bluuebunny/crossref_metadata_2025 huggingface dataset:
Relaxed predation selection on rare morphs ofEnsatinasalamanders (Caudata: Plethodontidae) promotes a polymorphic population in a novel dune sand habitat
Authors: Rich Caitlyn , Reilly Sean B , Sinervo Barry
Published: November 2020

The ring species Ensatina represents a classic example of locally adapted lineages. The Monterey ensatina (Ensatina eschscholtzii eschscholtzii) is a cryptic subspecies with brown coloration, although a recently discovered polymorphic population within a wind-blown sand region also contains leucistic (pink) and xanthistic (orange) morphs. In the present study, the frequency of leucism/xanthism was mapped across the subspecies’ range, revealing that these morphs are generally rare or absent except within regions containing light-coloured substrate. Attack rates were estimated using clay models of the three morphs, deployed only at the crepuscular period and during the night, on both light and dark substrates at a site within the dune sand region. Model selection found that the interaction between morph and substrate colour best predicted attack rates. Typical morphs had equal attack rates on both substrates while xanthistic and leucistic morphs incurred significantly fewer attacks on light vs. dark substrate, and there was no significant difference in attack rates among morphs on light substrates. These results support the idea that xanthistic and leucistic morphs are poorly adapted for dark substrates compared to typical morphs, but they are more or less equally adapted for light substrates. We suggest that this microgeographic island of relaxed selection on light-coloured morphs helps to explain the existence of this polymorphic population.
A Divide & Conquer Approach to Leads-to Model Checking
Authors: Phyo Yati , Minh Do Canh , Ogata Kazuhiro
Published: November 2020

The paper proposes a new technique to mitigate the state explosion in model checking. The technique is called a divide & conquer approach to leads-to model checking. As indicated by the name, the technique is dedicated to leads-to properties. It is known that many important systems requirements can be expressed as leads-to properties, thus it is worth focusing on leads-to properties. The technique divides an original leads-to model checking problem into multiple smaller model checking problems and tackles each smaller one. We prove a theorem that the multiple smaller model checking problems are equivalent to the original leads-to model checking problem. We conduct two case studies demonstrating the power of the proposed technique.
Effects of the MitraClip on right heart function and tricuspid valve regurgitation
Authors: Ahmed A
Published: November 2020

The MitraClip has been established as a therapeutic option for patients with symptomatic mitral regurgitation (MR) and increased risk of Surgery. MR is often combined with a decrease in right heart function due to the volume and pressure overload it leads to. The effects of MR reduction by MitraClip on right heart function is currently not adequately determined. The study further addresses the question of whether and when it makes sense to correct combined tricuspid regurgitation (TR).

Methods

All Patients that took part in this study underwent 2D and 3D Echocardiography before MitraClip implantation as well as six months afterwards. RV Function was evaluated through 4 Parameters: Tricuspid annular plane systolic excursion (TAPSE) in mm, tricuspid annular systolic velocity (TASV) in cm/s, right ventricular fractional area change (RVFAC) in % and myocardial performance index (MPI). Estimated right ventricular systolic pressure (RVSP) in mmHg was used as evidence for the presence of pulmonic Hypertension. Further Parameters determined the severity of TR and the dimensions of the right ventricle (RV) and atrium (RA) in cm respectively the volume in ml.

Results

60 Patients were recruited (63% male, Age 81.4±7.1). Six Months (±3) after MitraClip implantation a significant improvement in right heart parameters was noticed. Most of the parameters used in this study showed a significant change. (TASV 9.3±2.4 vs. 10.5±2.6, p=0.01), (RVFAC 33.1±10.9 vs. 39.0±9.6, p<0.05). TAPSE showed an improvement by trend (16.1±4.6 vs. 17.4±4.8, p=0.06). RVSP showed a significant decrease (51.9±12.3 vs. 44.6±13.4, P<0.05). However, Dimensions and Volume of the right atrium and ventricle showed no significant change. On the other hand, the average TR severity has noticeably declined after 6 months (2.1±0.7 vs. 1.6±0.6, p<0.05). Flow Convergence and Vena contracta of Tricuspid regurgitation also demonstrated a significant reduction (Flow Convergence 7.6±4.5 vs. 5.9±2.5, P=0.01), (Vena contracta 6.8±2.5 vs. 5.4±1.9, p<0.05).

Conclusion

MitralClip leads to a reduction in Mitral regurgitation which leads to a significant improvement in the right heart parameters, especially the RV Function. A noticeable decrease in the TR severity was often seen as an accompanying effect. An initially wait-and-see approach to a residual TR appears justified.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Heart Center University Clinic Dresden, Germany
Value of a comprehensive exercise echocardiography assessment for patients with hypertrophic cardiomyopathy
Authors: Peteiro Vazquez J.C , Peteiro J , Barriales-Villa R , Larranaga-Moreira J , Martinez-Veira C , Martinez-Veira C , Castro-Dios D , Fernandez-Fernandez X , Monserrat L
Published: November 2020

Background

Exercise echocardiography (ExE) may assess left ventricular (LV) systolic and diastolic function, LV outflow tract (LVOT) obstruction and mitral regurgitation (MR). We aimed to assess the feasibility and prognostic value of the assessment of all these issues during exercise in patients with hypertrophic cardiomyopathy (HCM).

Methods

LV systolic and diastolic function, LVOT gradients, and MR were evaluated during ExE in 285 patients with HCM (age 60±14 years, 168 men) and preserved LVEF (≥50%). Recordings were obtained at rest and peak exercise for regional/global LV systolic function and at rest and within 1.5 min after exercise for the rest of assessments: LVOT gradients, MR and ratio of early LV inflow velocity to early tissue Doppler septal annulus velocity (E/e').

Results

Feasibility was 100%, 97%, 98% and 98% for LV systolic function, E/e', LVOT gradients, and MR assessments at exercise, respectively. Thirty-seven patients (13%) had LVOT obstruction at rest, and 76 (27%) developed exercise-induced LVOT obstruction. Mean resting LVEF was 63±3%. New wall motion abnormalities (WMAs) were detected in 38 patients (13%). E/e'>15 was observed in 108 patients at rest (38%) and in 119 at exercise (42%). Corresponding figures for significant MR (moderate or severe) were 20 (7%) and 17 (6%). During follow-up of 3.9±2.5 years, 21 patients had a hard event (cardiac death or transplantation, appropriate discharge of a defibrillator, stroke, myocardial infarction, hospitalization for heart failure), 33 a combined event (hard plus new atrial fibrillation or syncope), and 53 a combined event plus any interventionism.

After adjustment, LV wall thickness, resting LVEF, maximal workload in Metabolic Equivalents (METs), and E/e' post-exercise resulted independent predictors of hard events (HR=1.45, 95% CI: 1.21–1.74, p<0.001; HR=0.80, CI: 0.71–0.89, p<0.001; HR=0.73, 95% CI: 0.62–0.86, p<0.001; HR=1.08, 95% CI: 1.02–1.14, p<0.009, respectively). Independent predictors of combined events included also LV wall thickness, resting LVEF, and METs, along with therapy with beta-blockers at the time of ExE (HR=1.29, 95% CI: 1.12–1.50, p=0.001; HR=0.89, CI: 0.81–0.97, p=0.012; HR=0.83, 95% CI: 0.74–0.93, p=0.001; HR=2.51, 95% CI: 1.20–5.25, p=0.015), whereas the model for combined events+any interventionism consisted of beta-blockers, LV wall thickness, LA dimension, METs and new WMAs. (HR=2.15, 95% CI: 1.20–3.86, p=0.01; HR=1.17, 95% CI: 1.03–1.32, p=0.02; HR=1.07, CI: 1.02–1.11, p=0.005; HR=0.90, 95% CI: 0.82–0.98, p=0.01; HR=2.33, 95% CI: 1.17–4.63, p=0.016)

Conclusions

A comprehensive assessment during ExE is feasible for patients with HCM and provides significant incremental prognostic information

Funding Acknowledgement

Type of funding source: None
Beat-to-beat variability in the tricuspid annulus dimensions and dynamics is markedly increased in atrial fibrillation
Authors: Naser J , Ciobanu A , Wen S , Thaden J , Nkomo V , Pislaru C , Eleid M , Pellikka P , Pislaru S
Published: November 2020

Background

Atrial fibrillation (Afib) leads to beat-to-beat variability in cycle length; however, whether there is associated beat-to-beat variability in the tricuspid annulus (TA) dimensions or variability in the time in cardiac cycle when TA reaches maximal size is unknown.

Purpose

We aim to assess the beat-to-beat variability in the TA dimensions in Afib compared with sinus rhythm (SR).

Methods

Images were obtained from 58 patients (29 in Afib, 29 in SR) undergoing either 3D TTE or TEE examination. We measured TA in 3–6 cardiac cycles per patient using commercially available software (TomTec 4MV).

Results

Median absolute difference in maximal TA area over 3–6 cardiac cycles was 1.60 cm2 (range 0.35 cm2 to 4.08 cm2) in Afib vs. 1.17 cm2 (range 0.32 cm2 to 2.19 cm2) in SR, p=0.0063. Median absolute difference in the maximal circumference was 0.79 cm (range 0.09 cm to 2.2 cm) in Afib vs 0.54 cm (range 0.12 cm to 1.43 cm) in SR, p=0.0175. A total of 118 cardiac cycles were analyzed in patients in SR and 147 in Afib. Timing of maximal TA area was most commonly recorded at end-diastole (80–100% of the R-R interval) in 62% of cycles in SR; however, it was distributed over a broad range in Afib, p<0.0001, [Figure].

Conclusion

Afib leads to significant beat-to-beat variability in the maximal TA area, minimal TA area, maximal TA circumference, and in the time of maximal TA area. These findings suggest that accurate assessment of TA dimensions should be based on continuous tracking of the TA over several cardiac cycles, especially in patients with Afib. These observations have significant implications for device sizing in percutaneous tricuspid valve interventions.

Timing of Maximal TA Area

Funding Acknowledgement

Type of funding source: None
Sex, body size and right atrial volume are the main determinants of tricuspid annulus geometry in healthy volunteers. A 3D echo study using a novel, commercially-available dedicated software package
Authors: Mihalcea D , Guta A.C , Caravita S , Parati G , Vinereanu D , Badano L.P , Muraru D
Published: November 2020

Tricuspid annulus (TA) sizing is essential for percutaneous and surgical procedures. Guidelines recommend to assess TA size by 2D echo (2DE) linear dimension; but TA is a complex 3D structure.

Aim

To identify physiological determinants of TA geometry parameters and their reference values using 3D echo (3DE) and a novel, commercially-available software in healthy volunteers.

Methods

254 healthy volunteers (113 men, mean age 47±11 years) were evaluated by 2D and 3DE. 3DE TA analysis was made in 228 of them (feasibility=90%). TA 3DE area, perimeter, diameters, sphericity index and coaptation (Figure) were assessed at mid-systole using a dedicated software package (4D AutoTVQ, GE Healthcare, Horton, N). 3D right atrial (RA) and ventricular (RV) volumes were measured.

Results

Normal values of 3D TA geometry parameters, RV and RA volumes are presented in table. 3D TA area, perimeter and diameters correlated with BSA (r=0.33 to 0.5, p<0.001) and were larger in men, independently of BSA (p<0.0001). There were no age-related changes in TA parameters (r<0.25, p=0.0001). 2D TA diameters measured in apical 4ch and RV focused views were significantly smaller than 3DE 4ch diameter (16±2 and 16±3 vs 17±3, p<0.0001). RA maximal volumes had the strongest correlation with 3D TA area (r=0.65), compared with RV end-diastolic (r=0.55) and end-systolic (r=0.51) volumes (p<0.0001). By multivariable linear regression, RA maximal volume, sex and BSA, but not RV volumes, were independent predictors of 3D TA area (R2=0.46, p<0.0001).

Conclusions

Reference values for TA metrics should be sex-specific and indexed to BSA. 2DE underestimates TA dimensions. Even if both RA and RV volumes correlate significantly with TA area, only RA maximum volume was an independent predictor of its size at mid-systole.

3D tricuspid annulus parameters

Funding Acknowledgement

Type of funding source: None
Intraprocedural mean mitral pressure gradient predicts mortality in percutaneous edge-to-edge mitral repair for functional mitral regurgitation
Authors: M-Labbe B , Rajakulasingam R , Davies A , Connolly L , Rajani P , Jiliu P , Di Mario C , Smith R , Vazir A
Published: November 2020

Introduction

Percutaneous edge-to-edge mitral repair is a safe treatment method for functional (FMR) and degenerative (DMR) mitral regurgitation. Iatrogenic mitral stenosis remains a concern and periprocedural transoesophageal echocardiography is essential for real-time monitoring of mean mitral pressure gradient (intra-MMPG) and to guide clip deployment.

Purpose

Published data suggests intra-MMPG predicts clinical outcome and mortality only in DMR patients. We sought to validate these findings in a large high-volume UK center cohort with prolonged follow-up and further explore its use to predict mortality in functional MR patients.

Methods

All consecutive patients who underwent edge-to-edge mitral repair between 2010 and 2020 were analysed. The intra-MMPG and the severity of MR grade from the transoesophageal echocardiogram post-clip deployment (intra-MRgrade) were collected. Statistical analysis using covariates before and after edge-to-edge repair were compared using paired tests and cox regression models were used to assess the relationship of covariates with all-cause mortality. p<0.05 was deemed as statistically significant.

Results

We analysed data from 246 consecutive patients, 65% were men and mean age was 76±11 years. Pre-procedure LVEF was 49±15%, TAPSE was 16±6 mm, severity of MR was 3.8±0.5, 80% had NYHA III/IV and 45% had FMR. Post procedure, there was a significant reduction in severity of MR grade (3.8±0.5 to 1.7±0.8; p<0.001) and a reduction in LVEF (49±15 to 45±15%; p<0.001). There were significant improvements in NYHA class (3.2±0.6 to 2.0±0.6; P<0.0001) and LV outflow tract VTI (15±5 to 17±4 cm; p<0.001).

Patients were followed-up for a median of 1021 days (inter-quartile range 289 to 1555) during which 76 patients died. Multivariate survival analysis (see table) showed that the increase in intra-MMPG was independently associated with mortality for FMR, but not for DMR. Furthermore, higher intra-MRgrade was associated with mortality for FMR patients only.

Conclusion

Intraprocedural mean mitral pressure gradient (intra-MMPG) predicts mortality in percutaneous mitral edge-to-edge repair for FMR, but not for DMR, herby challenging previously published data.

Funding Acknowledgement

Type of funding source: None
Effect of age and parity on maternal diastolic function in middle trimester pregnant women with normal left ventricular ejection fraction and potential link of diastolic function to pre-eclampsia
Authors: Zhu D , Chen W.Y , Pan Y.C , Cui M
Published: November 2020

Background

It has been suggested that maternal cardiac adaptations during pregnancy differ between nulliparous and multipara women and also vary according to the age. Impaired cardiac function precedes pre-eclampsia.

Purpose

To evaluate effect of age and parity on maternal cardiac diastolic function in middle trimester among pregnant women with normal left ventricular ejection fraction as well as correlation between impaired diastolic function and pre-eclampsia.

Methods

Pregnant women with singleton pregnancies carried from 13 weeks to 20 weeks and left ventricular ejection fraction (LVEF) ≥50% were identified. Diastolic function parameters were assessed using transthoracic echocardiography. Pre-eclampsia was identified from medical records.

Results

376 pregnant women were included (median age: 30 years; median gestational age: 14 weeks; 171 multiparous women). LVEF was 66%. Impaired cardiac diastolic function was seen in 7.8% of pregnant women <35 years compared with 28.6% of those ≥35 years (p=0.000). ROC curve showed women with maternal age over 32 began to have a higher rate of impaired cardiac diastolic function (AUC=0.704, p=0.000, sensitivity=54.5%, specificity=75.3%). There was no difference in diastolic function indices between maternal women grouped by parity. After adjustment for confounders, maternal age can be independent effect factor of Em declined (P<0.05). Em<13cm/s was significantly associated with pre-eclampsia occurrence (HR 8.56; 95% CI: 3.40–21.57) after adjusting for the confounders.

Conclusion

Maternal age is an independent impact factor for diastolic function decline. There is no difference in cardiac diastolic function between nullipara and multipara. Pre-eclampsia occurrence is significantly higher in patients with diastolic function decline at mid-gestation. The utility of risk stratification using diastolic function at mid-gestation may improve the survival outcomes of pregnant women.

Association between Em and PE risk

Funding Acknowledgement

Type of funding source: None
Right ventricular morphology and function undergo complex changes after cardiac surgery
Authors: Wejner-Mik P , Kasprzak J.D , Szymczyk E , Wdowiak-Okrojek K , Ammer A , Religa G , Kaszczynski T , Lipiec P
Published: November 2020

Background

An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique.

Methods

The study population comprised 122 patients (92 men, mean age 65±11 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2±2 days prior to surgery (TTE1), and 7±4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12±2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function (such as TAPSE, systolic velocity of tricuspid annulus (S'), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS), as well as a new parameter introduced by our team - RV shortening fraction (RV SF), calculated as the change in mid RV transverse diameter.

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S' and GLS; p<0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. Additionally during the postoperative period an increase in the value of a RV SF by 12.85% was observed. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Grant Polish Cardiac Society
Restoration of normal sinus rhythm in atrial fibrillation: impact of reverse remodelling of right chambers on tricuspid regurgitation severity
Authors: Soulat-Dufour L , Benhamou-Tarallo I , Lang S , Ederhy S , Ancedy Y , Adavane-Scheuble S , Chauvet-Droit M , Nhan P , Jean M , Ben Said R , Scheuble A , Boccara F , Addetia K , Lang R , Cohen A
Published: November 2020

Background

The severity of tricuspid regurgitation (TR) in patients with restored normal sinus rhythm (SR) after atrial fibrillation (AF) has been poorly assessed.

Purpose

Our study aimed to assess (1) right chamber remodelling and (2) TR severity in patients with AF who have had their rhythms restored to normal sinus.

Methods

We prospectively evaluated 94 consecutive patients hospitalized for AF who received either ablation, direct current cardioversion, or pharmacological therapy. Patients were divided into two groups according to their cardiac rhythm at 6 months follow up (6M): restoration to SR (SR group, n=54), persistence of AF (AF group, n=40). TR vena contracta (VC), TR grade severity was divided into 4 grades using an integrated approach (0: none or trace; 1: mild; 2: moderate; 3: severe TR). Two dimensional (2D) end diastolic (ED) tricuspid annulus (TA) diameter in the apical 4 chambers view, three-dimensional (3D) indexed volumes (3D Vi) of the right atrium (RA) and right ventricle (RV) in end systole (ES) and ED were acquired using transthoracic echocardiography at admission and at 6M.

Results

At 6M, in the SR group a significant improvement in TR VC (Figure A) and TR grade (Figure B) were noted, whereas there was no differences in the AF group (0.41 vs. 0.42cm, p=0.24 for TR VC; 1.70 vs. 1.76, p=0.16 for mean TR grade). In the SR group a significant reduction in 3D ES RV Vi, 2D ED TA diameter, 3D ES and ED Vi of the RA (Table) were observed. Regression of TR VC was correlated with regression of right cavities parameters (ρ=0.47, p<0.001 for 2D ED TA diameter; ρ=0.34, p<0.005 for 3D ES RA Vi; ρ=0.33, p<0.005 for 3D ED RV Vi; ρ=0.29, p<0.005 for 3D ES RV Vi).

Conclusion

Restoration of normal SR in patients with AF results in beneficial remodelling of right cavities at 6M of follow-up which were associated with a significant decrease in TR severity. Strategies for normal SR restoration in patients with AF and TR should be vigorously attempted.

TR Evolution

Funding Acknowledgement

Type of funding source: None
Association betweenLeft Atrial Appendage function assessed by speckle-tracking echocardiography and the presence ofLeft Atrial Appendage stasis in patients with atrial fibrillation
Authors: Mao Y , Chan C , Ma M.M , Jiang R.H , Yang Y , Wang Y.H , Jiang C.Y
Published: November 2020

Objectives

The aim of this study was to determine the association of LAA left atrial appendage funtion as assessed by speckle-tracking imaging with LAA stasis and thrombus in patients with nonvalvular atrial fibrillation (AF).

Methods

A total of 154 consecutive patients with AF referred for transesophageal echocardiography (TEE) were prospectively enrolled. Of these, 29 (18.8%) patients had LAA dense spontaneous echo contrast (SEC) and/or thrombus. Besides standard echocardiography we assessed global, basal, middle and apical LAA longitudinal strain (LS) in mid-esophageal TEE views obtained at 0°, 45°, 90° and 135° by using speckle-tracking echocardiography (STE).

Results

Patients were comparable with regard to the clinical data. A subgroup with LAA stasis or thrombus had enlarged LAA size, impaired LAA emptying fraction (LAAEF) and reduced LAA emptying velocity than control group.LAA global and segmental LS were significantly decreased in patients with dense SEC or thrombus. Receiver operating characteristic curve analysis revealed that the LAAEF of 61.5%, the LAA GLS of 8.02%, LAA segmental LS of (basal) 8.07%, (middle) 9.08%, (apical) 8.43% (P<0.0001) were the optimal cutoff values for distinguishing both subgroups. All the LAA strain parameters as well as LAAEF were independently associated with the presence of LAA stasis or thrombus in multivariate analyses, with additional significance over the CHA2DS2-VASc score.

Conclusion

Speckle-tracking echocardiography may be used to describe LAA function during AF, allowing identification of patients with higher risk of LAA stasis or thrombus and providing incremental value over the CH2ADS2-VASc Score.

Figure 1

Funding Acknowledgement

Type of funding source: None
Myocardial work: a new way to predict fibrosis in patients with hypertrophic cardiomyopathy
Authors: Valentim Goncalves A , Aguiar Rosa S , Moura Branco L , Galrinho A , Fiarresga A , Rocha Lopes L , Thomas B , Baquero L , Mota Carmo M , Cruz Ferreira R
Published: November 2020

Aims

Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) adds prognostic information in patients with hypertrophic cardiomyopathy (HCM). Whether Myocardial work (MW), a new parameter on transthoracic echocardiographic (TTE), can predict significant fibrosis in HCM patients is unknown.

Methods

Single-centre evaluation of consecutively recruited HCM patients in which TTE and CMR were performed. MW and related indices were calculated from global longitudinal strain (GLS) and from estimated left ventricular pressure curves. The extent of LGE was quantitatively assessed. LGE ≥15% was chosen to define significant fibrosis.

Logistic regression analysis was used to find the variables associated with LGE ≥15% and cut-off values were determined.

Results

Among the thirty-two patients analysed mean age was 57±16 years, 18 (56%) were male patients and the mean left ventricular ejection fraction by TTE was 67±8%.

Global constructive work (GCW), global work index and GLS were significant predictors of LGE ≥15%. A cut-off ≤1550 mmHg% of GCW was able to predict significant fibrosis with a sensitivity of 92% and a specificity of 79%, while the best cut-off for GLS (>−15%) had a sensitivity of 86% and a specificity of 72%.

Conclusion

GCW was the best parameter to predict significant left ventricular myocardial fibrosis in CMR, suggesting its utility in patients who may not be able to have a CMR study.

Myocardial Work and LGE in CMR in HCM

Funding Acknowledgement

Type of funding source: None
Carotid intima-media thickness and subclinical left heart dysfunction in the general population
Authors: Nakanishi K , Daimon M , Yoshida Y , Ishiwata J , Sawada N , Hirokawa M , Kaneko H , Nakao T , Mizuno Y , Morita H , Di Tullio M , Homma S , Komuro I
Published: November 2020

Background

Although carotid intima-media thickness (IMT) is an established marker of atherosclerosis and carries independent risk for cardiovascular disease, its possible association with subclinical cardiac dysfunction has not been extensively evaluated. Left ventricular global longitudinal strain (LVGLS) and peak left atrial longitudinal systolic strain (PALS) can detect subclinical left heart dysfunction.

Purpose

This study aimed to investigate the association between carotid IMT and subclinical left heart dysfunction in a large sample of the general population without overt cardiac disease.

Methods

We examined 1,161 participants who underwent extensive cardiovascular examination. Ultrasonography of common carotid artery was performed for the measurement of maximal carotid IMT. LVGLS and PALS were assessed by 2-dimensional speckle-tracking echocardiography.

Results

Mean age was 62±12 years, and 56% were male. The prevalence of abnormal LVGLS (>−18.6%) and PALS (<31.4%) was greatest in the upper quartile of carotid IMT (both p<0.001; Figure). In multivariable analyses, carotid IMT was associated with abnormal LVGLS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.003) as well as PALS (adjusted odds ratio = 1.33 per 1SD increase of IMT, p=0.005) independent of traditional cardiovascular risk factors, echocardiographic parameters including LV ejection fraction, LV mass index and diastolic dysfunction, and pertinent laboratory parameters. The independent association between carotid IMT and PALS persisted even after adjustment for LVGLS. When carotid IMT was examined as a categorical variable, the upper quartile of carotid IMT carried a significant risk of abnormal LVGLS and PALS in a fully-adjusted model including echocardiographic and laboratory parameters (adjusted odds ratio 2.27 and 3.03 vs. lower quartile, both p<0.01).

Conclusion

Participants with increased IMT had significantly impaired LV and LA function in an unselected community-based cohort. This association may be involved in the higher incidence of cardiovascular disease in individuals with increased carotid IMT.

Funding Acknowledgement

Type of funding source: None
Regional left ventricular myocardial work index in culprit territory predicts early left ventricular remodelling in patients with st-segment elevation myocardial infarction
Authors: De Paula Lustosa R , Van Der Bijl P , Knuuti J , Goedemans L , El Mahdiui M , Montero-Cabezas J , Kostyukevich M , Fortuni F , Ajmone Marsan N , Bax J.J , Delgado V
Published: November 2020

Background

The association between left ventricular (LV) myocardial work index (LVMWI) derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings and adverse LV dilatation i.e. remodelling has not been evaluated.

Purpose

To assess the predictive value of regional LVMWI for LV remodelling at baseline echocardiography in patients with ST-segment elevation myocardial infarction (STEMI).

Methods

This retrospective study included 350 patients (265 men, mean age: 61±10 years) with STEMI treated with primary percutaneous coronary intervention and optimal medical therapy. Clinical variables, conventional echocardiographic parameters, global and segmental measures of LVMWI were recorded at baseline. The primary endpoint was early LV remodelling defined as increase in LV end-diastolic volume (LVEDV) ≥20% at 3 months after the index event.

Results

Eighty-seven patients (24.9%) presented with early LV remodelling. The global and regional LVMWI in the culprit territory were significantly lower in patients with early LV remodelling. Univariate and multivariate logistic regression analyses were performed to identify predictors of early LV remodelling. At the index event, troponin I peak, LVEDV and LVMWI in the culprit territory were independently associated with early LV remodelling (Table).

Conclusions

In STEMI patients treated with primary percutaneous coronary intervention and optimal medical therapy, the regional LVMWI in the culprit territory at echocardiography before discharge is independently associated with troponin I peak and LVEDV in predicting early LV remodelling.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology
Predictors of left ventricular remodelling in patients after active myocarditis
Authors: Koziel M , Boidol J , Klys J , Miszalski-Jamka K , Kalarus Z , Kukulski T
Published: November 2020

Background

Myocarditis may be a challenging diagnosis because of diversity of clinical presentations. Thus, the clinical course and ventricular remodelling in this disease seems to be unpredictable.

Aims

To assess predictors of left ventricular remodelling in patients after active myocarditis.

Methods

Database from a high-volume, tertiary cardiology center was analysed to identify patients with active myocarditis, based on clinical presentation and ≥1 diagnostic criteria from different categories (including electrocardiography/ holter, elevated troponin T/I levels, functional or structural abnormalities on cardiac imaging or tissue characterization by cardiac magnetic resonance) between 2016 and 2019. Left ventricle global longitudinal strain (GLS), mechanical dispersion (standard deviation of time to peak longitudinal strain derived from all left ventricle segments in 3 apical views) were calculated. Response (left ventricular positive remodeling measured by transthoracic echocardiography) was defined as end-systolic volume (ESV) reduction ≥15% from a baseline value or end-diastolic volume (EDV) reduction ≥15%.

Results

61 consecutive patients were enrolled. The median follow-up was 1.4 years (range: 0.3–4.0). During entire follow-up period mortality rate in patients was 1.6%. Multivariate Cox regression model including significant baseline differences as covariates reported that QRS durations (HR 1.31, 95% CI 1.17–1.57, P=0.049) and mechanical dispersion (HR 1.03, 95% CI 1.01–1.07, P=0.036) were independently associated with left ventricular positive remodelling with ESV reduction. Mechanical dispersion (HR 1.04, 95% CI 1.02–1.06, P=0.040) was independently associated with left ventricular positive remodelling with EDV reduction.

Conclusions

Mechanical dispersion and QRS duration are independent predictors of left ventricular remodelling in patients after active myocarditis.

Funding Acknowledgement

Type of funding source: None
Left atrial adaptation to different overloads: is atrial enlargement always related to atrial dysfunction?
Authors: Mimbrero Guillamon M , Loncaric F , Nunno L , Tirapu L , Sanchis L , Montserrat S , Doltra A , Bijnens B , Sitges M
Published: November 2020

Introduction

The adaptative response to different loading conditions of the left atrium (LA) has been scarcely studied. This might have clinical implication in terms of risk of emboli and atrial fibrillation development. Our aim is to assess function in enlarged LA with 3-dimensional (3D) echocardiographic volume assessment and speckle-tracking deformation analysis, and compare findings between patients with arterial hypertension (HTN), mitral regurgitation (MR) and endurance athletes (EA).

Methods

A population of 478 subjects were enrolled: 57% (n=273) EA, 37% (n=176) patients with well-controlled HTN and 6% (n=29) with moderate-to-severe MR. From this cohort, we selected the patients with enlarged atriums defining a 2D cut-off value of ≥34 mL/m2. These patients underwent 2D and 3D echocardiography. LA function was assessed with speckle-tracking analysis and phasic volume indices.

Results

LA enlargement was seen in 63% (n=299) of the cohort: 80% (n=219) of EA, 30% (n=53) of HTN and 93% (n=27) of MR patients. Analysis of LA function in these patients is shown in Table 1. As expected, MR was related to the largest LA volumes, followed by athletes - which had significantly larger volumes than HTN patients. LA reservoir strain and LA ejection fraction, as well as LA conduit strain and LA passive Ejection Fraction, were preserved in the athletes group while reduced in HTN and MR, whereas the LA contractile strain and LA active Ejection Fraction were reduced only in the MR subgroup.

Conclusions

These findings suggest that LA adapts differently to pressure and volume overload and also influenced by the amount of overload. Additionally, LA enlargement may not be associated with the same degree of LA dysfunction in different at-risk populations.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Fundaciό La Maratό de TV3
Clinical usefulness of relative apical sparing pattern for predicting functional recovery after transcatheter aortic valve implantation in patients with severe aortic stenosis
Authors: Matsuda K , Okayama H , Kazatani T , Okabe H , Kido S , Aono T , Tanaka Y , Kosaki T , Kawamura G , Shigematsu T , Kawata Y , Hiasa G , Yamada T , Kazatani Y
Published: November 2020

Background

Relative apical sparing pattern (RASP) is thought to be associated with prognosis in patients with cardiac amyloidosis or left ventricular hypertrophy (LVH). Although almost all patients with severe aortic stenosis (AS) have LVH, little is known about the effect of transcatheter aortic valve implantation (TAVI) in patients with severe AS exhibiting a RASP.

Purpose

This study aimed to elucidate the effect of TAVI on left ventricular global longitudinal strain (LS; LVGLS) in patients with severe AS exhibiting a RASP.

Methods

Eighty-four patients who underwent transfemoral or subclavian TAVI were evaluated. They were divided into the RASP and non-RASP groups. The average apical LS divided by the sum of the average mid and basal LS values of >1.0 was defined as the RASP. We analyzed the difference between pre- and post-TAVI LVGLS (ΔGLS = post-TAVI LVGLS − pre-TAVI LVGLS).

Results

Of the 84 patients (mean age, 84.5±3.9 years; 24 men), 15 (17.9%) exhibited a RASP. No significant difference in mean pre-TAVI LVGLS was found between the RASP and non-RASP groups (−16.6% ± 3.8% vs. −15.8% ± 3.9%). The ΔGLS in the RASP group was significantly higher than that in the non-RASP group (−0.97% ± 2.5% vs. −2.6% ± 3.0%; P<0.05). Multivariate analysis revealed that relative apical longitudinal strain was an independent predictor of ΔGLS (β = 0.35, p=0.002).

Conclusion

Relative apical longitudinal strain was associated with LVGLS recovery. The effect of TAVI on LVGLS in patients with a RASP is inferior to that in patients without a RASP.

Funding Acknowledgement

Type of funding source: None
Echocardiographic assessment of the impact of percutaneous revascularisation of chronic total occlusion on myocardial function and electrical stability, two-year follow up period
Authors: Petrovic O , Juricic S , Arnautovic N , Paunovic I , Trifunovic-Zamaklar D , Rakocevic I , Boricic-Kostic M , Aleksandric S , Milasinovic D , Dobric M , Tesic M , Ivanovic B , Stankovic G , Stojkovic S
Published: November 2020

Background

Chronic total coronary occlusion (CTO) is frequent finding in patients with ischaemic heart disease, but it is not clear yet how it affects myocardial function, especially electrical stability. Myocardial strain by echocardiography can objectively quantify extent and timing of myocardial deformation. Echocardiographically derived dyssynchrony, mechanical dispersion, is good predictive tool for patients at risk of ventricular arrhythmias.

Purpose

The purpose of this study was to evaluate the influence of chronic total occlusion percutaneous coronary intervention (CTO PCI) on myocardial contractility and arrhythmogenicity.

Methods

We analysed total of 35 CTO patients (age 56±9, 86% male). Convectional echocardiographic exam with two dimensional speckle tracking echocardiography (2D STE) was performed before CTO PCI and after 24 months of follow-up. Peak longitudinal strain was assessed in 17 left ventricular segments. 2D STE computed global longitudinal strain (GLS). Time intervals from start of Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time interval from 17 left ventricular segments, reflecting myocardial contraction heterogeneity.

Results

24 months after CTO PCI patients showed no change in ejection fraction (EF) (55.75±7.56% vs. 56.03±6.29%, p=0.622). There was slight improvement in GLS (−14.89±2.81% vs. −15.93±2.64%, p<0.05), Mechanical dispersion was significantly reduced (62.78±23.44ms vs 47.96±12.10ms, p<0.001)

Conclusion

CTO recanalization improved GLS without changes in left ventricular EF after 24 months. Mechanical dispersion as a surrogate for arrhythmogenic substrate was reduced by CTO PCI.

Funding Acknowledgement

Type of funding source: None
Right ventricular speckle tracking in patients with heart failure – a comparison of right ventricular measures
Authors: Lundorff I.J , Sengeloev M , Pedersen S , Modin D , Bruun N.E , Hansen T.F , Biering-Soerensen T , Godsk Joergensen P
Published: November 2020

Background

RV dysfunction is associated with increased mortality and morbidity in patients with heart failure. Due to the complex shape and position of the RV, assessing RV function from echocardiographic images remains a challenge.

Purpose

We have previously found that global longitudinal strain from 2DSTE is superior to left ventricular ejection fraction (LVEF) in identifying HFrEF patients with high risk of mortality. In this study we wanted to examine RV 2DSTE in patients with HFrEF and compare its prognostic value to conventional RV measures.

Methods and results

Echocardiographic examinations were retrieved from 701 patients with HFrEF. RV estimates were analysed offline, and end point was all-cause mortality. During follow-up (median 39 months) 118 patients (16.8%) died. RV GLS and RV FWS remained associated with mortality after multivariable adjustment, independent of TAPSE (RV GLS: HR 1.07, 95% CI 1.02–1.13, p=0.010, per 1% decrease) (RV FWS: HR 1.05, 95% CI 1.01–1.09, p=0.010, per 1% decrease). This seemed to be caused by significant associations in men as TAPSE remained as the only independent prognosticator in women. All RV estimates provided prognostic information incremental to established risk factors and significantly increased C-statistics (TAPSE: 0.74 to 0.75; RVFAC: 0.74 to 0.75; RVFWS: 0.74 to 0.77; RVGLS: 0.74 to 0.77).

Conclusions

RV strain from 2DSTE was associated with mortality in patients with HFrEF, independent of TAPSE and established risk factors. Our results indicate that RV strain is particularly valuable in male patients, whereas in women TAPSE remains a stronger prognosticator.

RV GLS and the risk of mortality

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): PGJ reports receiving lecture fee from Novo Nordisk.
Evidence for abnormal deformational reserve in hypertrophic obstructive cardiomyopathy on exercise: is this a true fingerprint?
Authors: Halmai L , Ward M , Kardos A , Nemes A , Neubauer S , Wong J , Pantazis A
Published: November 2020

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by muscle hypertrophy and fibrosis, interfering with force generation and relaxation. Abnormal ventricular (LV) myocardial deformation have been demonstrated in patients with HOCM at rest, but there is lack of data regarding the deformational mechanics in exercise in obstructive HCM.

Aims

To assess the adaptability of LV deformational behaviour to physical exercise in HOCM patients as compared to healthy controls and to examine if Deformational Imaging (DMI) can provide additional information.

Methods

28 obstructive HOCM (age 51.2±14.2yrs; 16 men, LVOT-obstruction 56±19mmHg at rest or on Valsalva maneuver) and 32 control subjects (50.9±6.8 yrs, 19 men from the MAGYAR-PATH Registry) underwent bicycle stress Echo (ESE) with full conventional 2D- and Doppler TTE, 2D- and 3D-Speckle Tracking Analysis (DMI) and 3D-Full Volume assessment both at rest and on submaximal ESE.

Results

At rest, the HOCM group had lower GLS (−14.6±4.5 vs 18.4±2.6%, p<0.01) but higher CS (−32.9±5.1 vs 28.8±2.3%) and Twist (9.9±2.6 vs 6.1±2.2°) than in control subjects. Exercise induced an increase in all strains in control subjects but less in HOCM (GLS: −21.4±3.5 vs 15.1±3.0% and CS: −33.9±3.6 vs 34.1±4.2% in controls). The increase of LV twist was blunted in HOCM (Δ1.2 vs Δ3.6° in controls). The PSS was more pronounced in HOCM on ESE (46.6±12.0 vs 21.2±9.6%, AUC: 0.71 for predicting HOCM), the UTR was slower (118±2.1 vs 133.1±14.1°/s) and occurred later in HOCM. The MD of Strain increased in HOCM on ESE (Δ85.1 vs Δ8.1ms in controls). The Twist had positive correlation with LVOT-obstruction (R2=0.54, p<0.01) and inverse correlation with UTR (R2=−0.72, p<0.02). The UTR/Twist ratio diminished only in HOCM on exercise (−6.0±0.8 vs −13.1±2.5 1/s). The MD, the PSS on ESE and the UTR/Twist ratio predicted the HOCM deformation phenotype accurately (AUC: 0.72, cut-off 6.0 1/s).

Conclusions

The HOCM patients had attenuated Strain and Rotational response on exercise implying impaired deformational adaptability with post-systolic shortening and pronounced mechanical dispersion of peak Strain on exercise which was more accurate to identify the HOCM phenotype than other Echo-indices. These findings support evidence for reduced systolic-diastolic coupling efficiency in HOCM patients on exercise which can contribute to the development of exercise-related breathlessness, dynamic LVOT-obstruction and arrhythmias in patients with HOCM. These distinct deformational patterns on exercise can help in the differential diagnosis of patients with LV hypertrophy of unknown aetiology with good sensitivity and specificity and can also aid in the risk stratification workup in HOCM.

DMI Predictors for HOCM

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Milton Keynes University Hospital Research Founding
Influence of lesion location on the accuracy of CT derived FFR: head-to-head comparison with invasive FFR
Authors: Moshage M , Smolka S , Achenbach S , Ammon F , Ferstl P , Goeller M , Bittner D.O , Uehlein S , Bal Z , Marwan M
Published: November 2020

Background

The accuracy of CT-derived FFR (FFRCT) has been repeatedly reported. However, the influence of lesion location on accuracy is unknown. Therefore, we evaluated the diagnostic accuracy of FFRCT to detect lesion-specific ischemia and determined the influence of lesion location (proximal vs. distal vessel segments) compared to invasively measured FFR in patients with suspected CAD.

Methods

A total of 136 vessels in which “Dual-Source”-CT coronary angiography had been performed due to suspected CAD and who were further referred for invasive coronary angiography with invasive FFR measurement within three months of the index CT examination were retrospectively identified and screened for inclusion in this analysis. Patients with either left main coronary artery stenoses, bifurcation or ostial stenoses were excluded. Invasive FFR was measured using a pressure wire (CERTUS®, St. Jude Medical, Minnesota, USA or Verrata®, Volcano, San Diego, USA). FFRCT was calculated using an on-site prototype (cFFR Version 3.0, Siemens Healthineers, Forchheim, Germany). All vessels were analyzed by an experienced observer blinded to the results of invasive FFR. Stenoses with invasively measured FFR ≤0.80 were classified as hemodynamically significant. We evaluated the diagnostic accuracy of FFRCT in proximal vs. non-proximal vessel segments. Proximal lesions included stenoses located in segment one, six, eleven and twelve. All other stenoses were categorized as distal lesions.

Results

Out of 136 coronary stenoses, 47 (35%) were located in proximal segments and 89 (65%) lesions were located in distal segments. Compared to invasive FFR, the sensitivity of FFRCT to correctly identify/exclude hemodynamically significant stenoses in proximal vessel segments was 93% (95% CI: 68–99.8%) and the specificity was 100% (95% CI: 89–100%), compared to a sensitivity of 72% (95% CI: 46.5–90%) and a specificity of 87% (95% CI: 77–94%) for FFRCT in distal lesions. The positive predictive value was 100% and the negative predictive value was 97% (95% CI: 82.8–99.5%) compared to a positive predictive value of 59% (95% CI: 42–93.9%) and a negative predictive value of 93% (95% CI: 85.4–96.3%) for proximal vs. distal vessel segment, respectively. This corresponds to an accuracy of 98% vs. 84%, respectively (p=0.02). ROC-Curve analysis showed a slightly higher – albeit non-significant – area under the curve for FFRCT to detect hemodynamic relevance in proximal lesions compared to distal lesions (AUC 0.95, p<0.001 vs. AUC: 0.86, p<0.001, respectively, p=0.2).

Conclusion

FFRCT obtained using an on-site prototype shows overall a high diagnostic accuracy for detecting lesions causing ischemia as compared to invasive FFR with a trend towards better diagnostic performance in proximal vessel segments.

Funding Acknowledgement

Type of funding source: None