bluuebunny/crossref_metadata_2025 huggingface dataset:
Can echocardiography be used in the diagnosis of fatty liver disease?
Authors: Strzelczyk J , Boszko M , Kalinowski P , Ziarkiewicz-Wroblewska B , Styczynski G
Published: January 2025

Background

Liver steatosis is a common, usually asymptomatic hepatic disorder caused most often by insulin resistance and hepatotoxic factors. It is currently regarded as a sensitive imaging biomarker of the metabolic syndrome and an independent risk factor of future cardiovascular events. Diagnosis of fatty liver in the cardiologists office may be of potential clinical value, revealing the presence of previously unknown metabolic disorder and influencing the prognostic assessment, as well as treatment of cardiovascular disease. The assessment of liver steatosis during transthoracic echocardiography has not yet been validated.

Purpose

To investigate the accuracy of echocardiography in the diagnosis of fatty liver disease in severely obese individuals.

Methods

We conducted a retrospective analysis of liver and right kidney images acquired during preoperative echocardiography (GE, Vivid 9, 1.7/3.3MHz, sector probe, abdominal preset) in 220 severely obese patients (mean age 41.5 years, BMI 43.6 kg/m2, 67.3% of females) admitted for bariatric surgery with liver biopsy. Echocardiographic diagnosis of fatty liver was based on computer-aided (HRI – hepatorenal index) and visual analysis of the liver-kidney echogenicity contrast. Images were randomly divided into training (n=111) and validation (n=109) sets with similar proportion of patients with steatosis in each set. The evaluation was performed by a cardiologists not trained in abdominal ultrasound. Increased brightness of liver tissue relative to adjacent right kidney cortex was classified as steatosis, while similar brightness as lack of steatosis. Sensitivity, specificity, positive and negative predictive values were calculated using histopathologic results as reference.

Results

The prevalence of liver steatosis in the studied group was 68%. The sensitivity, specificity, positive and negative predictive values of the echocardiographic diagnosis of liver steatosis were as follows: 1) for HRI method: 90%, 81%, 91% and 81%, respectively; 2) for visual method: 88%, 77%, 89% and 75% - by an observer experienced in echocardiography and 96%, 57%, 82%, and 87% by the first unexperienced observer and 87%, 81%, 92% and 72% by the second unexperienced observer, respectively. ROC curve analysis of the HRI method showed area under the curve of 0.879, with the optimal cut-off value of HRI 1.34 for the presence of steatosis. Spearman correlation coefficient between HRI and degree of steatosis was 0.68 (p<0.001).

Conclusions

Visual or computer aided echocardiographic screening for fatty liver based on comparison of liver-kidney echogenicity contrast seems feasible, even for unexperienced observers. Its implementation into everyday clinical practice may improve prognostic assessment and help to optimize treatment in patients with cardiovascular diseases.
Impact of the treatment with TNF inhibitors and JAK Inhibitors on arterial stiffness and lipid parameters in rheumatoid arthritis patients: a cross-sectional study
Authors: Dimova-Mileva M , Gerganov G A , Georgiev T A
Published: January 2025

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory joint disease associated with an increased cardiovascular risk. Treating disease activity with biologic and synthetic disease-modifying antirheumatic drugs (DMARDs) diminishes cardiovascular risk, but the vascular effects of different biologic and targeted synthetic drugs are poorly understood. Echo-tracking parameters of carotid artery can reveal arterial stiffness as a marker of subclinical atherosclerosis.

Methods

Patients with RA of at least 6 months of duration, treated with TNF inhibitors or JAK inhibitor - upadacitinib(UPA) and healthy subjects underwent ultrasound examination of carotid artery using the Aloka ProSound Alpha 7. The measurements included pulse-wave velocity (PWVβ), beta-stiffness, augmentation index (AI), arterial compliance (AC), and Ep (Elastic Modulus) and laboratory examination of lipid parameters. Disease activity of RA was measured using Disease activity scores - DAS28-CRP, DAS28-ESR, and Clinical Disease Activity Index (CDAI). Data were analyzed with SPSS v29 and the Kruskal-Wallis test was used to determine statistical differences among the three groups.

Results

97 subjects, mean age 55.36±11.84, 83% females. Of them 38 on TNF inhibitors, 36 on UPA, and 23 controls. The three groups were similar in age, BMI, smoking status, and Framingham risk score. Disease activity and disease duration did not differ between the two patients groups. PWV was significantly higher in the UPA group compared to controls but not significantly different from the TNF group. (6.825 vs. 5.8022 vs. 6.468, p=0.034 UPA vs. Control, p=0.59 UPA vs. TNF) (fig.1). AC was lower and Ep was higher in the UPA group compared to controls (0.6511 vs. 0.8678, p=0.032 and132 kPa vs. 92.3, p=0.04 respectively). Total cholesterol levels were higher in the UPA group compared to TNF treated patients and to the control group (fig.2).

Conclusion

Echo-traching examination of the carotid artery is an easily perfomed, non-invasive and highly informative method of detecting early signs of vascular impairment in patients with RA treated with TNF inhibititors and JAK inhibitor. Treatment with UPA increases the levels of total cholesterol.
Usefulness of echocardiographic parameters of myocardial work in the evaluation of left ventricular function in patients with severe aortic valve stenosis undergoing transcatheter aortic valve impla
Authors: Polewczyk A , Pietrzyk E , Polewczyk M , Jarek D , Dudek D
Published: January 2025

Background

Myocardial work (MW) is a new echocardiographic parameter used in the assessment of cardiac energy expenditure.

Purpose

The aim of the current study was to evaluate changes in left ventricular MW parameters in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

Methods

One hundred and thirty five consecutive patients who underwent TAVI at one center were evaluated before and after procedure by transthoracic echocardiography (TTE) with the assessment of MW indices: global constructive work (GCW), global wasted work (GWW), global work index (GWI) and global work efficiency (GWE).

Results

The comparison of MW parameters before and on average after 5.9 days after TAVI showed a significant increase in GCW: 1314,48± 487,53 vs 1438,22 ± 468,86 (p<0,001), GWW: 238,82 ± 160,67 vs 258,84 ± 145,09 (p= 0,045) and GWI: 966,45 ± 456,06 vs 1045,16 ± 428,68 and no significant change in GWE: 81,55 ± 10,46 vs 82,47 ± 7,75 (p=0,401). The increase in GCW and GWI parameters after TAVI strongly correlated with left ventricular ejection fraction (LVEF) and pressure aortic gradient (PGA) before the procedure. A significant increase in GWE was observed in patients with LVEF <30% (p=0,043).

Conclusions

Echocardiographic assessment of myocardial work parameters is a valuable method of documenting hemodynamic changes in patients with severe aortic stenosis before and after TAVI. Long-term left ventricular overload in patients with aortic stenosis results in a global decrease of myocardial work parameters, therefore, rapid decompression increases the effective work of the heart.
Enhanced detection of aortic stenosis using a multimodal deep learning approach combining ECG and chest X-ray data
Authors: Nagai S , Nishimori M , Shinohara M , Tanaka H
Published: January 2025

Background/Introduction

The early detection of aortic stenosis (AS) is crucial due to its increasing prevalence in the aging population. In Japan, approximately 2.84 million people over the age of 60 are estimated to have AS, with around 560,000 requiring surgical intervention. However, the annual number of treatments, including transcatheter aortic valve implantation and surgical aortic valve replacement, is limited to about 20,000 cases, far fewer than needed. Early diagnosis and treatment are essential for a better prognosis, whereas delays result in poor outcomes. Although transthoracic echocardiography (TTE) is the standard for diagnosing AS, it is often performed on symptomatic patients, and the time required to gain proficiency in TTE makes it unsuitable for widespread screening. In contrast, ECGs and chest X-rays are more accessible and commonly used inhealth checkups. Recent advances in AI have shown potential in predicting valvular diseases from ECGs and AS from chest X-rays, but using these methods individually has limitations. We hypothesized that combining ECG and chest X-ray data could enhance the accuracy of AS predictions through a deep learning model.

Methods

We utilized data from patients who underwent ECG, chest X-rays, and echocardiography at the Department of Cardiology, Kobe University Hospital, between January 1, 2012, and December 31, 2022. Patients with mild or more severe AS were considered positive cases. Mild AS was defined as Vmax ≥ 3.0 m/s, mPG ≥ 20 mmHg, and AVA ≤ 1.5 cm².The dataset, consisting of 23,886 patients with 1,442 positive cases, was divided into training (14,438 patients), validation (4,673 patients), and test (4,775 patients) datasets. The ECG model was developed using ResNet and Transformer architectures, while the chest X-ray model used EfficientNet. These models were combined using cooperative learning loss. The model's performance was evaluated using ROC curves and AUC, accuracy, precision, recall, F1-score for binary classification of AS.

Results

The cooperative learning model achieved a test accuracy of 0.879, a test AUC PR of 0.300, a test AUC ROC of 0.822, a test recall of 0.493, a test specificity of 0.904, and a test precision of 0.247 in the binary classification of AS.

Conclusion(s)

The multimodal deep learning model that combines ECG and chest X-ray data proved effective in diagnosing aortic stenosis, demonstrating its potential as a valuable tool for early detection and improved patient outcomes.
Inflammatory and imaging predictors of development of ischemic mitral regurgitation following ST-elevation myocardial infarction
Authors: Valeur A , Dregoesc I , Grymyr L M D , Berg-Hansen C E , Bleie Ø , Steigen T , Manole S , Larsen T , Urheim S , Iancu A , Cramariuc D
Published: January 2025

Background

Development of ischemic mitral regurgitation (MR) after ST-elevation acute myocardial infarction (STEMI) is a complex process that is less understood mechanistically, challenging to assess by standard echocardiography and associated with worse cardiovascular outcomes.

Purpose

To identify predictors of post-STEMI MR through serial assessment of biomarkers of inflammation and myocardial injury, and cardiac remodeling by echocardiography and cardiac magnetic resonance (CMR).

Methods

In the Registry for Post-myocardial Infarction Left Ventricular Remodeling and Heart Failure Prevention (REDEFINE-HF), 94 patients with STEMI (60±10 years, 76% men) were investigated in the acute infarction phase and at 6-month follow-up by both bio- and imaging markers. Left ventricular (LV) end-diastolic (EDV) and end-systolic (ESV) volumes were assessed by both echocardiography and CMR. MR ẃas graded by a multiparametric echo-approach as by current guidelines. LV filling pressures were estimated from the mitral peak early diastolic flow to annulus velocity ratio (E/e´). Additionally, the extent of microvascular obstruction and intramyocardial hemorrhage (an index of reperfusion injury) were assessed by CMR at baseline. The primary outcome was a composite of death, heart failure hospitalizations, and acute myocardial infarction during follow-up.

Results

In acute STEMI phase, 57% of patients had mild and 13% moderate MR, with an increase in prevalence to 79% mild and 15% moderate MR at 6-month follow-up (p<0.001). Patients with both acute-phase and 6-month follow-up MR had higher baseline troponin T and interleukin-6, higher concomitant LV filling pressures and echo-ESV, and larger infarction size by CMR (all p<0.05). In logistic regression analysis, mild-moderate acute-phase MR was associated with higher LV CMR-ESV after adjustment for clinical, biochemical and imaging confounders (p<0.05, R2=0.42). In Cox regression analysis, mild-moderate 6-month post-STEMI MR was predicted by higher baseline interleukin-6 (HR 1.01 [1.00-1.03] and more extensive acute-phase intramyocardial hemorrhage (HR 1.20 [1.03-1.40]) and microvascular obstruction by CMR (HR 1.14 [1.03-1.23]) (all p<0.05), but not by comorbidities, daily medication, total ischemic time, culprit vessel or extent of coronary artery disease. During 19±8months follow-up, 17 events occurred, all in patients with ischemic MR at follow-up (bootstrap p<0.001). Higher age and larger LV CMR-ESV were independent predictors of the composite outcome (-2Log likelihood 50, both p<0.05).

Conclusion

Ischemic mild-moderate MR occurs through complex interactions between inflammatory, microvascular and tissue remodeling pathways. A multimodality approach combining bio- and imaging markers helps identify individuals at risk for this clinical condition pertaining negative prognostic implications.
Evaluation of cardiovascular remodeling parameters as FMD, Zva, GLS in patients with aortic stenosis
Authors: Banka P , Mecka K , Gruchlik B , Niemiec R , Pytlewski A , Wybraniec M , Mizia-Stec K
Published: January 2025

Introduction

Aortic stenosis (AS) is one of the most common acquired valvular heart defects in adults. In recent years, there has been increasing interest in effects of AS on remodeling of cardiovascular system, especially on microcirculatory function (flow-mediated dilation (FMD) and left ventricle global longitudinal strain (GLS). Some studies indicate that increased valvuloarterial impedance (Zva) is a marker of excessive LV hemodynamic load and identifies aortic stenosis patients with poor outcome.

Purpose

The aim of the study was to assess an influence of AS and hemodynamic type of AS on FMD, Zva and LV GLS as markers of cardiovascular remodeling.

Methods

Overall of 153 (66 females, 87 males; mean age: 71,5 ± 11,5 years) patients were included in the study: 86 patients with severe and moderate AS (42 females, 44 males; mean age 74,8 ± 12,2 years), and 67 ( 24 females, 43 males; mean age: 67,2 ± 8,9 years) controls. Based on standard transthoracic and transesophageal echocardiography 77 patients with severe AS (39 females, 38 males; mean age: 75,9 ± 10,5 years) were divided into subtypes: (1) high-gradient AS, (2) low-flow low-gradient with preserved LVEF AS, (3) low-flow low-gradient with reduced LVEF AS, (4) normal-gradient low-flow AS. FMD was measured on the brachial artery at rest and 5 minutes after vessel occlusion in all patients. GLS and Zva were evaluated for all patients. Zva was calculated on the basis of the following equation: Zva = (SAP * MG)/SVi, where SAP is the systolic arterial pressure, MG is the mean transvalvular pressure gradient and SVi is stroke volume index.

Results

The mean FMD in patients with AS was significantly lower 5.84 ± 0,47 % compared to the control group 9.66 ± 0,064 (p<0.001). In terms of GLS, patients with aortic stenosis had a lower mean GLS 14.05 ± 3,09 % , compared to controls 15.76 ± 3,74% (p=0.0028), with a similar LVEF of 54.6% and 52.5%, respectively. Mean FMD in the high-gradient, low-flow low-gradient with preserved LVEF, low-flow low-gradient with reduced LVEF, normal-gradient low-flow subgroups were 5.17%,6.3%, 1.85% and 6.96%, respectively. The mean GLS in the high-gradient, low-flow low-gradient with preserved LVEF, low-flow low-gradient with reduced LVEF, normal-gradient low-flow subgroups were -13.54%, -15.54% -10.5%, -13.46%, respectively. In the aortic stenosis group, the mean Zva was significantly higher at 5.62 ± 1.75 mmHg*ml-1*m2 compared to the control group at 4.80 ± 1.33 mmHg*ml-1*m2 (p=0.001334).

Conclusion

Aortic stenosis and hemodynamic type of AS has a significant impact on cardiac and vascular function, as reflected by changes in FMD, Zva, GLS values. Assessment of these parameters is crucial in monitoring patients with AS, allowing early detection of deterioration in cardiac function and appropriate therapeutic interventions.

Flow-mediated dilation (FMD)

Global longitudinal strain
Identifying echocardiographic predictors of late gadolinium enhancement in severe aortic stenosis patients undergoing transcatheter aortic valve implantation: insights from cardiac MRI
Authors: Hirata K , Kuwabara K , Matsuo Ý , Yokoi Ý
Published: January 2025

Background

Aortic stenosis (AS) is prevalent among the elderly. Accurate prognostic assessment in AS is crucial for optimizing patient management and outcomes. Identifying factors associated with Late Gadolinium Enhancement (LGE), a cardiac MRI marker, can help in risk stratification. LGE-positive individuals have a poorer prognosis, including a twofold increased risk of mortality and adverse cardiovascular events.

Purpose

The purpose of this study was to identify echocardiographic predictors of LGE in patients with severe AS.

Methods

Data from 58 patients with severe AS scheduled for transcatheter aortic valve implantation (TAVI) were analyzed. Echocardiograms and MRI scans were performed within two weeks before TAVI. The average age of the patients was 81.5 years, and 60% were male. LGE was present in 16 patients (27.6%). Univariate logistic regression identified significant echocardiographic factors associated with LGE, which were then included in a multivariate analysis.

Results

Univariate analysis showed significant echocardiographic factors: large left atrial volume (LAD >34 ml/m²) (P = 0.0116), septal mitral annular velocity (e' septal) (P = 0.0281), left ventricular mass index (LVMi) (P = 0.0350), and left atrium size (P = 0.0453). Multivariate analysis indicated large left atrial volume (Coeff = 0.636), septal mitral annular velocity (Coeff = -0.563), left ventricular mass index (Coeff = 0.126), and left atrium size (Coeff = 0.345) were associated with LGE. Measures of AS severity, including aortic valve area (AVA), peak aortic velocity (Vmax), and mean pressure gradient (mean PG), were not significantly associated with LGE.

Conclusion

Large left atrial volume, septal mitral annular velocity, left ventricular mass index, and left atrium size are echocardiographic factors associated with LGE in patients with severe AS. These predictors could assist clinicians in identifying high-risk patients and improving management strategies.
Abnormal strain pattern in arrhythmogenic mitral valve prolapse, the importance of the basal inferolateral myocardial wall
Authors: Nagy A , Czimbalmos C S , Herczeg S Z , Bor A , Apor A , Lakatos B , Toth A , Geller L , Vago H , Merkely B
Published: January 2025

Introduction

The rare, but clinically relevant arrhythmogenic form of mitral valve prolapse (MVP) can lead to malignant arrhythmias and sudden cardiac death. The aim of our study was assessing the characteristics of arrhythmogenic mitral valve prolapse (AMVP), especially regarding the parameters that could be used in risk stratification.

Patients and methods: Thorough examinations were performed on 44 patients living with mitral valve prolapse and mitral annular disjunction, including their medical history and symptoms, blood pressure measurement, 12-lead ECG, 24-hour Holter monitoring, transthoracic echocardiography with 2D strain measurement and cardiac magnetic resonance imaging (CMR). The patients were divided into an arrhythmogenic and a non-arrhythmogenic group, according to the criteria determined in the consensus statement of the ESC. For the strain measurement, we included a control group of 20 patients matching in age and gender.

Results

53% of patients had inferior ST-T abnormalities and 74% reported palpitation. The prevalence of syncope was higher in the arrhythmogenic group (42,1% vs. 12,5% vs.; p=0,038). In 86,4% of patients the degree of mitral regurgitation was mild or moderate. Left ventricular volumes measured by 3D echocardiography exceeded the upper limit of the normal range with normal left ventricular ejection fraction. The global longitudinal strain (GLS) value was significantly lower in the MVP patients than GLS in the healthy control group (-21,9±2,0 % vs. -20,3±2,4 %; p=0,019). Compared to the control group the longitudinal strain values of the inferolateral (-22,2±8,8 vs. -28,8 ± 7,0; p=0,008) and inferior (-13,2±6,3 vs. -20,9±4,1; p=0,001) basal segments were significantly reduced. In 47% of the patients, late gadolinium enhancement (LGE) could be detected in the inferolateral region with CMR.

Conclusions

Inferior ECG abnormalities and palpitations are common among patients with MVP, but due to their low specificity they are not suitable for risk stratification. However, syncope can be considered an alarming sign. The typical pattern of segmental longitudinal strain abnormalities and the similar localization of LGE on CMR indicate the importance of the basal inferolateral segment in AMVP.
Multi-modality non-invasive assessment of cardiopulmonary haemodynamics using cardiovascular magnetic resonance pulmonary transit time and echocardiography
Authors: Haaf P , Segeroth M , Winkel D J , Kaufmann B A , Strebel I , Yang S , Cyriac J , Wasserthal J , Lopez-Ayala L , Sauter A , Mueller C , Bremerich J , Zellweger M
Published: January 2025

Introduction

Pulmonary transit time (PTT) is the time it takes blood to pass from the right ventricle to the left ventricle via the pulmonary circulation, making it a potentially useful marker for heart failure. We assessed the association of PTT with diastolic dysfunction and mitral valve regurgitation.

Methods

We evaluated routine stress perfusion cardiovascular magnetic resonance (CMR) scans in 83 patients including assessment of PTT with simultaneously available echocardiographic assessment. Relevant diastolic dysfunction (DD) and mitral valve regurgitation (MVR) were defined as exceeding grade I (impaired relaxation, mild regurgitation). PTT was determined from CMR rest perfusion scans. Normalized PTT (nPTT), adjusted for heart rate, was calculated using Bazett's formula.

Results

Higher PTT and nPTT values were associated with higher grade DD and MVR. The diagnostic accuracy for prediction of DD as quantified by the area under the ROC curve (AUC) was 0.73 (CI 0.61 to 0.85; p=0.001) for PTT and 0.81 (CI 0.71 to 0.89; p<0.001) for nPTT. For MVR the diagnostic performance amounted to an AUC of 0.80 (CI 0.68 to 0.92; p<0.001) for PTT and 0.78 (CI 0.65 to 0.90; p<0.001) for nPTT. PTT values < 8 s rule-out presence of DD and MVR with a probability of 70% (Negative predictive value 78%).

Conclusion

CMR-derived PTT is a readily obtainable hemodynamic parameter. It is elevated in patients with DD and moderate to severe MVR. Low PTT values make the presence of DD and MVR - as assessed by echocardiography - unlikely.

Pulmonary Transit Time

Pulmonary Transit Time
Prognostic value of echocardiography-based right ventricular-pulmonary artery coupling estimation in acute decompensated heart failure
Authors: Safarova N , Islamova M , Safarova A , Kobalava Z H
Published: January 2025

Background

Right ventricular-pulmonary artery coupling (RV-PA coupling) represents the relationship between RV contractility and RV afterload. RV-PA uncoupling occurs when RV contractility cannot increase to match RV afterload. This leads to RV dysfunction and right heart failure in the end. The value of RV-PA uncoupling in patients with chronic heart failure with reduced and preserved ejection fraction as a determinant of clinical status and strong predictor of cardiovascular death, rehospitalization for heart failure was demonstrated by literature worldwide. However, there are few studies estimated RV-PA uncoupling prognostic value in patients with acute decompensated heart failure (ADHF) upon admission.

Purpose

To assess echocardiographic parameter of RV-PA coupling and its prognostic value in patients with ADHF.

Methods

A single-centre observational study included 171 patients admitted to the city clinical hospital with ADHF (51.5% male, 70 (62;80) years old, arterial hypertension 93%, previous myocardial infarction 39.8%, HF with preserved ejection fraction (HFpEF) 36.8% (n=63), HF with reduced EF (HFrEF) 41.5% (n=71), HF with mid-range EF (HFmrEF) 21.6% (n=37), diabetes 36.8%, NYHA functional class III – 52.1%, class IV – 40.2%, NTproBNP 1683 (830;2944) pg/ml, serum creatinine 105 (86;126.4) µmol/l, eGFR 54.2 (44.1;67.8) ml/min/1.73 m2, potassium 4.5 ± 0.7 mmol/l, echocardiography parameters - left ventricle ejection fraction (LVEF) 44 (30;55)%, pulmonary artery systolic pressure (PASP) 51.2±17.3 mmHg, tricuspid annular plane systolic excursion (TAPSE) 15.4±4.7mm. RV-PA coupling estimated by the ratio between tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) ratio was evaluated upon admission using two-dimensional echocardiography. TAPSE/PASP < 0.36 mm/mmHg was considered as RV-PA uncoupling. Survival analysis was perfomed using Kaplan-Meier curves. Differences were considered statistically significant when p <0.05.

Results

A statistically significant impact of RV-PA uncoupling on hospitalization, estimated by echocardiography, for heart failure (HF) and for all-cause hospitalization was revealed. Among patients with RV-PA uncoupling the risk of hospitalization for HF increased by 25% (RR 1.251; 95%CI: 1.020-1.539, p=0.042), and the risk of all-cause hospitalization - by 20-24% (RR 1.240; 95% CI: 1.001-1.537; p=0.049). Hospitalization rates for HF (OR 2.07; 95%CI: 1.02–4.02; p=0.042) and all-cause hospitalization (OR 1.96; 95%CI: 1.00–3.86; p=0.049) were 2 times higher.

Conclusion: The identified prognostic value of echocardiography-based RV-PA uncoupling estimation in ADHF regardless of phenotype indicates the advisability of its assessment upon hospitalization. TAPSE/PASP can serve as an important simple tool for risk stratification of patients, optimizing their management and improving the long-term survival of patients.
Utilizing echocardiographic findings and machine learning to predict elevated left ventricular filling pressures in patients with preserved ejection fraction
Authors: Andersson P , Lindow T , Lindqvist P , Venkateshvaran A
Published: January 2025

Background

Estimation of left ventricular filling pressures (LVFP) is important for accurate diagnosis and prognosis of heart failure (HF). The current ASE/EACVI algorithm for identifying elevated LVFP shows modest performance in the setting of preserved ejection fraction (EF) (1). Left atrial reservoir strain (LASr) has been proposed as a novel and additional diagnostic marker to identify elevated LVFP in HF with preserved EF (HFpEF) (1). While machine learning has shown good diagnostic performance utilising conventional echocardiographic findings (2), the incremental value of LASr has not been adequately explored using ML models.

Purpose

This study aimed to evaluate the performance of a machine learning (ML) model that integrates clinical and echocardiographic data including LASr to identify elevated LVFP in the setting of suspected HF with preserved EF.

Methods

Patients with dyspnoea, EF ≥50% and sinus rhythm undergoing right heart catheterisation (RHC) and near-simultaneous echocardiography were selected from the KARUM database. Patients with atrial fibrillation, pacemakers, significant valvular disease or infiltrative cardiomyopathy were excluded. Elevated LVFP was defined as invasive pulmonary artery wedge pressure (PAWP) ≥15 mmHg.

The dataset was split into 75% for model development (training set) and 25% for unbiased testing of model performance (test set). Missing numerical and categorical variables were imputed based on the training data using Bayesian Ridge regression and K-Nearest Neighbours, respectively. Recursive Feature Elimination (RFE) was used to reduce the number of variables. A comprehensive grid search with repeated 10-fold cross-validation was employed to optimise hyperparameters for an XGBoost (Xtreme Gradient Boosting) ML model.

The model with the highest mean area under the receiver operating characteristic curve (AUC) across cross-validation folds was reported and selected as the final model, with its performance reported on the independent test set. Finally, we applied SHapley Additive exPlanations (SHAP) to evaluate and rank the individual variable importance.

Results

Of 210 patients, 157 were allotted for model development (training set) and 53 for reporting model performance (test set). Ten significant variables were identified through RFE. The best-performing XGBoost model achieved a mean AUC of 86.6 % across the cross-validation folds and maintained good diagnostic performance in the test set with an AUC of 89.4% (95% CI: 79.1-99.7%) (Fig 1). Applying SHAP ranked the variables and found LASr the most important variable (Fig 2).

Conclusion

An ML model based on clinical and echocardiographic data, including LASr, demonstrated good diagnostic performance in identifying elevated LVFP in the setting of suspected HF with preserved EF.

ROC Curve for XGBoost Model

SHAP summary plot
Peak atrial longitudinal strain identifies patients with acute decompensated heart failure at high risk of cardiac death
Authors: Millan Vela J , Arias Godinez J A , Fritche Salazar J F , Beltran Ontiveros L D , Tobias Morales A K , Ortiz Leon X A , Posada Martinez E L , Ruiz Esparza Duenas M E , Rodriguez Zanella H
Published: January 2025

Background

Heart failure (HF) is an increasing health problem with high morbidity and mortality. Left atrial function has prognostic relevance in long-term survival of patients with HF. However, its prognostic value in patients with acute decompensated heart failure (ADHF) is less well studied.

Objective

The main objective of this study was to assess the association between PALS (peak atrial longitudinal strain) and cardiovascular (CV) death in patients ADHF.

Methods

A prospective single center study was performed. We enrolled patients admitted with ADHF according to the current European guidelines criteria. Clinical and biochemical data were collected. Echocardiography was performed during the first 24 hours of admission including quantification of left ventricular, right ventricular and left atrial function. Patients were followed up during hospitalization and at discharge. PALS was quantified by a single vendor equipment, using four and two chamber dedicated left atrial views and semi-automated software. The primary outcome was cardiovascular death at 3 years of follow-up. Variables were compared between patients with and without cardiovascular death. A ROC curve was constructed to define the best cut-off point, sensitivity, and specificity of PALS to predict the primary outcome.

Results

Sixty patients were included. The median age was 58 (24-90) years, 26% were female. Median NT-PRO BNP 5168 (186-70000) pg/mL, Creatinine clearance 70.6 ± 31.1 ml/min, hemoglobin 14.6 (1.5-19.3) g/dL. Left ventricular indexed end-diastolic volume 74.8 (26.8-181) ml/m2, left ventricular indexed end-systolic volume 51.4 (6.7-170.6) ml/m2, left ventricle ejection fraction 62.2 ± 13.6 %. Patients with cardiovascular death during follow-up, had lower LVEF 24 ± 8.3 vs 33.9 ± 13.8 % (p<0.033) and lower PALS 7.2 (4-14) vs (17 (3-39) %;(p< 0.002). In the ROC curve analysis, in the best-case scenario, an atrial strain value lower than 12% had a sensitivity of 72% and 90% of specificity for predicting cardiovascular death. Survival analysis demonstrated better survival in patients with PALS higher than 12%.

Conclusions

Left atrial strain is useful in patients with ADHF to identify patients at higher risk of cardiac death. According to our results, patients with PALS lower than 12% constitute a high-risk group in whom a closer follow-up and intensive treatment might be needed. Future studies are needed to confirm our findings.

Survival according to PALS in ADHF
Cardiac reverse remodeling after SGLT2i therapy: beyond the sex
Authors: Prosperi S , Monosilio S , D' Amato A , Angotti D , Tonti G , Pedrizzetti G , Cimino S , Filomena D , Netti L , Badagliacca R , Severino P , Vizza C D , Maestrini V
Published: January 2025

Background

Sodium-Glucose Transport Protein 2 Inhibitors (SGLT2i) have proven beneficial cardiac reverse remodeling effects in heart failure (HF) regardless the ejection fraction (EF). The imaging studies focus mainly on the left ventricle (LV) or atrium (LA) remodeling, with an existing lack in knowledge regarding the right ventricle (RV). In addition, there are no studies analysing the effect of sex on SGLT2i’s cardiac remodelling.

Purpose

To explore the cardiac reverse remodeling in a group of HF patients before and after 6 months from SGLT2i therapy initiation and to investigate the influence of sex on cardiac reverse remodeling.

Methods

We enrolled HF patients naive to SGLT2i prior therapy commencing (on top to the maximum of HF tolerated therapy). Data were collected before therapy (T0) and at 6 months (T1). The LV, LA and RV dimensions and function were evaluated with both standard and advanced echocardiographic parameters, including ejection fraction (EF), fractional area change (FAC), global longitudinal and circumferential strain (GLS and GCS). The LV filling pressure were estimated basing on the ratio between mitral pulse Doppler E wave velocity and the mean of e’ tissue Doppler velocity between septum and lateral wall (E/e’). The NYHA Class and pro-BNP values were also collected. Patients were then divided according to sex.

Results

Forty-nine patients were recruited (mean age 73±12 y.o., 69% male and 31% female). Comparing echocardiographic parameters at T0 and T1, a significant reduction in both systolic and diastolic LV volumes along with a significant improvement in LV EF, GLS and GCS were detected. Furthermore, we found a significant increase of LA-EF and GLS, RV-GLS and FAC. A significant reduction of NYHA Class (NYHA > 2 = 35,7% at T0 vs 20,7% at T1; p 0,006) and pro-BNP values were observed (pro-BNP median value 912 (425 – 2308) pg/ml at T0 vs 556 (271 - 915) pg/ml at T1 (p =0,039). The analysis based on sex revealed a similar improvement of the LV volumes, EF, GLS and GCS. Regarding LA and RV, male showed a reverse remodeling comparable to the entire population, while female, although confirming a similar trend, did not reach the statistical significance (limited cohort).

Conclusions

After 6 months of therapy with SGLT2i, HF patients showed a significant improvement in LV, LA and RV function, and a decrease of pro-BNP values. The sex analysis showed a similar tendency of reverse cardiac remodeling in the two sexes, although in female LA and RV improvement did not reach statistical relevance. These data suggest that SGLT2i determined a global cardiac reverse remodeling, regardless of sex.

Table 1

Table 2
Simple exercise echocardiography parameters can enhance diagnosis of early heart failure with preserved ejection fraction (HFpEF)
Authors: Ng S , Pan J , Xavier R , Lewis A J M , Rider O J
Published: January 2025

Background

Early heart failure with preserved ejection fraction (HFpEF) is characterised by exertional dyspnoea or intolerance. The non-specific nature of these symptoms and a lack of accurate diagnostic tools leave many undiagnosed and untreated. Whilst exercise right heart catheterisation is the recommended gold-standard, it is not widely available owing to technical challenges and its invasive nature. Exercise echocardiography offers a pragmatic compromise but its evidence-base in HFpEF diagnosis remains scarce, with significant variation in exercise protocols and assessment criteria.

Purpose

Using multimodality exercise imaging, the study aims to (1) correlate current recommended echocardiographic parameters at rest and exercise with functional capacity, symptom burden and adverse haemodynamic features (2) identify other echocardiographic parameters that interrogate mechanisms of exertional dyspnoea, thus improving early HFpEF diagnosis.

Method

Symptomatic patients with confirmed HFpEF or intermediate (INT) risk of HFpEF (as defined by the HFA-PEFF diagnostic algorithm) were prospectively enrolled alongside age-matched healthy control subjects. All participants underwent rest and 35W exercise echocardiography, exercise cardiac magnetic resonance imaging (e-CMR), 6-minute walk test (6MWT) and a Kansas City Cardiomyopathy Questionnaire (KCCQ-CSS).

Results

46 HFpEF patients, 39 INT and 19 controls were recruited. The HFpEF and INT groups had similarly reduced functional capacity (6MWT HFpEF 363 vs. INT 384 vs. Control 492m) and worse patient-reported outcomes (KCCQ-CSS HFpEF 70 vs. INT 73 vs. Control 97) compared to age-matched controls. Despite more favourable serum NTproBNP, rest and stress E/e’ in the INT group, cardiac output augmentation during 35W exercise (ΔCI) on e-CMR was similarly blunted when compared to the HFpEF cohort (Table 1). Importantly, echocardiographic parameters in the current HFpEF diagnostic algorithm such as E/e’ and indexed left atrial volume (LAVI) do not correlate with 6MWT distance, KCCQ-CSS or ΔCI after adjusting for age, hypertension and body mass index (Figure A). Across this heterogeneous study cohort, rest and exercise LV septal S’ and RV S’ better correlated with 6MWT distance, KCCQ-CSS score and adverse haemodynamic features (ΔCI and right ventricular-pulmonary artery coupling) (Figures B-C).

Conclusion

Symptomatic patients at intermediate-risk of HFpEF share adverse haemodynamic features and functional impairment to those with diagnosed HFpEF. Using multimodality exercise imaging, we propose simple tissue doppler imaging parameters and assessment of cardiac reserve during exercise echocardiography better elicit mechanisms of exertional dyspnoea, beyond current recommendations. Further validation studies exploring these parameters are needed to advance the role of non-invasive imaging in early HFpEF diagnosis.

Table 1

Figure 2
Echocardiographic left atrial stiffness index predicts high left ventricular filling pressures in patients with acute heart failure: an observational prospective study
Authors: Camilli M , Amore L , Iannaccone G , Lombardo A , Montone R A , Lupi L , Adamo M , Metra M , Crea F
Published: January 2025

Introduction

In acute heart failure (AHF) patients, non-invasive estimation of left ventricular filling pressures (LVFPs) appears crucial to guide management. Although poorly investigated, left atrial (LA) mechanics play a pivotal role in this setting. Interestingly, recent findings indicate that combining LARS with conventional diastolic echocardiographic parameters, such as E/e’, may yield even more reliable estimations of LVFPs.

Purpose

This report sought to assess the correlation of echocardiographic LA stiffness index with invasive LVFPs and its diagnostic accuracy as compared to other parameters used in clinical practice.

Methods

In this observational, prospective study, 104 patients with suspected acute coronary syndrome and signs/symptoms of AHF were enrolled. Available invasive estimation of LVFPs was required. Comprehensive echocardiography was performed for all patients, including LA reservoir strain (LARS). LA stiffness index was derived as early diastolic transmitral inflow velocity/mitral annulus early diastolic velocity [E/e']/LARS. Predictive models based on LA stiffness index and LARS were built and tested in independent populations by randomly assigning patients to a "training group" for model building and a "test group" for model evaluation, using simple random sampling. Sampling was carried out with the "sample" function of R, with a 4:1 group ratio. Models’ performances were evaluated in the independent population "test group" against the guideline-recommended echocardiographic flowchart for the assessment of diastolic dysfunction.

Results

Invasively measured LVFPs showed a strong correlation with LA stiffness index (Spearman ρ = 0.773, p < 0.0001), as well as with LARS and E/e’. Receiver operating characteristic (ROC) curve analysis was used to demonstrate better accuracy performed by LA stiffness index than other echocardiographic metrics in predicting high LVFPs. Guideline-recommended assessment of diastolic function was finally compared to LARS and LA stiffness index performances in an independent population group; we were hence able to obtain a LA stiffness threshold of 0.48 with a positive predictive value of 91.7% and a negative predictive value of 88.9% in identifying patients with high LVFPs.

Conclusions

For the first time, diagnostic performance of LA stiffness index has been investigated in a heterogeneous AHF population, providing correlations with invasively measured LVFPs and comparisons with established diastolic function metrics.
Sensitivity and specificity of relative apical sparing pattern of global longitudinal strain in the diagnosis of cardiac amyloidosis: a systematic review and meta-analysis
Authors: Khan M I , Alzahrani T , Ahmad O , Janjua M , Omer M H , Alayary I , Alamro B , Alsergani H , Fadel B , Mohty D
Published: January 2025

Background

Cardiac amyloidosis (CA), characterized by a progressive infiltration of amyloid fibrils in cardiac tissue, presents a diagnostic challenge due to its resemblance to other cardiomyopathies by echocardiography. Although reduced left ventricular (LV) global longitudinal strain associated with a relative apical sparing pattern (RELAPS) has been associated with CA, its diagnostic accuracy has varied across studies.

Purpose

The aim of this systematic review and meta-analysis was to assess the diagnostic accuracy of using a quantitative RELAPS on 2D-echocardiography to differentiate patients with either transthyretin (ATTR) or light-chain (AL) cardiac amyloidosis from those with other causes of cardiomyopathies.

Methods

A comprehensive literature search was performed using PubMed, Scopus, Web of Science, and Cochrane databases from inception till May 2024. We included cohort original studies that reported the sensitivity and specificity of a quantitative RELAPS in differentiating ATTR-CA or AL-CA from other types of cardiomyopathies. RELAPS was defined as average apical longitudinal strain segments divided by the sum of average basal plus average mid longitudinal strains segments. Meta-analysis was performed using bivariate random effects regression to calculate sensitivity and specificity summary estimates. Subgroup analysis assessed the impact of different RELAPS cutoff values (1.0 and 0.9) on diagnostic performance. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool.

Results

A total of 20 studies with 4308 patients were included in our meta-analysis, comprising 2,063 CA patients: 1,066 with ATTR-CA, 942 with AL-CA, and 55 unclassified CA patients. Eight studies used a cutoff of ≥0.9 to define the presence of RELAPS, while twelve studies used a cutoff of ≥1.0.

The estimated sensitivity of RELAPS irrespective of the cutoff used for cardiac amyloidosis was 67% (95% confidence interval (CI): 59 - 75), with a specificity of 85% (95% CI: 78 - 90). Subgroup analysis revealed that a RELAPS cutoff >1.0 had higher specificity (87%, 95% CI: 79 - 93) but lower sensitivity (57%, 95% CI: 40 - 72), whereas a cutoff of 0.9 showed higher sensitivity (69%, 95% CI: 65 - 73) but lower specificity (83%, 95% CI: 75 - 90).

Conclusion

Our results confirm that the RELAPS pattern is an effective and simple diagnostic tool for detecting cardiac amyloidosis using echocardiography, demonstrating fairly good sensitivity and excellent specificity. Moreover, the choice of RELAPS cutoff value impacts diagnostic performance, highlighting its potential role in enhancing the accuracy of echocardiographic evaluations in suspected cases of cardiac amyloidosis.

Forest Plot
Platelet/lymphocyte ratio levels as a predictor for echocardiographic abnormalities in patients with systemic lupus erythematosus
Authors: Gonzalez-Gonzalez V , Cardenas-De La Garza J A , Arvizu-Rivera R I , Galarza-Delgado D A , Azpiri-Lopez J R , Colunga-Pedraza I J , Polina-Lugo R L , Gonzalez-Melendez A , Guajardo-Aldaco A L , Elizondo-Benitez M F , Cardoso-Casco D I
Published: January 2025

Background

Platelet/lymphocyte ratio (PLR) has recently been described as a predictor for adverse cardiovascular outcomes, such as heart failure and coronary artery disease. In systemic lupus erythematosus (SLE), PLR has been studied as a marker of disease activity. PLR has not been evaluated as a cardiovascular biomarker in SLE.

Purpose

To compare the prevalence of echocardiographic abnormalities between normal and high PLR in patients with SLE.

Methods

Cross-sectional, retrospective, descriptive study. Women older than 18 years who met the ACR/EULAR 2019 classification criteria for the diagnosis of SLE. Patients with a history of cardiovascular disease, other connective tissue diseases, or pregnancy were excluded. The platelet/lymphocyte ratio (PLR) was calculated by dividing the platelet count by the lymphocyte count; a value >172.68 was considered a high PLR. Transthoracic echocardiography was performed by a certified cardiologist blinded to clinical information. Diastolic dysfunction was defined according to the following parameters: mitral flow E/A ratio, septal and lateral E/E' ratio, left atrial volume, and mitral valve deceleration time. The distribution between groups was assessed with the Kolmogorov-Smirnov test. Comparisons were made using the Chi-square test or Fisher's exact test and the Student T test or Mann-Whitney U test, as appropriate. A p-value>0.05 was considered statistically significant.

Results

A total of 54 patients were included. The mean age was 35.1 ± 11.8 years. Disease activity measured by SLEDAI was similar between groups (8.0 vs 9.0, p=0.434) and disease duration was longer in patients with high PLR (116 months vs 60 months, p=0.023). The median PLR was 157.1 ± 91.2. There was no difference in indexed left ventricular mass or diastolic dysfunction patterns between patients with high PLR and SLE patients with normal PLR. Complete results are shown in Table 2.

Conclusion

The prevalence of echocardiographic abnormalities is not higher in those with high PLR compared with those with normal PLR in patients with SLE. Prospective studies with serial measurements of PLR are needed to evaluate its prognostic utility in cardiovascular outcomes in patients with SLE.
Early detection of CTRCD by echocardiography among patients with breast cancer treated with anthracycline and trastuzumab stratified by HFA-ICOS risk classes
Authors: Al Farhan H , Saadoun Khalaf N A H
Published: January 2025

Background

Cancer therapy-related cardiac dysfunction (CTRCD), particularly with anthracyclines and trastuzumab, can be seen frequently among patients with breast cancer. Early detection of CTRCD is crucial to prevent irreversible myocardial damage and heart failure. Echocardiography measurements including left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) have a vital role in early detection of CTRCD.

Purpose

To detect subclinical left ventricular systolic dysfunction by using 2D-GLS in patient with breast cancer on Anthracycline -Trastuzumab stratified by Heart Failure Association - International Cardio-Oncology Society (HFA-ICOS) risk stratification.

Methods

A cross-sectional study conducted at the cardio-oncology service in Iraq from August 2022 to June 2023 enrolled women with breast cancer referred for echocardiography. The sample included females with more than 18 years old, treated with Anthracycline and/or Trastuzumab, with normal baseline left ventricular function (LVEF 54%). Results were considered abnormal if LVEF < 52% and/or GLS < -18%.

Results

Among 100 patients included in the study, 30 were treated with Anthracycline, 20 with Trastuzumab, and 50 with a combination of both treatments. The mean age was 48.14 ± 8.64 years. Of 65 patients with known HFA-ICOS risk stratification, GLS impairment was found in 3 patients with high HFA-ICOS risk class. There was no right ventricular dysfunction (normal TAPSE). Results are shown in Table 1.

Conclusions

Subclinical LV systolic dysfunction (GLS impairment) was found in all of the patients with high HFA-ICOS risk class in addition to some of the patients with medium HFA-ICOS risk. Early risk stratification helps identify high-risk patients, enabling close monitoring and cardioprotection strategies. Early detection of subclinical LV dysfunction can improve standard of care of the patients.