bluuebunny/crossref_metadata_2025 huggingface dataset:
3D right ventricular ejection fraction and longitudinal strain are independent predictors of major adverse cardiovascular events in patients with rrhythmogenic right ventricular cardiomyopathy
Authors: Hosseini L , Sadeghpour A , Maleki M , Alizadehasl A , Rezaeian N , Zadehbagheri F , Bakhshandeh H , Hosseini S
Published: November 2020

Introduction

Evaluation of right ventricular (RV) function is essential in the follow up of patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Role of advance echocardiography including 3D transthoracic echocardiography (3DTTE) for evaluation of 3D RV function and RV longitudinal strain in predicting prognosis in ARVC patients, has not been well investigated.

Purpose

We aimed to evaluate 3DTTE parameters in predicting major advance cardiovascular events (MACE) defined as ventricular arrhythmia, cardiac hospitalization, heart transplantation, and death in ARVC patients.

Methods

Forty-eight definite ARVC subjects based on the 2010 Task force criteria were evaluated with standard 2D transthoracic echocardiography (2DTTE) and 3DTTE. Patients with poor image quality were excluded. RV function was evaluated by 2D and 3D TTE including: fractional area change (FAC), RV global and free wall longitudinal strain (RV2DGLS and RV2DFWLS) and 3D RV ejection fraction (RV3DEF), RV global and free wall longitudinal strain (RV3DGLS, and RV3DFWLS). The patients were followed up for a median period of 12 months (6–18 months) to record MACE.

Results

Forty-eight patients with mean age =38.5±14 years; 79.2% male, and mean RV3DEF =30.33%, were included. During the mean follow up 12 months, 12 patients (25%, with mean RV3DEF = 24.8±9%) experienced MACE whereas mean RV3EF in patient without any cardiovascular events during follow up was 34.21±9%. The most common causes of hospitalization were arrhythmia, right-sided heart failure, and RV clot as the following: Ventricular arrhythmia in 7 patients (14.6%, with mean RV3DEF = 29.01±8.82%), RV clot in 2 cases (4.2%, with mean RV3DEF = 20.2%), right-sided heart failure in 3 patients (6.3%, with mean RV3DEF = 16.83±3.6%) that 2 of them (2.1%, with mean RV3DEF = 14.58±0.63) underwent heart transplantation.

Logistic regression analysis revealed RV3DTTE (p-value = 0.03, OR=0.90, CI: 0.82–0.99), RV3DGLS (p-value = 0.05, OR=1.27, CI: 0.99–1.61) and RV3DFWLS (p-value = 0.01, OR=1.29, CI: 1.05–1.59), predicted cardiac adverse events, but there were no significant association between RV2DGLS, RV2DEWLS and FAC with MACE.

Conclusion

RV3DEF, RV3DGLS, and RV3DFWLS were powerful predictors of morbidity and mortality and can be useful as a valuable method in the prediction of major cardiovascular complications in ARVC patients.

Funding Acknowledgement

Type of funding source: None
Feasibility of intracardiac echocardiography for assessment of renal blood flow in humans
Authors: Stojadinovic P , Sramko M , Wichterle D , Peichl P , Cihak R , Kautzner J
Published: November 2020

Background

Intracardiac echocardiography (ICE) is routinely used for guiding cardiac ablation procedures. However, the potential of ICE for measurement of renal artery (RA) blood flow (RABF) has not been fully exploited.

Aims

To investigate the feasibility of ICE for the assessment of RABF and to evaluate its reproducibility in humans.

Methods

The study included 15 patients undergoing catheter ablation of atrial fibrillation guided by ICE (age: 61±14 years, body mass index: 30±5 kg/m2, left ventricular ejection fraction: 57±6%, serum creatinine: 80±29 μmol/l). During sinus rhythm, the ICE probe was withdrawn from the right atrium to the inferior vena cava until the right RA with its ostium became visible. Blood flow in the RA was visualized by colour flow mapping. The RA diameter was measured at 10 mm from the ostium. RABF at this location was measured by pulse wave Doppler. Velocity-time integral (VTI) was delineated manually and averaged over five consecutive beats. RABF was calculated by the formula: RABF = (RA radius)2 x π x VTI x heart rate. To assess reproducibility of the method, the ICE probe was repositioned in the right atrium and the measurement of RABF was repeated by the same operator.

Results

The right RA was visualized in all 15 patients. No procedure-related clinical complications occurred. The mean RA radius was 2.5±0.4 mm. In all cases, the angle of incidence during the measurement of VTI was <5°. The mean RABF was 403±163 and 399±156 ml/min during the first and the second measurement, respectively (p=0.7 by a paired t-test, coefficient of variation 5,3±3,8%; see Figure for Bland-Altman plot).

Conclusions

This study demonstrated that measurement of RABF by ICE is feasible and has reasonable intra-observer reproducibility. The method can be used to study RABF during various interventions and hemodynamic conditions.

Figure 1. Intra-individual reproducibility

Funding Acknowledgement

Type of funding source: None
Prognostic role of myocardial work in patients with heart failure and reduced ejection fraction treated by sacubitril/valsartan
Authors: Galli E , Bouali Y , Laurin C , Gallard A , Hubert A , Bidaut A , Leclercq C , Donal E
Published: November 2020

Background

The non-invasive assessment of myocardial work (MW) by pressure-strain loops analysis (PSL) is a relative new tool for the evaluation of myocardial performance. Sacubitril/Valsartan is a treatment for heart failure with reduced ejection fraction (HFrEF) which has a spectacular effect on the reduction of cardiovascular events (MACEs).

Purposes of this study were to evaluate 1) the short and medium term effect of Sacubitril/Valsartan treatment on MW parameters; 2) the prognostic value of MW in this specific group of patients.

Methods

79 patients with HFrEF (mean age: 66±12 years; LV ejection fraction: 28±9%) were prospectively included in the study and treated with Sacubitril/Valsartan. Echocardiographic examination was performed at baseline, and after 6- and 12-month of therapy with Sacubitril/Valsartan.

Results

Sacubitril/Valsartan significantly increased global myocardial constructive work (CW) (1023±449 vs 1424±484 mmHg%, p<0.0001) and myocardial work efficiency (WE) [87 (78–90) vs 90 (86–95), p<0.0001]. During FU (2.6±0.9 years), MACEs occurred in 13 (16%) patients. After correction for LV size, LVEF and WE, CW was the only predictor of MACEs (Table 1). A CW<910 mmHg (AUC=0.81, p<0.0001, Figure 1A) identified patients at particularly increase risk of MACEs [HR 11.09 (1.45–98.94), p=0.002, log-rank test p<0.0001] (Figure 1 B).

Conclusions

In patients with HFrEF who receive a comprehensive background beta-blocker and mineral-corticoid receptor antagonist therapy, Sacubitril/Valsartan induces a significant improvement of myocardial CW and WE. In this population, the estimation of CW before the initiation of Sacubitril/Valsartan therapy allows the prediction of MACEs.

Funding Acknowledgement

Type of funding source: None
Non-invasive myocardial work reference ranges in healthy children
Authors: Sabatino J , Borrelli N , Leo I , Avesani M , Piccinelli E , Josen M , Paredes J , La Bella S , Indolfi C , Di Salvo G
Published: November 2020

Background

Myocardial work (MW) estimation by pressure-strain loops (PSL) allows a non-invasive assessment of myocardial performance, as recently demonstrated in adult patients.

Aim

Aim of this study is to provide the reference values for global myocardial work index (MWI), constructive work (MCW), wasted work (MWW), and work efficiency (MWE) in a group of healthy children.

Methods

Assessment of MW was performed using a commercially available software package. MW was measured from PSLs areas, derived from non-invasive LVP curves combined with strain acquired speckle tracking echocardiography (STE).

After calculating GLS, values of brachial blood pressure were inserted and the time of valvular events by echocardiography were indicated, then the software was able to measure non-invasive PSLs.

Results

Two-dimensional (2D) standard and speckle-tracking echocardiography were performed in 90 healthy children (mean age 9.9±4.9 [1–17] years, females: 57%) together with the assessment of MW by means of PSLs.

Mean ± standard deviation, 5° and 95° percentile values for global MWI, MCW, MWW, and MWE in the whole population were 1769±254 mm Hg, (1354–2193); 2201±290 mm Hg, (1657–2658); 78±47 (29–163) mm Hg%; 96±1.8 (92–99)%, respectively.

Conclusions

The assessment of MW is feasible in healthy children. This study provides useful 2-dimensional echocardiographic reference ranges for novel indices of non-invasive MW.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): ESC Training Grant 2019
Flow mapping of Intraventricular velocity behaviour along the early diastolic filling streamline in patients with atrial fibrillation: implication for HFpEF
Authors: Berlot B , Jug B , Moya Mur J.L , Rodriguez Munoz D , Fernandez Golfin C , Zamorano J.L
Published: November 2020

Aims

Intraventricular velocity distribution reflects left ventricular (LV) diastolic function and can be measured non-invasively by flow mapping technologies. We sought to compare intraventricular velocity gradient during early diastole – obtained by vector flow mapping (VFM) technology – in consecutive patients with normal ejection fraction (EF >55%) and atrial fibrillation (AF) with and without clinical evidence of heart failure (HFpEF), and controls in sinus rhythm. We hypothesised that the VFM-derived Intraventricular Velocity Gradient over e' ratio (GrIV/e') would discriminate between the groups beyond conventional echocardiographic markers of elevated LV filling pressure.

Methods and results

Two-dimensional streamline fields were obtained using VFM technology in 120 subjects, i) 60 in sinus rhythm with normal systolic and diastolic function, ii) 29 out-patients with AF and no signs or symptoms of heart failure, and iii) 31 patients in AF hospitalized with signs of HFpEF. We compared the intraventricular gradient along the early diastolic streamline between groups, and correlated it with conventional echocardiographic parameters. GrIV/e' was the lowest in control group, followed by AF without HFpEF and the highest in AF HFpEF groups (GrIV/e' = 0.5±0.2, vs 0.9±0.4 vs. 2.0±1.2, p<0.001, Figure, left). Conversely, LV filling pressure as determined by E/e', while lowest in the control group, failed to discriminate between patients with AF with and without (E/e' = 10.0±3.7 vs. 9.5±2.1, p=0.456, Figure, right).

Conclusion

The novel VFM parameter – reflecting early-diastole intraventricular dynamics – may discriminate between patients with AF with and without HFpEF beyond conventional echocardiography. While further studies are need to validate its clinical impact, GrIV/e' has the potential to become a novel parameter for diastolic function assessment in this population.

VFM vs. Conventional echo parameter

Funding Acknowledgement

Type of funding source: None
Which single echo parameter is the best marker of left ventricular filling pressure?
Authors: Khan F , Inoue K , Remme E.W , Andersen O.S , Gude E , Skulstad H , Chetrit M , Garcia-Izquierdo Jaen E , Ha J.W , Klein A.L , Kikuchi S , Ohte N , Nagueh S.F , Smiseth O.A
Published: November 2020

Background

Estimation of left ventricular filling pressure (LVFP) is highly relevant in clinical practice. Invasive pressure remains the gold standard, but a number of echocardiographic parameters that correlate with LVFP are used as non-invasive markers of pressure.

Purpose

We investigated how different echocardiographic parameters correlated with invasively measured LVFP, and how accurately those parameters could differentiate between normal or elevated LVFP.

Method

We performed a prospective, multicenter, multinational and multivendor study in an all comer population of 322 patients with suspected heart failure or other cardiovascular disease. 194 patients had EF ≥50% and 129 had EF <50%. LVFP was measured by right- or left heart catheterization, as pulmonary capillary wedge pressure or pre-A LV diastolic pressure, respectively.

When excluding all special patient populations defined in the 2016 recommendations for echocardiographic evaluation of LV diastolic function, 213 patients remained. Of these 135 had EF ≥50% and 74 had EF <50%.

Echocardiography was performed within 1 day of catheterization. Previously recommended cut-off values for established parameters were used to determine the accuracy of classifying LVFP as normal or elevated. For left atrial (LA) reservoir strain, based on ROC analysis, a cut-off value of <18% was used as marker of elevated LVFP.

Results

LA reservoir strain and the ratio of peak mitral early flow velocity (E) and LA reservoir strain (E/LA strain) showed the best correlations to LVFP (Table 1, Figure 1). They also had the highest accuracy, 75% for both, in classifying LVFP as normal or elevated in the whole patient population. E/LA reservoir strain provided no additional diagnostic value to using LA reservoir strain alone.

In HFpEF patients accuracy was essentially similar for LA strain, E/LA strain and E/e', whereas in HFrEF patients the two former tended to be better than E/e'.

Conclusion

Parameters containing LA reservoir strain showed the best correlation to LVFP. This indicates that LA reservoir strain may have a role in evaluation of LVFP.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority
Aortic regurgitation is not created equal: outcomes of bicuspid versus tricuspid aortic valve regurgitation
Authors: Yang L.T , Benfari G , Nkomo V.T , Enriquez-Sarano M , Pellikka P.A , Michelena H.I
Published: November 2020

Background

Bicuspid aortic valve (BAV) is an important cause of AR; these patients belong to a young and male predominant population and are distinctively different from tricuspid aortic valve (TAV). However, the differences between BAV and TAV in AR have not been completely explored.

Purpose

To explore differences between patients with BAV and TAV in hemodynamically significant aortic regurgitation (AR).

Methods

Consecutive patients with ≥moderate-severe AR were retrospectively identified from 2006 to 2017.

Results

Of 798 patients (502 with TAV, mean age 67±14 years; 296 with BAV, mean age 46±14 years) followed for 6.1±3.6 years, 403 underwent AV surgery (AVS); 154 died during follow-up.

BAV men (94%) tended to become symptomatic when left ventricle enlarged; TAV patients became symptomatic before left ventricular (LV) enlargement. During follow-up, BAV patients had lower mortality (hazard ratio [HR], 0.19; P<0.0001) and higher incidence of AVS (HR, 1.28; P=0.01) than TAV, which attenuated after adjusted on age, sex, comorbidities, LV ejection fraction (LVEF), functional class, and time-dependent AVS. In a propensity-matched cohort, differences of survival and incidence of AVS between BAV and TAV were not demonstrated. After a median of 6.3 (IQR: 3.3–9.3) years, 53 patients died post-AVS; TAV patients having class I surgical triggers had poor survival than TAV-non-class I patients and BAV patients with and without class I triggers (Figure). Class I triggers had no effect on BAV patients regarding post-AVS survival. LVEF<60% was associated with increased mortality in both TAV and BAV.

Conclusions

The correlation between larger LV size and symptomatic status only applied in BAV men. Patients with BAV and significant AR tended to have better survival and higher incidence of AVS, likely driven by inherent younger age and less comorbidity than patients with TAV. Class I surgical triggers had heavier negative impact on poor survival in TAV patients. The cutoff of LV dysfunction in AR may be LVEF 60%.

Figure 1. Kaplan-Meier curves post-AVS

Funding Acknowledgement

Type of funding source: None
Left atrial strain as a pre-operative prognostic marker for patients with severe primary mitral regurgitation
Authors: Mandoli G.E , Pastore M.C , Benfari G , Maccherini M , Lisi G , Cameli P , Lisi M , Lisi E , Tsioulpas C , Carrucola C , Vigna M , Montesi G , Valente S , Mondillo S , Cameli M
Published: November 2020

Background

For patients with severe mitral regurgitation (MR), new indices are needed to optimize surgical timing before irreversible myocardial dysfunction.

Purpose

We investigated the prognostic role of left atrial (LA) strain by speckle tracking echocardiography after mitral surgery for severe MR, and its association with LA fibrosis.

Methods

70 patients with primary severe MR undergoing echocardiography before mitral surgery were enrolled. Patients with other valvular disease > moderate, left bundle branch block, coronary artery disease, heart failure (HF), pacemaker implantation, heart transplantation, poor acoustic window, were excluded. The primary composite endpoint included HF and mortality; the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10). LA fibrosis was assessed by atrial biopsy specimens.

Results

Of 62 patients eligible, 32 had composite events (medium follow-up: 3.3±2.5 years for event-group, 7.6±1 years for non-event group). Characteristics of our study population are summarized in Table 1. With Kaplan-Meier analysis (Fig. 1), PALS provided a good risk stratification; it also was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was a strong association between PALS and secondary endpoint (NYHA: r2=0.11, p=0.04; Borg CR10: r2=0.10, p=0.02) and an inverse correlation between PALS <21% and LA fibrosis (r2=0.80; 76.6±20.7% vs 31.9±20.8%; p<0.0001).

Conclusions

Global PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

Figure 1

Funding Acknowledgement

Type of funding source: None
Is 3D analysis of longitudinal strain useful to predict long-term cardiac events in patients undergoing early mitral valve surgery?
Authors: Volpato V , Mantegazza V , Tamborini G , Gripari P , Muratori M , Alamanni F , Zanobini M , Fusini L , Pepi M
Published: November 2020

Background

In patients with mitral valve prolapse (MVP) and significant mitral regurgitation (MR), the presence of reduced 3D left ventricular (LV) global longitudinal strain (GLS) has already been described. However, precise data about this finding in predicting long-term cardiac events are lacking, especially in patients after MV surgery. Particularly, few data are available about the role of 3D GLS in events prediction in patients diagnosed with Barlow or Fibro-Elastic-Deficiency (FED) disease.

Aim

To determinate whether 3D LV GLS may identify a subgroup of patients with MVP and severe MR at higher risk for cardiac events after MV surgery.

Methods

We studied 143 patients diagnosed with MVP with normal LV function, who underwent isolated MV surgery between 2011 and 2017 for severe MR. A comprehensive 2D transthoracic echocardiography (TTE) analysis was performed, degree of MR was obtained using the PISA method (Proximal Isovelocity Surface Area), degree of tricuspid regurgitation was visually estimated. 3D analysis using custom software provided measurement of left atrial (LA) and right atrial (RA) dimension, right ventricular (RV) dimension and function and LV size and function including global longitudinal strain (GLS). Cardiac events (including cardiac death, arrhythmia, hospitalization for heart failure, embolic events or arrhythmia) were recorded during a follow-up of 4.6±2 years.

Results

Study patients were diagnosed with Barlow or FED in 92 (65%) and 51 (35%) of cases, respectively. The baseline 3D analysis showed left chambers dilatation with normal LV function and normal GLS, normal right chambers and systolic pulmonary artery pressure (sPAP). Based on 3D GLS, patients were divided in Group 1 (N=84, 59%, normal GLS ≥−21%) and Group 2 (N=59, 41%, reduced GLS ≤−20%). No differences were noted at baseline between groups (Table 1). At the follow-up, 43 events were recorded, including 1 death, 12 hospitalizations (3 for heart failure, 3 for embolic events and 6 for atrial fibrillation – AF) and 30 minor arrhythmic events, mostly premature ventricular complex (PVCs) and AF. The Kaplan Meier analysis showed no differences in cardiac events between groups (Figure 1, A). Among patients with Barlow, a significant difference in events was detected between patients with reduced and normal GLS at the Kaplan Meier analysis (Figure 1, B). This finding was not found in FED patients.

Conclusions

Patients undergoing MV surgery for MVP with initial LV remodeling and normal function, seem to be characterized by a low rate of major cardiac events. Interestingly, only in the Barlow population, a reduced 3D LV GLS strain may detect cases at higher risk of minor cardiac events, mostly minor arrhythmia.

Funding Acknowledgement

Type of funding source: None
Right ventricle to pulmonary artery coupling improves early after transcatheter aortic valve implantation and this is related to improved left atrial function
Authors: Calin A , Cadil D , Parasca C.A , Mateescu A.D , Rosca M , Enache R , Beladan C.C , Ginghina C , Deleanu D , Chioncel O , Bubenek S , Iliescu V , Popescu B.A
Published: November 2020

Background

Transcatheter aortic valve implantation (TAVI) improves not only left heart remodeling but also has an upstream effect on the right ventricle and pulmonary vasculature. Right ventricle (RV) to pulmonary artery (PA) coupling, a parameter which integrates RV systolic performance at a given degree of afterload, was associated with all-cause mortality in these patients (pts). Our aim was to evaluate the short-term effect of TAVI on RV-PA coupling and the main determinants of RV-PA coupling in pts with aortic stenosis (AS) undergoing transfemoral TAVI.

Methods

We have prospectively enrolled 102 consecutive pts (76±8 years, 57 men) with severe AS undergoing TAVI. All pts underwent a comprehensive echocardiogram both before and 30 days after TAVI, including speckle tracking echocardiography (STE) for myocardial deformation analysis. Peak values of global longitudinal left ventricular strain (GLS), left atrial strain (LAε, reservoir function), and late diastolic LA strain rate (ASr, contractile function) were measured. The ratio of tricuspid annular plane systolic excursion (TAPSE) to PA systolic pressure (PASP) was used as an estimate of RV-PA coupling.

Results

Compared with baseline, there was a significant increase in LV ejection fraction after TAVI (54±12% vs 50±13%, p=0.04), a significant reduction in LV mass (147±35 vs 171±44 g/m2, p<0.001) and increase in absolute GLS values (14±3% vs 12±5%, p=0.007). Indexed LA volumes decreased (49±19 vs 55±19 ml/m2, p=0.03) while both global LAε and ASr improved significantly after TAVI (16±8% vs 13±7%, p=0.01 and −1.2±0.6 vs −0.9±0.6%, p=0.01). A significant improvement of TAPSE/PASP values (0.069±0.026 vs 0.057±0.025 cm/mm Hg, p<0.001) was found after TAVI, indicating an enhanced RV-PA coupling. In multivariable regression analysis global LAε was independently related to RV-PA coupling, both before and after TAVI (R=0.54, p=0.003 and R= 0.39, p<0.001). The increase in RV-PA coupling was significantly related to the increase in LAε (p=0.005).

Conclusions

Our results confirm that relief of aortic valve obstruction by TAVI has beneficial effects on the RV-PA coupling, that occur early after intervention. This is accompanied by a significant improvement in LV and LA deformation. Moreover, there is a significant correlation between LA function and RV-PA coupling both before and after TAVI. Enhanced RV-PA coupling after TAVI is related to improved LA strain, suggesting the contribution of LA function in modulating right heart function in this setting.

Funding Acknowledgement

Type of funding source: None
Left atrial dysfunction and dyssynchrony in paroxysmal atrial fibrillation: data from the akershus cardiac examination 1950 study
Authors: Solberg M.G , Aagaard E.N , Berge T , Roenningen P.S , Enger S , Nygaard S , Pervez O , Orstad E.B , Kvisvik B.A , Lyngbakken M.N , Rosjo H , Steine K , Tveit A
Published: November 2020

Background

Left atrial (LA) strain measurements by speckle tracking echocardiography (STE) are predictive markers of cardiovascular morbidity, including atrial fibrillation (AF). LA mechanical dispersion (LA MD) is a new parameter derived from STE. A reduction of LA strain is considered to reflect LA dysfunction, while increased LA MD may reflect LA dyssynchrony.

Purpose

To assess LA dysfunction and dyssynchrony, as measured by STE, in patients with paroxysmal AF (pAF).

Methods

A subset of 616 participants in the Akershus Cardiac Examination 1950 Study were divided into three groups: (1) A healthy group (n=179) defined by excluding AF, coronary artery disease, stroke, hypertension, chronic obstructive pulmonary disease, body mass index >30, left ventricular ejection fraction <50%, transmitral E/e' >14 or E/A >2.0, (2) A non-healthy group (n=350) of participants without pAF, but with any of the above conditions, (3) A group with pAF, but in sinus rhythm at examination (n=87). LA reservoir strain (LASr), conduit strain (LAScd) and contractile strain (LASct), as well as LA MD were assessed by STE. MD was defined as the standard deviation (SD) of time from ECG R to peak atrial longitudinal strain (SD-TPS), and corrected by RR-interval (SD-TPS/RR), expressing LA MD as a percentage of the cardiac cycle. Comparisons were made by Mann-Whitney U-test due to non-normal distributions.

Results

Mean age was 63.5±0.5 years and 46.6% were women. LASr, LAScd and LASct were significantly lower, and LA MD significantly higher in the pAF group compared to the healthy and non-healthy groups (Table; Figure).

Conclusion

The present study has demonstrated LA dysfunction and dyssynchrony in patients with pAF, which may reflect LA remodeling and increased fibrosis.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority
Left ventricle myocardial deformation pattern in severe aortic valve stenosis without cardiac amyloidosis. AMY-TAVI study
Authors: Bastos Fernandez M , Lopez Otero D , Lopez Pais J , Pubul Nunez V , Neiro Rey C , Pena Gil C , Alvarez Barredo M , Martinez Monzonis M.A , Trillo Nouche R , Cacho Antonio C , Gonzalez Ferrero T , Antunez Muinos P.J , Torrelles Fortuny A , Perez Dominguez M , Gonzalez-Juanatey J.R
Published: November 2020

Background

The Longitudinal Strain (LS) pattern in cardiac amyloidosis (CA) typically spares the apex of the heart, and this is a sensitive and specific finding that can be used to distinguish AC from other causes of left ventricular (LV) hypertrophy.

Purpose

To assess the clinical profitability of the LV deformation echocardiographic criteria derived from LS described as suggestive of CA, in patients with severe symptomatic aortic stenosis (AS) without amyloidosis referred for TAVI.

Methods

Within AMY-TAVI study (NCT03984877). Prior to TAVI implantation, conventional echocardiographic parameters were analyzed, along with LV deformation parameters and strain phenotype using Speckle-Tracking Echocardiography. Strain derived Indices accepted for CA screening were calculated: RELAPS: relative apical LS (average apical LS/sum of the average basal and mid LS); SAB: septal apical to base ratio (apical septal LS/basal septal LS); EFSR: ejection fraction strain ratio (LVEF/GLS). After implant, technetium pyrophosphate99 scintigraphy and proteinogram were performed to diagnose or exclude CA, and those patients in which CA was excluded were selected.

Results

109 patients were consecutively included. The mean age was 81±6 yo, 58% were women. The mean aortic valve area (AVA) was 0.7±0.1 cm2 and the mean LVEF was 57.8±15%. Strain analysis could only be performed in 92 patients. Of these, 39 (42%) presented a LV strain pattern with relative apical sparing of LS respect to basal and middle segments (RELAPS>1 pattern); 82 patients (89%) SAB was >2.1; and 39 (42%) showed EFSR >4.1. The RELAPS>1 pattern was significantly associated with greater severity of AS based on AVA (0.7 cm2 in RELAPS <1 vs 0,6 cm2 in RELAPS >1, p=0.041), maximum velocity (4,4 vs 4,7 m/s, p=0.018), maximum aortic valve gradient (81 vs 91 mmHg, p=0.021) and medium gradient (49 vs 56 mmHg, p=0.020); higher degree of LV hypertrophic remodeling (Maximum wall thickness 14,3 vs 16,1 mm, p=0,003; Relative wall thickness 0,5 vs 0,6 mm, p=0,008); LV mass index: 168 vs 192 gr/m2, p=0,005; LV end-diastolic volume 112 vs 91 ml, p=0,005), and significantly lower myocardial contraction fraction (0,22 vs. 0,18, p=0,001).

Conclusions

In our series, patients with severe symtomatic AS without CA referred for TAVI frequently present a strain phenotype with relative apical preservation and a LVEF/GLS ratio similar to those described in CA. Our results suggest that the classic patterns of CA are common in patients with severe AS, in absence of said pathology, which limits its use for CA screening in these patients.

Polar map patterns according to RELAPS

Funding Acknowledgement

Type of funding source: None
Incremental benefits of echocardiographic indices over clinical parameters for screening cardiac amyloidosis in patients with left ventricular hypertrophy
Authors: Saito M , Nakao Y , Higaki R , Yokomoto Y , Ogimoto A , Suzuki M , Kawakami H , Hiasa G , Okayama H , Inoue K , Ikeda S , Yamaguchi O
Published: November 2020

Background

Cardiac amyloidosis (CA), characterized by amyloid protein deposition in the heart, is a treatable disease. Although left ventricular (LV) wall thickness is the most established imaging predictor for CA, several echocardiographic indices including deformation parameters also contribute to the screening of CA. However, it is unclear whether additive values of echocardiographic indices have greater benefit over the conventional clinical predictors for the screening of CA. Therefore, we sought to compare the incremental benefits of echocardiographic indices over the clinical parameters for the screening of CA and externally validate their incremental benefits.

Methods

We retrospectively studied 295 consecutive patients (median age, 67 years; male, 65%; mean LV wall thickness (MWT), 12 mm) with LV hypertrophy who underwent echocardiography as well as the detailed work-up for myocardium (Biopsy, technetium pyrophosphate scintigraphy (99mTc-PYP) or cardiac magnetic resonance imaging). CA was diagnosed through biopsy or 99mTc-PYP. The clinical model considers patients' age and the low-voltage in electrocardiography in reference to previous studies. Continuous echocardiographic variables were represented in binary through generally accepted external cutoff points. The incremental benefits of the echocardiography findings over the clinical model were assessed using with the help of both receiver-operated characteristic curve analysis and comparison of area under the curves. Furthermore, these incremental benefits were validated in the external validation sample (median age, 70 years; male, 69%; MWT, 12 mm).

Results

Among the enrolled patients, CA was observed in 18% of cases. Table presents the results of this study. Of the echocardiographic parameters, relative apical sparing pattern (RASP) was the greatest contributor for improvement of diagnostic accuracy of the clinical model. The next greatest contributor was LV wall thickness, followed by left atrial reservoir strain (LAS), E/e', left atrial volume index, ejection fraction strain ratio, and pericardial effusion, respectively. Similarly, RASP, LV wall thickness, global longitudinal strain, ejection fraction, LAS, and granular sparkling showed significant incremental benefit in the validation cohort. Only mean wall thickness, LV wall thickness, LAS, E/e' and RASP consistently improved the diagnostic accuracy of the clinical model.

Conclusion

During the screening process, adding LV wall thickness, LAS, and RASP to the clinical parameters may be useful for the accurate diagnosis of CA in patients with LV hypertrophy.

Figure 1

Funding Acknowledgement

Type of funding source: None
Non-invasive myocardial work: an echocardiographic measure of post-infarct scar on contrast-enhanced cardiac magnetic resonance imaging
Authors: El Mahdiui M , Van Der Bijl P , Abou R , De Lustosa R.P , Van Der Geest R , Ajmone Marsan N , Delgado V , Bax J.J
Published: November 2020

Background

Late gadolinium contrast enhanced cardiac magnetic resonance (LGE CMR) imaging accurately quantifies the extent of fibrosis and transmurality in chronically infarcted left ventricular (LV) segments, and identifies viability. Moreover, CMR characterizes the remote, non-infarcted zone, which is an emerging region of interest following ST-segment elevation myocardial infarction (STEMI). Non-invasive myocardial work is a novel LV function parameter - calculated from speckle-tracking strain echocardiography and sphygmomanometrically-determined blood pressure, which has shown excellent correlation with invasively measured myocardial work.

Purpose

To explore the relation of non-invasively estimated parameters of LV myocardial work to post-infarct scar on LGE CMR, and to compare myocardial work indices between the infarct core and remote zone in STEMI patients who were treated with primary percutaneous coronary intervention (PCI).

Methods

Patients with a STEMI who underwent primary PCI and LGE CMR, in addition to echocardiographic studies where non-invasive myocardial work analysis was feasible, were included. The LV was subdivided into non-infarcted, non-transmural and transmurally infarcted segments. The remote zone was defined as the non-infarcted myocardial segment diametrically opposed to the infarct core, without any evidence of LGE. Myocardial work indices were compared with linear mixed models, ANOVA and Wilcoxon signed rank tests.

Results

53 patients (89% male, age 58±9 years) and 689 segments were analysed. The mean scar burden comprised 14±7% of the total LV mass and 76 (11%) segments showed transmural LGE. The following non-invasive myocardial work indices: myocardial work index (MWI), constructive work (CW) and myocardial work efficiency (MWE) showed a significant inverse relationship with infarct transmurality (p<0.05 for all comparisons) while a positive trend was observed for wasted work (WW) (p=0.086) (Figure 1). The core zone demonstrated lesser MWI (1237±568 vs. 1514±518 mmHg%; p=0.010), CW (1331±627 vs. 1827±537 mmHg%; p<0.001) and MWE (92 (84–98) vs. 98 (95–99) %; p<0.001) as well as greater WW when compared to the remote zone (107 (26–196) vs. 26 (10–90) mmHg%; p=0.001).

Conclusions

In STEMI patients who underwent primary PCI, MWI, CW and MWE were significantly related to the extent of transmural infarction, while WW demonstrated a trend. MWI, CW and MWE were significantly lower, and WW higher, in the core zone compared to the remote zone. Non-invasive myocardial work indices may provide an echocardiographic method for determining post-infarct viability, as well as characterization of the remote zone.

MW and scar transmurality on LGE CMR

Funding Acknowledgement

Type of funding source: None
Sex-specific difference in the association between arterial stiffness and subclinical left ventricular dysfunction
Authors: Yoshida Y , Nakanishi K , Daimon M , Ishiwata J , Sawada N , Hirokawa M , Kaneko H , Nakao T , Mizuno Y , Morita H , Di Tullio M , Homma S , Komuro I
Published: November 2020

Background

Increased arterial stiffness has been proposed as one of the key mechanisms of incident heart failure with preserved ejection fraction (HFpEF). However, the possible association between arterial stiffness and subclinical left ventricular (LV) dysfunction and possible sex-specific differences remain unclarified. LV strain is emerging as a highly sensitive tool to unmask early LV abnormalities.

Purpose

We investigated whether increased arterial stiffness is independently associated with subclinical LV dysfunction in a large community-based cohort without overt cardiovascular disease.

Methods

We examined 1,155 participants who underwent extensive cardiovascular examination. Speckle-tracking echocardiography was employed to assess LV global longitudinal strain (LVGLS) and circumferential strain (GCS), and arterial stiffness was assessed by cardio-ankle vascular index (CAVI).

Results

Mean age was 62±12 years, and 56% were male. CAVI as continuous variable was associated with abnormal LVGLS (>−18.6%), independent of cardiovascular risk factors and pertinent laboratory and echocardiographic parameters (adjusted odds ratio [OR] 1.23, p=0.034), whereas there was no relationship with LVGCS. In sex-stratified analysis, more pronounced association between quartiles of CAVI and abnormal LVGLS was observed in women than in men (unadjusted OR = 6.43 in women and 2.46 in men for upper quartile vs. lower quartile, both p<0.01; Figure). Multivariable analyses demonstrated that CAVI was significantly associated with abnormal LVGLS independent of cardiovascular risk factors in both sexes. However, after further adjustment for LV mass index and diastolic parameters, the independent association persisted in women (adjusted OR 1.49, p=0.041), but not in men (adjusted OR 1.15, p=0.209).

Conclusion

Increased arterial stiffness was independently associated with decreased LVGLS even in the absence of overt cardiovascular disease; a sex-specific pattern exists in the alteration of vascular-ventricular coupling, which might partially explain the greater susceptibility to HFpEF in women.

Funding Acknowledgement

Type of funding source: None
Left ventricular mechanical dispersion in flow-gradient patterns of severe aortic stenosis
Authors: Lavall D , Kuprat L.K , Kandels J , Stoebe S , Hagendorff A , Laufs U
Published: November 2020

Purpose

Patients with severe aortic stenosis are classified according to flow-gradient patterns. We investigated whether left ventricular (LV) mechanical dispersion, a marker of dyssynchrony and predictor of mortality, is associated with low-flow status in aortic stenosis.

Methods and results

400 consecutive patients with QRS duration <120ms were included in the retrospective analysis. Patients with severe aortic stenosis (aortic valve area ≤1.0cm2) were classified as normal-flow (NF; stroke volume index >35ml/m2) high-gradient (HG; mean transvalvular gradient ≥40mmHg) (n=79), NF low-gradient (LG) (n=62), low-flow (LF) LG ejection fraction (EF) ≥50% (n=57), and LF LG EF<50% (n=23). Patients with moderate aortic stenosis (aortic valve area 1.5–1.0cm2; n=95) and patients with chronic systolic heart failure (n=84) without aortic stenosis served as comparison groups. Similar values of mechanical dispersion (calculated as standard deviation of time from Q/S onset on electrocardiogram to peak longitudinal strain in 17 left ventricular segments) was observed in patients with NF HG (49.4±14.7ms), NF LG (43.5±12.9ms), LF LG EF≥50% (47.2±16.3ms) and moderate aortic stenosis (44.2±15.7ms). Mechanical dispersion was increased in patients with LF LG EF<50% (60.8±20.7ms) and in chronic heart failure (59.4±16.7ms) (p<0.05 for both vs. NF HG‡, NF LG†, LF LG EF≥50%§ and moderate*; Figure). Mechanical dispersion correlated with LV end-systolic volume index (r=0.2530, p<0.0001), LVEF (r=−0.2895, p<0.0001) and global longitudinal strain (r=0.3108, p<0.0001), but not with parameters of aortic stenosis.

Conclusion

Mechanical dispersion was similar among flow-gradient subgroups of severe aortic stenosis with preserved LVEF, but increased in patients with low-flow low-gradient and reduced LVEF. These findings indicate that mechanical dispersion is rather a marker of systolic myocardial dysfunction than of aortic stenosis.

Figure 1

Funding Acknowledgement

Type of funding source: None
Glucagon like peptide-1 receptor agonists and their combination with sodium-glucose cotransporter-2 inhibitors improve myocardial deformation and work index in type-2 diabetes after 12-month treatment
Authors: Ikonomidis I , Pavlidis G , Thymis J , Birba D , Kalogeris A , Kousathana F , Kountouri A , Balampanis K , Parissis J , Andreadou I , Katogiannis K , Frogoudaki A , Vrettou A.R , Iliodromitis E , Lambadiari V
Published: November 2020

Background/Introduction

Type-2 diabetes mellitus (T2DM) exacerbates mechanisms of atherosclerosis and heart failure.

Purpose

We investigated the effects of insulin, glucagon like peptide-1 receptor agonists (GLP-1RA), sodium-glucose cotransporter-2 inhibitors (SGLT-2i) and their combination on LV myocardial function of T2DM patients.

Methods

A hundred-sixty T2DM patients (age: 58±10 years) were randomized to insulin (n=40), liraglutide (n=40), empagliflozin (n=40) or their combination (GLP-1RA+SGLT-2i) (n=40) as add-on to metformin. We measured at baseline, 4 and 12 months post-treatment: a) global LV longitudinal strain (GLS), systolic (LongSr) and diastolic (LongSrE) strain rate, global circumferential (GCS) and radial (GRS) strain, peak twisting (pTw), peak twisting velocity (pTwVel) and peak untwisting velocity (pUtwVel), b) global myocardial global work index (GWI), global constructive (GCW) and global wasted myocardial work (GWW) derived by pressure-myocardial strain loops using speckle tracking imaging.

Results

At 4 and 12 months post-treatment, all patients improved GLS, GCS, GRS and pUtwVel (p<0.05). At 12 months, GLP-1RA or GLP-1RA+SGLT-2i provided a greater increase of GLS (11.5% and 13% vs. 6.8% and 2.3%), GCS (11.9% and 14.6% vs. 7.3% and 3.4%), GRS (3.8% and 4.3% vs. 2.2% and 1.6%), GWI (12.7% and 17.4% vs. 3.1% and 2%), GCW (12.3% and 15% vs. 2.2% and 7.8%) and a greater reduction of GWW (38.7% and 41.6% vs. 13.5% and 4.9%) compared with insulin or SGLT-2i, despite a similar HbA1c reduction (p<0.05 for all comparisons) (Table). Patients under combined treatment with GLP-1RA+SGLT-2i achieved a 2-fold reduction of pTw and a 2-fold increase of pUtwVel than those under each one regimen or insulin (p<0.05). The dual therapy showed the greatest effect on measured myocardial markers in patients with LVEF <55% (p<0.05).

Conclusions

Twelve-month treatment with GLP-1RA or combination of GLP-1RA and SGLT-2i showed a greater improvement of myocardial deformation and effective cardiac work than insulin or SGLT-2i treatment in T2DM. The combined therapy as second line was superior to either insulin, or GLP-1RA and SGLT-2i separately.

Funding Acknowledgement

Type of funding source: None
A deep learning approach to automate high-resolution blood vessel reconstruction on computerised tomography images with or without the use of contrast agents
Authors: Chandrashekar A.C , Handa A.H , Shivakumar N.S , Lapolla P.L , Grau V.G , Lee R.L
Published: November 2020

Background

Existing methods to reconstruct vascular structures from a computed tomography (CT) angiogram rely on injection of intravenous contrast to enhance the radio-density within the vessel lumen. Pathological changes present within the blood lumen, vessel wall or a combination of both prevent accurate 3D reconstruction. In the example of aortic aneurysmal (AAA) disease, a blood clot or thrombus adherent to the aortic wall within the expanding aneurysmal sac is present in 95% of cases. These deformations prevent the automatic extraction of vital clinically relevant information by current methods.

Objectives

In this study, we utilised deep learning segmentation methods to establish a high-throughput and automated segmentation pipeline for pathological blood vessels (ex. Aortic Aneurysm) in CT images acquired with or without the use of a contrast agent.

Methods

Twenty-six patients with paired non-contrast and contrast-enhanced CT images were randomly selected from an ethically-approved ongoing study (Ethics Ref 13/SC/0250), manually annotated and used for model training and evaluation (13/13). Data augmentation methods were implemented to diversify the training data set in a ratio of 10:1. We utilised a 3D U-Net with attention gating for both the aortic region-of-interest (ROI) detection and segmentation tasks. Trained architectures were evaluated using the DICE similarity score.

Results

Inter- and Intra- observer analysis supports the accuracy of the manual segmentations used for model training (intra-class correlation coefficient, “ICC” = 0.995 and 1.00, respective. P<0.001 for both). The performance of our Attention-based U-Net (DICE score: 94.8±0.5%) in extracting both the inner lumen and the outer wall of the aortic aneurysm from CT angiograms (CTA) was compared against a generic 3-D U-Net (DICE score: 89.5±0.6%) and displayed superior results (p<0.01). Fig 1A depicts the implementation of this network architecture within the aortic segmentation pipeline (automated ROI detection and aortic segmentation). This pipeline has allowed accurate and efficient extraction of the entire aortic volume from both contrast-enhanced CTA (DICE score: 95.3±0.6%) and non-contrast CT (DICE score: 93.2±0.7%) images. Fig 1B illustrates the model output alongside the labelled ground truth segmentation for the pathological aneurysmal region; only minor differences are visually discernible (coloured boxes).

Conclusion

We developed a novel automated pipeline for high resolution reconstruction of blood vessels using deep learning approaches. This pipeline enables automatic extraction of morphologic features of blood vessels and can be applied for research and potentially for clinical use.

Automated Segmentation of Blood Vessels

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): University of Oxford Medical Research Fund, John Fell Fund
Impact of baseline feature tracking multi-detector row computed tomography-derived left ventricular global longitudinal strain on left ventricular functional recovery in TAVI patients
Authors: Gegenava T , Bijl P , Vollema M , Kley F , Weger A , Hautemann D , Reiber J , Ajmone-Marsan N , Bax J , Delgado V
Published: November 2020

Background

Advances in left ventricular (LV) analysis with dynamic multi-detector row computed tomography (MDCT) permit measurement of LV global longitudinal strain (GLS) and have shown their impact on risk stratification of patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI).

Purpose

To evaluate the influence of baseline feature tracking (FT) MDCT- derived LV GLS on LV functional recovery in severe AS patients undergoing TAVI.

Methods

A total of 194 patients with severe AS (50% male, 80±7 years) with dynamic MDCT data allowing LV GLS measurement with a novel FT algorithm and having complete echocardiography evaluation at baseline, at 3–6 months and at 1 year follow-up were evaluated. FT MDCT-derived LV GLS was measured at baseline and the study population was divided according to a cut-off value of MDCT LV GLS −14% (≤−14% [more preserved LV systolic function] vs. >−14% [more impaired LV systolic function]).

Results

Transthoracic echocardiography (TTE)-derived Left ventricular ejection fraction (LVEF) increased over time in both groups: in patients with preserved and reduced MDCT LV GLS, and reached a higher value in patients with preserved MDCT LV GLS (52±7% at baseline, 55±7% at 3–6 months, 58±7% at 1 year follow-up vs. 43±10% at baseline, 49±10% at 3–6 months, 53±11% at 1 year follow-up; p=0.016) (Figure 1). TTE-derived LV GLS also showed greater improvement for patients with preserved MDCT LV GLS (−17±3% at baseline, −18±3% at 3–6 months, −20±3% at 1 year follow-up vs. −12±3% at baseline, −15±3% at 3–6 months, −16±3% at 1 year follow-up; p=0.027) (Figure 1).

Conclusions

In severe AS patients treated with TAVI, LV function improves significantly at 3–6 and at 12 months' follow-up and shows superior recovery in patients with more preserved baseline MDCT LV GLS, suggesting that MDCT-derived LV GLS has an important impact on LV functional recovery after TAVI.

Funding Acknowledgement

Type of funding source: None