bluuebunny/crossref_metadata_2025 huggingface dataset:
Agreement between automated echocardiography and expert cardiologist for aortic valve hemodynamic parameters in severe aortic stenosis patients
Authors: Abramikas Z , Kazukauskiene I , Sablauskas K , Cesnaite G , Vrublevska G , Pugaciauskaite K , Balciunaite G , Glaveckaite S
Published: January 2025

Background

Aortic stenosis is one of the leading valve diseases. Transthoracic echocardiography (TTE) is the primary imaging technique for diagnosing aortic stenosis, providing comprehensive evaluations of valve hemodynamics and cardiac remodeling. However, it is time-consuming and requires significant expertise. While automated echocardiographic tools hold promise in potentially streamlining diagnostic processes and reducing measurement variability, their accuracy and reliability relative to expert cardiologist measurements require validation.

Purpose

To assess the agreement of aortic valve (AV) hemodynamic parameters derived from automated echocardiography analysis software compared to measurements performed by experienced cardiologists.

Methods

Fifty-eight patients with severe symptomatic aortic stenosis underwent comprehensive TTE evaluation. Each patient underwent a comprehensive TTE evaluation, where several key parameters were measured. For AV assessment, maximum velocity (Vmax), maximum gradient (Gmax), mean gradient (Gmean). TTE measurements were performed using standard protocols and guidelines. AV measurements were obtained from multiple acoustic windows, ensuring optimal visualization and alignment for accurate velocity and gradient assessments. Automated analysis algorithms were applied to the same echocardiographic studies to perform analogous measurements of AV parameters.

Results

The analysis demonstrated a high yield of 94.83% for aortic valve (AV) parameters. Pearson correlation analysis revealed strong agreement between human and AI measurements for AV Vmax, AV Gmax, and AV Gmean, with correlation coefficients of 0.78, 0.80, and 0.77, respectively. There was minimal bias for AV Vmax (0.1, ± 0.81 limits of agreement) and AV Gmax (bias of 3.34, ±30.02 limits of agreement). However, AV Gmean exhibited a bias of -3.63 (±22.14 limits of agreement).

Conclusion

The study shows strong agreement between automated and human measurements for aortic valve parameters.
Right ventricular dysfunction in ischemic vs nonischemic dilated cardiomyopathy
Authors: Saraiya S , Agrawal A , C R
Published: January 2025

Background

Non-ischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM) can both lead to right ventricular (RV) dysfunction. Data on direct head to head comparisons of the two entities regarding RV size and function using state-of-the-art imaging techniques is sparse. Such a comparison may help to better understand the underlying pathophysiology of RV dysfunction in both NICM and ICM. Also, differentiation between the two etiologies for cardiomyopathy has important therapeutic implications because ICM may benefit from coronary revascularization.

Purpose

The aim of this study was to investigate RV function using conventional transthoracic and tissue Doppler echocardiography in patients with dilated cardiomyopathy (ICM and NICM groups) and compare the various parameters of the RV assessment in both the groups and correlate with etiology of cardiomyopathy.

Methods

35 patients with NICM and 35 patients with ICM, both groups with LVEF<35% evaluated at our center were included in the study. Transthoracic echocardiography was done for all of them for assessment of Right ventricular volumes and function using conventional and Tissue Doppler parameters.

Results

Baseline LVEF was similar in the two groups with mean LVEF of 28% in ICM group and 27% in NICM group [p=0.71]. RV dysfunction was seen in 22 (62.9%) patients in ICM group as compared to 25 (71.4%) patients in NICM group [p=0.445]. PAH was present in 31(44.3%) patients, with presence of PAH more common in NICM group (n=18, 51.4%) as compared to ICM group (n=13, 37.1%) [p=0.009]. There was a significant positive correlation between LVEF & RV Basal S’ velocity (R2 0.33, p=0.02) and LVEF & TAPSE (R2 0.309, p=0.03) in the ICM group. Presence of more than mild MR (p=0.047), TAPSE < 1.5 cm (p<0.001) and RV Basal S’ velocity < 8.6 cm/s (p=0.02) were significant predictors of RV dysfunction in these patients.

Conclusion

RV dysfunction is common in both NICM and ICM patients. However, there is no significant association of underlying cause of LV dysfunction with presence of RV dysfunction in these patients. Pulmonary artery hypertension was more common in patients in NICM group.
Echocardiographic nomograms of heart chambers and great arteries in peruvian children living at high altitude according to sex
Authors: Mekonnen D , Ren C , Pilgrim T , Spitzer E
Published: January 2025

Background

Reference values in pediatric echocardiography are crucial for clinical decision making. The availability of nomograms may support interpretation of the echocardiographic findings and clinical diagnosis. Cardiac chamber dimensions vary according to body size, age, sex, and to some extent, geographic background in children.

Purpose

The aim of this study was to establish two-dimensional and M-mode echocardiographic reference values for cardiac chambers, outflow tracts and great vessels for school children living at high altitude, differentiated between male and female.

Methods

This is a post-hoc analysis from a cluster randomized cross-sectional survey of rheumatic heart disease in school children in Arequipa, Peru. Children with normal echocardiographic screening were included for this sub-study. The echocardiograms were acquired with a portable machine and the images were analyzed centrally with a standardized methodology. Body surface area (BSA) was used as an independent variable to predict the mean values of echocardiographic measurements for both male and female groups. Reference values are presented with z-scores and nomograms based on the sex.

Results

A total of 985 students from ages 5-16 years were included. The Haycock formula provided the best fit and was used when presenting data as predicted values for a given BSA. The z-score and nomograms for all essential dimensional measures of cardiac chambers and great vessel, as well as functional surrogates are presented based on sex. Left ventricular chamber and mass are presented in Figure 1 and right ventricular dimensions are presented in Figure 2.

Conclusions

Normal reference values and nomograms of cardiac chamber, outflow tracts and great arteries in healthy school children living at high altitude based on sex were reported. These data partly cover a gap in existing pediatric echocardiographic nomograms.

Left ventricular chamber and mass

Right ventricular dimensions
Hypercontractile phenotype of the left ventricle in patients with heart failure with preserved ejection fraction: too strong to be normal?
Authors: Wang Y , Zhang Q , Wang S , Xu Y , Yin L
Published: January 2025

Background

Hypercontractile phenotype (HP) of the left ventricle (LV) is an actionable therapeutic target in patients with chronic coronary syndromes (CCS), but its prevalence and meaning in patients with heart failure and preserved ejection fraction (HFpEF) remains unclear.

Purpose

To assess the myocardial work correlates of the HP in patients with HFpEF.

Methods

In a prospective, observational, single-center, cross-sectional study, we recruited 62 healthy controls (55 ± 7 yrs, 36 males, 58.1%) and 129 patients (58 ± 8 yrs, 70 males, 54.3%) with HFpEF referred for resting transthoracic echocardiography with volumetric echocardiography and assessment of global work efficiency (GWE). We measured systolic blood pressure (SBP) with a cuff sphygmomanometer. We assessed quantitatively LV end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), force (SBP/ESV), stroke volume (SV), arterial elastance (SBP/SV), ventricular-arterial coupling (VAC, as SV/ESV), and cardiac output (CO= SV*heart rate).HP was identified a priori as value >7.87 mmHg/ml, corresponding to a value exceeding > 2SD (95% of values) of the distribution in normals. GWE was assessed with a single vendor together with global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and GWE.

Results

LVEF and GLS values were similar in normal and HFpEF (EF: 63.3±4.7% vs 67.2±6.3%, p > 0.05; GLS: 21.4±1.4% vs 19.1±2.7%, p > 0.05). However, at individual patient analysis, 42 patients of the HFpEF group showed HP (32.6%). Compared to controls and patients with HFpEF without HP, HP patients showed higher values of heart rate and EF but lower values of SV, LVESV, LVEDV, similar values of GLS, and markedly higher values of GWI, GCW, and GWW with lower GWE. Multivariable linear regression analysis showed that force was independently associated with GWE (β=-0.356, P=0.002) and LVEF (β=0.219, P<0.0001), NTproBNP was independently associated with GWW (β=0.589, P=0.020) and GWE (β=-31.120, P<0.0001).

Conclusion

A HP of the LV with high force is frequent in HFpEF and is associated with a small heart, reduced SV, and lower mechanical efficiency with higher global work but a disproportionate increase in wasted work. Work analysis is more effective than GLS in identifying HFpEF with HP.
Comparison of algorithms of left ventricular diastole function assessment in hypertensive individuals with preserved ejection fraction
Authors: Zhemanyuk S , Syvolap V
Published: January 2025

The aim of the study was to compare two echo-algorithms of the assessment of the left ventricular diastole function (2016 the American Society of Echocardiography/the European Association of Cardiovascular Imaging and the 2024 British Society of Echocardiography guidelines) in routine clinical practice.

Methods

We retrospectively enrolled 142 adult hypertensive patients with cardiovascular disease of different aetiologies who underwent transthoracic echocardiography examination (2D imaging, Doppler) for routine clinical indications. It was measured echocardiography parameters for diastolic function evaluation as transmitral Doppler E wave, mitral annular Tissue Doppler Imaging e`septal and e` lateral, average E/e`, left atrium volume index, the velocity of tricuspid regurgitation.

Results

Overall, a total of 90 subjects were finally included (mean age 61.8 years (95% CI 59.1 to 64.5), 44.4% women) who had preserved left ventricular (LV) ejection fraction (≥50%). By applying the 2024 recommendations, 11% of individuals fulfilled the criteria for impaired diastolic function with elevated filling pressure, 83 % of subjects were diagnosed with normal diastolic function, and only 4.4% had impaired diastolic function with normal filling pressures. Meanwhile, according to the 2016 recommendations, 12 % were diagnosed with diastolic dysfunction, 54% had a normal diastolic function and 34%subjects had indeterminate diastolic function, and required additional examination.

Conclusions

This study demonstrates that a low number of individuals with impaired diastolic function with normal filling pressures was classified based on British recommendation 2024, however, a high number of patients with indeterminate diastolic function was diagnosed through guideline 2016. The new echocardiographic approach for estimating the left ventricular diastole function presented in 2024 could have higher clinical utility, especially in resource-limited settings for routine examination of hypertensive patients.
Atrial strain and strain rate in a general population: do these measures improve the assessment of elevated NT-proBNP levels?
Authors: Roesner A , Kornev M , Caglayan H A , Queiros S , Malyutina S , Ryabikov A , Kudryavtsev A V , Schirmer H
Published: January 2025

Background and Purpose

Noninvasive assessment of elevated filling pressure in the left ventricle (LV) remains an unresolved problem. Of the many echocardiographic parameters used to evaluate diastolic pressure, the left atrial strain and strain rate (LA S/SR) have shown promise in clinical settings. However, only a few previous studies have evaluated LA S/SR in larger populations.

Methods

A total of 2033 participants from Norwegian and Russian (Know Your Heart) population studies, equally distributed by age and sex, underwent echocardiography, including atrial and ventricular S/SR and NT-proBNP measurements. Of these, 1069 were identified as healthy (without hypertension (HT), atrial fibrillation (AF), or structural cardiac disease) and were used to define the age- and sex-adjusted normal ranges of LA S/SR. Furthermore, the total study population was divided into groups according to ejection fraction (EF) ≥50%, EF <50%, and AF. In each group, uni- and multiple regression and receiver operating characteristic curve analyses were performed to test LA and LV functional parameters as potential indicators of NT-proBNP levels above 250 ng/ml.

Results

The mean LA S/SR values in this study were higher than those in previous large studies, whereas the lower references were comparable. In normal hearts, atrial total strain (ATS) and mitral valve E deceleration time (MV DT) were independent factors indicating elevated NT-proBNP levels, whereas in hearts with reduced EFs, the independent indicators were peak atrial contraction strain (PACS) and LV stroke volume. The areas under the curve for these significant indicators to discriminate elevated NT-proBNP levels were 0.639 (95% confidence interval (CI): 0.577-0.701) for normal EF and 0.805 (CI: 0.675-0.935) for reduced EF.

Conclusion

The results confirm good intra-study reproducibility, with mean values in the upper range of previous meta-analyses. In the future automated border-detection algorithms may be able to generate highly reproducible normal values. Furthermore, the study showed atrial S/SR as an additional indicator of elevated NT-proBNP levels in the general population, demonstrating the incremental value of both ATS and PACS in addition to conventional and ventricular strain echocardiography. Thus, the LA S/SR may be regarded as an important addition to the multiparametric approach used for evaluating LV filling.

Normal Ranges

ROC curve analysis
Optimal cut plane for the measurement of tricuspid annular plane systolic excursion: how should we measure TASPE?
Authors: Murayama M , Kaga S , Yamaguchi M , Yokoyama S , Nishino H , Goto M , Yanagi Y , Kambayashi M , Shimono Y , Nakamura K , Tamaki Y , Ishizaka S , Iwano H , Nagai T , Anzai T
Published: January 2025

Introduction

Assessment of right ventricular systolic function plays an important role in management of cardiovascular disease. Tricuspid annular plane systolic excursion (TAPSE) is the most widely used quantitative parameter; however, there is a lack of evidence regarding the appropriate cut plane for its measurement.

Purpose

This study aimed to elucidate the optimal cut plane for TAPSE measurement, focusing on the incidence angle of the M-mode cursor and relationship to an angle-independent right ventricular systolic parameter.

Methods

This retrospective study included 113 adult patients referred for echocardiography for a variety of clinical indications. TAPSE was measured using the M-mode in the standard, focused, and modified apical four-chamber views (Figure 1). Incident angles between the M-mode cursor and the direction of the lateral tricuspid annulus movement were also measured. Right ventricular free wall longitudinal strain was measured as an angle-independent parameter.

Results

TAPSE measured from the modified apical four-chamber view was the largest among the three approaches (standard apical four-chamber view: 20.7 ± 5.2 mm; focused apical four-chamber view: 19.9 ± 4.7 mm; modified apical four-chamber view: 22.9 ± 5.5 mm; one-way repeated measures ANOVA P < 0.001) (Figure 2A). The incident angle was the smallest in the modified apical four-chamber view (standard apical four-chamber view: 24.1 ± 9.8 degrees; focused apical four-chamber view: 28.6 ± 11.0 degrees; modified apical four-chamber view: 14.7 ± 7.9 degrees; one-way repeated measures ANOVA P < 0.001) (Figure 2B). TAPSE from the modified apical four-chamber view showed a better correlation with right ventricular free wall longitudinal strain compared to other approaches (standard apical four-chamber view: r = 0.632 [95% confidence interval: 0.506 to 0.731], p < 0.001; focused apical four-chamber view: r = 0.626 [95% confidence interval: 0.499 to 0.727], p < 0.001; modified apical four-chamber view: r = 0.700 [95% CI: 0.592 confidence interval 0.783], p < 0.001, respectively).

Conclusions

The modified apical four-chamber view was the most optimal for TAPSE measurements owing to the largest value and the smallest incident angle. Standardization of measurements to the modified apical four-chamber view would provide accurate assessment of the right ventricular systolic function in daily practice.

Figure 1

Figure 2
Right ventricular function of patients with multiple myeloma treated with carfilzomib
Authors: Fraix A , Basin S , Cezar M , Pace N , Filippetti L , Schulmann S , Selton-Suty C , Huttin O , Chabot F , Chaouat A , Valentin S
Published: January 2025

Carfilzomib is an irreversible proteasome inhibitor used for treatment of multiple myeloma which improves progression-free survival and reduces the risk of death. Several adverse effects are described and especially cardiovascular events. Pathophysiological mechanisms are not fully understood but oxidative stress may damage cardiomyocytes (1).

Most common cardiovascular side effects are arterial hypertension, left heart failure, arrhythmia and thromboembolic events. Therefore, transthoracic echocardiogram (TTE) is recommended prior to the initiation of treatment and throughout the follow-up. Carfilzomib has also been shown to be associated with the development of pulmonary hypertension, however the effect on right ventricular function remains unknown (2). We aimed to evaluate the evolution of right ventricular (RV) function and RV-pulmonary artery coupling under carfilzomib.

This retrospective study included thirty-six patients diagnosed with multiple myeloma with a median age of 65.5 [58.8 – 71.5] years. The main comorbidity was systemic hypertension (n=18, 50%) and twenty-eight (77.8%) patients received at least one line of chemotherapy before carfilzomib. Every patient underwent TTE before and during treatment with carfilzomib.

Our results showed that the baseline TTE revealed preserved left ventricular (LV) function with a median LV ejection fraction of 60 [58.8 – 63.5] % without LV dilatation. Concerning RV function, tricuspid annular plane systolic excursion (TAPSE) was 24.5 [21.1 – 27.3] mm, and lateral tricuspid annulus peak systolic velocity (S’ wave) was 13.0 [11.7 – 15.0] cm/s. Systolic peak tricuspid regurgitation velocity (peak TRV) was measured at 2.4 [2.2 – 2.6] m/s. RV-pulmonary artery coupling, estimated by TAPSE/sPAP ratio was 0.94 [0.79 – 1.11] mm/mmHg. During the follow up, TAPSE significantly decreased under carfilzomib treatment at 21.5 [19.9 – 25.3] (p=0.03). TAPSE decreased in more than 57.1% of patients with a mean of 5.4 ± 4.1 mm. However, peak TRV was not different during follow-up (2.4 [2.3 – 2.5]] m/s, p=0.97) nor TAPSE/sPAP ratio (0.88 [0.80 – 1.10] mm/mmHg, p=0.17).

These data are the first to suggest that carfilzomib may impair right ventricular (RV) function even in the absence of evident pulmonary hypertension. Therefore, close monitoring of RV function in patients treated with carfilzomib is crucial due to the risk of RV side effects. Transthoracic echocardiography (TTE), particularly the follow-up of tricuspid annular plane systolic excursion (TAPSE), seems to be a valuable screening tool for monitoring these patients before they undergo more specific evaluations.
Right ventricular function and pulmonary coupling in relation to loop diuretic resistance in patients with congestive heart failure
Authors: Zaborska B , Imiela T , Pilichowska-Paszkiet E , Imiela A M , Bednarczyk T , Piszcz K , Budaj A
Published: January 2025

Background

Right ventricular (RV) dysfunction has been proven to be a prognostic factor among heart failure (HF) patients. Loop diuretic resistance (LDR) is associated with worse clinical outcomes, greater symptom burden and mortality. Limited data exist to characterise the relation between RV and kidney function, especially LDR.

Purpose

To assess relationship of different echocardiographic RV function parameters with loop diuretic resistance in patients with congestive HF exacerbation.

Methods

Consecutive patients with congestive HF exacerbation were prospectively included in the study. LDR was defined as persistent congestion on the 4th day of hospital stay despite high i.v. loop diuretic dose. Transthoracic echo with detailed assessment of right heart geometry and function, clinical and biochemical parameters were evaluated on the 1st and 4th day of hospital stay. A TAPSE/PASP ratio was used to assess RV to pulmonary circulation coupling. Results are presented as mean±standard deviation or median (interquartile range).

Results

40 patients were included in the study with median age 84 (72,8; 86) years, mean left ventricle ejection fraction (EF) 37.3±13.0 %, mean E/e’ 18.6±5.0, median NT-proBNP 8967.5 (3024; 15241) pg/ml. LDR was found in 14 (35%) patients. Univariate analysis identified the following risk factors for LDR: pulmonary artery systolic pressure (PASP), right ventricle to pulmonary circulation coupling index (TAPSE/PASP ratio), serum creatinine concentration, serum urea concentration, serum low-density cholesterol (LDL) concentration (results are shown in the table). TAPSE/PASP on admission correlated negatively with NT-pro BNP (r -0.44 , p=0.007) and positively with diuresis/40mg of furosemide (r 0.38, p=0.02). In the multivariable model, the significant negative relationship between LDR and TAPSE/PASP (beta coefficient -0.653, p= 0.047) as well as LDL (beta coefficient -0.055, p=0.043) was observed.

Conclusions

TAPSE/PASP, one of the most significant non-invasive indexes of RV failure, assessed at admission might be a clinically relevant marker of LDR in patients with congestive HF exacerbation.

Study group characteristics
Arrhythmogenic mitral annular disjunction: papillary muscle abnormalities as a novel component
Authors: Sienkiewicz K , Wabich E , Dorniak K , Fijalkowska J , Szurowska E , Fijalkowski M , Danilowicz-Szymanowicz L
Published: January 2025

Purpose

Mitral annular disjunction (MAD) is a relatively common condition that can be associated with ventricular arrhythmias. This study aims to assess the significance of abnormalities in the left ventricular papillary muscles, as detected by cardiac magnetic resonance imaging (MRI), and their correlation with the echocardiographic Pickelhoube sign and arrhythmogenic burden in patients with MAD.

Methods and Materials

A retrospective study was conducted involving 63 consecutive patients with MAD identified via a 1.5T MRI scanner. All patients underwent echocardiography, and 51 patients (81%) also completed a 24-hour Holter electrocardiography. The study evaluated the visual presence of the dark papillary muscle sign (dark PAP), late gadolinium enhancement in the papillary muscles (PAP LGE), and the echocardiographic Pickelhoube sign, known to be associated with a higher risk of ventricular arrhythmias. Additionally, the 24-hour Holter ECG assessed the number of premature ventricular contractions (PVCs), using a threshold of more than 1000 beats per 24 hours, and the presence of nonsustained ventricular tachycardia (nsVT).

Results

The average MAD length in the study population was 5.29 ± 0.43 mm (95% CI). The dark PAP sign was observed in 42 patients (67%), PAP LGE in 11 patients (17%), and the echocardiographic Pickelhoube sign in 34 patients (54%). Ventricular arrythmias (nsVT and more than 1000 PVCs per 24 hours) were found in 24 patients (38%). The dark PAP sign was significantly associated with the echocardiographic Pickelhoube sign (p < 0.001). Ventricular arrhythmias (PVCs) were more frequent in patients with PAP LGE (p < 0.03). The small number of nsVT cases (6 patients) precluded statistical analysis.

Conclusion

The study found that the dark PAP sign correlates with the echocardiographic Pickelhoube sign, and PAP LGE is associated with a higher burden of ventricular arrhythmias. Further prospective studies in larger populations are needed to evaluate the potential of papillary muscle characteristics in risk stratification for ventricular arrhythmias in patients with MAD.

dark PAP positive

dark PAP negative
Maladaptive remodeling reduces survival in patients with moderate aortic stenosis and preserved ejection fraction
Authors: Petrovic O , Paunovic I , Jovanovic I , Rakocevic I , Vidanovic S , Tesic M , Boricic-Kostic M , Vratonjic J , Milasinovic D , Mehmedbegovic Z , Trifunovic-Zamaklar D , Ivanovic B , Stankovic G
Published: January 2025

Background

Aortic valve stenosis (AS) is a common cause of left ventricular (LV) pressure overload and subsequent hypertrophy and diastolic dysfunction. The extent of LV hypertrophy does not necessarily correlate with the severity of valve stenosis and excessive LV remodeling can be seen in moderate AS. Therefore aortic stenosis is the disease of valve and myocardium. Left ventricular hypertrophy (LVH) with different geometric patterns is associated with adverse prognosis, The concept of staging AS disease rather than merely classifying AS based on hemodynamic severity seems more appropriate. Current guidelines do not address whether aortic valve replacement should be recommended in patients with moderate aortic valve stenosis regardless of the presence of LV dysfunction.

Purpose

This study aimed to investigate differences in left ventricular remodeling and its impact on survival in patients with unequivocally moderate aortic stenosis and preserved LV ejection fraction.

Methods

We retrospectively analyzed 182 unequivocally moderate AS patients (57% were male, age was 70±9), who underwent transthoracic echocardiography from March 2018 to November 2021. AS severity was defined by specific threshold values peak velocity 3-4 m/sec, an MPG 20-40 mmHg and an AVA 1-1.5 cm. All values were concordant and suggested moderate AS. All patients were in sinus rhythm and with LV ejection fraction >50%. We calculated the LV mass index (LVMI) and ventricular geometry was assessed with a relative wall thickness (RWT). Left ventricular hypertrophy (LVH) was defined as LV mass index >95g/m2 in women and >115g/m2 in men and was defined as concentric when associated with a RWT>0.42 and eccentric when RWT was ≤0.42. Concentric remodeling was defined as normal LVM index and increased RWT. The follow-up assessment in December 2023 ascertained vital status and data on aortic valve replacement (AVR).

Results

LVH was present in 91 patients (50%). Eccentric LVH was present in 49 (27%), concentric LVH in 42 (23%), and concentric remodeling in 27 (15%). During a median 41 months follow-up, 49 (27%) deaths occurred. 32 (18%) patients undervent AVR. As expected, LV hypetrophy was associated with all-cause mortality (HR 2.556; CI: 1.007-6.448; p = 0.048), and if concentric hypertrophy was present mortality was even higher (HR 3.736; CI: 1.553-8.992; p = 0.003) AVR had a non-statistically significant protective effect (HR 0.654; CI: 0.193 -2.220; p = 0.496).

Conclusion

Maladaptive remodeling is associated with worse outcomes in patients with moderate AS. RWT is important for identification of abnormal geometry. Further studies investigating the adequate timing of AVR in patients with moderate AS with maladaptive LV response are needed.
Left ventricular, left atrial dysfunction and BNP progression in asymptomatic moderate and severe aortic stenosis
Authors: Dulgheru R , Lambert A , Damas F , Demarneffe N , Postolache A , Lancellotti P
Published: January 2025

Introduction and aim

Aortic stenosis (AS) is the most common valve disease in industrialized countries. Its prevalence is set to increase considerably in the coming years as the population ages (1). Data regarding the natural evolution in patients with moderate and severe AS are derived from cohorts of patients from 30 years ago (2, 3). We have thought to analyze the evolution of clinical, echocardiographic parameters and blood brain natriuretic peptide (BNP) in a recent cohort of truly asymptomatic patients with moderate to severe AS followed in the Valve Clinic. We also wanted to determine which is the echocardiographic parameter who’s annualized change will influence all-cause mortality in these patients.

Methods

We have enrolled 63 patients with moderate or severe truly asymptomatic AS (negative exercise test in each patient) followed up in our Valve Clinic from 2010 to 2023 who had at least 2 or 3 transthoracic echocardiographic examination (TTE) of excellent quality while still asymptomatic. All patients had a complete TTE with images suitable for left ventricular (LV) and left atrial (LA) deformation analysis by 2D speckle tracking. All conventional TTE parameters were analyzed as well as BNP measurements at the time of the TTE. Patients were followed up (mean follow up of 401 days) and all-cause mortality was assessed.

Results

Our results show progression of AS severity, a decrease in LV systolic function (GLS decreased significantly but LVEF and SV index remained changed), progression of LV diastolic dysfunction (progressive increase in E /e' ratio, in LA index volume with a significant decrease in LA reservoir function (PALs)). A progressive increase in estimated systolic pulmonary arterial pressure (PAPs) and a higher probability of pulmonary hypertension during follow-up was observed, while RV function parameters, TAPSE and S’ remained unchanged. BNP levels increased significantly over time. No patient was lost to follow-up and 23 (36.5%) patients died, 3 of cardiovascular cause. After adjustment for sex, age, presence of type 2 diabetes and coronary artery disease, all-cause mortality seemed to be significantly higher in patients with a decrease in LA reservoir function during follow-up (OR 0.77, CI 0.59-0.99, p=0.046).

Conclusion

To our knowledge, this is the first longitudinal contemporary study to describe the progression of AS and of all parameters of LV, LA, RV function and PHT in moderate to severe truly asymptomatic AS patients followed in a Valve Clinic. A higher risk of all-cause mortality was seen in patients with a poorer LA reservoir function. Annualized changed in LV and LA functional parameters may become a tool to improve risk stratification and therapeutic decision-making in asymptomatic severe AS if larger studies were to confirm our findings.
Impact of strictly defined phenotypes of tricuspid regurgitation on clinical outcome
Authors: Hu C , Li W , Tsai W
Published: January 2025

Background

Moderate to severe tricuspid regurgitation (TR) is widely recognized as a significant contributor to right ventricular (RV) failure and mortality. Our previous study using a step-by-step approach to classified phenotypes of TR has shown different phenotypes of TR had different effects on RV remodeling. Current study was tried to find the impacts of these phenotypes on clinical outcomes.

Methods

There were 670 patients (7.7%) exhibited moderate to severe TR in our echocardiography laboratory from January to June 2018. These participants were classified into 8 phenotypes by a step-by-step approach including primary TR, secondary TR related to RV instrumentation, related to left heart disease, related to congenital heart disease, related to pulmonary hypertension, related to RV myopathy, atrial TR, and true idiopathic TR. Combined outcome endpoints included death, heart failure, acute coronary syndrome, stroke, and new arrhythmia.

Results

There were 28 participants lost follow-up and only 6 participants had been classified as RV myopathy were excluded. The remaining 636 participants (mean age 70.9 ± 15.4 years, 254 (40%) men) were included in the study. After mean follow-up 43.2 ± 27.9 months, a total of 321 (50.5%) participants reached combined endpoints. Different phenotypes demonstrated different rates of outcomes included 43.7% in primary TR, 66.7% in secondary TR related to RV instrumentation, 58.1% in left heart disease, 45.8% in congenital heart disease, 51.5% in pulmonary hypertension, 42.6% in atrial TR, and 29.9% in true idiopathic TR. After multivariate COX regression analysis, independent factors for prognosis included TR phenotypes (HR 1.079, 95% CI 1.000-1.165), age (HR 1.023, 95% CI 1.013-1.033), eGFR (HR 0.991, 95% CI 0.985-0.996), systolic pulmonary pressure (HR 1.008, 95% CI 1.002-1.013), RV fractional area change (HR 0.986, 95% CI 0.977-0.995), and left ventricular ejection fraction (HR 0.989, 95% CI 0.980-0.998). The Kaplan-Meier curves significantly separated according to different TR phenotypes (Log Rank p < 0.001).

Conclusion

The identification and classification of different TR phenotypes according to our step-by-step approach had significant impact on patient outcomes. Simply using this step-by-step approach from echocardiography can identify high risk TR patients who urge for further intervention.
Acute postprocedural myocardial strain changes after transcatheter edge-to-edge mitral valve repair
Authors: Peszek-Przybyla E , Gallina T , Jedrzejek M , Michalewska-Wludarczyk A , Pysz P , Wojakowski W , Smolka G
Published: January 2025

Introduction

Despite the increasing utilization of transcathether edge-to-edge mitral valve repair (TEER) its effect on global myocardial function and segmental performance remains poorly understood. The immediate changes in volume and wall tension induced by the TEER procedure present an interesting area of study, regarding their influence on myocardial function, which may be crucial for future understanding of cardiac mechanics.

Purpose

The purpose of this study is to investigate the direct impact of TEER implantation on changes in left ventricle function and geometry

Methods

A prospective observational study was conducted involving consecutive patients undergoing TEER for severe MR. Echocardiographic assessments were performed before and in the cath-lab, immediately after the procedure, with strain analysis performed using speckle-tracking echocardiography.

Results

The study includes 27 patients with severe MR, with a mean age of 77 ± 5.9 years. The analysis revealed no significant changes in LVEF before and after the procedure (41,7% vs 40,7%, p= 0,234, respectively). However, it shows a significant decrease in global longitudinal strain (GLS) post-procedure compared to pre-procedure (-10.7% vs -12.4%, p=0.019, respectively). Subgroup analysis of individual myocardial segments demonstrated significant reduction in strain values between pre- and post-procedure assessments, particularly in segments 3, 9, 12, 17, and 18.

Conclusion

The findings suggest that TEER for severe MR leads to acute changes in myocardial strain, particularly in myocardial segments at the region of papillary muscles. This phenomenon may be caused by the tension of the subvalvular apparatus due to TEER procedure. Changes in strain analysis were observed despite no changes in EF. Further research is necessary to elucidate the clinical implications of these findings and their impact on patient outcomes.
Clinical impact of right atrium function on tricuspid regurgitation
Authors: Rocca B , Pilan M , Benfari G , Bergamini C , Maffeis C , Tafciu E , Ribichini F L
Published: January 2025

Background

tricuspid regurgitation (TR) is frequent, and its related systemic venous congestion is associated with mortality.

Purpose

This study aims to evaluate the role of right atrial (RA) function, measured using the strain technique, on the medium- to long-term clinical effects of tricuspid regurgitation (TR). Our primary objective was to analyze the impact of RA function, measured at baseline, on a composite endpoint consisting of death and/or hospitalization for predominantly right-sided heart failure. The secondary endpoints are hospitalizations, worsening of renal function, and an increase in diuretic dosage (DD).

Methods

We performed a single center, prospective, observational study regarding adult patients with tricuspid regurgitation and measurable effective regurgitant orifice area (EROA) and a state of hemodynamic stability that underwent a complete echocardiography and full cardiologic evaluation in our Institution, from January 2020 to February 2023. Those patients with acute HF, poor quality imaging, previous repair or prosthetic replacement of the tricuspid valve, and severe renal or hepatic insufficiency were excluded. Patients were assessed clinically at each follow up.

Results

134 patients were included (females 62%, mean age 73 ± 13 years old). Median follow up was 23,5 months (12 - 34 months). TR was functional in 87% of cases and was more than moderate in 52% of cases. Mean RA strain was 18,7 ± 11,2%, and divided patients in low strain (LS) and high strain (HS). HS was associated with lower increase and frequently a decrease in DD (-5,5 ± 44,7 mg vs 20,8 ± 63,2 mg, p = 0,009) but no echocardiographic variable independently predicted an increase in DD. Patients with worsening renal function had significantly lower RA (16.7 ± 10.6% vs 20.7 ± 10.9%, p 0.042). LS independently predicted a worsening renal function (OR 3,07; 95% CI 1,026-9,2). RA strain was significantly lower in hospitalized patients (13.1 ± 8 vs 20.3 ± 11.4, p<0.001). Cox regression analysis showed a LS to be an independent predictor of the composite endpoint (adjusted HR 3.1, 95% CI 1.101 – 8.74) correcting for other clinical and echocardiographic variables. ROC curve analysis showed an RA strain cut-off of 18.5% to have a sensitivity of 79% and specificity of 56% in predicting the combined endpoint.

Conclusions

RA strain is associated with DD and LS patients have higher DD at follow up. RA strain is an independent predictor of worsening renal function. RA function measured by strain is an independent predictor of the composite endpoint of death and/or hospitalization.
Prediction of mortality and heart failure admission with the mitraScore after percutaneous mitral valve repair: an external validation study
Authors: Barreiro Mesa L , Ruiz Ortiz M , Esteban Martinez F , Delgado Ortega M , Rodriguez Almodovar A , Ojeda Pineda S , Roldan Guerra A , Urbano Sanchez C , Aguayo Cano N , Suarez De Lezo J , Lopez Aguilera J , Gonzalez Manzanares R , Pan Alvarez Osorrio M , Mesa Rubio D
Published: January 2025

Background

Prediction of events is critical in decision-making for transcatheter edge-to-edge mitral valve repair (TEER). A new score has been reported for this aim, the MitraScore, that showed adequate performance for predicting death and heart failure rehospitalization in an external validation cohort described in the original publication.

Purpose

Our aim was to perform an external validation of this prognostic score in an independent sample.

Methods

The MitraScore assigned 1 point to each independent predictor of mortality found in the validation cohort: age ≥75 years, anemia, glomerular filtrate rate <60 mL/min/1.73 m2, left ventricular ejection fraction <40%, peripheral artery disease, chronic obstructive pulmonary disease, high diuretic dose, and no therapy with renin-angiotensin inhibitors. We calculated the MitraScore in every subject of a prospective cohort of patients treated with TEER in a single institution from November 2011 to January 2024. Association of the score with mortality and the combined end-point of heart failure admission or death was assessed by the Cox proportional hazard method and Kaplan Meier curves. Discrimination was studied by receiver operating characteristics (ROC) curve.

Results

A total of 191 consecutive patients (median age [p25-75] 74 [64-80] years, 33% female) were included in the study. Our sample differed significantly from the original derivation and validation cohorts in several baseline variables (figure 1). After a median follow up of 24 [9-50] months, 92 patients (48.4%) had 160 admissions for heart failure and 73 patients died (38.2%). MitraScore, as a continuous variable, had a significant association with mortality and the combined end-point in follow-up, either by univariate Cox analysis (HR 1.36 [1.11-1.66] per each score point, p=0.003 for all-cause mortality, and HR 1.35 [1.11-1.65] per each score point, p=0.003 for the combined end-point), and Kaplan Meier analysis (figure 2). Discrimination by ROC analysis was nearly significant for both end-points (C statistics 0.58 [0.50-0.67], p=0.052 for all-cause mortality, and HR 0.58 [0.49-0.66], p=0.068 for the combined end-point).

Conclusion

The MitraScore, considered as a continuous variable, was significantly associated with mortality and the combined end-point of heart failure admission or death in follow-up in the present external validation study. These data support the use of this prognostic index in risk stratification for patients treated with TEER.
PISA method correction by leaflet tethering angle and regurgitant jet velocity, and its association with outcomes in patients with secondary tricuspid regurgitation
Authors: Gagliardi M F , Tomaselli M , Penso M , Badano L P , Clement A , Radu N , Heilbron F , Gavazzoni M , Hadareanu D R , Oliverio G , Fisicaro S , Pece C , Delcea C , Muraru D
Published: January 2025

Background

Although the correction of the proximal isovelocity surface area (PISA) method has been shown to improve the accuracy of assessing the severity of secondary tricuspid regurgitation (STR), its clinical impact remains to be investigated.

Purpose

To compare the strength of the association of the quantitative parameters of STR severity obtained from the corrected and conventional PISA methods with outcomes in patients with either atrial- or ventricular STR.

Methods

We used both the conventional and corrected PISA method to obtain effective regurgitant orifice area (EROA and EROAc, respectively), regurgitant volume (RegVol and RegVolc, respectively), and regurgitant fraction (RegFr and RegFrc, respectively) in 519 consecutive patients (75±12 years, 44% men, 74% ventricular STR) with moderate and severe STR. The endpoint was a composite of heart failure hospitalization and all-cause death.

Results

EROAc, RegVolc, and RegFrc were significantly larger than EROA (bias= 21 mm2, Limits of agreement, LOA= 25 mm2), RegVol (bias= 18 mL, LOA= 18 mL), and RegFr (bias= 24%, LOA= 17%) (P < 0.001 for all). After a follow-up of 19±15 months, 210 patients reached the endpoint. Threshold values for an excess of events using the corrected PISA parameters were larger in patiets with ventricular (EROAc = 51 mm², RegVol = 42 mL) than atrial STR (EROAc = 46 mm², RegVolc = 30 mL), except the RegFr that was significantly smaller in patients with ventricular STR (56% vs. 69%). Using time-dependent ROC curves, the AUCs of the parameters obtained from the corrected PISA were more closely associated with outcomes at two years than those obtained with the conventional PISA: EROAc vs. EROA (0.62 vs. 0.60, p<0.001), RegVolc vs. RegVol (0.63 vs. 0.62, p=0.001), and RegFrc vs. RegFr (0.66 vs. 0.63, p<0.001) in patients with ventricular STR. Conversely no significant differences between AUCs were detected in patients with atrial STR. In both univariable and multivariable analyses, both EROA and EROAc, RegVol and RegVolc, or RegFr and RegFrc consistently emerged as independently associated with outcomes in patients with ventricular STR (p<0.001 for all). Conversely, in patients with atrial STR, although EROA and EROAc retained their independent predictive power, neither uncorrected nor corrected RegVols and RegFrs were found to be independent predictors of outcomes after multivariable adjustment.

Conclusions

Correcting the PISA method for the leaflet tethering angle and the velocity of the regurgitant jet provides larger quantitative parameters of STR severity. In patients with ventricular STR, the parameters obtained with the corrected PISA method are more closely associated with those obtained with the conventional PISA.
Prognostic significance of tricuspid regurgitation grading using different echocardiographic approaches
Authors: Mattig I , Romero Dorta E R , Frumkin D , Kretzschmar H , Sommer A , Redel A M , Buchstaller J , Sanchez Gomez O J , Pieske-Kraigher E , Stangl K , Hindricks G , Dreger H
Published: January 2025

Introduction

Tricuspid regurgitation (TR) is routinely graded using quantitative and qualitative echocardiographic parameters. The current grading scheme consists of five TR grades and primarily incorporates vena contracta (VC) and effective regurgitation orifice area (EROA) assessed by the proximal isovelocity surface area (PISA) method. Additionally, an angle-corrected PISA method was proposed as the standard approach seem to underestimate especially ventricular TR.

Purpose

Since different measurements may lead to different TR severity grades, the present study aimed to evaluate the prognostic significance of TR grading using various approaches.

Methods

Hospitalized patients with heart failure (HF) according to current guidelines of the European Society of Cardiology (ESC) were enrolled from 2020 to 2022 (NCT04570098). Inclusion criteria comprised an echocardiographic examination up to three months prior to study participation. TR was graded into the categories moderate to torrential according to the recommended standard, including all quantitative and qualitative parameters as proposed by the guidelines, biplane VC, PISA EROA, and angle-corrected PISA EROA. Survival status was assessed during twelve-month follow-up. Cox regression analysis and log-rank test were used to evaluate the prognostic value of TR grades according to the different echocardiographic methods with the reference category none or mild TR.

Results

A total of 1003 HF patients were enrolled, including 66% with none or mild TR. The prevalence of moderate to torrential TR depending on the use of the different methods was as follows: 18% moderate, 10% severe, 2% massive, and 3% torrential TR according to quantitative and qualitative parameters; 12% moderate TR, 6% severe TR, 4% massive TR, and 4% torrential TR assessed by PISA EROA; 9% moderate TR, 6% severe TR, 3% massive TR, and 6% torrential TR according to angel-corrected PISA EROA; as well as 13% moderate TR, 14% severe TR, 4% massive TR, and 1% torrential TR measured by VC. During the study period, the overall-mortality rate reached 15%. A more severe TR was associated with an increase in mortality regardless of the TR grading approach (log-rank test p<0.001). As shown in Table 1, only TR grading based on VC consistently demonstrated an increased mortality risk across all severity grades.

Conclusion

There are various parameters for TR quantification used in clinical routine. Overall, a more severe TR was associated with an increase in all-cause mortality in HF patients. VC may be superior to PISA EROA and angle-corrected PISA EROA to differentiate the mortality risk of moderate to torrential TR.