.5, CI 0.32–6.7, p=0.62), respectively, and no associations between PM and NYHA class 3–4 (OR 1.2, CI 0.70–2.0, p=0.52) or CCS 3–4 (OR 1.3, CI 0.24–6.6, p=0.79), respectively. The survival after ASA was not reduced in patients with BBB (HR 0.73, CI 0.53–1.01, p=0.06) or PM (HR 0.78, CI 0.52–1.17, p=0.24) (see Figure 1A and B).

Conclusions: Development of BBB or need for a PM after ASA was not associated with inferior symptomatic outcome or reduced survival, thus concerns for the negative impact of impaired cardiac conduction on the clinical outcome after ASA were not confirmed.

Table 1. Associations between bundle branch block and NYHA functional class 3&#x2013;4 at latest clinical follow-up in patient treated with alcohol septal ablation

Odds ratio

95% confidence limits


Post procedural BBB (right or left)




Pre-defined confounders









Ejection fraction




Resting LVOT gradient








Overall p>0.001. ASA, Alcohol septal ablation; IVSd, Inter-ventricular septum dimension; NYHA, New York Heart Association; LVOT, Left ventricular outflow tract.


Massey RJ, Diep PP, Ruud E, Aakhus S, Beitnes JO
Graft versus host disease and left ventriclular function in long-term survivors after allogeneic haematopetic stem cell transplantation at young age

Introduction: Allogeneic haematopetic stem cell transplantation (allo-HSCT) is a complex therapy involving myeloablative chemotherapy and/or radiation therapy, both well documented to cause adverse effects to heart function. These patients are also at risk of the detrimental effects of graft-versus-host-disease (GVHD).

Purpose: GVHD has previously been attributed to left ventricular (LV) dysfunction, LV remodeling, and pericardial disease. This study aims to describe cardiac function in long term survivors of allo-HSCT and to investigate the influence of GVHD.

Methods: This cross sectional study included 104 individuals (53.8% female). Age at allo-HSCT was (mean±SD) 17.8±9.6 years, age at follow-up was 35.0±11.7 years, and time to follow-up was 17.2±5,6 years. The majority (98,1%) received myeloablative chemotherapy and 12.5% received radiation therapy. Acute (aGVHD) and chronic GVHD (cGVHD) were graded by the Glucksberg and Schulman scale, respectively. The cumulative incidence of GVHD was 64.4% (52.9% aGVHD, 38.5% cGVHD and 26.9% both). Echocardiography (GE E9) was performed following the EAVI recommendations. LV ejection fraction (EF) and global longitudinal strain (GLS) were used to evaluate LV systolic function. LV cardiac mass and relative wall thickness (RWT) were used to determine LV geometry. Pericardial fluid or thickening were classified as pathological. Groups were compared by t-test and Fishers exact test as appropriate.

Results: EF≤53% was found in 35,6% and GLS≤-17% was found in 32.7% of patients. No statistical significant difference (p<0.05) was found between groups for EF, GLS or RWT. Pericardial pathology was observed in 7 patients in the GVHD group and in only 1 patient without GVHD (p=0.25).

Conclusion: LV systolic dysfunction was found to be highly prevalent in allo-HSCT patients. Cause of which was found not to be associated with GVHD. Furthermore, no significant evidence of LV remodeling was observed in GVHD. Pericardial pathology was more prevalent in GVHD, however did not reach statistical significance.

Total (n=104)

GVHD (n=67)

No GVHD (n=37)

p value

2D EF %





2D LVEDVindex (ml/m2)





2D LVESVindex (ml/m2)





GLS mean %





LVIDindex (cm/m2)










Values indexed to body surface area.


Smiseth OA: Imaging the dyssynchrony. Where are we?



Cardiomyopathies: Diagnosis and outcome  - Haugaa KH

Center for Cardiological Innovation