bluuebunny/crossref_metadata_2025 huggingface dataset:
Is warfarin associated with higher risk of thrombus in left atrial appendage than direct oral anticoagulants?
Authors: Kagawa E , Kato M , Oda N , Kunita E , Nagai M , Shiota H , Dote K
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke, and anticoagulation therapy is utilized to prevent thromboembolism.

Purpose

This study is to investigate the incidence of thrombus in left atrial appendage detected by transoesophageal echocardiography (TOE) under anticoagulation therapy with warfarin or direct oral anticoagulants (DOAC).

Methods

Between 2005 and 2016, the patients who underwent TOE under anticoagulation therapy due to atrial fibrillation more than one month were enrolled in this study. The patients were divided into 2 groups according to whether treated with warfarin or DOAC and baseline characteristics and incidence of LAA thrombus were assessed.

Results

Among the 313 study patients, 243 (78%) were treated with warfarin. The patients treated with warfarin were elder (median 73 y vs. 67 y [interquartile range 66 – 78 y vs. 58 – 72 y], P < 0.01), the body mass index was lower (23.2 vs. 24.0 [21.0 – 25.4 vs. 21.3 – 26.9], P = 0.03). The prevalence of male sex (64% vs. 71%, P = 0.26) were similar between the 2 groups. The previous history of hypertension (69% vs. 59%, P = 0.10), diabetes (24% vs. 19%, P = 0.32), vascular disease (30% vs. 26%, P = 0.52), and ischemic stroke were similar between the 2 groups (30% vs. 23%, P = 0.22). The prevalence of CHA2DS2-VASc score > 1 (84% vs. 59%, P < 0.01) and the d-dimer level (0.7 vs. 0.5 mcg/ml [0.5 – 1.8 vs. 0.5 – 0.5 mcg/ml], P < 0.01) were higher in the warfarin groups than those of the DOAC. The velocity of LAA was slower in the warfarin group than those of DOAC (35 vs. 55 cm/s [21 – 54 vs. 38 – 68 cm/s], P < 0.01). The incidence of detection of LAA thrombus was 19% in the warfarin group and 3% in the DOAC group (P < 0.01). In the warfarin group, the PT-INR were lower in the patients with LAA thrombus (1.38 vs. 1.66 [1.11 – 1.92 vs. 1.34 – 2.03], P = 0.03).

Conclusions

The higher risk of ischemic stroke and out of range PT-INR may be the cause of the higher incidence of LAA thrombus in the patients treated with warfarin than those with DOAC.

Abstract Figure.
Acute change in left atrial performance in patients with atrial fibrillation undergoing catheter ablation using AutoStrain
Authors: Katbeh A , De Potter T , Geelen P , Nagumo S , Balogh Z , Albano M , Van Camp G , Penicka M
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): International PhD Program in Cardiovascular Pathophysiology and Therapeutics CardioPaTh

Background

Radio-frequency catheter ablation (CA) is associated with changes of left atrial (LA) structure and function. However, the data on the accuracy of automated analysis of LA strain (LAS) are unavailable. Therefore, the aim of the present study was to compare automated with manual LAS analysis in patients with atrial fibrillation (AF) undergoing CA during sinus rhythm.

Methods

We prospectively enrolled 36 consecutive patients (age: 62 ± 22 years, 33% female) with symptomatic AF and preserved  left ventricular (LV) ejection fraction (≥50%) undergoing the CA during sinus rhythm. All patients underwent comprehensive echocardiography at 1-day pre-CA and at 1-day post-CA. Reservoir and contractile LAS were assessed using both the automated and the manual technique as average of segmental values in apical four-chamber (4CH) view using the onset of QRS as a reference point.

Results

Radio-frequency CA was associated with significant decrease in magnitude of reservoir and contractile LAS in all patients, and increase in LA end-systolic (max) and end-diastolic (min) volume index (all p < 0.001) (figure 1). The correlation between (semi-) automated and manual LAS assessment was excellent in all measurements (figure 2). The manual correction was needed in 7 out of 36 patients (19%). Despite this, the time needed to perform AutoStrain-derived analysis was significantly lower than the time needed for the manual LAS analysis (12 ± 3 ms vs. 40 ± 5 ms, p < 0.01). Moreover, in 10 randomly selected patients, the AutoStrain showed significantly lower interobserver variability than the manual LAS analysis (3.1% vs. 6.7%, p < 0.01). 

Conclusion

The AutoStrain-derived LAS analysis showed a high correlation with manual LAS analysis. Moreover, the AutoStrain technique was associated with significantly shorter analysis time and lower interobserver variability compared with the manual technique.

Abstract Figure.
Patients with a DPP6 risk- haplotype for familial idiopathic ventricular fibrillation have normal left systolic function but abnormal deformation
Authors: Bruin De- Bon H , Wilde AAM , Amin AS , Ten Sande JN , Van Der Ree MH , Postema PG , Bouma BJ
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

An aberrant DPP6 mutation haplotype on chromosome 7 is associated with familial idiopathic ventricular fibrillation in severely affected Dutch families with numerous cases of  sudden cardiac death (SCD) So far, no clinical parameters could be linked to predict SCD risk other than this genetic predisposition. In various other cardiac disease, global longitudinal strain (GLS) and mechanical dispersion (MD), both markers of left ventricular (LV) dysfunction, are predictive tools for patients at risk for ventricular arrhythmias (VA) and SCD. The goal of the current study was to investigate whether LV dysfunction, detected by GLS and MD, is present in patients with DPP6 haplotype.

Method

DPP6 risk-haplotype carriers with sufficient echocardiographic images were included as cases (n = 31, 15 males mean age 41 ± 11 years) and individuals evaluated during cascade screening who were tested but appeared not to be affected as controls (n = 14, 7 males, mean  age 39 ± 12 years). Echocardiographic bi-plane ejection fraction (LVEF), GLS and MD of the left ventricular were determined.

Results

LVEF was similar between DPP6 cases (57.3%) and controls (60.5%, p = 0.07). In contrast, the GLS of the LV (-18.0%) of DPP6 cases was significant lower compared to controls (-21.1%, p < 0.0001). MD in DPP6 cases (43.4ms) was significantly higher than in controls (26.7ms, p < 0.0001).

Conclusion

DPP6 risk- haplotype carriers have similar LVEF, but significant lower LV-GLS and higher mechanical dispersion than controls. These findings can be used for clinical discrimination. Whether these markers can be used for prediction of clinical events has to be determined after a longer follow up.

echocardiographic characteristics controls DPP6 p-value LVEF (%) 60.5 57.3 0.07 GLS LV (%) -21.2 -18.0 0.0001 MD ( ms) 26.7 43.4 0.0001
Interatrial block is related to atrial dysfunction in hypertensive subjects
Authors: Tirapu Sola L , Loncaric F , Mimbrero M , Mendieta LG , Nunno L , Sanchis L , Doltra A , Montserrat S , Bijnens B , Sitges M
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): La Marató TV3

Background

Interatrial block (IAB), a delay of conduction of the sinus stimulus from right to left atria (LA), is defined as surface ECG P-wave duration ≥120 ms. Arterial hypertension (AH) and IAB have been related to development of atrial fibrillation.

Aim

To investigate the IAB prevalence in a cohort of AH patients and relate it to LA function.

Methods

162 patients with well-regulated AT were included. 12-lead ECG were performed and analysed with a digital caliper. 2D and 3D echocardiography were performed, and LA function assessed with speckle-tracking deformation imaging. 

Results

The median age was 56 ± 6 years, 54% were males. Average duration of AH was 10 ± 6 years. IAB was seen in 25% of AH patients.  The comparison between groups is shown in Table 1. There were no differences in demographic characteristics,  QRS complex duration (p = 0.179) or left ventricular (LV) size and function between subgroups. LA was enlarged in IAB patients, which was coupled with impairment of the LA reservoir strain. 

Conclusion

Our results show considerable prevalence of IAB in AH patients. The demonstrated LA enlargement and function impairment is not associated with LV dysfunction, therefore suggesting an independent role of IAB in atrial remodeling.

Table 1 Interatrial block P value Yes (n= 40) No (n= 142) Age 59 (54-62) 57 (53-61) 0.157 Female gender 16 (40%) 58 (48%) 0.467 Duration of Hypertension (years) 10 (6-12) 8 (5-15) 0.421 Systolic blood pressure (mmHg) 136 (125-150) 136 (127-147) 0.799 Diabetes 3 (8%) 16 (13%) 0.410 LVEDV (mL) 73 (63-91) 71 (57-87) 0.424 E/A 0.98 (0.84-1.25) 0.94 (0.79-1.11) 0.230 E/e’ 7.0 (4.9-8.9) 6.6 (5.2-8.4) 0.779 LVEF (%) 63 ± 7 64 ± 6 0.864 LV global longitudinal strain (%) 21.22 ± 2.63 21.19 ± 2.30 0.932 3D LA maximal volume (mL/m2) 36 (30-39) 30 (26-37) 0.028 3D LA minimal volume (mL/m2) 16 (12-18) 14 (11-17) 0.050 LA reservoir strain (%) 27.64 (24.90-31.23) 29.55 (26.17-32.81) 0.032 LA conduit strain (%) 13.91 (10.71-15.47) 14.37 (11.75-16.72) 0.192 LA contractile strain (%) 14.46 (11.86-16.59) 15.52 (13.66-16.96) 0.079 LVEDV Left Ventricular End Dyastolic Volume
Dynamics of left ventricle myocardial deformation, soluble ST2 and cardiotrophin-1 in hypertensive women on combined valsartan/hydrochlorothiazide therapy
Authors: Kolesnyk M , Sokolova MV , Nikityuk OV , Horlova IV
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background. The treatment-induced regression of left ventricular hypertrophy (LVH) is associated with improved prognosis in patients with arterial hypertension. However, the assessment of LVH by echo is restricted by substantial measurement variability and low sensitivity to changes during follow-up. The alternative approach could be the dynamic evaluation of myocardial deformation parameters and biochemical markers of cardiac remodeling. The purpose of this study was to assess the dynamics of left ventricle (LV) myocardial deformation, soluble ST2 and cardiotrophin-1 levels in hypertensive women treated with combination of valsartan/hydrochlorothiazide.

Methods. The study involved 100 postmenopausal women (mean age – 57.7 ± 4.3 years) with uncomplicated arterial hypertension. All patients were treated with combination of valsartan (80-320 mg; average dose 195 mg) and hydrochlorothiazide (12.5 mg). Ambulatory blood pressure monitoring, conventional and 2-dimensional speckle tracking echocardiography were performed before and 6 months after treatment. The concentrations of cardiotrophin-1 and soluble ST2 were determined by ELISA method. The data are presented as median and interquartile range.

Results. Treatment with valsartan/hydrochlorothiazide was effective and well tolerated. Target blood pressure level was achieved in 64 % of the patients. The LV global longitudinal strain (GLS) raised significantly after 6 months of treatment (Table). We found the reduction of mechanical dispersion - parameter, which indirectly reflects myocardial tissue homogenicity. The levels of circulating cardiotrophin-1 and soluble ST2 decreased by 37.93% and 19.74%, respectively (p < 0.0001).

Conclusions. The 6-month therapy with valsartan/hydrochlorothiazide was associated with improvement of myocardial deformation parameters with concomitant reduction of soluble ST-2 and cardiotrophin-1 levels. These markers could be more sensitive than standard parameters for hypertensive patients" follow-up. However, this approach should be confirmed in future studies.

Parameter Baseline 6-month p Office SBP, mm Hg 148 (140; 157) 135 (124; 143) <0.0001 Office DBP, mm Hg 89 (82; 96) 81 (74; 87) <0.0001 LV GLS, % -19.6 (-18.1; -21.1) -20.4 (-18.9; -21.8) 0.01 Mechanical dispersion, ms 43 (37; 51) 41 (37; 48) 0.04 Cardiotrophin-1, pg/ml 12.2 (9.4; 16.81) 8.5 (6.26; 10.82) <0.0001 Soluble ST2, ng/ml 25.3 (17.93; 29.72) 18.2 (13.93; 25.96) <0.0001 Values are given as median and interquartile range
Electromechanical changes of the myocardium after anthracycline chemotherapy
Authors: Ozbay B , Kemal H , Simsek E , Cakar B , Yavuzgil O
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background and objectives

The most common side effects of chemotherapeutics in breast cancer is on the cardiovascular system. Global longitudinal strain (GLS) is the only parameter recommended for follow-up in current guidelines with limited evidence. Other strain imaging parameters and electrical changes after chemotherapy is not well studied. It is not known whether electrical or mechanical changes occur initially. The aim of this study is to evaluate repolarization parameters on ECG and mechanical changes together after chemotherapy in breast cancer patients.

Subjects and method

Consecutive patients who received chemotherapy due to breast cancer were included. Strain echocardiography and ECGs were performed pre-treatment (T0) and 3rd month after chemotherapy (T2). Additionally, just in three hours of first dose of chemotherapy (T1) another ECG was performed.  QT and QT correction for heart rate (QTc), QT dispersion (QT disp) and QTc dispersion (QTc disp), T wave peak to end time (Tpe) and Tpe corrected for QT-QTc measurements were performed (figüre 1 and 2). GLS, longitudinal strain for myocardial layers, circumferential strain (CS), radial strain (RS) and torsion measurements were performed. All mechanical and electrical parameters from different time intervals were compared.

Results

Thirty-five consecutive patients (35 females, mean age 48.9 ± 11.8 years) who received chemotherapy (mean doxorubicin cumulative dose 415 ± 32 mg/m2) due to breast cancer were included. There was no significant change in mean GLS values before and after treatment (T0 -%18.8 ± 6.82, T1 18.6 ± 3.5 p = 0,863 respectively). However, there was a significant decrease in CS, RS and torsion (T0 -%17,2 ± 3,5, T1-%13 ± 2,84 p <0,001, T0 %45,1 ± 8,3, T1 %35,6 ±10 p <0,001 and T0 %12,1 ± 3.5, T1 %7.7 ± 2.1 p <0,001, respectively). QT, QTc, QTc disp and Tpe, Tpe/QTc parameters were prolonged just after chemotherapy and were still prolonged 3 months after ((QTc: T1 440.01 ± 27.63, T2 468.00 ± 38.98, T3 467.86 ± 35.09), (QTc disp T1 55.48 ± 20.22, T2 78.59 ± 16.15, T3 66.16 ± 14.62), (Tpe (QTc) T1 104 ± 18.52, T2 148.62 ± 19.16, T3 139.77 ± 21.63), (Tpe/QTc T1 0.213 ± 0.05, T2 0.281 ± 0.08, T3 0.258 ± 0.06).

Conclusion

  Electrical and mechanical functions of the heart could be impaired together acutely even three months after doxorubicin chemotherapy. Cardio toxicity should be evaluated in terms of both electrically and mechanically.

Abstract Figure. ECG repolarization parameters
Role of myocardial deformation analysis in the early detection of subclinical Left Ventricular dysfunction in breast cancer under anthracyclines and trastuzumab
Authors: Benmalek R , Krikez I , Maaroufi A , Abouriche A , Bendahou H , Habbal R , Haffadi M , Tawfik N , Benider A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction : Cardio-oncology field has notably raised interest this past decade, it considerably improved cancer patients’ quality of care by monitoring and preventing complications of cardiotoxic treatment like anthracyclines and trastuzumab. Transthoracic echocardiography (TEE) plays a major role in the baseline assessment and follow-up of cardio-oncology patients. While left ventricular ejection fraction (LVEF) still has its place in cardiac monitoring, new modalities like myocardial deformation imaging with speckle tracking strain analysis, show great potential for early detection of subclinical LV dysfunction.

Purpose : The aim of this study was to evaluate the role of Global Longitudinal Strain (GLS) in the early detection of cardiotoxicity and its correlation to LVEF.

Methods : We conducted a longitudinal prospective study including all the breast cancer patients treated with anthracyclines and/or trastuzumab  followed in the Casablanca cardio-oncology unit from January 2017 to December 2019. All patients underwent baseline TEE, and were followed-up every 3 months after that, with GLS assessment whenever it was possible. We evaluated the frequency of GLS drop and its correlation to LVEF reduction.

Results : Out of a total of 793 patients, 677 had available LV GLS assessment. Among them, 83 (12,3%) decreased their GLS during follow-up, 67% of which had no concomitant drop in LVEF. In these patients, impaired LV GLS values were noted at 1 month after chemotherapy and at 3, 6, and 12 months compared with baseline (-22,3 ± 1.8% at baseline, -18.1 ± 2.3% at 1 month, -17.7 ± 2.1% at 3 months, -17.1 ± 2.2% at 6 months, and -16.9 ± 2.1% at 12 months (p < 0,0001). LV GLS at 3 months was strongly correlated to cardiotoxicity (LVEF < 50%) at 12 months (p < 0,0001). A cut-off LV GLS value of -17,7% was then retained to identify LVEF alteration at the end of follow-up. Moreover, lower GLS values were observed in patients under Doxorubicin with a mean cumulative dose >180 mg/m2 (p = 0,0019), while LVEF remained normal. Finally, our study found that GLS at 1 month and 3 months had a prognostic value, since the lower GLS was, the poorest the patient’s clinical outcome was, with further development of symptomatic heart failure (p = 0,0038).

Conclusion : Our study demonstrates that myocardial deformation analysis enables detection of early and progressive subclinical cardiac dysfunction, and GLS at 3 month was positively correlated to LVEF drop at 12 months. Thus, routine GLS should be used in patients undergoing cardiotoxic chemotherapy in order to early detect cardiotoxicity and prevent irreversible cardiac dysfunction by early initiating cardio-protective treatment.
Correlation of global longitudinal strain with disease severity in liver cirrhosis
Authors: Dimitroglou Y , Aggeli C , Alexopoulou A , Alexopoulos T , Patsourakos D , Polytarchou K , Kastellanos S , Angelis A , Vasilieva L , Mani I , Tsioufis K , Dourakis SP , Tousoulis D
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction/purpose

Cirrhotic cardiomyopathy is characterized by high cardiac output, reduced peripheral resistance and diastolic dysfunction and has been correlated with cirrhosis severity and prognosis. Global longitudinal strain (GLS) is a sensitive marker of cardiac dysfunction which is considered relatively independent of preload and afterload conditions and thus may be of high diagnostic significance in this special population. We sought to investigate alterations of GLS relating to disease severity in cirrhotic patients.

Methods

Echocardiographic analysis of 51 consecutive cirrhotic patients was performed. Images were acquired and analyzed off-line. GLS was calculated with a semi-automatic way using dedicated software.  Clinical and biochemical examination were used to assess severity of liver disease by calculating Child-Pugh class (class C patients have more severe disease than class B and A patients) and MELD-Na score (increased score as the disease progresses).

Results

Mean age was 58.4 ± 8.7 years, 38 (74.5%) were males. Among patients, 22 (43.1%) were Child-Pugh class A, 17 (33.3%) Child-Pugh B and 12 (23.5%) Child-Pugh C and mean MELD-Na score was 15.3 ± 7.5. Mean left ventricular end-systolic volume (LVEDV) was 117 ± 29ml, mean stroke volume (SV) 72.5 ± 19.9ml , mean left ventricular ejection fraction (LVEF) 61.0 ± 5.0%, mean systolic blood pressure (SBP) 128 ± 13mmHg, mean ratio of peak transmitral to peak annular (septal) velocity during early diastole (E/e’ ratio) 10.4 ± 4.5, mean left atrial volume index (LAVI) 37.4 ± 11.8 ml/cm2  and mean GLS -21.6 ± 2.6%. GLS of Child-Pugh class A patients (-20.3 ± 2.4) was higher (less negative) than GLS of Child-Pugh class B (-22.2 ± 2.2) and class C (-23.0 ± 2.8) patients. Difference between groups B and C was non-significant (figure). Severity of cirrhosis as determined by higher MELD-Na score correlated with LAVI (r = 0.592, p < 0.001), SV (r = 0.554, p < 0.001), GLS (r=-0.441, p = 0.001) and LVEDV (r = 0.428, p = 0.002). GLS correlated with SV (r=-0.369, p = 0.008) but not with preload (LVEDV), or afterload (SBP). In a linear regression model, GLS was independently associated with Meld-Na score when adjusting for age, SBP, LVEDV and NASH etiology [B=-0.139 (-0.252; -0.025), p = 0.018].

Conclusions

GLS is lower (more negative) in patients with liver cirrhosis as disease progresses a relation not affected by preload and afterload conditions. Further research works are required to explain the underlying pathophysiology and to assess prognostic significance of reduced GLS values in patients with advanced cirrhosis.

Abstract Figure. GLS stratified by Child-Pugh score
Can left ventricular speckle tracking imaging be used in left ventricular non-compaction cardiomyopathy screening? A study of healthy paediatric athletes with and without echocardiographic criteria
Authors: Dorobantu D , Radulescu CR , Riding N , Mcclean G , Adamuz C , Ryding D , Perry D , Mcnally S , Stuart AG , Oxborough D , Wilson M , Williams CA , Pieles GE
Published: February 2021

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): The study was support by a contractual research partnership between the University of Bristol and Canon Medical Systems UK

Background

Left ventricular non-compaction (LVNC) is a rare cardiomyopathy, with hypertrabeculation often observed in athletes. In confirmed LVNC, LV systolic strain and rotational mechanics have been shown to be abnormal. Whether healthy athletes meeting echocardiographic LVNC criteria exhibit abnormal myocardial mechanics is not known.

Purpose

The aim of this study is to evaluate the prevalence of healthy paediatric athletes meeting the Jenni criteria for LVNC and how this relates to LV systolic function and rotational mechanics.

Methods

Professional athletes under 18 years undergoing comprehensive pre-participation screening (2014-2017) at two sports academies were included. Jenni criteria for LVNC were assessed from short axis LV views. Global and segmental peak systolic longitudinal (Sl) and circumferential strain (Sc), basal rotation (basal Rot) and apical rotation (apical Rot) were calculated using speckle tracking imaging.

Results

A total of 201 boys (11.9-18 years, median 15.1 years) were included, with diverse ethnicity (47.7% Arab, 28.5% Black, 21.8% White, and 2% other) and sports background (60% football, 21.2% athletics, 18.8% other).

Of these n = 16 (8%) met the Jenni criteria for LVNC and were more likely to be of Black ethnicity than Arab or White (12.7% vs 4.4% or 9.5%). There were no differences in global, lateral or septal Sl, basal, mid or apical Sc, basal Rot or apical Rot between participants with or without Jenni criteria for LVNC (Table 1).

Conclusions

In healthy paediatric athletes, those meeting the criteria for LVNC (8%) do not have abnormal longitudinal, circumferential strain and rotational mechanics, compared to those without LVNC criteria. This finding supports the use of speckle tracking echocardiography as a tool in differentiating pathological changes reported in LVNC from exercise associated adaptations observed in athletes during preparticipation screening.

LV mechanics Jenni criteria presence With Jenni criteria Median (IQR) Without Jenni criteria Median (IQR) p value Global LV Sl -18.6% (-19.1;-17.7) -18.6% (-19.7;-17.8) 0.7 Lateral Sl -18.3% (-18.8;-17.2) -18.5% (-19.8;-17.6) 0.5 Septal Sl -18.6% (-20.6;-17.3) -18.7% (-20.1;-17.7) 0.7 Basal LV Sc -23% (-24.6;-21.6) -23.3% (-25.7;-21.6) 0.7 Mid LV Sc -24.9% (-27.1;-23.2) -25.1% (-27.1;-22.5) 0.9 Apical LV Sc -27.8% (-32.3;-24.8) -26% (30.5;-22.4) 0.2 Basal Rot -4o (-4.7;-2.5) -3.8o (-5.3;-2.5) 0.9 Apical Rot 6.4o (5.2;7.1) 4.4 (2.9;7.1) 0.2
Global longitudinal strain and mechanical dispersion at rest in exercise stress echocardiography for detecting obstructive coronary artery disease: a pilot study
Authors: Sugito S , Ferreira D , Hardy J , Turner S , Boyle A , Cooke H
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Exercise stress echocardiography (ESE) is a commonly used investigation for risk stratification in coronary artery disease (CAD). The added value of resting indices such as Global Longitudinal Strain (GLS) and Mechanical Dispersion (MD) to detect obstructive CAD is not well established and would be of significant clinical benefit.

PURPOSE

To evaluate the diagnostic value of GLS and MD at rest and post-exercise during ESE to detect obstructive CAD, defined by angiographic stenosis >70% in any major coronary artery.

METHODS

Retrospective cohort study of 80 consecutive patients who underwent ESE and had coronary angiography (invasive or CT) within 6 months. Retrospective speckle tracking strain analysis was performed on digitally archived video-loops, using vendor independent software. Data on demographics, medications, outcomes and ESE characteristics were collected and analysed.

RESULTS

In 49 (61.3%) patients with any CAD >70%, GLS at rest was lower (-13.9% ± 4.2 vs -16.1% ± 5.2, p-value = 0.04), and MD at rest was higher (81ms ± 43 vs 58ms ± 28, p-value = 0.008), when compared to patients without CAD >70%. GLS and MD measured post-exercise were not significantly different between groups. Ejection fraction (EF) and Wall Motion Score Index (WMSI) at rest and post-exercise were not significantly different between groups. A resting GLS cutpoint of -14% had a sensitivity and specificity of 57/68%, comparable to the development of new regional wall motion abnormalities (71/39%) and peak WMSI >1.2 (59/48%). Additionally, in 39 (48.8%) patients who had >70% stenosis in the left anterior descending (LAD) artery, LS in the LAD territory segments was lower (-16.2% ± 4.4 vs -18.3% ± 4.7, p-value = 0.04), when compared to patients without >70% stenosis in the LAD artery.

CONCLUSION

Resting GLS was lower and MD higher in patients undergoing ESE, who have any CAD >70% compared to patients who do not have any CAD >70%. Resting GLS and MD may increase diagnostic accuracy during ESE to predict obstructive CAD. Further prospective studies evaluating the utility of resting indices to predict functionally significant CAD are required.
Relationship between natriuretic peptides and left atrial mechanics and their relation to recurrence of atrial fibrillation following catheter ablation
Authors: Olsen FJ , Darkner S , Goetze JP , Chen X , Henningsen K , Pehrson S , Svendsen JH , Biering-Sorensen T
Published: February 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation (grant no.: 09-04-R72-A2408-22545, 10-04-R78-A2929-22588, 11-04-R84-A3230-22650, and 18-R125-A8534-22083), and the Heart Centre Research Committee at Rigshospitalet, Copenhagen.

Background

The relationship between natriuretic peptides and atrial distension is not completely understood. Furthermore, how they can be used together clinically has not been fully explored.

Purpose

We sought to examine their interrelationship and how they relate to atrial fibrillation (AF) recurrence following catheter ablation.

Methods

Patients scheduled for catheter ablation as part of a randomized controlled clinical trial were included. Patients who underwent pre-operative echocardiography and had natriuretic peptide measurements performed, specifically mid-regional proANP (MR-proANP) and N-terminal proBNP (NT-proBNP), were included in this analysis. Echocardiography included assessment of atrial distension by left atrial strain.

The outcome was AF recurrence at 6 months after a 3-month blanking period. Logistic regression was performed to assess the association between log-transformed natriuretic peptides and AF. Multivariable adjustments were made for age, gender, randomization, and LVEF.

Results

Out of 99 patients 44 developed AF. No differences in natriuretic peptides nor echocardiographic measures were observed between the outcome groups.

Neither MR-proANP nor NT-proBNP were univariable predictors of AF recurrence (MR-proANP: OR = 1.06 (0.99-1.14), p = 0.09, per 10% increase; NT-proBNP: OR = 1.01 (0.98-1.05), p = 0.38, per 10% increase). These findings were unchanged after multivariable adjustments. However, atrial strain significantly modified the association between MR-proANP and AF (p for interaction = 0.009) such that MR-proANP was a significant predictor of AF in patients with high atrial strain values (OR = 1.24 (1.06-1.46), p = 0.008, per 10% increase) but not in patients with low atrial strain values. Among patients with high atrial strain values, an MR-proANP > 116pmol/L was associated with a 10-fold increased risk of AF (OR = 9.78 (2.21-43.33), p = 0.003). figure.

Conclusion

Atrial natriuretic peptide predicts AF recurrence in patients with preserved atrial distension. Assessing atrial distension by echocardiography may assist the clinical interpretation of atrial natriuretic peptide concentration.

Abstract Figure.
Mechanical dispersion is associated with clinical and subclinical coronary artery disease in patients on chronic renal replacement therapy with normal left ventricular ejection fraction
Authors: Stefanovic M , Stankovic I , Jemcov T , Janicijevic A , Zec N , Kusic Milicevic J , Markovic M , Vidakovic R , Neskovic AN
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since coronary artery disease (CAD) is the leading cause of mortality in patients with end-stage renal failure, early detection of CAD in these patients presenting with still normal left ventricular (LV) systolic function is of clinical importance.

Aim

To investigate the correlation between electrical and mechanical dispersion and CAD in dialysis patients with normal LV systolic function.

Material and methods: This prospective study included 78 dialysis patients who underwent a 12-channel electrocardiogram and echocardiographic examination to determine electrical and mechanical myocardial dispersion. A coronary calcium score using cardiac computed tomography was also assessed in a group of 20 patients without known CAD. Electrical dispersion was defined as the difference between the longest and shortest corrected QT interval (QTc). Mechanical dispersion (MD) was defined as either standard deviation of mechanical contraction duration of all LV segments (MD_SD) or the difference between the longest and shortest duration of mechanical contraction (MD_delta). The duration of mechanical contraction was determined by myocardial strain analysis.

Results

Previously known CAD was present in 11 (14%) patients, while pathologic Q wave was absent in all patients. No significant correlation was observed between QTc dispersion and both MD parameters (p > 0.05 for both). Both MD parameters (p = 0.007 for MD_SD; p = 0.026 for MD_delta), but not electrical dispersion (p = 0.584), showed a discriminative power for detecting previously known CAD (Figure). In patients without known CAD, neither QTc dispersion nor MD_SD showed a correlation with coronary calcium score (p > 0.05 for both). MD_delta showed a strong correlation with both total and coronary calcium score in the territory of the left anterior descending coronary artery (r = 0.62; p = 0.004) in patients without previously known CAD.

Conclusion

Mechanical dispersion is associated with known CAD in dialysis patients with normal LV systolic function. The range of mechanical myocardial contraction duration (MD_delta) correlates with subclinical coronary atherosclerosis.

Figure. Discriminative power of mechanical and electrical dispersion for the detection of coronary artery disease

Abstract Figure.
Clinical importance of left atrial infiltration in cardiac transthyretin amyloidosis
Authors: Bandera F , Martone R , Chacko L , Ganesananthan S , Gilbertson JA , Ponticos M , Petrie A , Cappelli F , Guazzi M , Potena L , Rapezzi C , Leone O , Hawkins P , Gillmore JD , Fontana M
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

 The clinical significance of left atrial (LA) involvement in ATTR amyloidosis cardiomyopathy (ATTR-CM) has not been characterized. The aims of this study were to characterize: (1)LA pathology in explanted ATTR-CM hearts; (2)LA mechanics using echocardiographic speckle-tracking in a large cohort of ATTR-CM patients; (3)to study the association with mortality.

METHODS AND RESULTS

Congo red staining and immunohistochemistry was performed to assess the presence, type and extent of amyloid and associated changes in 5 explanted ATTR-CM atria. Echo speckle-tracking was used to assess LA reservoir, conduit, contractile function and stiffness in 906 ATTR-CM patients (551 wt-ATTR-CM;93 T60A-ATTR-CM;241 V122I-ATTR-CM;21 other).

There was extensive ATTR amyloid infiltration in the 5 atria with loss of normal architecture, vessels remodelling, capillary disruption and subendocardial fibrosis. Echo speckle-tracking in 906 ATTR-CM patients demonstrated increased atrial stiffness [median(25th-75th quartile) 1.83(1.15-2.92)] that remained independently associated with prognosis, after adjusting for known predictors (lnLA stiff:HR = 1.26,CI 1.07-1.57;p = 0.009). There was substantial impairment of the three phasic functional atrial components [reservoir 8.86(5.94-12.97)%; conduit 6.5(4.53-9.28)%; contraction function 4.0(2.29-6.56)%]. Atrial contraction was absent in 21.6% of patients whose ECG showed sinus rhythm (SR)-"atrial electro-mechanical dissociation"(AEMD). AEMD was associated with poorer prognosis compared to SR patients with effective mechanical contraction (p < 0.0001). AEMD conferred a similar prognosis to patients in AF.

CONCLUSION

The phenotype of ATTR-CM includes significant infiltration of the atrial walls with progressive loss of atrial function and increased stiffness, which is a strong independent predictor of mortality. AEMD emerged as a distinctive phenotype identifying patients in SR with poor prognosis.

Abstract Figure.
Automated echocardiographic left ventricular strain measurements using deep learning
Authors: Rogstadkjernet M , Zha SZ , Klaeboe LG , Larsen CK , Aalen JM , Scheirlynck E , Droogmans S , Cosyns B , Smiseth OA , Haugaa KH , Edvardsen T , Samset E , Brekke PH
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Research Council of Norway

Background

Speckle tracking echocardiography (STE) provides quantification of left ventricular (LV) deformation and is useful in the assessment of LV function. STE is increasingly being used clinically, and every effort to simplify and standardise STE is important. Manual outlining of regions of interest (ROIs) is labour intensive and may influence assessment of strain values.

Purpose

We hypothesised that ROIs from clinical echocardiographic exams could be used to train a deep learning (DL) model which could automate strain calculation by predicting ROIs with comparable fidelity to trained cardiologists.

Methods

Data consisted of still frames with cardiologist-defined ROIs from 435 clinical echocardiographic exams from a university hospital outpatient clinic. Exams included healthy subjects and patients with ischemic heart disease, heart failure, valvular disease and conduction abnormalities. Three frames surrounding mid-systole from standard apical views were paired with the mid-systolic ROI for training. Image quality was classified as high, medium or low by an experienced cardiologist prior to model training, and low quality images were excluded. The dataset was randomly split into 68%/17%/15% sets for training, validation and testing. A standard Unet architecture was used, with a combination of binary cross entropy and Dice loss functions. A total of 1025 images were used for final model training and testing, with augmentation used to extend the dataset. Predicted ROIs were reintroduced into commercially available echocardiographic analysis software to automatically calculate longitudinal strain (LS) values.

Results

The average absolute difference between manually measured and DL-assisted LS was 0.98 percentage points (95% confidence interval 0.82-1.13) for the final model. A Bland-Altman plot revealed very few outliers and no bias in the difference between manual and DL-assisted strain measurements.

Conclusion

The current study demonstrates that DL-assisted, automated strain measurement is feasible, and provides strain results within an acceptable range of intra- and interobserver variation. Employing DL in echocardiographic analysis could further facilitate adoption of STE parameters in clinical practice and research, and improve reproducibility.

Abstract Figure. Bland-Altman plot. Manual and DL ROIs
Prognostic utility of early systolic lengthening by speckle tracking in patients undergoing coronary artery bypass graft
Authors: Brainin P , Lindberg S , Olsen F , Pedersen S , Iversen A , Galatius S , Fritz-Hansen T , Gislason G , Soegaard P , Moegelvang R , Biering-Soresen T
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Independent Research Fund Denmark

Background

Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, has been linked to myocardial viability and contractile dysfunction. We assessed the long-term prognostic potential of ESL in coronary artery bypass graft (CABG) patients.

Methods

We retrospectively included patients (n = 709; mean age 68 years; 85% men) who underwent speckle tracking echocardiography (median 15 days) prior to CABG. Endpoints were cardiovascular death (CVD) and all-cause mortality. We assessed amplitude of ESL (%), defined as peak positive strain, and duration of ESL (ms), determined as time from Q-wave on the ECG to peak positive strain. We applied Cox proportional hazards models adjusted for the clinical risk tool, EuroSCORE II.

Results

During median follow-up of 3.8 years [IQR 2.7 to 4.9 years], 45 (6%) experienced CVD and 80 (11%) died. In survival analyses adjusted for EuroSCORE II, amplitude of ESL was associated with CVD (HR 1.37 [95%CI 1.13 to 1.66], P = 0.001) and all-cause mortality (HR 1.31 [95%CI 1.13 to 1.54], P = 0.001). Similar findings applied to duration of ESL and CVD (HR 1.17 [95%CI 1.08 to 1.26], P < 0.001) and all-cause mortality (HR 1.14 [95%CI 1.07 to 1.21], P < 0.001). The prognostic value of ESL amplitude was modified by sex (P interaction < 0.05), such that it was greater in women for both endpoints (Figure 1A-B). When adding ESL duration to EuroSCORE II, the net reclassification index improved significantly for both CVD and all-cause mortality.

Conclusions

Assessment of ESL provides independent and incremental prognostic information in addition to the EuroSCORE II for CVD and all-cause mortality in CABG patients. The prognostic value was greater in women.

Abstract Figure. Prognostic value of ESL amplitude by sex
Predicting heart failure transition and progression: a weighted risk score from bio-humoral, cardiopulmonary and echocardiographic stress testing
Authors: Pugliese NR , De Biase N , Conte L , Gargani L , Mazzola M , Fabiani I , Natali A , Dini FL , Frumento P , Rosada J , Taddei S , Borlaug BA , Masi S
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Aims. We tested the prognostic role of a risk score including bio-humoral evaluation, cardiopulmonary-echocardiographic stress (CPET-ESE) and lung ultrasound, in patients with heart failure (HF) with reduced and preserved ejection fraction (HFrEF and HFpEF), and subjects at risk of developing HF (American College of Cardiology/American Heart Association Stages A and B).

Methods and results. We evaluated 318 subjects: 94 in Stages A-B, 194 in Stage C (85 HFpEF and 109 HFrEF), and 30 age and sex-matched controls (Stage 0). During a median follow-up of 18.5 months, we reported 40 urgent HF visits, 31 HF hospitalisations and 10 cardiovascular deaths. Cox proportional-hazards regression for predicting adverse events identified five independent predictors and each was assigned a number of points proportional to its regression coefficient: Δstress-rest B-lines >10 (3 points), peak oxygen consumption <16 mL/kg/min (2 points), minute ventilation/carbon dioxide production slope ≥36 (2 points), peak systolic pulmonary artery pressure ≥50 mmHg (1 point) and resting N-terminal pro-brain natriuretic peptide (NT-proBNP) >900 pg/mL (1 point). We defined three risk categories: low-risk (<3 points), intermediate-risk (3-6 points), and high-risk (>6 points). The event-free survival probability for these three groups were 93%, 52% and 20%, respectively. Hazard Ratio was 4.55 for each risk category upgrade (95% confidence interval [CI], 3.44-5.93). The area-under-curve for the scoring system to predict events was 0.92 (95% CI 0.88-0.96).

Conclusion. A multiparametric risk score including indices of exercise-induced pulmonary congestion, markers of cardiopulmonary dysfunction and NT-proBNP identifies patients at increased risk for HF events across the HF spectrum.

Table 1 Variable EPYC score EPYC score <3 (low risk) n = 217 EPYC score 3-6 (intermediate risk) n = 70 EPYC score >6 (high risk) n = 31 p-value (between risk categories) Event-free (n = 244) 0 (0 - 2) 210 (97) 32 (46) 2 (6) <0.0001 With events (n = 74) 6 (4 - 9) 7 (3) 38 (54) 29 (94) <0.0001 p-value (event-free vs with events) <0.0001 <0.0001 <0.0001 <0.0001 Stage 0-Controls (n = 30) 0 (0 - 1) 30 0 0 <0.0001 Stages A-B (n = 94) 1 (0 - 2) 85 (45) 6 (9) 3 (10) <0.0001 Stage C-HFpEF (n = 85) 3 (1 - 6)*† 46 (25) 29 (41) 10 (32) <0.0001 Stage C-HFrEF (n = 109) 4 (2 - 7)*† 56 (30) 35 (50) 18 (58) <0.0001 p-value (between HF Stages) <0.0001 <0.0001 <0.0001 <0.0001 Values are mean ± standard deviation, n (%), or median [25th quartile, 75th quartile]. * p < 0.01 vs Stage 0-Controls; † p < 0.01 vs Stages A-B. Abstract Figure 1
Residual mitral regurgitation impact on outcomes after mitraclip therapy: five-year follow-up from the GRASP registry
Authors: Caggegi AM , Capranzano P , Scandura S , Mangiafico S , Castania G , Salerno T , Milici A , De Sanctis J , Bentivegna A , Frazzetto M , Sardone A , Di Salvo ME , Grasso C , Capodanno D , Tamburino C
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background – Although percutaneous mitral valve repair is an attractive alternative treatment option for patients with severe mitral regurgitation (MR) at high surgical risk, residual MR is commonly observed after the procedure and little is known about its impact on outcomes after MitraClip therapy, expecially in patients with severe left ventricular (LV) impairment.

Purpose – The aim of this prospective, observational study was to evaluate the impact of residual MR (MR ≤1+ vs. MR >1+) on long-term outcomes of mitral valve repair with the MitraClip System in high surgical risk patients presenting with moderate-to-severe or severe MR and with severe reduction of LV ejection fraction (EF).

Methods – Patients enrolled in the prospective Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation (GRASP) with functional MR and EF ≤30% who were eligible at almost five-year follow-up were included in the present analysis.  The primary endpoint was death at 5-year follow-up.  Also echocardiographic parameters at baseline and 5-year follow-up and rehospitalization rates were assessed.

Results – A total of 139 patients were included: 92 (66.2%) with post-procedural residual MR ≤1+ and 47 (33.8%) with residual MR > 1+ (41 patients with residual MR 2+, 5 with residual MR 3+, 1 with residual MR 4+).  Comparable clinical and echocardiographic baseline characteristics were observed between the two groups except for NYHA functional class IV and implanted pace-maker (more frequent in patients with residual MR >1+) and previous myocardial infarction (more frequent  in patients with residual MR ≤1+). At 5-year follow-up, no significant differences were reported in the primary endpoint (49.6% in patients with residual MR ≤ 1+ vs. 65.3% in patients with residual MR > 1+, p 0.203) and in cardiac death (37.8% in patients with residual MR ≤ 1+ vs. 42.6% in patients with residual MR > 1+, p 0.921). Cox regression analysis identified residual MR > 1+ as an independent predictor of re-hospitalization (HR 0.51, 95% CI 0.28-0.92, p =0.026). At 5-year follow-up,  a significant reduction in left ventricular end-systolic volume was  observed in patients with residual MR ≤ 1+.

Conclusions – At 5-year follow no significant differences in survival emerged in patients with severe  LV dysfunction undergoing MitraClip therapy regardless residual MR. Nevertheless residual MR > 1+ emerged as an indipendent predictor of re-hospitalization.
Cardiac care of Non-COVID-19 patients during the SARS-CoV-2 pandemic: The pivotal role of CCTA
Authors: Conte E , Mushtaq S , Mancini M , Annoni A , Formenti A , Muscogiuri G , Baggiano A , Guglielmo M , Guadenzi-Asinelli M , Gigante C , Assanelli E , Pontone G , Pepi M , Andreini D
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Aims

To describe the role of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic test for symptomatic patients with suspected CAD in a hub center for cardiovascular emergencies in the presence of limited access to hospital facilities during the COVID-19 pandemic.

Methods and Results

From March 9th to April 30th, during the peak of the COVID-19 pandemic, a consecutive cohort of symptomatic patients with high clinical suspicion of CAD and clinical indication to CCTA were enrolled in a hub hospital in Milan, Italy. When obstructive coronary artery disease was detected (>70% diameter stenosis in a proximal coronary segment or >90% stenosis in any coronary segment) patients were referred to invasive coronary angiography (ICA). Clinical follow-up was assessed in patients in whom ICA was considered deferrable.

Overall, 58 consecutive patients were included. Ten (17.2%) symptomatic patients underwent ICA according to CCTA findings, while in 48 (82.8%) patients ICA was deferred. No clinical events were recorded after a mean follow-up of 49.7 ± 16.8 days. In nine out of ten patients referred to ICA, severe coronary artery disease was confirmed and treated accordingly. Changes in medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA.

Conclusion

We report a potential pivotal role for CCTA in the triage of non-COVID-19 patients with suspected  CAD during the SARS-CoV-2 pandemic. CCTA may be helpful for identifying patients who necessitate ICA, ensuring adequate resource utilization during the pandemic.