bluuebunny/crossref_metadata_2025 huggingface dataset:
Flexible 3D printing of the mitral valve apparatus and left coronary artery for patients with complex anatomical variations in mitral valve surgery
Authors: Man J P , Bouma B J , Chamuleau S A J , Schuuring M J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Injury to the left circumflex artery (LCA) occurs in an estimated 2.7% of patients undergoing mitral valve (MV) surgery. The average distance from the LCA to the MV varies substantially between patients but is on average 3.1 ± 1.3mm. In unfavorable anatomical variations, a 3D print of relevant anatomical structures could be helpful for a surgeon to be aware of the situation and determine a surgical strategy. In this case such a 3D print is made of a 66 year old patient with mitral valve regurgitation and a P2 prolapse assessed in the heart team for MVS.

Purpose

To create a flexible heart model using Computed tomography (CT) and Transesophageal echocardiography (TEE) scans of this patient that utilizes the synergistic information derived from both modalities and provides an improved method for surgical preparation in cases with unfavorable anatomical variations.

Method

CT and TEE scans of the heart and mitral valve are acquired and fused using Mutual information registration. Both modalities are used in the print as TEE is the gold standard for evaluating the MV prior to surgery while on CT the LCA can be visualized and the ventricle can be imaged with a higher spatial resolution. The combined reconstructions are hollowed and smoothed using Meshmixer and the Poisson disk sampling tool of Meshlab to make the reconstruction suitable for 3D printing, enhance visibility of the relevant anatomy and achieve the desired flexibility of the model.

Results

A flexible 3D model of the left side of the heart of a patient is created. The model consists of reconstructions of the left coronary artery (CT), the left side of the heart (CT), and the mitral valve (TEE). To expose the LCA, an indent in the tissue surrounding the LCA was made. At the apex of the heart and at the left lateral side a small window in the ventricle was created for visibility. A flexibility resembling the flexibility of tissue was created by hollowing a with walls of 1.2mm thickness and printing with Agilus 30 Clear (with a shore A value of 30) .

Conclusion

To our knowledge this is the first 3D print for the planning of mitral valve surgery in which CT and TEE scans are combined into one flexible print. The flexible 3D print with exposed coronary arteries allows for assessment of the mitral valve regurgitation deficit and determine a surgical strategy because of the flexibility of the model, and as the LCA is exposed in this model, the surgeon can adapt his surgical approach based on the location of the LCA.
CT-derived modified Duke score is associated with pericoronary Fat Attenuation Index and predicts severity of coronary inflammation
Authors: Halatiu V B , Benedek I , Rodean I P , Cojocariu L O , Mihaila T , Blindu E , Rosca A , Matyas B B , Szabo E , Parajko Z , Gerculy R , Benedek T
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): The IntelFat project - "Epicardic adipose tissue, local inflammation and the vulnerability of atherosclerotic plaques - computational imaging study based on artificial intelligence" financed by UEFISCDI 689/02.03.2021 (Contract number 206/2021).

Background

The modified Duke derived from coronary computed tomography angiography (CCTA) was designed to predict cardiovascular outcomes based on the severity of coronary stenosis. However, it does not take into consideration the presence or severity of peri-coronary inflammation. The peri-coronary fat attenuation index (FAI) is a novel imaging marker determined by CCTA which reflects the degree of inflammation in the coronary tree in patients with coronary artery disease.

Purpose

To assess the association between the modified Duke score assessed by CCTA, cardiovascular risk factors and peri-coronary FAI in the coronary arteries.

Methods

One hundred sixty-nine patients who underwent CCTA for typical angina were assigned into two groups based on the modified Duke score: group 1 – patients with low score ≤ 3 (n=105) and group 2 – patients with high score > 3 (n=64). Demographic data, cardiovascular risk factors (hypertension, hypercholesterolemia, diabetes and smoking), and the FAI-score for all three coronary arteries were collected for all patients.

Results

Patients with increased values of the modified Duke score were significantly older compared to those with a low score (64.5 ± 8.75 vs. 61.0 ± 10.12; p = 0.001). No differences were found between the two groups in terms of gender distribution, hypertension, hypercholesterolemia or smoking history (all p > 0.5). Compared to patients in group 1, those in group 2 presented more frequently type 2 diabetes, (54.35% vs. 45.65%; p = 0.008). FAI score was significantly higher in patients from group 2, who presented a significantly higher score of inflammation compared to the patients in group 1, especially at the level of the right coronary artery (FAI score 16.45 ± 15.83 vs. 10.6 ± 14.09; p = 0.02 for the right coronary artery, 12.72 ± 8.05 vs. 9.6 ± 6.56; p = 0.01 for the circumflex artery, and 10.35 ±10.18 vs. 8.7 ± 8.89; p = 0.18 for the left anterior descending artery).

Conclusion(s)

CT-derived modified Duke score is increased in patients with DM and correlates well with local perilesional inflammation, as assessed by the FAI score at different levels of the coronary circulation.
Photon counting detector CT can identify mild coronary artery in-stent restenosis more reliably
Authors: Vertes M , Balogh H , Nagy N , Kerkovits N , Vecsey-Nagy M , Boussoussu M , Vattay B , Szilveszter B , Merkely B , Maurovich-Horvat P , Simon J
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University.

Introduction

The improved spatial resolution of photon-counting detector CT (PCD-CT) allows better image quality and less artefacts even in high-density structures, such as coronary artery stents.

Purpose

Our aim was to compare the prevalence of coronary artery in-stent restenosis using conventional CT and PCD-CT.

Methods

Our retrospective study included consecutive patients with coronary artery stents who underwent coronary CT angiography (CCTA) either with PCD-CT between January and December 2022 or with a 280-slice conventional CT scanner in 2019. The following categories were used: none, not severe, severe in-stent restenosis and stents with non-diagnostic image quality.

Results

Altogether 253 patients were included in our study (215 patients who underwent CCTA with a conventional CT and 38 patients who had PCD-CT examination). The mean age was 62.7±10.8 years and 46.8% were women. In-stent restenosis was detected significantly more frequently in case of PCD-CT examination, as compared to conventional CCTA (47.7% and 27.4%, respectively; p = 0.023). Among the 15 patients who underwent ultra-high resolution PCD-CT examination, only one (6.7%) had a non-diagnostic image quality for the assessment of in-stent restenosis, while 34 cases (15.8%) were non-diagnostic in the conventional CCTA group.

Conclusions

The better image quality provided by PCD-CT notably helps the evaluation of in-stent restenosis and can therefore contribute to the identification of mild in-stent restenosis. Moreover, the number of non-diagnostic CCTA scans can be decreased by using ultra-high resolution technique.
Short period of training in 3D echocardiography provides good feasibility and reproducibility of right ventricular assessment in heart failure
Authors: Memis H , Mihaila Baldea S , Mihalcea D , Dodita D , Andreescu A , Vasile D , Velcea A , Visoiu I S , Vinereanu D
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): PROHEART 3D.

Background

Right ventricular (RV) dysfunction is an independent risk factor for increased mortality and morbidity. Standard approach for assessing is 2-dimensional echocardiography (2DE). However, 2DE is prone to errors due to increased variability of the anatomical cut-planes and geometrical assumptions due to the complex triangular and "wrapped-around" RV shape. Meanwhile, 2DE reflects mainly the RV longitudinal function, at the expense of the radial and global RV functions. 3D echocardiography (3DE) enabled itself as a more accurate method for assessment of cardiac volumes and calculation of ejection fraction (EF), but with a cumbersome learning time-curve.

Objectives

To establish if trainees in 3DE provide feasible and reproducible 3D measurements of RV size and function, by comparison to 2DE assessment, after a short period of training by an expert in echocardiography.

Methods

161 consecutive patients (58±17 years, 71% males, 3D left ventricular EF 35±10%), hospitalized for heart failure (HF), underwent standard precordial 2DE acquisitions and 3DE multi-beat full-volumes of the RV. One expert in both 2DE and 3DE, and one fellow trained for 2 years in 2DE and for 3 months in 3DE, performed measurements of both 2DE and 3DE parameters for RV size and function, in a blinded fashion. 2DE parameters were measured first, in the following order: RV diameter, RV end-diastolic (RVED) and end-systolic (RVES) areas, RV fractional area change (RV FAC), tricuspid annular plane systolic excursion (TAPSE), tricuspid annular systolic velocity (RV S’), and RV free wall longitudinal strain (RV LS). Then, 3D RVED and RVES volumes were measured, and RV ejection fraction (RVEF) was calculated, using a semi-automated software package. Endocardial borders were corrected, as needed.

Results

Feasibility of 2DE and 3DE was 97% and 92%, respectively, patients being excluded due to poor quality images, similarly for expert vs. trainee. Mean RVED volume was 94.0±30.6 ml/m2, and mean RVEF was 37.3±9.6%. Reproducibility of 2DE parameters obtained by the expert vs. trainee were good for the assessment of RV longitudinal function (TAPSE, RV S', and RV LS), but suboptimal for the assessment of RV size and global function (RV diameter, RV areas, and RV FAC) (Table). Reproducibility of 3DE parameters obtained by the expert vs. trainee were also good, even after a short period of training (3 months) (Table).

Conclusions

A short period of training in 3DE provides a good feasibility and reproducibility of the assessment of RV size and function, in a large cohort of hospitalized patients with HF. 3DE might be a more reliable method than 2D for the initial assessment of patients with HF.
Cardiac dysfunction rather than aortic valve stenosis severity drives exercise intolerance and adverse hemodynamics
Authors: Hoedemakers S , Verwerft J , Reddy Y , Delvaux R , Stroobants S , Jogani S , Claessen G , Droogmans S , Cosyns B , Borlaug B , Herbots L , Verbrugge F
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Aortic valve stenosis (AS) and heart failure with preserved ejection fraction (HFpEF) present with similar cardiac alterations, but their overlap is poorly understood.(1–3).

Purpose

To study left ventricular (LV) hypertrophy, diastolic dysfunction, left atrial (LA) dysfunction, hemodynamics, and exercise capacity according to HFpEF status versus AS severity.

Methods

Patients (n=206) with at least moderate AS (aortic valve area ≤0.85 cm2/m2) and discordant symptoms underwent cardiopulmonary exercise testing with simultaneous echocardiography. The population was stratified according to the probability of underlying HFpEF by the H2FPEF score [0–5 (AS/HFpEF-) vs. 6–9 points (AS/HFpEF+)] and AS severity (Moderate vs. Severe).

Results

Mean age was 73±10 years with 40% women. Stratification yielded 41 AS/HFpEF+ (20%) versus 165 AS/HFpEF- (80%) and 139 Severe (67%) versus 67 Moderate (33%) AS patients. AS/HFpEF+ patients had a lower LV global longitudinal strain, impaired diastolic function, reduced LV compliance, and more pronounced LA dysfunction compared to AS/HFpEF- patients. The mean pulmonary arterial pressure-cardiac output (mPAP/CO) slope was significantly higher in AS/HFpEF+ versus AS/HFpEF- (5.4±3.1 vs. 3.9±2.2 mmHg/L/min, respectively; p = 0.003), mainly driven by impaired cardiac output (CO) reserve and chronotropic incompetence, with signs of right ventricular-pulmonary arterial (RV-PA) uncoupling. AS/HFpEF+ versus AS/HFpEF- was associated with a lower peak aerobic capacity (11.5±3.7 vs. 15.9±5.9 mL/min/kg, respectively; p<0.0001), but did not differ between Moderate and Severe AS (14.7±5.5 vs. 15.2±5.9mL/min/kg, respectively; p = 0.6).

Conclusions

A high H2FPEF score is associated with a reduced exercise capacity and adverse hemodynamics in patients with moderate to severe AS. Both exercise performance and hemodynamics correspond better with intrinsic cardiac dysfunction than AS severity itself.
Myocardial contraction fraction: an underused imaging biomarker
Authors: Kurdi H , Thornton G , Shiwani H , Artico J , Abiodun A , Patel K , Schelbert E , Treibel T , Manisty C , Moon J , Davies R
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The Myocardial contraction fraction (MCF% – stroke volume over myocardial volume) is an alternative/complementary measure of cardiac function to the ejection fraction (EF% – stroke volume over end diastolic volume), (1–2). It is dimensionless, does not need allometric scaling, is easy to compute and intuitive: the stroke volume produced per unit of myocardium, with some data for its utility in different forms of hypertrophy, (3–5). EF limitations (eg HFpEF) are well known. We explored the potential utility of MCF in a variety of cardiac diseases.

Purpose

To define reference ranges for MCF in normal and disease using a large dataset, exploring sex and age-related differences. To evaluate and compare the potential use of MCF as a prognostic biomarker compared to the more commonly used LVEF.

Methods

3 cohorts were used:

1. Health: 3,541 subjects from UK biobank, supplemented by 72 local healthy volunteers (UKB lower age limit is 45) to define normality and age/sex differences.

2. Disease: n=380 with a range of diseases : 125 HCM, 157 Fabry disease (FD) and 26 Transthyretin (TTR) Amyloid.

3. Prognostic cohort: n=1500 patients from a single centre with outcomes (26% death or hospitalisation with heart failure over a median 5.5years follow-up)

All CMR images were analysed using a clinically validated artificial intelligence (AI) algorithm for convenience of large-scale analysis (6) to determine MCF and LVEF.

Results

Health: There was no significant changes in MCF with age but there was a significant sex difference (male 0.94, range 0.68–1.2; female 1.10, range 0.82–1.37 p<0.05)—see figure 1. Disease: MCF values for each disease cohort is shown in figure 2, all with a significant reduction compared to the healthy controls. Values ranged from 0.47 with Amyloid to 0.94 with Fabrys. Outcome: MCF strongly predicted patient outcomes – and was a more powerful predictor than LVEF (LVEF chi-squared=84 vs MCF chi-squared=160).

Conclusion

MCF is a complementary measure of cardiac performance to LVEF and equally as logical, intuitive and easy to calculate. It is frequently reduced even when LVEF is normal, and is a much stronger predictor of outcome than LVEF.
The impact of BMI on myocardial work and left atrial strain in young overweight patients with preserved left ventricular ejection fraction
Authors: Trimarchi G , Lofrumento F , Taverna G , Mancinelli A , Cusma Piccione M , Manganaro R , Trio O , Di Bella G , Zito C , Carerj S
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Overweight and obesity are a health problem of growing significance all over the world with increasing prevalence in both developed and developing countries. Numerous studies have demonstrated a relationship between obesity and cardiovascular diseases, underscoring the need to early treat this pathological condition. Overweight and obesity cause structural and functional changes on left ventricular (LV) and left atrial (LA) performance, which lead to heart failure.

Purpose

to evaluate the impact of BMI on myocardial work parameters and left atrial strain and to early detect LV and LA performance changes in overweight patients.

Methods

80 young individuals were prospectively enrolled, distinguishing between overweight patients with BMI greater than or equal to 25 to 29.9 kg/m^2 (n= 36; 45 ±11 years) and normal weight patients with BMI greater than or equal to 18.5 to 24.9 kg/m^2 (n=44; 43±9 years). All patients underwent transthoracic echocardiogram to calculate global longitudinal strain (GLS), global work index (GWI), global work efficiency (GWE), global wasted work (GWW), global constructive work (GCW) and left atrial strain.

Results

Overweight patients have higher BSA (1,9±0,16 vs 1,6±0,17 mq; p<0,0001), Diastolic Blood pressure (81±12 vs 74±10 mmHg; p = 0,01) mean arterial pressure (98±15 vs 91±11 mmHg; p = 0,01), Heart Rate (71±13 vs 70±12 bpm; p = 0,02) and Global Longitudinal Strain (−19,3% ±1,7 vs −20,3% ±1,8; p = 0,02). With respect to myocardial work parameters, in overweight patients GWE (93% vs 95%; p = 0,01) is significantly reduced, whereas GWW (132 vs 102 mmHg%; p = 0,03) is significantly increased. Left atrial reservoir (LAres) (36% vs 40%; p = 0,04) and conduit (19% vs 24%; p = 0,005) function are significantly reduced in overweight patients. BMI inversely correlates with GWE (r=-0,36; p = 0,005) and LAres (r=-0,33; p = 0,007), whereas it directly correlates with GWW (r=0,31; p = 0,006).

Conclusions

Overweight induces early LV and LA performance changes that can be precociously detected by myocardial work and left atrial strain, in order to better characterize individual cardiovascular risk profile.
Intracavitary blood flow dynamics in the systemic right ventricle: a 4D-Flow MRI study
Authors: Pasqualin G , Riva A , Sturla F , Bevilacqua F , Giese D , Chessa M , Redaelli A , Votta E , Lombardi M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Failure of the systemic right ventricle (SRV) is based on morphological differences between right and left ventricles (RVs and LVs). RV adaptation to systemic afterload includes increased circumferential (GCS) over longitudinal global myocardial strain (GLS) with an unknown impact on intracavitary blood flow distribution. This study aimed to explore the SRV pattern of hemodynamic forces (HFs).

Methods

4D-Flow cardiovascular magnetic resonance data were acquired using a prototype sequence on a 1.5-T MAGNETOM Aera. The ratio between transverse (inferior-anterior, HFIA and septal-lateral, HFSL) and longitudinal (basal-apical, HFBA) HFs (RRMS) was calculated as in Figure 1, for systole and diastole.

Results

We enrolled 12 adults with SRV (6 D-transposition of great arteries after atrial switch operation and 6 L-transpositions) and 12 age-matched healthy subjects (41±12 vs 42±13,p = 0.89).

SRVs reported comparable end-diastolic volumes (83±18 ml/m2), ejection fraction (60±8%) and GLS (−20.2±3.8%) to control RVs (75±13 ml/m2,p = 0.18; 64±5%,p = 0.25; −23±5.6%,p = 0.21). Differently, SRV mass (55±24 g/m2) and GCS (−18.9±7.8%) were greater than RVs (20±3 g/m2,p<0.001 and −12.4±4,p = 0.016) and comparable to control LVs (57±11 g/m2,p = 0.7 and −20.2±3.8%,p = 0.3). The 4D-Flow analysis showed that SRV systolic RRMS (0.98±0.31) was similar to LVs (0.94±0.27,p = 0.78) but lower than RVs (1.32±0.45,p = 0.04). This reflected a significantly increased HFBA with respect to RVs (0.338±0.150 vs. 0.162±0.097, p = 0.0025) and similar to LVs (0.462 ± 0.186, p = 0.087). Concomitantly, a moderate correlation was demonstrated between SRV systolic HFBA magnitude and GCS (r2=0.47,p = 0.013). During diastole, SRVs showed lower HFBA (0.173±0.086) than LVs (0.304±0.104,p = 0.0028), revealing a diastolic RRMS (0.74 ± 0.14) comparable to RVs (0.73 ± 0.17,p = 0.95) and significantly different from LVs (0.50 ± 0.19,p = 0.003).

Conclusions

In SRVs, RRMS is similar to LVs during systole, possibly as a result of increased GCS. Inversely, the SRV filling appears to be closely related to ventricular morphology as suggested by RRMS comparable to RVs during diastole.
Right ventricular to pulmonary artery coupling change after catheter ablation of atrial fibrillation
Authors: Bonelli A , Degiovanni A , Cersosimo A , Spinoni E G , Bosco M , Dell'era G , Patti G , Adamo M , Curnis A , Moreo A , De Chiara B C , Gigli L , Giannattasio C , Metra M , Inciardi R M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular (RV) to pulmonary artery (PA) coupling can be assessed using the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP). Although its use has been widely adopted in clinical practice, less is known about its role in patients with atrial fibrillation (AF) and its change after catheter ablation.

Purpose

The aim of this study is to assess the changes and the clinical impact of RV-PA coupling in patients with AF who underwent catheter ablation.

Methods

This is a prospective study that enrolled patients undergoing catheter ablation for AF between March 2021 and September 2022 in three tertiary centers in Italy. We evaluated the changes in RV structure and function and TAPSE/PASP between baseline and the 3-month follow-up and their relation with AF relapse after procedure.

Results

A total of 135 patients were included (mean age 65.2 ± 9.1 years; 68% males, mean left ventricular ejection fraction [LVEF] 56.9 ± 7.9%). Patients in the lowest tertile (TAPSE/PASP < 0.67 mm/mmHg) were older, with and LVEF and LV global longitudinal strain (LVGLS). They also showed lower TAPSE, S’ wave at Tissue Doppler and RV global strain and higher PASP.

In the overall population, after 3 months from the ablation procedure, we observed a significant increase of TAPSE (from 22.4 ± 4.1 to 24.0 ± 3.8, p < 0.001), a reduction of PASP (from 29.5 ± 6.6 to 27.9 ± 7.7, p = 0.030) and an increase in TAPSE/PASP from 0.81 ± 0.27 to 0.93 ± 0.29 (p < 0.001). The latter improved both in the patients who were in sinus rhythm (p = 0.031) and with AF (p = 0.003) at baseline.

Compared to patients in the highest TAPSE/PASP tertile, those in the lowest one (TAPSE/PASP < 0.67 mm/mmHg) showed an increased risk of AF relapse after catheter ablation (OR 4.33, 95% confidence interval 1.25 – 14.96, p = 0.020). Moreover, the increase of TAPSE/PASP ratio during the follow-up period was associated with a reduced probability of AF relapse, after adjustment for covariates (OR 0.70, 95% confidence interval 0.49 – 0.99, p = 0.046).

Conclusion

In a multicenter cohort of patients with AF undergoing catheter ablation, a significant improvement of RV-PA coupling, assessed by the TAPSE/PASP ratio, has been observed, regardless of rhythm at admission. Moreover, TAPSE/PASP at baseline, and its change, may represent a useful parameter to predict AF relapse after the procedure.
Should we use a semi-quantitative assessment of apical rocking to predict outcome in CRT patients?
Authors: Puvrez A , Mirea O , Wouters L , Bezy S , Beela A , Duchenne J , Donal E , Voigt J U
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Apical rocking (AR) is a systolic septal-to-lateral motion of the apex observed on echocardiography in the apical 4-chamber view in some patients with a ventricular conduction delay. It is a strong predictor for outcome after cardiac resynchronization therapy (CRT) and has been suggested as selection criterion for CRT. Critics argue that simple visual assessment of AR may be too subjective for clinical use. Speckle-tracking based myocardial motion analysis may allow to objectify AR and may reduce a potential observer dependence.

Purpose

To compare the visual assessment of AR (VAR) to the semi-quantitative assessment of AR (QAR) in patients for the prediction of (i) volume response and (ii) all-cause death after CRT. To assess interobserver agreement for VAR and QAR.

Methods

We retrospectively analyzed data from 166 patients with a first CRT implantation. All patients had an echo before CRT implantation and approximately 1 year after implantation. VAR and QAR analysis were performed by three experienced observers on echocardiographic apical 4-chamber views before CRT implantation. QAR was obtained by performing speckle-tracking in the apical segments of the lateral and septal wall. A negative lateral displacement with a positive septal displacement during systole was considered as AR (Figure). Areas under the ROC-curves (AUC) for prediction of volume response were determined and compared using the DeLong method. Volume response was defined as a ≥15% decrease in left ventricular end-systolic volume (LVESV) within 1 year. Patients were followed for a mean duration of 5.2 years. Hazard ratios (HR) for all-time all-cause death after CRT were calculated using an univariate Cox proportional-hazards regression model. Interobserver agreement was analysed using the intraclass correlation coefficient (ICC) based on an average measurement, absolute agreement, two-way mixed effects model.

Results

77% (n = 122) of patients were volume responders. Seven patients died before follow-up echocardiography. 31% (n = 52) of patients died during follow-up. AUC for volume response were similar for VAR and QAR (0.73 vs 0.72, p = 0.782). HR for all-time all-cause death were similar for VAR (0.39, 0.25–0.61; p<0.001) and QAR (0.37, 0.23–0.59; p<0.001). ICC was good for VAR (0.78; 0.55–0.90) and QAR (0.84; 0.67–0.93).

Conclusion

Semi-quantification of AR (QAR) using speckle-tracking technology achieves comparable results as the simple visual assessment of AR (VAR) when performed by an experienced reader for prediction of volume response and prediction of all-cause death in patients eligible for CRT. Interobserver agreement for VAR and QAR was similarly good. QAR could be used as confirmation of the visual assessment and may support clinicians less familiar with the visual assessment.
Is relevant to add stress echocardiography with semi-supine bicycle at the screening of pulmonary hypertension in systemic sclerosis patients?
Authors: Ayala- Leon M I G U E L , Ramirez-Sanchez P , Rodriguez-Reyna T , Mercado-Velazquez P , Orihuela-Sandoval C , Hernandez-Oropeza J L
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Pulmonary hypertension (PH) is the leading cause of death in systemic sclerosis, with a 50% mortality rate within three years of PH diagnosis. The 3-year survival of patients with SSc and PH is estimated to be 56% compared with 94% for those without PH.(1,2). Patients with SSc are at risk of developing group 1 to 3 PH. Detection of PH with echocardiography at rest remains the essential clinical tool; several studies suggested that in patients with SSc, an even earlier change would be the abnormal increase in pulmonary pressures with exercise. (3–6)

Purpose

Exercise-induced pulmonary hypertension may represent an early but clinically relevant phase in the spectrum of pulmonary vascular disease. On the other hand, increases in mean pulmonary artery pressure on exercise echocardiography can be followed over time, indicating the progression of the pulmonary vascular disease before PH.

Methods

Observational, prospective, cross-sectional, and analytical study.

A basal transthoracic echocardiogram (TTE) and physical stress echocardiogram test were performed, and a TTE follow-up at four years.

Results

40 patients. A follow-up was 48 months ED 6 months. Women (93%). Mean age of 49.8 ED 11.4 years. 9.8% of the patients had systemic arterial hypertension; no patient had diabetes mellitus or other chronic-degenerative diseases.

28 (68.3%) patients had the limited cutaneous variety, and 13 (31.7%) patients had the diffuse type.

In the basal TTE at the first visit, all had a low probability of presenting pulmonary hypertension; in the follow-up echocardiogram, 11 (26.8%) patients showed a high likelihood of pulmonary hypertension.

TTE with a cycle ergometer at first visit: 19 (46.3%) patients presented PSAP >50 mmHg, 16 (39%) patients gave DeltaPSAP >24 mmHg, 19 (46.3%) patients showed a relationship mPAP >30 mmHg + PVR > 3 mmHg/L/min

The correlation between stress test variables and the high probability of pulmonary hypertension at follow-up was PSAP>50 mmHg exercise (r 0.58, p<0.001). Delta PSAP >24 mmHg exercise(r 0.40, p 0.011). mPAP>30 mmHg + PVR>3 mmHg/L/min exercises (r 0.45, p 0.003). PVR and >3 mmHg/L/min (r 0.15, p 0.310).

Conclusion(s)

Exercise-induced pulmonary hypertension is a promising tool in screening patients with systemic sclerosis for the detection of pulmonary hypertension at earlier preclinical stages.

Identifying patients with closer follow-up for TTE at rest every 3 to 6 months and not every year as suggested in this disease.
Troponin and NT-proBNP in the prediction of impaired myocardial deformation after STEMI
Authors: Tomoaia R , Beyer RȘ , Zdrenghea D , Dadarlat-Pop A , Hada N C , Moldovan O , Chetan I M , Fringu F I , Cismaru G L , Minciuna I A , Pop D
Published: June 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): University of Medicine and Pharmacy “Iuliu Hațieganu” Cluj- Napoca.

Introduction

One adverse consequence that may follow an ST-elevation myocardial infarction (STEMI) is left ventricular (LV) remodeling. The majority of evidence indicates speckle-tracking echocardiography and global longitudinal strain may identify early changes in deformation after MI, while circumferential strain (GCS) is less extensively studied. However, since strain is thought to be afterload-dependent, the global work index (GWI), a novel afterload-incorporating parameter recently evolved.

Objective

The aim of this study was to determine whether the levels of high-sensitive troponin and NT-proBNP, two variables known to be of prognostic significance in STEMI, might indicate whether GCS and GWI are more impaired after STEMI.

Material and methods

60 patients with STEMI and preserved LVEF who underwent PCI were included in the study. Using a Vivid E95 scanner, early echocardiography (2–4 days) was performed, and the EchoPac BT13 software (GE Vingmed ultrasound) was used for analysis. Both conventional and deformation parameters were assessed. GWI was determined by using pressure-strain loops (strain and estimated LV pressure from the peak arterial brahial cuff pressure). ROC curves were used to determine the optimal cut-off values of Troponin and NT-proBNP to predict the values below the median for each of the studied parameters (GCS and GWI).

Results

The mean age of the patients was of 68±13 years and 55% were male. The majority of the patients presented with anterior MI (n=29, 48.3%), followed by inferior MI (n=25, 42%). Patients frequently reported hypertension (n=45,75%), while others had dyslipidemia (n=15, 25%), diabetes (n=8, 13.3%), and smoking (n=23, 38.3%) as cardiovascular risk factors. The median values of NT-proBNP were 600 [280–1930] pg/mL and 0.52 mg/dL [0.16–1.6] for troponin, respectively. Mean values of GCS were −11.6 ± 5.1% and of GWI were 927 ± 403 mmHg%.

We analysed the ROC curves of troponin and NT-proBNP to predict values below the median of −10% for GCS and of 937mmHg% for GWI (Fig.1). We found that troponin values > 0.612 mg/dL (AUC 0.674, 95% CI 0.541 to 0.790, p = 0.014, Se 66%, Sp 71%) and NT-proBNP values > 715 pg/mL (AUC 0.678, 95 %CI 0.545 to 0.793, p = 0.0117, Se 59%, Sp 74%) were able to predict more impaired GWI. Interestingly, only troponin values > 0.315 mg/dL, a threshold that was lower than in the case of GWI, were able to predict more impaired GCS (AUC 0.755, 95% CI 0.627 to 0.857, p<0.0001, Se 91%, Sp 58%).

Conclusion

High sensitive troponin and NT-proBNP may indicate more impaired myocardial mechanics after STEMI. Both GCS and GWI, a parameter integrating strain and afterload, may provide additional information In the early stages of remodeling following MI.
Discordance between conventional functional parameters and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction
Authors: Tolvaj M , Radu N , Cascella A , Muraru D , Lakatos B , Fabian A , Tokodi M , Tomaselli M , Gavazzoni M , Perelli F , Merkely B , Badano L P , Kovacs A , Surkova E
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EFOP-3.6.3-VEKOP-16-2017-00009 project.

Background

The conventional echocardiographic parameters of the right ventricular (RV) systolic function (e.g., tricuspid annular plane systolic excursion - TAPSE, fractional area change - FAC) only partially portray the complex functional characteristics of the RV; therefore, they may fail to capture the full spectrum of RV dysfunction and associated adverse clinical outcomes. 3D echocardiography-derived RV ejection fraction (RVEF) is a well-validated and reproducible parameter that overcomes these limitations.

Purpose

We aimed to investigate the discordance between TAPSE, FAC and RVEF in RV systolic function grading and associated outcomes.

Methods

Two retrospective databases from different centers including consecutive patients with various cardiac diseases who underwent clinically indicated 2D and 3D echocardiography (n=750) were analysed. Patients were followed up for the occurrence of all-cause mortality. RVEF was measured by a single, commercially available 3D software package. Guideline-recommended cut-off values were used to indicate RV systolic dysfunction (TAPSE<17 mm, FAC<35%). RVEF <45% served as the "ground truth" of RV dysfunction.

Results

Among patients with normal RVEF (n=511), 109 (21%) had reduced TAPSE, 168 (33%) had reduced FAC, and 49 (10%) had both reduced TAPSE and FAC. Among patients with reduced RVEF (n=239), 108 (45%) had normal TAPSE, 57 (24%) had normal FAC, and 38 (16%) had both normal TAPSE and FAC. Correspondingly, sensitivity and specificity for discrimination of RV systolic dysfunction (RVEF<45%) were 66% and 70% for TAPSE, and 71% and 76% for FAC on ROC analysis, respectively (Figure 1).

During the median follow-up time of 3.7 years, 112 patients (15%) died. Using univariable Cox regression, TAPSE (HR [95% CI]: 0.911 [0.881–0.942]), FAC (0.940 [0.924–0.957]), and RVEF (0.928 [0.913–0.944]) were all significant predictors of mortality (p<0.001). Interestingly, combination of the functional assessments based on either TAPSE or FAC with RVEF separates four risk groups that differ significantly in terms of all-cause mortality (Kaplan-Meier curves, Figure 2, log-rank p<0.05).

Conclusion

Guideline-recommended cut-off values of conventional echocardiographic parameters of RV systolic function are only modestly associated with RVEF-based assessment. This phenomenon may hinder the proper risk stratification of patients with RV systolic dysfunction.
Left atrial strain to predict post-operative atrial fibrillation in patients undergoing coronary artery bypass grafting
Authors: Pastore M C , Degiovanni A , Sozzani M , Giordano A , Grisafi L , Salvatici C , Lorenz V , Cameli M , Patti G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Post-operative atrial fibrillation (POAF) is a common complication occurring after cardiac surgery. POAF is associated with higher risk of stroke, cardiac arrest and congestive heart failure, as well as prolonged in-hospital stay. Revealing left atrial (LA) subtle structural/functional abnormalities before the operation may help identifying patients most prone to develop POAF in order to apply appropriate preventive strategies and implement approaches of post-operative diagnosis and treatment.

Purpose

Our study was aimed at assessing the potential usefulness of LA strain parameter by speckle tracking echocardiography (STE) as independent predictor of POAF in patients undergoing coronary artery bypass graft (CABG).

Methods

Patients referred to isolated CABG were prospectively enrolled in two Italian centers. Patients with age <18 years, history of AF, previous cardiac surgery, hypo-/hyper-thyroidism or unfeasible STE were excluded. All patients underwent transthoracic echocardiography <7 days before the operation. Baseline clinical features, intra-operative parameters and post-surgery clinical data were also collected. Primary study endpoint was the relationship between pre-surgery LA strain data and occurrence of POAF before discharge.

Results

Overall, 260 patients were enrolled (age 67.5 ± 8.6 years, 82% males). POAF occurred in 98 patients (38%) at a mean of 2.3 ±1.5 days after the operation. A global PALS <26.2% prior surgery represented the optimal threshold to predict POAF with an AUC of 0.66 (p<0.0001). At multivariate analysis, global PALS and age were independent predictors of POAF (Table 1). A model including PALS <26.2% and age >70 years was associated with a >4.5-fold increased risk of POAF at discharge (HR 4.87, 95% CI 2.43–9.76, p<0.0001). At ROC analysis this model identified those patients developing POAF with a specificity of 85%, Kaplan Meier curves confirmed its significant prediction for lower POAF-free survival (Figure 1).

Conclusions

The combined use of age and pre-surgery global PALS may help clinicians to identify patients at higher risk of POAF after isolated CABG. This approach can be useful in selecting patients who may be candidate to preventive anti-arrhythmic strategies, as well as to stricter and longer monitoring to early detect and treat POAF.
Myocardial work and left heart strain variation according to different grades of mitral regurgitation severity and symptoms
Authors: Pastore M C , Mandoli G E , Vannuccini F , Lisi M , Iuliano M A , Santoro A , Niglio F P , Barilli M , Lorenz V , Focardi M , Cavigli L , D'ascenzi F , Valente S , Cameli M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial work (MW) estimation by pressure-strain loops using an implemented speckle tracking software has showed to estimate LV contractile properties overcoming the load-dependency limit of left ventricular (LV) global longitudinal strain (GLS). This has proved useful particularly in clinical setting characterized by frequent hemodynamic variations, such as heart failure and valvular heart disease. However, the variation of MW parameters across different stages of mitral regurgitation (MR) and its impact on symptoms has never been investigated.

Objective

The aim of this observational study was to assess the variations of MW and deformation parameters of left heart chambers in mild, moderate and severe MR.

Methods

Consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery.

Clinical evaluation, blood sample tests, ECG and echocardiography were performed. Speckle tracking analysis completed by myocardial work were performed offline. Patients were then divided into groups first according to MR severity. Differences among the groups were analyzed by student T test (or non-parametric tests for non-normally distributed variables) and predictors of symptoms (as NYHA class ≥ 2) were explored by logistic regression analysis.

Results

Overall, 120 patients were enrolled (40 mild, 40 moderate, 40 severe MR). LV GLS improved according to severity, while Global PALS reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved in patients with moderate and severe MR, while global work efficiency (GWE) showed a trend towards reduction in patients with higher grades of MR. Global work index did not change significantly in the three groups (Fig.1). Among strain parameters, global PALS emerged as a predictor of NYHA class (R2=0.2, p<0.001) These results are explained by the pathophysiology of MR, characterized by a mechanism of attempted LV compensation to volume overload with increased contractility parallel to the disease progress, although with low efficacy on increasing LV stroke volume and increased wasted work; while LA and diastolic function have an early reduction which is associated with the occurrence of symptoms.

Conclusions

Myocardial deformation parameters of the left heart chambers accurately reflect the pathophysiologic mechanisms of MR stages and are associate with the burden of symptoms.
Novel handheld ultrasound with spectral Doppler modality allows for reliable valvular blood flow velocity assessment
Authors: Filipiak D , Kasprzak J D , Lipiec P
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Handheld Ultrasonographs (HUD) have soldified their position as a entry-level echocardiographic tool tailored for introducing non-invasive imaging diagnostics to everyday clinical practice. Current approach to valve assessment with the use of HUD could only involve qualitative method based on the visual detection of morphologic abnormalities and color Doppler assessment. It was not until recently that, Quantitative analysis was enabled with the implementation of spectral doppler to the HUD.

Purpose

To assess if HUD featured with spectral Doppler modality enables for reliable evaluation of the valvular flow velocity.

Methods

102 consecutive patients reporting to the cardiological emergency room underwent HUD examination involving both the measurement of mitral valvular flow velocity with the pulsed wave Doppler and aortic valvular flow with continuous wave Doppler. Subsequently, the same parameters were measured with the high end stationary workstation, and acquired results were treated as reference. Mitral valvular blood velocity > 1,3 m/s and atrial valvular blood flow velocity >2,0 m/s. were considered as abnormal values.

Results

The correlation between the measurements of maximum velocity through mitral valve obtained with the HUD and standard echocardiography was high (r=0,85; p<0,0001; 95% CI 0,78–0,89). The Bland-Altman plot showed no clinically relevant bias (mean difference 0,06 m/sec, upper limits of agreement 0,2 m/sec lower limit of agreement 0,32 m/s). Accelerated valvular blood flow (present in 4 pts) was detected with HUD with sensitivity of 75 % (95% CI: 19%-99%), specificity of % (95% CI: 96%-100%), positive predictive value of 100% (95% CI: 29%-100%), negative predictive value of 99% (95% CI: 95%-100%). Corresponding assessment of aortic valve showed the following correlation: r=0,87; p<0,0001; 95% CI 0,81–0,91). The Bland-Altman plot analysis indicated small underestimation bias of −0,17 m/sec (P < .001), upper limits of agreement of 0,47 m/sec, lower limit of agreement −0,81. Accelerated valvular blood flow (found in 7pts): sensitivity of 57% (95% CI: 19%-90%), specificity of 100% (95% CI: 96%-100%), positive predictive value of 100% (95% CI: 40%- 100%), negative predictive value of 97% (95% CI: 91%-99%).

Conclusion

Correlations calculated between the results of valvular blood flow measured with HUD and conventional workstation proved to be very strong. HUD examination enables for detection of accelerated blood flow through mitral and aortic valves with high positive and negative predictive value.
Characterization of right-sided strain parameters in atrial and ventricular functional tricuspid regurgitation
Authors: Galloo X , Dietz M F , Fortuni F , Prihadi E A , Cosyns B , Bax J J , Ajmone Marsan N
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial functional tricuspid regurgitation (A-FTR), defined as TR due to prominent right atrial (RA) dilatation without significant right ventricular (RV) remodelling, has recently emerged as a distinct subtype of FTR, and can be distinguished from ventricular FTR (V-FTR), defined by significant RV remodelling leading to annular dilatation and leaflet tethering. However, so far no data has been reported on the values of RV and RA strain in these patients.

Purpose

To evaluate potential differences in right-sided strain parameters in patients diagnosed with severe atrial and ventricular FTR.

Methods

Patients with severe FTR, without a cardiac implantable electronic device, were categorized as V-FTR when in sinus rhythm and either having left-sided cardiac disease, pulmonary hypertension, or moderate/severe RV dysfunction. Patients, in sinus rhythm or atrial fibrillation, with no other cause of annular dilatation and impaired leaflet coaptation than RA dilatation were classified as A-FTR. Extensive echocardiographic assessment was performed, including 2D-speckle-tracking strain analysis.

Results

A total of 525 patients with severe FTR (mean age 66 ± 15 years, 42% male) were included, of which 401 patients (76%) were classified as V-FTR and 124 patients (24%) as A-FTR. Baseline clinical and echocardiographic characteristics are shown in Figure 1. Patients presented with mild RV dilatation (RV end-diastolic area 12.9 ± 4.0cm2/m2) and RV dysfunction (RV free wall longitudinal strain [FWLS] 18.3 ± 6.8%), and with moderate-to-severe RA dilatation (RA max volume 36.8 [26.9 – 52.2] ml/m2) and moderate-to-severe RA dysfunction (RA reservoir strain 17.0 [11.0 – 27.0] %). Corresponding to the phenotype, patients with A-FTR presented with significantly smaller RV size and better RV function (Figure 1). However, despite overall normal values of RV function by RV fractional area change, tricuspid annular plane systolic excursion (TAPSE) and RV FWLS, 27% of A-FTR patients showed reduced RV FWLS based on cut-off value of −20%. In addition, patients with A-FTR showed more dilated RA, as compared to patients with V-FTR, but with better RA function assessed by 2D-strain values (Figure 1). Notwithstanding, still 73% of the A-FTR-patients showed reduced RA strain values, when using the cut-off reported for normality of 34%.

Conclusion

Approximately 25% of patients diagnosed with severe FTR presented with A-FTR. These patients presented with significantly better right-sided strain parameters as compared to patients with V-FTR, despite more pronounced RA dilatation.