bluuebunny/crossref_metadata_2025 huggingface dataset:
Non-invasive estimation of myocardial work in aortic stenosis from modelling approach
Authors: Owashi K.P , Hubert A , Galli E , Donal E , Hernandez A.I , Le Rolle V
Published: November 2020

Background

The noninvasive assessment of myocardial work by pressure-strain loops (PSL) analysis is a recently introduced tool to estimate myocardial performance. PSL analysis cannot be applied to patients having an obstacle to LV ejection, as in the case of aortic stenosis (AS), because of the difficulty to estimate left ventricular (LV) pressure.

The purpose of this work is to propose a non-invasive model-based estimation of the left ventricular pressure curve in AS patients in order to evaluate myocardial work indices.

Methods

Twelve patients with moderate-to-severe AS underwent cardiac catheterization to acquire the LV pressure (Pexp-LV). All patients underwent a standard trans-thoracic echocardiography to extract regional myocardial strain curves and estimate the aortic valve area (AVA). Systolic and diastolic arterial pressures were also measured. The proposed cardiovascular system (CVS) model is composed of four main coupled sub-models simulating: i) cardiac electrical activities, ii) cardiac cavity, iii) the systemic and pulmonary circulation, and iv) cardiac valves (Figure 1, upper panel). A 2-step parameter identification strategy, based evolutionary algorithms, was implemented to learn LV parameters from Pexp-LV and to estimate patient-specific model-based LV pressure curves (Pmodel-LV) starting from parameters obtained from non-invasive hemodynamics. Global myocardial constructive work (GCW) and myocardial wasted work (GWW) were calculated using Pexp-LV and Pmodel-LV.

Results

A close match was observed between Pexp-LV and Pmodel-LV, with a mean total relative error of 12.27% (range 5.9% to 17.40%). When considering GCW and GWW, global correlation was equal to 0.92 (p<0.0001). In BA analysis, mean bias was −2.9 mmHg.%, which corresponds to relative bias equal to 0.11% with respect to the mean value of work indices (Figure 1, lower panel).

Conclusions

A model-based approach can be used to estimate LV pressure and myocardial work indices in patients with AS, and be provide a promising tool for the assessment of myocardial performance in patients with AS

Funding Acknowledgement

Type of funding source: None
Asymptomatic aortic regurgitation: diastolic function and type-B natriuretic peptide as prognostic factors
Authors: Abellas Sequeiros M , Garcia Martin A , Gonzalez A , Hinojar Baydes R , Rincon Diaz L.M , Vieitez Florez J.M , Lorente Ros A , Pardo Sanz A , Manjon Rubio H , Pascual Izco M , Moya Mur J.L , Casas E , Jimenez Nacher J.J , Zamorano J.L , Fernandez Golfin C
Published: November 2020

Introduction

The indication of valve replacement surgery in patients with severe aortic regurgitation (AR) is mainly based on the presence of symptoms or dilatation/dysfunction of the left ventricle (LV). However, diastolic function and natriuretic peptides have not been related to adverse outcomes in these patients. The aim of this study was to evaluate the prognosis impact of different diastolic function parameters as well as type-B natriuretic peptide (BNP).

Methods

Patients with moderate to severe or severe AR evaluated in the Heart Valve Clinic between 2013–2019 were evaluated. Those patients with classical indications for surgical aortic valve replacement (SAVR) at the moment of inclusion were excluded, as well as those patients with atrial fibrillation. Echocardiographic and analytical data were obtained from the medical history. End-point included cardiovascular mortality, SAVR and heart failure.

Results

A total of 126 patients were included. Median age was 65.0±17.7 years. Among them, 75 (59.5%) were men, 78 (62.4%) hypertensive, 44 (35.3%) suffered from dyslipidemia and 11 (9,6%) had ischaemic cardiomyopathy. During a median follow up of 31±17 months, 24.6% of the patients reached the combined end-point (n=5 developed heart failure, n=28 underwent SAVR, and n=4 died).

Among the diastolic parameters [E wave, A wave, E/A, E/e', left atrial volume and diameter, tricuspid regurgitation (TR) degree and pulmonary systolic pressure (PSP)], only TR degree and PSP were associated with a higher incidence of the combined endpoint: TR degree HR=2,08, p=0,039 and PSP HR= 1,1, p=0,007. BNP also showed prognostic impact for the combined endpoint (HR= 1,002, p=0,011).

Conclusions

In patients with asymptomatic significant AR, severity of TR, PSP and BNP levels are associated with worst prognosis. However, classical echocardiographic diastolic parameters do not show prognosis impact, probably due to the limitations of such parameters to identify diastolic dysfunction and high filling pressures in this population. Our findings support the use of PSP and TR over diastolic function parameters to better stratify left valvular patient risk in clinical practice.

Funding Acknowledgement

Type of funding source: None
Regurgitant fraction as a load-dependent parameter in tricuspid regurgitation quantitation
Authors: Liu Y , Dong L.L , Chen B.Q , Zuo W.X , Shu X.H , Ge J.B
Published: November 2020

Background

Regurgitant fraction (RF) is an accepted tool for valvular lesion quantitation in the left heart, while its role in tricuspid regurgitation (TR) is less studied.

Purpose

The aim of this study was to examine the determinants of RF in TR and its diagnostic utility for TR severity grading in comparison with regurgitant volume (RVol) using guideline recommended integrated algorithm as the reference standard.

Methods

114 pts with more-than-mild TR in the absence of pulmonary regurgitation or intracardiac shunt prospectively underwent 2D and 3D transthoracic echocardiography. 3D data sets of the right ventricle (RV) were obtained during breath hold. 3D RVol was calculated through subtracting the right ventricular outflow tract forward stroke volume (SV) from RV SV, where the outflow tract cross-sectional area was derived from single-view measured diameter. 3D RF was calculated by dividing 3D RVol with RV SV. 3D EROA was derived dividing 3D RVol with the velocity-time integral of TR.

Results

104 pts were included in the final analysis. 3D RF correlated well with 3D RVol (r=0.80, P<0.0001). Factors encompassing aetiology (organic/functional), heart rate, systolic pulmonary arterial pressure (sPAP), cardiac output, 3D EROA and RV end-diastolic volume index were included in multiple linear regression (R2=0.85), which demonstrated that RF was associated with sPAP (P<0.0001) but not RV end-diastolic volume index (P=0.116). Receiver operator characteristic analysis revealed significant difference in area under the curve between 3D RVol and 3D RF (Z=2.873, P=0.004). Such difference diminished in pts with elevated sPAP (Z=1.226, P=0.220), while remained in those with normal range sPAP (Z=2.897, P=0.004).

Conclusions

3D RF is less dependent on volume load but is significantly influenced by pressure load in TR quantitation. The diagnostic power of 3D RF in differentiating severe TR is comparable with 3D RVol in pts with elevated sPAP but is limited in pts with normal range sPAP.

Funding Acknowledgement

Type of funding source: None
Clinical significance of late diastolic tissue doppler parameters after onset of STEMI: from the view point of the timing of the echocardipography
Authors: Iwahashi N , Kirigaya J , Horii M , Abe T , Akiyama E , Okada K , Matsuzawa Y , Maejima N , Hibi K , Kosuge M , Ebina T , Tamura K , Kimura K
Published: November 2020

Background

The early transmitral flow velocity (E) divided by the early diastolic velocity of the mitral valve annulus (e') is referred to as the “E/e' ratio,” is useful even for ST elevation acute myocardial infarction (STEMI). However, the role of late diastolic velocity (a') which reveals the atrial function for STEMI is still unclear.

Objectives

We evaluated the clinical usefulness of tissue Doppler including atrial function for a first-time STEMI by long time follow up. Furthermore, we evaluated the meaning of each parameters by performing immediately after PCI or 2 weeks later.

Methods

We treated consecutive 571 first-time STEMI patients by immediate PCI within 12 hours after onset, and we examined 270 patients at immediately after PCI (GroupA, 65 years, 250 male) and 301 patients at 2 weeks after onset (GroupB, 64 years, 243 male). We examined trans mitral flow and TDI, then defined E/e' as LV filling pressure and A/a' as left atrial function. We followed them for a long time (>5 years). The primary end point (PE) was cardiac death or re-admission for heart failure (HF).

Results

We followed the patients in Group A for 10 years, Group B for 5 years. PE occurred in 64 patients in GroupA during 10 years, and 45 patients in GroupB during 5 years. We analyzed the univariate and multivariate Cox hazard analyses and we compared e' and a', E/e' and A/a' (Table). In GroupA, a' and A/a' were the independent predictors, on the other hand neither a' nor A/a' were the predictors in GroupB. E/e' was an independent predictor both in GroupA and B.

Conclusion

TDI parameters have different meanings by the timing of echocardiography after onset of a first-time STEMI. These results demonstrated that atrial dysfunction immediately after onset of STEMI suggests the poor prognosis after STEMI.

Cox Hazard Proportional Analysis

Funding Acknowledgement

Type of funding source: None
Relationship between pulmonary edema development and left atrium mechanical functions in patients with left ventricular hypertrophy
Authors: Aggul B , Korkmaz B , Vatanoglu E , Yuksel G , Avci I , Zeren G , Simsek B , Keles N , Tanboga H , Karabay C
Published: November 2020

Background

Since there is no proven treatment to reduce mortality in heart failure with preserved ejection fraction patients, to identify the predictors of decompensation are important in these patients.

Purpose

In this study, we aimed to evaluate the left atrium (LA) mechanical functions in patients with left ventricular hypertrophy (LVH) presenting with dyspnea and to investigate the predictors of pulmonary edema (PE).

Methods

This study was designed as a single-center cross-sectional study. Patients with LVH who presented to the emergency department with dyspnea were divided into two groups as PE (n=30) and non-PE (n=100). Mechanical functions of the LA were evaluated by speckle-tracking echocardiography. As a statistical method, diagnostic modelling was performed to demonstrate the relationship between demographic and echocardiographic features with the diagnosis of the patient (with or without PE). First, a basal model was created consisting of age, gender, body mass index (BMI), left ventricular mass index (LVMI), creatinine (Model 0). Then, different models were created by adding reservoir strain (S) (Model 1), conduit S, pump S, reservoir strain rate (SR), conduit SR and pump SR to the basal model, respectively. It was analyzed how each model made changes in performance criteria compared to the basal model.

Results

When the relationship between left atrial strain parameters and PE were analyzed, LA reservoir S (OR: 1.74 (1.14–2.64); p: 0.003) and LA pump SR (OR: 1.69 (1.07–2.64); p: 0.023) had found to be significantly associated with the development of PE. Another parameter associated with PE was admission creatinine value (OR: 1.52 (1.08–2.15), p-value: 0.016). In our study, LVMI is not a predictor for PE but, when the interaction of LA reservoir S and LVMI was considered, it is observed that decreased LA reservoir S is associated with more PE, especially in individuals with higher LVMI.

Conclusion

In this study, we found that the LA reservoir S is significantly associated with the development of PE in patients with LVH, especially in individuals with higher LVMI.

Interaction of reservoir S and LVMI

Funding Acknowledgement

Type of funding source: None
Comparison of global left ventricular myocardial work indices at baseline and after 3 months of st-segment elevation myocardial infarction
Authors: De Paula Lustosa R , Van Der Bijl P , Goedemans L , El Mahdiui M , Montero-Cabezas J.M , Kostyukevich M , Ajmone Marsan N , Bax J.J , Delgado V
Published: November 2020

Background

Global left ventricular myocardial work indices (GLVMWI) are derived from speckle tracking echocardiographic strain data in combination with non-invasive blood pressure recordings. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) are derived from these measures. GLVMWI in ST-segment elevation myocardial infarction (STEMI) remains unexplored and comparison between measures of GLVMWI at index event (baseline) and follow-up is unknown.

Purpose

To assess the evolution in GLVMWI in STEMI patients from baseline (index infarct) to 3 months' follow-up.

Methods

This retrospective study included 350 patients (265 men, mean age: 61±10 years) with STEMI treated with primary percutaneous coronary intervention and optimal, guideline-based medical therapy. Clinical variables, echocardiographic measures and GLVMWI were recorded at baseline and 3 months follow-up.

Results

Left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GWI, GCW and GWE improved significantly at 3 months follow-up with no significant difference in GWW (Table). These findings suggest that the impaired values of GLVMWI at baseline are related to stunning after STEMI and they recover at 3 months follow-up without further deterioration in GWW, which probably reflects irreversible myocardial damage.

Conclusions

In STEMI patients treated with primary percutaneous coronary intervention and optimal guideline-based medical therapy, GLVMWI assessed by speckle tracking strain echocardiography are significantly improved at 3 months follow-up, without significant changes in GWW. GLVMWI therefore have the potential to identify reversible and irreversible components of post-infarct myocardial damage.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Society of Cardiology Research Grant
Prognostic value of global longitudinal layer specific strain for patients with heart failure with reduced ejection fraction
Authors: Johnsen C , Sengeloev M , Joergensen P , Bruun N , Modin D , Alhakak A , Schou M , Gislason G , Fritz-Hansen T , Shah A , Biering-Soerensen T
Published: November 2020

Background

Novel echocardiographic software allows for layer-specific evaluation of myocardial deformation by 2-dimensional speckle tracking echocardiography. Endocardial, epicardial- and whole wall global longitudinal strain (GLS) may be superior to conventional echocardiographic parameters in predicting all-cause mortality in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

The purpose of this study was to investigate the prognostic value of endocardial-, epicardial- and whole wall GLS in patients with HFrEF in relation to all-cause mortality.

Methods

We included and analyzed transthoracic echocardiographic examinations from 1,015 patients with HFrEF. The echocardiographic images were analyzed, and conventional and novel echocardiographic parameters were obtained. A p value in a 2-sided test <0.05 was considered statistically significant. Cox proportional hazards regression models were constructed, and both univariable and multivariable hazard ratios (HRs) were calculated.

Results

During a median follow-up time of 40 months, 171 patients (16.8%) died. A lower endocardial (HR 1.17; 95% CI (1.11–1.23), per 1% decrease, p<0.001), epicardial (HR 1.20; 95% CI (1.13–1.27), per 1% decrease, p<0.001), and whole wall (HR 1.20; 95% CI (1.14–1.27), per 1% decrease, p<0.001) GLS were all associated with higher risk of death (Figure 1). Both endocardial (HR 1.12; 95% CI (1.01–1.23), p=0.027), epicardial (HR 1.13; 95% CI (1.01–1.26), p=0.040) and whole wall (HR 1.13; 95% CI (1.01–1.27), p=0.030) GLS remained independent predictors of mortality in the multivariable models after adjusting for significant clinical parameters (age, sex, total cholesterol, mean arterial pressure, heart rate, ischemic cardiomyopathy, percutaneous transluminal coronary angioplasty and diabetes) and conventional echocardiographic parameters (left ventricular (LV) ejection fraction, LV mass index, left atrial volume index, deceleration time, E/e', E-velocity, E/A ratio and tricuspid annular plane systolic excursion). No other echocardiographic parameters remained an independent predictors after adjusting. Furthermore, endocardial, epicardial and whole wall GLS had the highest C-statistics of all the echocardiographic parameters.

Conclusion

Endocardial, epicardial and whole wall GLS are independent predictors of all-cause mortality in patients with HFrEF. Furthermore, endocardial, epicardial and whole wall GLS were superior prognosticators of all-cause mortality compared with all other echocardiographic parameters.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Herlev and Gentofte Hospital
The behaviour of natural shear waves under different loading conditions
Authors: Bezy S , Duchenne J , Orlowska M , Wouters L , Caenen A , Keijzer L.B.H , Cvijic M , D'hooge J , Voigt J.-U
Published: November 2020

Background

Shear wave imaging (SWI) is a novel ultrasound technique based on the detection of transverse waves traveling through the myocardium using high frame rate echocardiography. These waves can be naturally induced e.g. by mitral valve closure (MVC). Their propagation velocity is dependent on the stiffness of the myocardium. Previous studies have shown the potential of SWI for the non-invasive assessment of myocardial stiffness. So far, the influence of loading on shear wave propagation velocities has not been extensively investigated.

Purpose

The aim of this study was to explore how loading changes affect shear wave propagation velocities after MVC.

Methods

Until now, 5 pigs (weight: 33.5±6.9 kg) were included. Echocardiographic images and left ventricular pressure recordings were simultaneously acquired during acute loading alterations: 1) preload was reduced by balloon occlusion of the vena cava inferior, 2) afterload was increased by balloon occlusion of the descending aorta and 3) preload was increased by intra-venous administration of 500 ml of saline. Left ventricular parasternal long-axis views were acquired with an experimental high frame rate ultrasound scanner (average frame rate: 1247±179 Hz). Shear waves were visualized on tissue acceleration maps by drawing an M-mode line along the interventricular septum. Shear wave propagation velocities after MVC were calculated by measuring the slope of the wave front on the acceleration maps (Figure A).

Results

The changes in left ventricular end-diastolic pressures (LV EDP) between baseline and each intervention are shown in Figure B. Preload reduction resulted in significantly reduced LV EDP (p<0.01). The shear wave propagation velocities after MVC dropped with preload reduction and increased significantly by increasing afterload as well as preload (both p<0.05) (Figure C). There was a good positive correlation between the change in LV EDP and the change in shear wave velocities (r=0.83; p<0.001) (Figure D).

Conclusion

The shear wave propagation velocity after MVC was significantly influenced by alterations in left ventricular loading conditions and changes in these velocities were related to changes in LV EDP. These results indicate that shear wave measurements at MVC might be a potential novel parameter for the estimation of left ventricular filling pressures. More pigs will be included in the future to further confirm these findings.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Fonds Wetenschappelijk Onderzoek - Vlaanderen
Inflammation and fibrosis biomarkers are related to atrial dysfunction in patients at risk of atrial fibrillation
Authors: Mimbrero Guillamon M , Loncaric F , Loncaric F , Nunno L , Nunno L , Tirapu L , Tirapu L , Montserrat M , Montserrat M , Sanchis L , Sanchis L , Doltra A , Doltra A , Bijnens B , Bijnens B , Sitges M , Sitges M
Published: November 2020

Introduction

Arterial hypertension mitral regurgitation and endurance training are risks factors for incidental atrial fibrillation (AF). Left atrial (LA) remodeling in the context of volume and pressure overload may be the substrate for AF development. Inflammation and subsequent fibrosis may be related to the development of this atrial remodeling. Our aim was to analyze if there is any correlation between inflammation and fibrosis biomarkers and left atrial dysfunction in blood samples of subjects with hypertension or mitral regurgitation and in endurance athletes.

Methods

A population of 478 subjects at risk of atrial fibrillation were enrolled to this study. The cohort was composed by 275 endurance athletes, 185 patients with arterial hypertension and 32 with moderate to severe mitral regurgitation. All patients underwent 2D (two-dimensional) echocardiography with speckle-tracking analysis (LA strain and LA strain-rate) and 3D (three-dimensional) echocardiography to assess LA volume and volume-based function. Furthermore, blood samples were obtained to measure plasma levels of BNP, troponin-I and the following fibrosis and inflammatory biomarkers: MMP-9 (Matrix Metalloproteinase 9), CXCL16 (CXC chemokine), CXCL6, FABP3, PIGF, OSM, endocan-1.

The whole cohort was divided into quartiles according to their reservoir strain value (surrogate of atrial relaxation impairment), and correlation between biomarkers, atrial 2D volumes and 3D volumes was calculated.

Results

Quartile ranges regarding reservoir strain (RS) were: 1st quartile (<28.9%), 2nd quartile (28,9%-32,1%), 3rd quartile (32,95–35,4), 4th quartile (>35,4%).

The first quartile (worse left atrial reservoir function) was mainly composed by hypertensive and mitral regurgitation subjects while the 4th quartile (with larger left atrium but better reservoir function) was mostly integrated by athletes. The 1st quartile (worse atrial function) showed higher levels of fibrotic (MMP-9) and inflammatory biomarkers (CXCL16, FABP3, PIGF, BNP, Troponin-I and PIGF) as compared to the other quartiles.

Conclusions

Inflammation and fibrosis biomarkers (CXCL16, FABP3, PIGF and MMP-9) are higher in subjects with worse LA reservoir function. This suggests a correlation among inflammation (fibrosis) and atrial dysfunction in a population at risk for AF development.

Biomarkers according RS quartiles

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Fundaciό La Maratό de TV3
Electromechanical delay by speckle-tracking echocardiography: a novel tool for distinguishing between Brugada syndrome and isolated right bundle branch block
Authors: D'Ascenzi F , Sanz De La Garza M , Anselmi F , Nunno L , Arbelo E , Jorda P , Marzotti T , Aprile F , Natali B.M , Brugada J , Sitges M , Mondillo S
Published: November 2020

Background

The electrocardiographic (ECG) definition of Brugada syndrome (BS) can be challenging because benign ECG abnormalities, such as right bundle branch block (RBBB), may mimic pathological ECG characteristics of BrS. However, although myocardial delay and deformation can be quantified by advanced imaging, it has not yet been used to differentiate between BrS and RBBB.

Purpose

The aim of this study was to characterize the electro-mechanical behavior of the heart of patients with type-1 BrS and subjects with isolated complete RBBB in order to differentiate these conditions.

Methods

In this two-center study, 66 subjects were analyzed by standard and speckle-tracking echocardiography (STE): 22 type-1 BrS, 24 isolated complete RBBB, and 20 healthy subjects. The participants were not treated by any drug potentially influencing myocardial conduction.

Results

Standard echocardiographic parameters did not differ among the groups. STE demonstrated that right ventricular (RV) mechanical dispersion (MD) was greater in RBBB as compared to BrS and controls (p<0.05). In patients with isolated RBBB, the greatest delay of RV time-to-peak longitudinal strain (TTP) was found in RV free-wall basal segments. Mean absolute deviations of TTP calculated for each left ventricular (LV) region were greater in patients with RBBB as compared to those with BrS and to controls with a localisation of the delay in LV antero-septal, anterior, lateral, and infero-septal basal segments (figure 1).

Conclusions

Advanced echocardiographic techniques may help to differentiate between BrS and RBBB. Indeed, STE allows to identify an electro-mechanical conduction delay in RBBB patients that is not found in patients affected by type-1 BrS.

Electromechanical delay by STE

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Italian Society of Cardiology
Prognostic role of left ventricular diastolic function assessed by speckle tracking echocardiography in patients after surgical ventricular repair
Authors: Nemchyna O , Solowjowa N , Dandel M , Hrytsyna Y , Stein J , Soltani S , Knierim J , Schoenrath F , Falk V , Knosalla C
Published: November 2020

Background

Assessment of left ventricular (LV) diastolic function brings important prognostic information for patients with heart failure and could be evaluated by speckle tracking echocardiography (STE). Less known about its role in patients planned for surgical ventricular repair due to LV aneurysm.

Purpose

The aim of this study was to evaluate the prognostic role of STE parameters of LV diastolic function for prediction of all-cause mortality in patients after surgical ventricular repair.

Methods

We retrospectively evaluated data of 163 consecutive pts (mean age 62.3±11.5 years, 74.8% males) with anteroapical LV aneurysm who underwent surgical ventricular repair combined with coronary artery bypass surgery (71.8%) Prognostic role for prediction of all-cause mortality was assessed for various STE parameters, including left atrial strain (LAS) measured as peak reservoir strain and for the ratio of early to late global longitudinal strain rate (GLSRe/GLSRa).

Results

During a median follow-up of 4.7 years (IQR: 1.6–8.9 years) there were 65 deaths, 5 year survival rate was 73.8 (95% CI 67–79%). Baseline ejection fraction, end-diastolic and end-systolic volumes of LV did not differ between pts who died and survived at 5 year after the surgery, whereas LAS was significantly higher and GLSRe/GLSRa was significantly lower in survivors. Cox proportional hazard model adjusted to demographic and clinical variables demonstrated that LAS and GLSRe/GLSRa were independent predictors of all-cause death, with HR of 0.79 (95% CI 0.66–0.95, p=0.012) for each 5% increase of LAS and HR of 1.24 (95% CI 1.1–1.4, p=0.001) for each 0.5 increase of GLSRe/GLSRa. Moreover, GLSRe/GLSRa remained an independent predictor after additional adjustment for LV end-systolic volume, sphericity index and presence of mitral insufficiency of grade 2 and higher. A significant difference in median survival time was demonstrated according to the following cut-offs: LAS ≥16.7% (12.1 vs. 6.4 years, p=0.01), GLSRe/GLSRa ratio ≥2.3 (3.3 years vs. 10.2 years, p=0.0005) (Figure). The classification and regression tree analysis with the application of all two-dimensional, Doppler and various speckle-tracking echocardiographic parameters revealed that GLSRe/GLSRa and LAS were the most important echocardiographic variables for risk stratification for 5-year mortality.

Conclusion

This study demonstrates that STE parameters of LV diastolic function are important predictors of all-cause mortality after surgical ventricular repair due to anteroapical aneurysm of LV and could be used in the preoperative decision-making process.

Funding Acknowledgement

Type of funding source: None
Prognostic value of peri-coronary adipose tissue attenuation and whole vessel and lesion plaque quantification on Coronary Computed Tomography Angiography
Authors: Hoshino M , Yang S , Sugiyama T , Zhang J , Kanaji Y , Yamaguchi M , Hada M , Sumino Y , Nogami K , Ueno H , Misawa T , Yonetsu T , Koo B , Kakuta T
Published: November 2020

Background

Peri-coronary adipose tissue attenuation expressed by fat attenuation index (FAI) on coronary CT angiography (CCTA) reflects peri-coronary inflammation and is associated with cardiac mortality. CCTA also provides two-dimensional and three-dimensional quantification of the individual component of atherosclerotic plaque and entire vessel. The atherosclerotic burden or disease extent in entire epicardial coronary arteries provides prognostic information in patients with coronary artery disease.

Purpose

This study sought to explore the prognostic significance of FAI values and whole vessel and lesion plaque quantification on CCTA in stable patients with intermediate epicardial stenosis evaluated by fractional flow reserve (FFR).

Methods

A total of 277 patients (277 lesions) with intermediate coronary stenosis who underwent FFR measurement and CCTA were studied. FAI was assessed by the crude analysis of the mean CT attenuation value (−190 to −30 Hounsfield units; higher values indicating inflammation) on CCTA. CT findings including whole vessel and lesion plaque quantification, and target vessel myocardial mass were investigated. Major adverse cardiovascular outcome (MACE) was defined as all cause death, cardiac death, myocardial infarction, unplanned revascularization, and heart failure requiring admission. Survivals from MACE were assessed.

Results

The mean FAI and the median FFR values were −71.6 and 0.77, respectively. FFR values were weakly albeit significantly correlated with FAI values. (r=−0.016, P=0.008.) MACE was occurred 43 (15.5%) patients during 5 years F-up. ROC analyses revealed that best cut-off value of FAI to predict MACE was −73.1. Kaplan-Meier analysis revealed that lesions with FAI ≥−73.1 had a significantly higher risk of MACE. (Chi-square 5.5, P=0.019) FFR values and the percutaneous coronary intervention were not predictive of MACE. Multivariate COX proportional hazards regression analysis revealed that age, remodeling index, and lesions with FAI ≥−73.1 were independent predictors of MACE.

Conclusion

The peri-coronary inflammation evaluated by FAI and CT remodeling index enhances cardiac risk prediction in chronic coronary syndrome patients with intermediate lesions. Non-invasive comprehensive CT assessment may help identify high risk patients of subsequent clinical events and provide enhanced patient management.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This study was supported in part by an unrestricted research grant from St. Jude Medical (Abbot Vascular, Santa Clara, CA, USA). The company had no role in study design, conduct, data analysis or manuscript preparation.
Meta-analysis of computed tomography and magnetic resonance imaging for diagnosing mycotic aneurysms
Authors: Wang T.K.M , Griffin B.P , Cremer P.C , Gamble G.D , Unai S , Shrestha N , Gordon S , Pettersson G , Desai M.Y
Published: November 2020

Background

Mycotic aneurysms are a serious complication of infective endocarditis and bloodstream infection with high mortality and morbidity. Computed tomography (CT) and magnetic resonance (MRI) play major roles in detecting mycotic aneurysms, but their accuracy is not well established warranting this meta-analysis.

Purpose

We aimed to assess the diagnostic performance of CT and MRI for mycotic aneurysms in this meta-analysis.

Methods

Pubmed, Cochrane and Embase were searched from 1 January 1980–30 June 2019 for diagnostic studies reporting both sensitivity and specificity of CT and/or MRI for detecting mycotic aneurysms, and pooled using random effects models and Meta-DiSc 1.4 software.

Results

Amongst 1507 articles searched, 15 studies with 622 scans for 249 mycotic aneurysms included. CT was performed in 13 studies and MRI in 5 studies, looking at aortic and cerebral mycotic aneurysm in 12 and 3 studies respectively. The pooled sensitivities and specificities for all mycotic aneurysms with 95% confidence intervals were for CT 0.82 (0.77–0.87) and 0.93 (0.89–0.95) respectively, and for MRI 0.79 (0.61–0.91) and 0.89 (0.81–0.95) (Figure). CT or MRI had pooled sensitivities and specificities of 0.84 (0.78–0.89) and 0.92 (0.89–0.95) for aortic and 0.71 (0.54–0.85) and 0.90 (0.83–0.95) for cerebral mycotic aneurysms. Heterogeneity and publication bias was observed in some pooled analysis.

Conclusion

CT and MRI had moderately high diagnostic accuracy for mycotic aneurysms. Sensitivity was numerically higher for detecting aortic than cerebral mycotic aneurysms, with similar specificity. Study heterogeneity, publication bias and modest sample size from the literature were important limitations, warranting larger and higher quality studies.

Forrest plots for CT and MRI pooled data

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): National Heart Foundation of New Zealand - Overseas Clinical and Research Fellowship
Adverse effects of exposure to ambient air pollution on coronary calcification
Authors: Huynh Q , Venkataraman P , Marwick T.H , Negishi K
Published: November 2020

Background

The association of air pollution with cardiovascular morbidity and mortality has been attributed to acute events (atherothrombosis). It is unclear whether air pollution may influence the subclinical stage of coronary artery disease (CAD). This study investigated the relationship between particulate matter <2.5μm (PM2.5) and nitrogen dioxide (NO2) with coronary calcium score (CCS).

Methods

This study included 606 asymptomatic adults (49% men, aged 56±7 years) recruited from the community in two States of Australia (Victoria and Tasmania). Annual PM2.5 and NO2 concentrations were matched with residential address. CCS was measured using coronary CT scan. Medical history, physical measurements, biochemistry, and socioeconomic status were recorded for assessment of confounders.

Results

Average exposure to PM2.5 and NO2 were 6.7±1.5 (ppm) and 3.6±2.1 (μg/m3), respectively. Of the 606 participants, 17% had high CCS (≥100) and 4% had very high CCS (≥400). Exposure to higher annual PM2.5 was associated with greater odds of high CCS (OR=1.20 [95% CI: 1.02, 1.42]) and very high CCS (OR=1.47 [95% CI: 1.03, 2.11]). Similar adverse associations were also present for NO2 and high CCS (OR=1.13 [95% CI: 1.02, 1.25]) and very high CCS (OR=1.25 [95% CI: 1.06, 1.47]). These findings were independent of age, sex, body size, smoking, comorbidities and socio-economic status.

Conclusions

Ambient air pollution was associated with degree of coronary calcification, independent of standard risk factors. The link between air pollution and CAD is not limited to acute events but appears to include atherogenesis.

Funding Acknowledgement

Type of funding source: None
Quantified coronary plaque volume provides superior risk stratification up to 10 years
Authors: Deseive S , Straub R , Kupke M , Kitslaar P , Broersen A , Hadamitzky M , Massberg S , Hausleiter J
Published: November 2020

Background

Automated plaque quantification derived from coronary CT angiogragphy datasets provides exact and reliable assessment of coronary atherosclerosis burden.

Purpose

To investigate the potential for category based reclassification of patients based upon quantified coronary plaque volume in patients with 10 years of follow-up.

Methods

Coronary PV was quantified with dedicated software in 1577 patients with suspected coronary artery disease. Cardiac death and acute coronary syndrome were defined as endpoint. Patients were initially classified as low, intermediate or high risk based upon the Morise score. Quantified PV was used to reclassify patients as shown in Figure 1 Panel A. The applied cutoffs (PV=0, PV0–110.5 mm3 and PV>110.5mm3) were established by previous work of our group. Categorical net reclassification improvement was used to compare the initial and updated patient stratification.

Results

Patients were followed for 10.4 years. The combined endpoint occurred in 59 patients, of whom 36 suffered from cardiac death, 18 had non-fatal myocardial infarction and 5 presented with unstable angina requiring recascularisation. The Morise score classified the majority of patients as intermediate risk patients (71%) and smaller proportions as low risk (21.9%) or high risk (7.1%). Quantified PV based reclassification resulted in reclassification of 800 (51%) patients. Of those, the majority was classified into a lower risk category (n=502). Calculation of the categorical NRI proved a significantly superior risk stratification when compared to the initial risk groups (0.48 with 95% CI 0.13 and 0.68, p<0.001). The reclassification matrix is shown in Figure 1 Panel B. After reclassification, the estimated 10-year event rates for low, intermediate and high risk patients were 0.6% (95% CI 0 and 1.3%), 4.8% (95% CI 2.4 and 7.2%) and 11.3% (95% CI 6.6 and 13.9%) respectively.

Conclusion

Quantified coronary PV permits an effective and useful approach to reclassify patients with suspected coronary artery disease into superior risk categories.

Funding Acknowledgement

Type of funding source: None
Association between the progression of aortic valve calcification and coronary atherosclerotic plaque volume
Authors: Lee S.E , Budoff M.J , Conte E , Hadamitzky M , Leipsic J.A , Cademartiri F , Pontone G , Stone P.H , Bax J.J , Narula J , Lin F.Y , Berman D.S , Min J.K , Shaw L.J , Chang H.J
Published: November 2020

Background

It is unclear whether the annual progression of aortic valve calcification (AVC) is associated with the progression of coronary atherosclerosis.

Purpose

We explored the association between AVC and the total and compositional plaque volume (PV) progression.

Methods

We performed a prospective multinational registry of consecutive patients who underwent serial coronary computed tomography angiography (CTA) at ≥2-year intervals. AVC, and total and compositional PV at baseline and follow-up were quantitatively analyzed. Multivariate linear regression models were constructed.

Results

Overall, 594 patients (56% male, 61.5±9.7 years old) were included (mean coronary CTA interval, 3.9±1.5 years). At baseline, AVC was 30.9±117.3. Normalized total PV at baseline was 122.3±219.4mm3, encompassing 41.9±116.8mm3 of calcified PV and 80.4±131.5mm3 of non-calcified PV. After adjustment of age, sex, clinical risk factors, and drug use, AVC at baseline was independently associated with total and all compositional PVs (all p<0.001). However, at follow-up, the annual progression of AVC was only associated with the annual progression of calcified PV (β=0.149, p=0.0089), but not with total and non-calcified PVs (all p>0.05) (Table, Figure).

Conclusion

The overall burden of coronary atherosclerosis is associated with AVC at baseline. However, the progression of AVC is associated only with the progression of calcified PV but not with that of total and non-calcified PV.

Representative case

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The National Research Foundation (NRF) of Korea funded by the Ministry of Science and ICT (MSIT)
Evaluation of adverse plaque characteristics in coronary computed tomography angiography using combined near infrared spectroscopy
Authors: Shin S
Published: November 2020

Background/Introduction

Coronary computed tomography angiography (CCTA) has developed rapidly, enabling the evaluation of coronary stenosis as well as plaque characteristics. However, it is not clear whether the adverse plaque characteristics found in CCTA are really vulnerable plaques. Near-infrared spectroscopy (NIRS) is able to quantify cholesterol within coronary arteries by the lipid core burden index (LCBI).

Purpose

The purpose of this study was to determine whether positive remodeling (PR), low attenuated plaque (LAP) and spotty calcificaiton (SC) found in CCTA have high LCBI values in NIRS.

Methods

The study was single center, prospective, and cross-sectional. A total of 84 patients who underwent NIRS during percutaneous coronary intervention after CCTA imaging for coronary artery disease were studied. PR, LAP and SC were identified in the plaques visible on CCTA, and LCBI and maxLCBI (4mm) were measured by NIRS on the same plaque.

Results

In the presence of PR and LAP in the plaque, the maxLCBI (4mm) [PR: 468±161 vs. 319±214, p=0.032, LAP: 475±178 vs. 278±191, p=0.006] and LCBI [PR: 190±74 vs. 132±104, p=0.044, LAP: 182±96 vs. 124±93, p=0.038] values were significantly higher than those in the plaque without PR and LAP. However, with and without SC, there was no significant difference between the maxLCBI (4mm) [474±181 vs. 336±208] and LCBI [183±77 vs. 142±102, p=0.127] values.

Conclusion

Among the adverse plaque characteristics found in CCTA, PR and LAP were clearly correlated with maxLCBI (4mm) and LCBI measured by NIRS, but SC was less correlated.

APC vs. LCBI

Funding Acknowledgement

Type of funding source: None
Sex-specific risk for ischemia by invasive fractional flow reserve according to coronary atherosclerotic features: results from the CREDENCE trial
Authors: Van Den Hoogen I.J , Gianni U , Bax A.M , Van Rosendael A.R , Tantawy S.W , Berman D.S , Chang H.J , Genereux P , Knaapen P , Narula J , Pontone G , Lin F.Y , Min J.K , Shaw L.J , Bax J.J
Published: November 2020

Background

Evolving evidence suggests unique sex-specific mechanisms underlying coronary artery disease (CAD). However, it remains unknown if certain coronary atherosclerotic features confer a higher risk for ischemia in women versus men.

Purpose

To determine the association between coronary atherosclerotic features on coronary computed tomography angiography (CCTA) and ischemia by invasive fractional flow reserve (FFR) in women versus men.

Methods

Secondary analysis of the CREDENCE trial, including patients referred for nonemergent invasive coronary angiography (ICA). All patients underwent CCTA with semi-automatic quantification of coronary atherosclerosis, as well as ICA with FFR interrogation of all major epicardial arteries ≥2 mm. Generalized estimating equations were calculated to assess the association between coronary atherosclerotic features and invasive vessel-specific ischemia (FFR ≤0.80). Sex interactions were tested, adjusted for age.

Results

From 612 patients (mean age 64±10 years, 30% women) with 1,686 analyzed vessels, a total of 436 (26%) vessels were ischemic. Women were significantly older than men (p<0.001), but with similar distribution of risk factors and medication usage (p≥0.09). In both women and men, all general and compositional features of coronary atherosclerosis were significantly associated with ischemia. However, tests for interaction (Figure 1) revealed higher relative odds for ischemia among women as compared to men for total percent atheroma volume ([PAV], p=0.006), the number of lesions with high-risk plaque (p=0.027), the number of lesions with >30% stenosis (p=0.030), noncalcified PAV <130 HU and <350 HU (p≤0.003), and calcified PAV (p=0.007).

Conclusion

Our results support a prominent influence of coronary atherosclerotic features that uniquely impact ischemic risk among women more so than men. These data support the role of CCTA for providing valuable information to guide management of symptomatic women.

Figure 1. Ischemic risk in women vs. men

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health - National Heart, Lung, and Blood Institute
Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC
Authors: Mizia-Stec K , Charron P , Blanes J.R.G , Elliott P , Kaski J.P , Maggioni A.P , Tavazzi L , Tendera M , Wybraniec M , Laroche C , Caforio A.L.P
Published: November 2020

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p<0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p<0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p<0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None
Late Gadolinium Enhancement at cardiac magnetic resonance predicts malignant ventricular arrhythmias in systemic sclerosis
Authors: Gargani L , Pugliese N.R , Meloni A , Bruni C , Todiere G , Guiducci S , Moggi-Pignone A , Lombardi M , Mavrogeni S , Matucci-Cerinic M , Pepe A
Published: November 2020

Background

Malignant arrhythmias due to cardiac involvement are a frequent cause of death in systemic sclerosis (SSc). Cardiac involvement, which is linked to both ischaemic and non-ischaemic fibrotic deposition, is often subclinical. Cardiovascular magnetic resonance (CMR) is the non-invasive gold standard for myocardial tissue characterization and can detect macroscopic myocardial fibrosis through late Gadolinium enhancement (LGE).

Aim

To evaluate the role of LGE to predict malignant arrhythmias requiring implantable cardioverter defibrillator (ICD) in SSc.

Methods

289 SSc patients underwent a thorough clinical evaluation and CMR exam using a 1.5 T scanner. Biventricular function parameter by SSFP cine images, oedema by STIR T2 images, and macroscopic fibrosis by LGE were assessed. Patients were followed-up and malignant ventricular arrhythmias requiring ICD implantation was considered as event.

Results

Out of 289 patients, 111 (38.4%) showed LGE and 83/111 (28.7% of the total population) showed a non-junctional distribution. During the follow-up (45±27 months), 10 patients needed ICD after malignant ventricular arrhythmias (7 patients with LGE, 3 patients without LGE). CMR predictors of cardiac events by univariate analysis were left and right ventricular ejection fractions, indexed right atrial area and non-junctional LGE. At multivariate analysis, macroscopic myocardial fibrosis detected by LGE was an independent predictor (hazard ratio 5.4; 95% C.I. 1.1–28.8, p<0.05; see figure for Kaplan-Meier curves).

Conclusions

Presence of ventricular LGE at CMR may represent an independent predictor for further malignant ventricular arrhythmias requiring ICD implantation in SSc patients.

Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None