bluuebunny/crossref_metadata_2025 huggingface dataset:
Land covers associated with forest expansion hot spots in the Nepal Himalaya
Authors: Budhathoki Karuna , Jamaludin Johanness , Schmidt-Vogt Dietrich , Webb Edward
Published: October 2024

Many regions of the Himalaya are experiencing forest expansion, signifying a widespread forest transition across this fragile mountain system. In the Nepal Himalaya, forest expansion is increasingly attributed to the narrative of cropland abandonment driven by rural outmigration. Understanding forest change dynamics as consequences of land use changes is critical in the context of rural mountain societies such as Nepal, which exhibit complex interactions between forest, agriculture, and livelihoods. We analysed forest gain in Nepal from 2000–2019 to inquire where and when forests have expanded and what land covers transitioned into forests. We integrated spatiotemporal analysis of national land cover maps and photointerpretation of very high resolution (VHR) imagery to improve analytical estimates. The Middle Mountain physiographic region experienced the strongest hot spots of forest gains relative to the high mountains or lowlands. Visual interpretation of VHR showed that 68.8% of forest gains since 2000 occurred on shrubland, and 26.5% on cropland. The dominance of shrubland-forest transitions implied that shrubland is an intermediate stage in a multi-decadal succession process, or a semi-permanent state such as arrested succession. Notably however, we also detected cropland-forest transitions occurring as fast as 6–10 years, indicating the potential for rapid forest succession if biophysical conditions permit. Thus, variations in land cover transitions to forests in the hills implicated multiple pathways of forest regeneration, reflecting a variety of spatiotemporally explicit drivers. Our results differ from previous studies because VHR image analysis accounted for land cover classification errors and improved land cover quantification. Further research on spatially explicit mechanisms and drivers of forest gain are needed to understand the synergies of forest, agriculture, and livelihoods to inform land use land cover policies that could be leveraged to enhance rural mountain livelihoods.
Forging Friendships
Authors: Rembis Michael
Published: October 2024

Asylum life could be harrowing and relentlessly monotonous. Yet the asylum was also a dynamic space where inmates worked and formed valued relationships with one another. Although not all inmates got along and prejudices common in the outside world continued to shape life within the institution, nearly all mad writers recounted the strong ties that bound them to their fellow inmates. Relationships forged through common experiences of distress and the trauma of institutional life and founded upon both formal and informal exchanges of labor created a widely understood sense of trust and reciprocity among inmates, which in turn enabled them to share the most intimate details of their lives with one another. Sometimes inmate friendships flowered into groups and clubs, which could be sanctioned by asylum staff but more often existed away from the watchful eyes of attendants, nurses, and physicians. Inmates helped one another survive, and when they could not, they mourned the loss of their friends. White, mostly middle-class, former inmates who wrote about their experiences worked to convey the complexities of institutional life and at the same time make sense of their experiences, while also forming a community of ex-inmates and affirming the humanity of the growing inmate population.
Autosomal recessive VWA1-related disorder: comprehensive analysis of phenotypic variability and genetic mutations
Authors: Nagy Sara , Pagnamenta Alistair T , Cali Elisa , Braakman Hilde M H , Wijntjes Juerd , Kusters Benno , Gotkine Marc , Elpeleg Orly , Meiner Vardiella , Lenberg Jerica , Wigby Kristen , Friedman Jennifer , Perry Luke D , Rossor Alexander M , Uhrova Meszarosova Anna , Thomasova Dana , Jacob Saiju , O'Driscoll Mary , De Simone Lenika , Grange Dorothy K , Sommerville Richard , Firoozfar Zahra , Alavi Shahryar , Mazaheri Mahta , Parmar Jevin M , Lamont Phillipa J , Pini Veronica , Sarkozy Anna , Muntoni Francesco , Ravenscroft Gianina , Jones Eppie , O'Rourke Declan , Nel Melissa , Heckmann Jeannine M , Kvalsund Michelle , Kapapa Musambo M , Wa Somwe Somwe , Bearden David R , Çakar Arman , Childs Anne-Marie , Horvath Rita , Reilly Mary M , Houlden Henry , Maroofian Reza
Published: October 2024

A newly identified subtype of hereditary axonal motor neuropathy, characterized by early proximal limb involvement, has been discovered in a cohort of 34 individuals with biallelic variants in von Willebrand factor A domain-containing 1 (VWA1). This study further delineates the disease characteristics in a cohort of 20 individuals diagnosed through genome or exome sequencing, incorporating neurophysiological, laboratory and imaging data, along with data from previously reported cases across three different studies. Newly reported clinical features include hypermobility/hyperlaxity, axial weakness, dysmorphic signs, asymmetric presentation, dystonic features and, notably, upper motor neuron signs. Foot drop, foot deformities and distal leg weakness followed by early proximal leg weakness are confirmed to be initial manifestations. Additionally, this study identified 11 novel VWA1 variants, reaffirming the 10 bp insertion-induced p.Gly25ArgfsTer74 as the most prevalent disease-causing allele, with a carrier frequency of ∼1 in 441 in the UK and Western European population. Importantly, VWA1-related pathology may mimic various neuromuscular conditions, advocating for its inclusion in diverse gene panels spanning hereditary neuropathies to muscular dystrophies. The study highlights the potential of lower quality control filters in exome analysis to enhance diagnostic yield of VWA1 disease that may account for up to 1% of unexplained hereditary neuropathies.
Anabolic steroids as the substrate for atrial fibrillation: a case report
Authors: Yebari Manal , Bouchaala Abderrahmane , Berraj Issam
Published: October 2024

Background

Atrial fibrillation (AF) is the most frequently encountered sustained arrhythmia worldwide. This supraventricular rhythm disorder is precipitated by advanced age, valvular heart disease, hypertension, heart failure, congenital heart defects, and others. However, the role of anabolic steroids (ASs) abuse in precipitating AF remains insufficiently researched and largely underreported, despite their known cardiovascular risks.

Case summary

We present the case of a 40-year-old male bodybuilder who was admitted to the emergency department with symptomatic AF. His medical history revealed the use of ASs, which was suspected to be the trigger. A thorough biological evaluation and echocardiography were performed, revealing no structural or functional cardiac abnormalities. After electrical cardioversion and discontinuation of AS use, the patient’s rhythm returned to normal, with no recurrence of arrhythmia during follow-up.

Discussion

This case highlights the potential but underexplored link between AS use and the onset of AF. Although ASs are known to affect cardiovascular health by promoting hypertension, left ventricular hypertrophy, and endothelial dysfunction, their role in arrhythmogenesis, particularly in AF, remains unclear. In this patient, the absence of other identifiable triggers, combined with the resolution of symptoms upon steroid cessation, strongly suggests a causal relationship. Further research is needed to clarify the mechanisms through which ASs may contribute to the development of AF, particularly in younger, otherwise healthy individuals such as athletes and bodybuilders. This case underscores the importance of awareness among clinicians regarding the potential cardiac risks associated with AS use.
Incidental non-infectious masses on cardiac implantable electronic device leads
Authors: Fernandes S , Dias M , Conde I , Silva R , Ferreira C , Vilela F , Mane F , Marques J , Vieira C , Rocha S
Published: October 2024

Introduction

Incidentally detected masses on the leads of cardiac implantable electronic devices (CIED) present a clinical challenge, raising suspicion of infective device endocarditis. Data on the prevalence of such findings are scarce and outdated.

Purpose

Our aim was to determine the prevalence and evaluate predisposing clinical factors of incidental non-infectious CIED lead masses during transoesophageal echocardiography (TOE).

Methods

In this retrospective single-centre study, we analysed all TOE examinations performed in patients with CIED leads between January 2010 and November 2023. Patients with suspected or confirmed infectious endocarditis were excluded from this study. Patients with and without incidental non-infectious lead masses were compared regarding clinical characteristics, anticoagulation, type of CIED, and indication for TOE.

Results

In total, 120 patients with CIED were included. Twenty-five patients (20,8%) presented with non-infectious CIED lead masses. Laboratory findings and cardiovascular risk factors, such as arterial hypertension, dyslipidaemia, diabetes mellitus or chronic kidney disease did not differ significantly between both groups. Moreover, no association was observed between the incidence of CIED lead masses and the type of CIED implanted. Of notice, patients without therapeutic anticoagulation had significantly higher prevalence of CIED lead masses (OR 2.59, 95% CI: 1.04-6.46.; p=0.02), whereas the distribution of CHA2DS2-VASc scores did not differ significantly between both groups.

Conclusion

Non-infectious CIED lead masses in TOE is a frequent incidental finding. The absence of the oral anticoagulation seems to be the only clinical risk factor for such finding in our study, suggesting possible thrombogenic etiology.

The high prevalence of incidental non-infectious lead masses should be kept in mind in order to avoid overdiagnosis of CIED infection and unnecessary lead extraction.
The impact of intravenous agitated saline contrast echocardiography on subclinical neuronal injury determined by neuron-specific enolase
Authors: Korkmaz K , Tulunay Kaya C , Us E , Tutar D E
Published: October 2024

Introduction

Patent foramen ovale (PFO) is a congenital defect in interatrial septum with 25-30% prevelance. Diagnostic methods include transesophageal echocardiography (TEE), magnetic resonance imaging (MRI), and computed tomography (CT), but transthoracic echocardiography (TTE) is the primary diagnostic method. TTE involves the injection of agitated saline intravenously, and the passage of microbubbles from the right atrium to the left atrium is monitored. The reliability of this method has been questioned in various case series, with a low incidence (0.062%) of generally transient, mild clinical cerebrovascular events reported. Silent cerebral ischemia (SSI) is asymptomatic, radiographically identified acute neuronal damage. SSI is associated with an increased risk of stroke, dementia, and cognitive impairment. Neuron-specific enolase (NSE) with high specificity for neural cells can be used to detect SSI. While symptomatic patients have been evaluated in reported case series, there is no study determining the relationship and reliability of intravenous agitated saline echocardiography (SCE) with SSI. This study aims to determine whether TTE, performed on patients with PFO without neurological history and a healthy control group, can cause SSI by evaluating NSE with SCE.

Materials and methods

52 patients undergoing SCE for color flow through interatrial septum or prominent interatrial septal aneurysm and are diagnosed with PFO were included. Additionally, 51 control patients without detected PFO or ASA were also included. Serum samples were taken from the patients before and 12 hours after the SCE test, and NSE levels were measured by the ELISA method.

Results

The mean baseline NSE level was 12.7 ng/mL with a median of 5.3 ng/mL in the PFO group, and in the control group, the mean was 9.1 ng/mL with a median of 6.4 ng/mL. At 12 hours, the mean NSE levels in the PFO group were 9.8 ng/mL with a median of 6.6 ng/mL, and in the control group, the mean was 12.7 ng/mL with a median of 5.8 ng/mL. The increase in NSE levels after SCE, was not statistically significant when comparing the PFO and control groups (p=0.77). No relationship was found between age, presence of interatrial septal aneurysm, presence of mitral annulus calcification, the number of bubbles passed in the SCE test, and the basal and 12-hour change in NSE levels (p=0.926). NSE level changes were found to be correlated between groups (p<0.001).

Conclusion

This study is the first to evaluate whether SCE causes subclinical neuronal damage. Our study suggests that when evaluated with NSE, the SCE method is safe and does not cause subclinical neuronal damage in patients without underlying neuronal susceptibility.results
The influence of genetic mutations on multilayer global longitudinal strain values in patients with hypertrophic cardiomyopaty
Authors: Engin K , Barman H A , Ebeoglu O , Geylan A , Guneysu S I , Ozyildirim S , Dogan S M
Published: October 2024

Background

Hypertrophic cardiomyopathy (HCM) is a hereditary heart muscle disorder characterized by diverse genetic mutations. Multilayer global longitudinal strain (GLS) analysis has emerged as a valuable tool for assessing myocardial function. This study aimed to investigate the influence of genetic mutations on myocardial deformation patterns in HCM patients using multilayer GLS analysis.

Methods

A total of 83 adult patients diagnosed with HCM were included in the study. Genetic testing was performed to identify specific genetic mutations associated with HCM. Echocardiographic assessments were conducted to measure multilayer GLS values for endocardial, mid-myocardial, and epicardial layers. Patients were divided into gene-positive and gene-negative groups for comparative analysis.

Results

In the gene-negative group (n=41), the mean age was 57.1 ± 11.0 years, whereas in the gene-positive group (n=42), it was 55.5 ± 11.6 years (p=0.516). Significant differences were observed in endocardial (-16.1 ± 2.3 vs. -13.4 ± 3.2, p < 0.001) and mid-myocardial (-14.2 ± 2.1 vs. -12.3 ± 3.1, p = 0.002) GLS involvement between gene-negative and gene-positive HCM patients. However, no significant disparity in epicardial strain was detected.

Conclusion

The findings demonstrated a greater involvement of the endocardial and mid-myocardial layers in the group of HCM patients with positive genetic mutations. Multilayer GLS analysis has the potential to aid in the identification of subtle alterations in myocardial function associated with specific genetic mutations, contributing to refined risk assessment and personalized management strategies for HCM patients.
Differences in left ventricular contraction in left bundle branch block with preserved and reduced ejection fraction: an evaluation using 2-dimensional speckle tracking echocardiography
Authors: Hara H , Shinkai W , Hosokawa K , Kaida T , Murakami M , Ito H , Niwano S , Ako J
Published: October 2024

Background

Left ventricular (LV) contraction in left bundle branch block (LBBB) is characterized by early septal contraction and delayed contraction of the lateral wall, but the process may differ depending on myocardial contractility in addition to the degree of conduction block.

Purpose

This study aimed to evaluate LV contraction in patients with LBBB by analysis of longitudinal strain (LS) and to compare it between patients with preserved LV ejection fraction (pEF: EF>50%) and reduced LV EF (rEF: EF<40%).

Methods

We studied 87 patients with LBBB. Fifty had pEF (EF 59±7%) with a mean QRS duration of 144±12ms, and 38 had rEF (EF: 29±4%) with a mean QRS duration of 147±12ms (p=0.32 vs. pEF). We also studied 43 patients without conduction block (Narrow-QRS; pEF, n=23; rEF, n=20). Patients with a heart rate less than 60 or greater than 80 beats/min during echocardiography or with a history of myocardial infarction were excluded. Three standard apical images were recorded, and the LS of one heartbeat starting at the beginning of the QRS was evaluated in 18 LV segments. When the strain waveform showed a negative peak during the pre-ejection period, it was identified as early systolic contraction (ESC), and the first negative peak that appeared after aortic valve opening (AVO) was identified as late systolic contraction (LSC). The time from the beginning of QRS to the peak of the LSC (Q-Peak) and the strain value at the end of the QRS were measured in each segment.

Results

In patients with LBBB, the septum contracted early, and ESC was seen mainly in the early contracted area. The lateral wall contraction was delayed, and the difference between the maximum and minimum Q-Peak was greater than the Narrow-QRS in the same EF category. Patients with rEF and LBBB had a larger number of segments with ESC and a smaller minimum Q-Peak than those with pEF. The difference between the maximum and minimum Q-Peak was greater for patients with rEF than for patients with pEF.

Conclusions

Although patients with LBBB had significant dyssynchrony due to conduction block even those with pEF, LV contractile properties were altered in patients with rEF and associated with further increased dyssynchrony.
Blood pressure in the early 40s impacts left atrial function by speckle-tracking strain two decades later: data from the ACE 1950 Study
Authors: Solberg M , Berge T , Ronningen P S , Enger S , Pervez M O , Orstad E B , Kvisvik B A , Aagaard E N , Lyngbakken M N , Ariansen I , Rosjo H , Tveit A
Published: October 2024

Background

With higher age, the left atrial (LA) wall stiffens, giving rise to impaired reservoir function and a compensatory increase in contractile function. The exposure of systemic blood pressures (BP) through life on the left heart chambers may be an explanation, but long-term follow-up studies are lacking. LA phasic function can be quantified by echocardiographic speckle-tracking strain analysis and provide prognostic information in cardiovascular disease.

Purpose

To explore the impact of BP in the early 40s on LA function assessed by strain two decades later.

Methods

A total of 3,706 individuals born in 1950 and residing in Akershus County, Norway, were included in the Akershus Cardiac Examination (ACE) 1950 Study. Baseline examinations were conducted between 2012-2015 and included echocardiography. Of those with available echocardiographic LA strain analyses, 2,399 participants had demographic and clinical data available from the Age 40 Program, a cardiovascular health survey performed when the participants were 40 years old. We assessed the impact of BP at age 40 on LA strain two decades later. Differences in LA reservoir (LASr) and contractile strain (LASct) between systolic (<120, 120-140 and >140mmHg) and diastolic (<70, 70-90, and >90mmHg) BP groups were assessed by ANOVA. Linear regression analyses were performed using BPs as continuous variables.

Results

Mean age of the 2,399 participants was 40.1±0.3 years at the time of the Age 40 program, and 63.9±0.6 years at the time of the ACE 1950 baseline examination. At age 40, 20.8% of participants had BP ≥140/ ≥90mmHg or used antihypertensive medication. Mean LASr was 35.1±9.2%, while mean LASct was 17.7±5.6%. LASr did not differ significantly between groups of systolic or diastolic BP. LASct, however, showed a statistically significant increase from lower to higher groups of both systolic and diastolic BP (Figure). In linear regression analyses, no associations were found between BPs and LASr, but systolic and diastolic BPs were both significantly associated with LASct (Table). The associations between BPs and LASct remained significant after adjustment for sex, BMI, daily smoking, resting heart rate and hypertension at age 40 (Table).

Conclusions

Higher systolic and diastolic BP in the early forties were associated with increased LA contractile function two decades later, but no significant changes in LA reservoir function were detected. This indicates contractile function as an early marker of subtle LA dysfunction.Figure.Table.
Right ventricular free wall longitudinal strain as a predictor of myocardial recovery in patients with advanced cardiogenic shock supported with the Impella device
Authors: Rapis K , Faragli A , Nelki V , Lo Muzio F P , Spillmann F , Tschoepe C , Alogna A
Published: October 2024

Background

Right ventricular (RV) dysfunction is a known independent factor influencing the outcome of patients in cardiogenic shock (CS). The aim of this monocentric retrospective study was to investigate the impact of left ventricular (LV) unloading on the right heart function and its predictive role regarding weaning following Impella device implantation in patients with profound CS due to LV failure.

Methods

We performed a retrospective analysis of 41 patients admitted to intensive care unit over a period of 3 years with CS due to LV dysfunction requiring support with Impella. Clinical and echocardiographic data were collected and correlated with weaning success. Finally, a multivariate analysis to identify independent predictors of weaning success was performed.

Results

After Impella implantation, the following was observed: right ventricular fractional area change (RVFAC) increased from a mean value of 28% to 38% (p=0.01), the tricuspid annular systolic velocity (TASV) increased from 9 cm/s to 10 cm/s (p=0.01), the velocity time integral right ventricular outflow tract (VTI RVOT) increased from 10 to 13 cm3/stroke (p=0.01), the right ventricular free wall longitudinal strain (RVFWLS) increased from -12% to -21% (p< 0.001). However, following LV unloading, a decrease in both RVFAC from 38% to 30% (p 0.01) and in VTI RVOT from 13 to 11 cm3/stroke (p<0.01) was observed. Moreover, there was a significant decrease in RVFWLS from -21% to -14% (p < 0.001). Notably, the percentage of change in RVFWLS between maximum and minimum (Δ%RVFWLSPmax-Pmin) support with Impella during the weaning process was significantly lower in weanable patients (34.5% in weaned vs 86% in non-weaned; p=0.038). Investigating the predicting ability of these parameters, Δ%RVFWLSPmax-Pmin emerged showing an AUC of 0.826 (0.690-0.962) in identifying non-weaned patients with a cut-off value of 38%. According to the multivariate analysis, Δ%RVFWLSPmax-Pmin in non-weaned patients remained the only significant parameter even considering possible confounders.

Conclusions

LV unloading with Impella in advanced CS patients improved RV function echocardiographic parameters. RVFWLS increased significantly after Impella implantation and its percentage of change between maximum and minimum support was significantly lower in weanable compared to non-weanable patients. Our findings suggest that RVFWLS could be used as a predictor of myocardial recovery allowing to identify weanable patients with adequate accuracy.
Left atrial reservoir strain measured by three-dimensional echocardiography is associated with major adverse cardiovascular events in the general population
Authors: Yafasov M , Javier Olsen F , Dyrby Johansen N , Grundtvig Skaarup K , Christian Hoejbjerg Lassen M , Soegaard P , Boje Jensen G , Schnohr P , Moegelvang R , Biering-Soerensen T
Published: October 2024

Background

Left atrial (LA) strain measured by three-dimensional (3D) echocardiography (3DE) is a novel way of evaluating LA function. The prognostic value of LA strain by 3DE in incident heart failure (HF) and cardiovascular (CV) death has not previously been documented.

Purpose

We south to investigate whether 3D LA strain measures were associated with incident heart failure (HF) and cardiovascular (CV) death in a population at low risk of CV events.

Methods

A total of 1,934 participants from a prospective longitudinal cohort study of the general population underwent a comprehensive transthoracic echocardiographic examination including 3DE where LA reservoir strain (LASr), conduit strain (LAScd) and contraction strain (LASct) were quantified. All participants were at sinus-rhythm during 3DE. The endpoint was a composite of HF and CV death. Cox proportional hazards regression was applied. Multivariable adjustments were made for the ARIC-HF risk score (age, gender, heart rate, systolic blood pressure, antihypertensive medication, diabetes, ischemic heart disease, smoking, and body mass index) and left atrial volume index.

Results

Mean age was 54±17 years, 43% were male. During a median follow-up time of 4.8 years (interquartile range 4.3-5.4 years), 89 participants (4.6%) either developed HF or died of a CV cause. In univariable analysis, LASr and LAScd, but not LASct were significantly associated with the outcome, but after multivariable adjustment only LASr remained significantly associated with outcome (HR 1.04 (95% CI: 1.01-1.08), p=0.016, per 1% decrease) while LAScd and LASct did not. LASr provided incremental prognostic information beyond the ARIC-HF risk score (continuous NRI 0.21±0.11, p=0.027). Compared to participants with a LASr in the 1st tertile (LASr>32%) Participants with an LASr in the in the 3rd tertile (LASr<26.5%) had an almost 7-fold increased risk of HF or CV-death (HR 6.93 (95% CI 3.29-14.58; p=0.001)(Figure).

Conclusion

LA reservoir strain assessed by 3DE was independently associated with incident HF and CV death, which was not the case for LA conduit and contraction strain. In addition, LA reservoir strain added incremental value beyond clinical risk scores.
Three dimensional biatrial expansion index as an independent predictor of outcome in dilated cardiomyopathy
Authors: Vijiiac A E , Scarlatescu A , Petre I , Onciul S , Vatasescu R
Published: October 2024

Background

Left atrial expansion index (LAEI) is a marker of left ventricular (LV) diastolic dysfunction and an outcome predictor in heart failure (HF). However, the role of the right atrial expansion index (RAEI) in the setting of left-sided HF is incompletely understood.

Purpose

We sought to evaluate the left, right and combined bi-atrial expansion index (BAEI) with three-dimensional (3D) echocardiography in a cohort of patients with dilated cardiomyopathy (DCM) and to assess their prognostic role.

Methods

We enrolled 121 consecutive patients (mean age 59±14 years, 74% men) with DCM in sinus rhythm, who underwent 3D echocardiography and were prospectively followed for 19±11 months for an endpoint of death, nonfatal cardiac arrest and HF hospitalization. As previously described, for the left atrium (LA), LAEI was measured as (3D LA Vmax – 3D LA Vmin) x 100/3D LA Vmin, where Vmax was the maximal end-systolic atrial volume and Vmin was the minimal end-diastolic atrial volume. For the right atrium (RA), RAEI was calculated as (3D RA Vmax – 3D RA Vmin) x 100/3D RA Vmin. BAEI was defined as the sum of LAEI and RAEI.

Results

55 patients (46%) reached the endpoint: there were 27 deaths, 5 nonfatal cardiac arrests and 23 readmissions for HF. Patients with adverse outcome had lower LAEI (52±25 vs. 63±36, p=0.047), lower RAEI (57±29 vs. 70±32, p=0.02), lower BAEI (108±46 vs. 133±55, p=0.008). In univariate Cox regression, all three expansion indices were predictors of adverse events: HR=3.23 [95% CI, 1.45-7.20], p=0.004 for LAEI, HR=2.12 [95% CI, 1.24-3.61], p=0.006 for RAEI, HR=3.99 [95% CI, 1.70-9.36], p=0.001 for BAEI. We constructed a multivariable model with well-established event predictors in DCM and one expansion index at a time. After adjustment for age, left ventricular ejection fraction, mitral regurgitation severity and pulmonary artery systolic pressure, all three expansion indices remained independent predictors of the composite endpoint: HR=2.75 [95% CI, 1.18-6.38], p=0.02 for LAEI, HR=1.86 [95% CI, 1.04-3.31], p=0.04 for RAEI, HR=3.53 [95% CI, 1.46-8.51], p=0.005 for BAEI. BAEI yielded the highest incremental prognostic power (likelihood ratio chi2 test=14, p=0.03) on top of the baseline model consisting of age, left ventricular ejection fraction, mitral regurgitation severity and pulmonary artery systolic pressure (likelihood ratio chi2 test=9).

Conclusion

In DCM, 3D atrial expansion indices are significantly lower in patients with major adverse events, reflecting a more impaired atrial reservoir dysfunction. Both LAEI, RAEI and BAEI were independent outcome predictors in patients with DCM. Combining the left and right atrial expansion indices might improve risk stratification, since BAEI had the highest predictive value after adjustment for confounders.
Mechanical wave velocities in acute myocardial infarction: an exploratory study using three-dimensional high frame rate echocardiography
Authors: Halvorsrod M , Mohajery M , Espeland T , Salles S , Stoylen A , Lovstakken L , Grenne B
Published: October 2024

Background

Evaluation of cardiac function is crucial for management of patients with acute myocardial infarction (AMI). Recently, high frame rate (HFR) echocardiography has enabled identification of fast-propagating mechanical waves (MW) within the myocardium. These waves have the potential to offer unique insights into myocardial tissue properties, including edema and fibrosis. However, the potential of 3D HFR echocardiography to accurately quantify MW velocities and thereby assess myocardial stiffness in AMI patients remains unexplored.

Purpose

To assess the feasibility of a novel method for estimating MW velocities using 3D HFR echocardiography in patients with AMI compared to healthy controls.

Methods

Twenty patients with first time ST-elevation myocardial infarction were included within 48 hours after reperfusion therapy. We used a commercially available ultrasound scanner to acquire conventional 3D high-quality (~20 frames per second) acquisitions and subsequent 3D HFR recordings (~820 frames per second). The high-quality recording was used to extract a myocardial mask to define the region of interest in the HFR acquisition to detect the atrial kick wave and generate a comprehensive 3D map of MW propagation and velocities. We compared MW velocities between these patients and twenty age- and sex-matched healthy controls.

Results

MW velocities were successfully measured in 93% of participants (17 patients and 20 controls). Global MW velocities were significantly higher in AMI patients compared to healthy controls (2.1±0.6m/s vs. 1.5±0.2m/s, p<0.001). Territorial values, corresponding to the theoretical perfusion area of the three main coronary arteries, were significantly higher in infarct-related territories in patients when compared to same territories in controls for all coronary territories: Right coronary artery: 1.9±0.7 m/s vs. 1.4±0.3m/s, p<0.05; Circumflex artery: 3.1±1.5m/s vs. 1.7±0.4m/s, p<0.01; and Left anterior descending artery: 1.8±0.5m/s vs. 1.4±0.2m/s, p<0.01.

Conclusions

Estimation of MW velocities using a novel 3D HFR echocardiography method was feasible in most patients with AMI and all healthy controls. MW velocities were higher in patients compared to healthy controls and infarcted compared to non-infarcted coronary territories. These findings confirm the potential of non-invasive myocardial tissue characterization by MW imaging.Boxplot of MW velocities3D HFR MW visualisation
Multi-vendor validation of automated left ventricular analysis from 3D echocardiography using artificial intelligence
Authors: Dillon J R , Zhao D , Ferdian E , Quill G M , Bhuva A N , Manisty C , D'silva A , Moon J , Lloyd G W , Edwards N C , Legget M E , Doughty R N , Young A A , Nash M P
Published: October 2024

Background

Accurate echocardiographic assessment of left ventricular (LV) function is dependent on both image acquisition and analysis. Although 3D echocardiography (3DE) is increasingly recommended for volume quantification, manually derived volumes are limited by operator subjectivity, variable image quality, and the lengthy duration of analysis. Consequently, several automated approaches based on artificial intelligence (AI) have been proposed to segment the LV cavity from 3DE and have demonstrated better accuracy and reproducibility compared to human experts. While the utility of AI models in the clinic depends on their ability to generalise to different populations and ultrasound vendors, the external validation of developed models remains limited.

Purpose

This study evaluates the ability of an existing AI model trained using data from a single vendor to accurately estimate routine 3DE LV indices in an independent external dataset acquired using equipment from a different vendor.

Methods

A previously published and internally validated deep learning model for segmentation of the LV cavity and myocardium from 3DE was used to automatically derive LV indices including end-diastolic volume (EDV), end-systolic volume (ESV), LV mass, and ejection fraction (EF) [1]. A second independent dataset consisting of paired 3DE and CMR images from 65 marathon runners from a different centre (using equipment from a different vendor) was subsequently used for external validation. Images from both datasets were subjectively scored from 1 (poor) to 5 (excellent) as a measure of image quality. Agreement with CMR as the reference was assessed using a two-way mixed effects intraclass correlation coefficient (ICC), supplemented by Bland-Altman analysis, to determine the model bias (between 3DE and CMR) and 95% limits of agreement (LOA). To assess whether performance could be improved by inclusion of multi-vendor data during training, the initial model was fine-tuned using a small subset (n=9) of images from the second centre.

Results

The mean image quality score from the second dataset was 2.5 (± 1.1), which was significantly lower than the mean of 3.4 (± 1.0) from the first dataset. Despite vendor and image quality differences, the initial model produced good agreement with CMR in EDV, ESV, and LV mass but only poor agreement in EF (Fig 1). Fine tuning greatly improved agreement in EF with reduced bias and narrower 95% LOA (Fig 2).

Conclusion

With the addition of a small number of cases for fine-tuning, AI models for automated LV analysis can achieve good performance analysing 3DE images acquired from a different vendor and population. Advancing model generalisability through more sophisticated data augmentation strategies may enable truly vendor-agnostic automated LV analysis from 3DE.
Development of machine learning models for prediction of left ventricular systolic dysfunction in patients with isolated left ventricular dilation
Authors: Saleh A , Sotelo M , Nona P , Wagner L , Rodgers C , Booker O , Andrikopoulou E
Published: October 2024

Background/Introduction

Isolated left ventricular dilation (ILVD), in the absence of concomitant LV systolic dysfunction, is a risk factor for new reduction in LV ejection fraction (LVEF) and adverse clinical outcomes. We assessed the performance of different machine learning (ML) models in predicting new reduction in LVEF in patients with ILVD.

Methods

A retrospective analysis of de-identified patient records in the Tempus Database with at least two transthoracic echocardiograms (TTE) conducted between January 2019 and December 2022 were retrospectively analyzed, with the follow up period ending in January 2023. Inclusion/exclusion criteria are shown in Figure 1A. Briefly, patients with ILVD were defined based on echocardiographic parameters as those with LVEF > 50% and LV end diastolic volume indexed (LVEDVi) > 62 mL/m2 for females and > 75 mL/m2 for males, without prior LVEF < 50% and/or grade 2/3 diastolic dysfunction. The endpoint was LVEF < 40% on future (≥90 days) TTE. Five hard voting ML models and one soft voting ensemble model were trained with data parsed from TTE reports (Figure 1B). Feature importance (SHAP) was calculated, and receiver operating characteristic (ROC) and Kaplan Meier curves evaluated the final model (Figure 1C-E).

Results

A total of 2,962 patients met the inclusion criteria. The median time from index to last TTE was 578 (IQR = 500) days. LVEF < 40% on follow up TTE was noted in 6% of patients (177 patients, median 478 days to endpoint, IQR = 535 days). Of the six models developed, the ensemble model had the highest ROC area under the curve (0.791, Figure 1D), precision (0.163), F1-score (0.266), and specificity (0.773). The ensemble model also had the lowest predicted prevalence (25.5%), although this was higher than the observed prevalence in the test set (5.7%). Patients predicted to develop LVEF < 40% had a 8.2x higher risk of developing LVEF < 40% within five years of index (p<0.001, Figure 1E). Feature importance showed that male gender, higher heart rate, lower LVEF at index TTE, higher LVEDVi, and lower tricuspid annular plane systolic excursion had the highest mean absolute impact on the model’s output probability (Figure 1C).

Conclusion

Using only data parsed from the index TTE, ensembling a model for the prediction of developing LVEF < 40% in patients with ILVD and without a history of LV diastolic or systolic dysfunction performed the best. Additional analyses including clinical variables such as comorbidities, symptoms, and medications may improve the model’s performance.
Residual mitral leaflet length independently indicates left ventricular outflow tract obstruction in hypertrophic cardiomyopathy
Authors: Zach D K , Batzner A , Schwegel N , Santner V , Hoeller V , Ablasser K , Morbach C , Stoerk S , Maack C , Reiter U , Rainer P P , Frantz S , Zirlik A , Seggewiss H , Verheyen N
Published: October 2024

Background

Due to its dynamic character, the diagnosis of left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM) often requires extensive exercise testing. Mitral valve alterations represent structural parameters that are not affected by load or contractility and influence left ventricular outflow tract (LVOT) gradients. The residual portion of the mitral valve extending past its coaptation (RML) has been postulated as a necessity to exhibit LVOTO.

Purpose

This study aims to assess the impact of RML length on the likelihood of LVOTO in HCM patients.

Methods

This is a cross-sectional, multi-center, registry-based analysis conducted at two HCM referral centers. The study included HCM patients with valid standardized transthoracic echocardiographic examinations. Blinded investigators performed post-processing echocardiographic analyses. LVOTO was defined as resting or dynamic peak LVOT gradients ≥30 mmHg.

Results

Among 270 HCM patients studied (43% women, mean age 58±14 years), 131 patients (49%) exhibited LVOTO, with 76 (28%) having undergone septal reduction therapy (SRT). Patients with obstructive HCM exhibited a more pronounced end-diastolic interventricular septum (IVSd) thickness (2.2±0.4 vs. 1.8±0.5 cm; p<0.001) and higher left ventricular ejection fraction (LVEF) (65±9 vs. 62±10%; p=0.009) compared to those without LVOTO (nHCM). Obstructive HCM patients demonstrated longer anterior (29±4 vs. 26±4 mm; p<0.001), posterior (23±4 vs. 20±4 mm; p<0.001), and residual mitral leaflets (11±3 vs. 7±3 mm; p<0.001) than nHCM patients. Multivariable logistic regression analysis adjusting for age, IVSd thickness, LVEF, anterior, and posterior mitral leaflet length identified RML length as an independent predictor of LVOTO [OR=1.47 (95% CI 1.30-1.66); p<0.001]. The area under the receiver-operating characteristic curve for RML length in identifying LVOTO was 0.82 (95% CI 0.77-0.87). RML length ≥9 mm demonstrated 73% sensitivity and 77% specificity in identifying obstructive HCM patients. Notably, these results remained statistically significant in sensitivity analyses selectively performed in HCM patients who had previously undergone SRT as well as in those who were SRT-naïve, respectively.

Conclusions

This study indicates RML length as an independent predictor of LVOTO in HCM patients. Moreover, RML length demonstrated high diagnostic accuracy in identifying LVOTO among HCM patients. Prospective studies are warranted to assess the added value of RML length in the diagnostic work-up of HCM patients.Figure:Diagnostic Accuracy of RML
Right ventricular myocardial work predicts heart failure hospitalizations irrespective of ejection fraction
Authors: Chilingaryan A , Tunyan L G , Asatryan A A , Sisakyan J G
Published: October 2024

Hospitalization for heart failure worsening (HFW) associates with increased subsequent rehospitalization rate and mortality irrespective of left ventricular ejection fraction (EF). However there’s little evidence regarding predictors of HFW to timely apply preventive measurements. Since right ventricular (RV) dysfunction often associates with more advanced stages of HF we assumed that RV myocardial work (MW) assessment might be used in prediction of HFW.

Methods

158 patients with HF (48% female) 58±7 years on guideline directed medical therapy in sinus rhythm and with at least one hospitalization in the last 6 months were enrolled in the study. Patients with HFrEF, HFmrEF and HFpEF were evenly represented. All patients were appropriately decongested prior to the study. The primary outcome was rehospitalization, HFW or cardiovascular death. RVMW was derived from RV global strain, including interventricular septum, and noninvasively estimated pulmonary arterial pressure (PAP). Systolic PAP (sPAP) was measured as the sum of maximum RV and right atrial (RA) pressure gradient (PGmax) from tricuspid regurgitation (TR) jet peak velocity and mean right atrial pressure (RAP) estimated from diameter and collapsing of inferior vena cava. Mean PAP (mPAP) was measured as the sum of PGmean RV-RA by tracing TR jet and RAP. Diastolic PAP was estimated as dPAP = 1.5 × [mPAP − (sPAP/3)]. Then RV global work index (RVGWI), constructive (RVGCW), and efficient work (RVGWE) were derived by the software dedicated for left ventricular MW. Left ventricular global longitudinal strain, left atrial (LA) reservoir strain (LAS), LA pump strain, LA volume index (LAVi), B lines, inferior vena cava, NT-pro-BNP, TAPSE/sPAP and RVMW were also measured. Patients followed up for 12 months.

Results

53 events were registered at 12 months of which 42 rehospitalizations due to HFW and 11 CV deaths. Among all parameters in the multivariate analysis lower RVGCW was associated with HFW (HR 0.978, 95% CI 0.973–0.998, p = 0.014). RVGCW was the most powerful predictor of CV events (AUC 0.91) with cut off value of 148 mmHg% that had 96% sensitivity and 88% specificity. Number of patients who died with RVGCW < 148 mmHg% was 8 of 11 (73%) total deaths (HR 0.421, 95% CI 0.083–0.986, p = 0.028).

Conclusion

RVGCW was a predictor of HFW and 1 year mortality in patients with HF irrespective of EF.
Left atrioventricular coupling index: association with diastolic dysfunction and prognostic implications in heart failure patients
Authors: Fortuni F , Biagioli P , Myagmardorj R , Mengoni A , Lupi A , Chua A P , Zuchi C , Sforna S , Di Pietro I , Viti C , Bax J , Ajmone Marsan N , Ambrosio G , Carluccio E
Published: October 2024

Background

Left atrioventricular coupling index (LACI), an index coupling left atrial (LA) to left ventricular (LV) volume at end-diastole (Figure 1), showed to be associated with prognosis in different clinical settings. However, the relation between LACI and LV diastolic dysfunction (DD) remains to be established.

Purpose

The present study aimed to investigate the association between LACI and LV DD and to assess its prognostic value in patients with heart failure (HF).

Methods

We retrospectively analyzed 1158 stable HF patients (mean age 66±12 years, 75% men) on optimal medical therapy (derivation cohort). Clinical and echocardiographic features were characterized across LACI tertiles. The independent prognostic value of LACI (endpoint: all-cause death/HF-hospitalization) was assessed by Cox regression and spline curve analyses. Results were validated in an external cohort of 242 HF patients.

Results

In the derivation cohort, the median LACI value was 0.29 (IQR:0.19-0.42). Patients in the third tertile (LACI>0.36) were older and presented with more advanced HF symptoms. While prevalence of grade-1 DD (ASE/EACVI classification) progressively decreased across LACI tertiles, the prevalence of grade-3 DD significantly increased (8%,23%, and 46% respectively, P<0.0001). A cut-off value ³0.26 identified moderate-to-severe DD with an area-under the-curve of 0.75. During follow-up (median 28 months, IQR:11-53), 407 (35%) patients reached the endpoint. On multivariable analysis, LACI was independently associated with outcomes (HR for 1-unit-increase 2.34; 95%CI 1.35-4.03; P=0.002 – Figure 2), showing incremental predictive value over the DD grading system (net reclassification improvement=0.150, P<0.0001). The prognostic value of LACI was consistent in the external validation cohort.

Conclusions

LACI is associated with DD severity and is an independent predictor of outcomes in HF patients.How to assess LACIPrognostic value of LACI in HF
Advanced versus conventional echocardiographic parameters of right ventricular-arterial coupling in heart failure
Authors: Sforna S , Fortuni F , Biagioli P , Massei F , Grassano D , Gobbi F , Fede E , Casini B , Ambrosio G , Carluccio E
Published: October 2024

Background

Right ventricular-arterial coupling (RVAC) is an important predictor of prognosis in heart failure (HF). Several echocardiographic RVAC parameters have been described. However, which one best reflects patient’s prognosis is still matter of debate.

Purpose

The aim of this study was to compare the predictive value of RVAC parameters derived from advanced echocardiography with that obtained from conventional echocardiography in HF patients.

Methods

Consecutive patients with stable HF and left ventricular (LV) systolic dysfunction (LVEF<50%, n=193) were studied by echocardiography. RVAC was assessed by tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP), tissue Doppler imaging Sm velocity (TDI Sm)/PASP, RV free wall longitudinal strain (RVFWLS)/PASP and tridimensional RVEF (3D-RVEF)/PASP. Primary composite endpoint was all-cause death/HF hospitalization.

Results

After a median follow-up time of 16.3 months, the endpoint occurred in 45 patients. At univariable analysis, all RVAC parameters were significantly associated with the outcome [TAPSE/PASP: HR 0.31 (95% CI 0.17-0.55), P<0.001; TDI Sm/PASP: HR 0.27 (95% CI 0.15-0.49), P<0.001; RVFWLS/PASP: HR 0.19 (95% CI 0.10-0.36), P<0.001; 3D-RVEF/PASP: HR 0.30 (95% CI 0.17-0.55), P<0.001; figure 1]. At multivariable analysis, after adjustment for MAGGIC risk score and NT-proBNP, TAPSE/PASP [HR 0.71 (95% CI 0.38-1.35), P = NS] and TDI Sm/PASP [HR 0.59 (95% CI 0.31-1.10), P = NS] were no longer statistically associated with the endpoint; however, both RVFWLS/PASP [HR 0.36 (95% CI 0.18-0.70), P < 0.01] and 3D-RVEF/PASP [HR 0.55 (95% CI 0.31-0.99), P < 0.05] maintained their prognostic value (figure 2).

Conclusions

Advanced RVAC echocardiographic parameters (RVFWLS/PASP and 3D-RVEF/PASP) are superior predictors of prognosis than those derived from conventional echocardiography (TAPSE/PASP and TDI Sm/PASP) in a contemporary cohort of HF patients with left ventricular systolic dysfunction.Figure 1Figure 2