bluuebunny/crossref_metadata_2025 huggingface dataset:
Epicardial adipose tissue thickness - a new predictive factor for coronary artery disease
Authors: Loghin-Turturica M , Iancu D , Gurzun M
Published: January 2025

Introduction

The role of pericardial adipose tissue has been investigated in numerous studies in relation to the development of coronary artery disease (CAD) and other cardiac pathologies. Total pericardial fat (TPF) consists of epicardial adipose tissue (EAT), which is located between the myocardium and the visceral pericardium, and pericardial fat (PCF), which adheres to the parietal pericardium. The suspected mechanisms are complex and include the acceleration of inflammation and oxidative stress as well as proximity to the coronary arteries.

Purpose

The aim of the study was to investigate the existence of a correlation between the thickness of epicardial and pericardial adipose tissue and the presence of CAD, with the hope of using this marker in the future for risk stratification of cardiovascular disease.

Methods

This study enrolled 264 patients with a mean age of 59,9 +/- 10.6 years, 60,6% (160 pts) male, with cardiovascular risk factors who were investigated for suspected CAD. In all patients, the thickness of the TPF, EAT, and the PCF were measured echocardiographically during end-diastole, at the anterior atrioventricular groove. Intra- and interobserver variability was excellent (ICC 0.995-0.998 and ICC 0.992-0.995 for all three layers).

Results

Out of the total patients included, 54,2% (142 pts) had lesions on conventional angiography, of which 46% had hemodynamically significant lesions requiring revascularization. There were no statistically significant differences in the thickness of the three layers according to the presence of cardiovascular risk factors (diabetes mellitus, smoking, hypertension) and there was no correlation with body mass index. There were statistically significant differences in the dimensions of the pericardial adipose tissue layers between the group of patients with CAD and the group of patients without CAD (EAT 7,1 +/-2,34 vs 5,07+/-2,36 mm, PCF 9.3+/-3,01 vs 7,2+/-2,9 mm and TPF 16,7+/-3,8 vs 12.59+/-4,3 mm, p=0.001 for all cases). There were no statistically significant differences between patients who had one, two, or all three coronary arteries affected (p=0.5). There is a significant correlation between EAT and TPF (r 0.81), PCF and TPF (r 0.83), but no significant correlation between the two substrates (r 0.44). Women without CAD had a lower epicardial layer thickness than men without CAD (4,8+/-0,26 vs 5,4+/-0,29,p <0,001), but this difference did not exist in those with CAD (6.9+/-0.47 vs 7.2+/-0.24).

Conclusions

The study shows that echocardiographic measurement of the thickness of pericardial adipose tissue layers is a feasible method, easy to perform with good intra- and interobserver reproducibility. The data presented suggest that the thickness of the pericardial adipose tissue layers (EAT and TPF) may represent an independent risk factor for CAD and could be included in the pre-test risk assessment of patients with suspected CAD.
A prospective study on the correlation of right atrial pressure determined non-invasively via inferior vena cava versus tricuspid E/e among patients undergoing dobutamine stress echocardiography
Authors: Manalili M K C , Go L
Published: January 2025

Background

Right atrial pressure (RAP) gives insight to a patient's cardiovascular hemodynamics and pulmonary status. It is used to estimate the pulmonary arterial pressure (PAP), but since its definite measurement requires right heart catherization, physicians tend to rely on non-invasive modalities such as echocardiography. Aside from the IVC method, secondary indices, such as tricuspid E/e' and hepatic vein flow pattern, may also be employed to estimate RAP. Methodology: This was a prospective observational single-center study done from November 2023 until April 2024 which included a total of 55 adult patients who underwent dobutamine stress echocardiography (DSE). Baseline characteristics and echocardiographic parameters were obtained, and RAP values using IVC (RAP IVC) and tricuspid E/e’ (RAP E/e’) methods were compared. The correlations of the derived systolic and mean PAP values using the two methods were also determined.

Results

The RAP IVC and RAP E/e’ values had statistically significant difference. The cut-off values used for tricuspid E/e’ overestimate RAP when compared with the IVC method. Analysis on sPAP values had mixed results as to the detection of pulmonary hypertension (PH). Grading of PH severity using derived mPAP values from the two methods also showed statistically significant difference. Lastly, our post-hoc analysis manifested that increasing dobutamine dose has a statistically significant effect to RAP determined via echocardiography.

Conclusion

At the time of this writing, estimating RAP using the tricuspid E/e’ method is not a good alternative to the IVC method. In addition, derived sPAP and mPAP values using tricuspid E/e’ also did not correlate with those determined using the IVC method. Higher tricuspid E/e’ cut-off values, larger sample size, and possible need for correction factors in the derivation of sPAP and mPAP may lead to better correlation between the two methods. Finally, our post-hoc analysis showed that dobutamine >10 mcg/kg/min can cause IVC dilatation and/or plethora, hence caution is needed when interpreting presence of IVC dilatation and/or plethora, and RAP and PAP estimates which were obtained using echocardiography among patients on dobutamine support.

Demographic and clinical profile

Algorithm of procedures
Assessment of cardiac structure and function 1.5 years after COVID-19: results from the EPILOC study
Authors: Schellenberg J , Matits L , Bizjak D , Peter R , Rothenbacher D , Deibert P , Friedmann-Bette B , Niess A , Goepel S , Erz G , Merle U , Kern W , Steinacker J
Published: January 2025

Background

Impaired left and right ventricular function have been observed mainly in hospitalized patients with acute SARS-CoV-2 infection. The long-term cardiac sequelae have not yet been conclusively clarified in large, well-defined cohorts. In addition, it is not yet certain whether cardiac function is related to persistent cardiopulmonary symptoms or reduced exercise capacity after COVID-19.

Purpose

Differences in cardiac structure and function in patients with suspected post-COVID syndrome (PCS) and in recovered control patients (CON) were analysed with regard to the association with cardiopulmonary symptoms and physical performance.

Methods

In this multicentre study, transthoracic echocardiography was performed in 1154 individuals (49±12 years, 760 women) 1.5 years after SARS-CoV-2 infection (October 2020 till April 2021) in southwest Germany. Left and right ventricular global longitudinal strain (LV/RV GLS) and RV free wall strain (FWS) were determined with post-processing software in 679 PCS and 475 CON. Cardiopulmonary exercise testing (CPET) was performed with a ramp protocol on a bicycle ergometer.

Results

PCS showed lower LV GLS (-20.25% vs. -20.73%, p=0.003), diastolic function (E/A 1.16 vs. 1.21, p=0.022) and TAPSE (24.45 vs. 25.05, p=0.022) compared to CON, while RV strain values did not differ. Echocardiographic parameters were within the normal clinical reference range. LV GLS was negatively associated with VO2max (p=0.004) and positively associated with rapid physical exhaustion (p=0.050), but not with cardiopulmonary symptoms.

Conclusions

Significantly reduced cardiac function in PCS compared to CON 1.5 years after SARS-CoV-2 infection could indicate long-term left myocardium involvement, while signs of RV involvement were inconsistent. The differences between the groups appear to be small and could be explained by deconditioning due to PCS or the more frequent presence of cardiovascular disease in PCS. Nevertheless, it cannot be ruled out that a slight reduction in cardiac function and physical performance could be a long-term consequence of COVID-19 in patients with persistent symptoms. Further (long-term) studies are therefore necessary to investigate the connection between persistent exercise intolerance and cardiac involvement. This could lead to further diagnostic steps and therapy recommendations.
Contribution of rotational mechanics to the differential echocardiographic diagnosis of myocardial hypertrophy versus myocardial infiltration
Authors: Garcia Martin G , Queipo Rodriguez A , Geraldo Martinez J , Galiana Talavera E , Hidalgo Mateos A , Gramage Sanchis P , Callizo Gallego R , Valls Serral A , Roldan Torres I , Mora Llabata V
Published: January 2025

Introduction

Increased left ventricular (LV) wall thickness can be caused by myocardial hypertrophy or infiltration. It is important to reach the correct diagnosis because of the major differences in prognosis and specific treatment.

Purpose

Our objetive was to analyze the contribution of LV rotational mechanics to the echocardiographic differential diagnosis between muscular hypertrophy versus myocardial infiltration.

Methods

We analyzed 107 patients with left ventricular hypertrophy [75 with myocardial hypertrophy secondary to hypertensive heart disease (HHD) and 32 patients with myocardial infiltration due to cardiac amyloidosis (CA)] using 2D-Echo speckle tracking. All patients had preserved LV ejection fraction (LVEF > 50%). We measured structural 2D-echocardiographic parameters, global longitudinal strain (GLS), and rotational parameters such as "Rotational Gradient" (°) between the LV basal rotation (°) and apical rotation (°) (twist if basal and apical rotations in opposite directions, or rigid rotation if basal and apical rotations in same directions) and "Wringing" as a normalized measure of Rotational Gradient per unit of longitudinal shortening (Rotational Gradient/GLS (°/%)), which includes the two movements that simultaneously occur during ventricular systole. SLG was obtained from 4-, 3- and 2-chamber apical planes, while basal and apical rotations were obtained from parasternal short-axis planes at these LV levels.

Results

Characteristics of study population are shown in Table 1. No differences in ventricular mass were observed between groups. The GLS was lower in the group of patients with CA, in addition to higher apical LS/basal LS+medial LS ratio. Twist Rotational Gradient showed no differences between the two groups, but its normalization according to ventricular shortening (Wringing) showed significant higher values in the group of patients with CA. Besides GLS <13.9% (AUC 0.92, p<0.0001, CI 95% 0.86-0.97), which is highly indicative of CA, wringing >1,39°/% (AUC 0.72, p <0.0001, CI 95% 0.61-0.82) proved to be a good supportive marker for CA diagnosis exhibiting a sensitivity of 75.0% and a specificity of 62.7%.

Conclusion

In patients with LV thickening and preserved LVEF, in addition to the information provided by myocardial longitudinal strain, the increase in ventricular wringing >1.39°/% is a useful parameter in the differential diagnosis of ventricular hypertrophy for CA.
A strain-based classification is associated with therapy success in cardiac resynchronization therapy-eligible patients
Authors: Duchenne J , Calle S , Stankovic I , Aalen J , Galli E , Larsen C , Puvrez A , De Buyzere M , Kongsgard E , Voros G , Penicka M , Donal E , Smiseth O , Timmermans F , Voigt J U
Published: January 2025

Introduction

Echocardiography-derived septal strain patterns stages are associated with a stepwise increase in survival for each increment in strain stage among patients treated with cardiac resynchronization therapy (CRT). However, it is unknown whether the strain stages could also predict survival in conservatively-treated (i.e. not CRT-implanted) patients.

Purpose

This study aims to investigate the interplay between septal strain patterns and long-term survival in both CRT- and conservatively-treated patients.

Methods

In this multicentre study, CRT-eligible patients from six European centres underwent speckle-tracking strain analysis on echocardiography. CRT-treated patients (CRT) were enrolled prospectively and assessed prior to device implantation. Conservatively-treated patients (CON) were assessed retrospectively. Dyssynchrony was graded through analysis of septal strain curves, categorizing patients into five distinct patterns, denoted as strain Stage-0 (no dyssynchrony) through strain Stage-4 (severe dyssynchrony) (Fig. A). The study endpoint was all-cause mortality.

Results

A total of 267 CRT patients (69% males, 89% left bundle branch block (LBBB) and QRS 166±20 ms) and 167 CON patients (69% males, 87% LBBB, QRS 155±25 ms) were included. Median follow-up time was 49 (40-57) months. CON patients within the highest strain stages had the worst outcome, whereas CRT-treated patients within the highest strain stages had the best survival (Fig. B). A stepwise increase in survival difference was observed between CRT and CON patients for each increment in strain stage (Fig. B-F). Hazard ratios (HR) were: Stage-0: 1.42 (95% CI: 0.59-3.44, p=0.436) / Stage-1: 2.63 (95% CI: 1.19-5.82, p=0.017) / Stage-2: 3.93 (95% CI: 1.20-12.83, p=0.024) / Stage-3: 5.74 (95% CI: 1.72-19.19, p=0.005) and Stage-4: 16.49 (95% CI: 4.84-56.21, p<0.001).

Conclusions

The strain stages demonstrated a strong survival benefit for CRT-treated compared to conservatively-treated, but CRT-eligible patients. Patients with more severe dyssynchrony (highest strain stages) have most benefit from CRT implantation. These findings underscore the potential value of the strain stages in refining risk stratification and patient selection of CRT.
Changes in left atrial strain in patients undergoing cardiotoxic anticancer treatment: a literature review and meta-analysis
Authors: Bombace S , De Luca V M , Farmakis I T , Laux G S , Hobohm L , Karbach S , Lurz P , Sannino A
Published: January 2025

Background

LA strain is an important marker of diastolic dysfunction, with increasing evidence supporting its role in various clinical conditions. While left ventricular global longitudinal strain (LVGLS) is well-established for clinical management and detecting cancer therapy-related cardiac dysfunction (CTRCD), the role of LA strain remains unclear.

Aim

This meta-analysis aimed to investigate the changes in left atrial (LA) strain in patients undergoing cardiotoxic anticancer treatment.

Methods

We conducted a systematic search of the MEDLINE, ISI Web of Science, and SCOPUS databases for studies reporting data on LA strain before and after cardiotoxic anticancer treatment (anthracycline and/or trastuzumab) and published up to April 2024. The study design adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

In total, 413 studies screened, 9 met the inclusion criteria, enrolling 1504 subjects with a mean age of 53.8 ± 11 years. Eight of nine studies focused exclusively on female patients with breast cancer exclusively, while the remaining study included 7% male patients and 19.6% with other types of cancer. Echocardiograms were performed before and 1 and 6 months after treatment initiation. There was a LVGLS change of 2.0% (95% CI 0.8 to 3.1) and a LVEF change of -1.3% (95% CI -1.9 to -0.6). Significant changes in LA strain parameters were observed, including an LA reservoir strain change of -3.2% (95% confidence interval [CI] -4.5 to -1.9) and an LA contraction strain change of 0.6% (95% CI 0.1 to 1.0). However, no significant change was noted for LA conduit strain with 1.3% (95 % CI -1.3 to 4.0).

Conclusions

Cardiotoxic anticancer treatment is associated with a significant decline in LA strain parameters. Further research is warranted to understand the implications of these changes, including their correlation with diastolic dysfunction, CTRCD, and clinical outcomes.

Changes in strain parameters
Enhancing left ventricular filling pressure estimation in patients with asymptomatic severe aortic stenosis patients, integration of left atrial reservoir strain analysis
Authors: Kaya E , Skulstad H , Kvaslerud A B , Broch K , Edvardsen T
Published: January 2025

Introduction

Estimating left ventricular filling pressure (LVFP) by echocardiography is challenging in patients with asymptomatic severe aortic stenosis (ASAS). The European Association of Cardiovascular Imaging has proposed an algorithm utilizing left atrial reservoir strain analysis (LARS) in patients with what was previously described as "undetermined LVFP". We aimed to validate this algorithm in patients with ASAS.

Methods

We performed right heart catheterization in 50 patients with ASAS. An end-expiratory pulmonary artery wedge pressure (PAWP) ≥ 15mmHg was used as a reference for increased LVFP. We compared indices of LVFP by echocardiography with invasive measurements to validate the algorithm in patients with ASAS.

Results

Nine patients (18%) had increased LVFP by RHC while 8 (16%) had increased LVFP by echocardiography. Only 2 of the 9 patients with invasively elevated LVPF were identified by echocardiography. On the other hand, among the 41 patients with normal LVFP, 35 (85%) were accurately identified as having a normal LVFP by echocardiography. Consequently, the echocardiographic algorithm had a sensitivity of 22% and a specificity of 85% in patients with ASAS (Table). As depicted in the figure, 9 patients were initially labelled as having undetermined LVFP. The addition of LARS, correctly excluded increased LVFP in 7 of these 9 patients (78 %).

Conclusion

LVFP estimation by echocardiography has low sensitivity for increased filling pressure in patients with ASAS. However, the inclusion of LARS significantly improves LVPF estimation correctly, particularly in patients initially classified as having undetermined pressure by conventional echocardiography.
The implication of left ventricular mechanical dispersion as a risk predictor for ventricular arrhythmia in patients with mitral valve prolapse
Authors: Alshehristani R , Al Hashimi A , Abdulhamza R
Published: January 2025

Background

Mitral valve prolapse (MVP) is considered a benign disorder, though it can be accompanied by ventricular arrhythmias. Speckle Tracking Echocardiography can be a promising tool for detecting early derangement.

Objectives

To determine whether the left ventricular (LV) mechanical dispersion derived by speckle tracking echocardiography can be considered a predictor for occurrence of ventricular arrhythmias in patients with MVP.

Materials and Methods

A cross-sectional study conducted on 63 MVP patients (37 females and 29 males) presented with palpitation, who were divided into two groups: Group 1 Arrhythmic patients with ventricular arrhythmias and Group 2 Non-Arrhythmic patients. All of them underwent comprehensive clinical and electrocardiographic examination, cardiac rhythm assessment by Holter monitoring, and comprehensive echocardiographic evaluation including speckle tracking technique.

Results

Ventricular arrhythmias (VA) were detected in 32 out of 63 patients. Ventricular bigeminy was the most common type of VA in arrhythmic patients. Unlike other echocardiographic parameters, the LV mechanical dispersion (MD) and the mitral annular disjunction (MAD) were found to be significantly higher in arrhythmic versus non-arrhythmic MVP patients (P<0.001). Furthermore, the mean LV MD was higher in patients with frequent ventricular ectopics versus infrequent ones (P= 0.003). The cut-off value for LV MD was 35.1 ms or higher (sensitivity 87%, specificity 71%) and for MAD was 2.7 mm or higher (sensitivity 82%, specificity 60%) in predicting VA in MVP patients.

Conclusions

LV mechanical dispersion in addition to MAD can be implemented in risk prediction for ventricular arrhythmias in patients with MVP presenting with palpitations.
Correlation of left ventricular global longitudinal strain by speckle-tracking echocardiography with invasive LV filling pressure
Authors: Nakhaee A , Sardari A , Larti F , Vahidi H , Mehrpooya M , Geraiely B
Published: January 2025

Introduction

The left ventricular (LV) systolic function can affect diastolic relaxation. The interaction of systolic and diastolic myocardial function resembles the mechanism of "coil compression and relaxation." This concept has gained significant attention in recent years, challenging the notion of "isolated diastolic dysfunction." Speckle tracking echocardiography (STE) is a sensitive and innovative method for evaluating global myocardial function beyond LVEF. This study examined the possible correlation between left ventricular longitudinal strain (GLS) and different LV filling pressures.

Method

Patients scheduled for diagnostic coronary angiography and left heart catheterization were included. The exclusion criteria were any degree of mitral stenosis, more than moderate mitral regurgitation or aortic stenosis, left bundle branch block, or atrial fibrillation. Measurements of LV end-diastolic pressure (LVEDP), LV min diastolic pressure (LVMDP), and LV pre-A diastolic pressure (LV pre-A) were taken via cardiac catheterization. On the same day, LV global longitudinal strain (LV GLS) was assessed using the EPIQ 7 Philips vendor.

Results

A total of seventy patients were studied (mean age: 50.24 ± 12.6 years; 60% male). The mean LVEF was 46.8% (SD:10.3), and the mean E/e’= 11.1 (SD:4.1). Pearson’s correlation coefficient showed a moderate negative relationship between LV GLS and LVEDP (R=-0.45, p<0.001), LVMDP (R=-0.44, p<0.001), and LV pre-A (R=-0.43, p<0.001).

Conclusion

The correlation of multiple invasive LV filling pressure parameters (LVEDP, LVMDP, and LV pre-A pressure) with LV GLS signifies the possible role of systolic parameters in predicting diastolic dysfunction. Integrating LV GLS with conventional algorithms may improve the non-invasive assessment of diastolic dysfunction.
Score-based or left atrial strain based assessment of heart failure with preserved ejection fraction in transcatheter aortic valve replacement
Authors: Von Roeder M , Rommel K P , Dumpies O , Maeder M , Wahl V , Rotta Detto Loria J , Kresoja K P , Richter I , Desch S , Lurz P , Thiele H , Abdel-Wahab M
Published: January 2025

Background

Heart failure with preserved ejection fraction (HFpEF) has recently been proposed as important comorbid condition in patients undergoing transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS). The H2FPEF-score and the HFA-PEFF-score are used to diagnose HFpEF, but their use might be hampered by lack of specificity in TAVR-populations. Left atrial reservoir strain (LARS) emerged as a powerful predictor of outcomes in patients with AS irrespective of ejection fraction (EF).

Purpose

To assess the prognostic value of the H2FPEF-score, the HFA-PEFF-score and of LARS for the prediction of outcomes after TAVR.

Methods

All consecutive patients undergoing TAVR with an LVEF was ≥50% between 01/2018 and 12/2018 were included if discharge echo and follow-up were available. The primary endpoint was all-cause death and readmission for decompensated HF. HFpEF was defined as an H2FPEF-score of ≥6 or an HFA-PEFF-score of ≥5 points. LARS was derived from 2-D-speckle-tracking and patients were divided in two groups according to LARS-median.

Results

Overall, 499 patients were available (Age 80 years (IQR 77-84)), including 58% woman. The H2PEFF-score was available in 92% and classified 204 patients (45%) as HFpEF with significant prediction of the primary endpoint (log-rank p=0.04). The HFA-PEFF-score was available in 91% and classified 414 patients (91%) as HFpEF with, but lacked prognostic significance (log-rank p=0.47). LARS was available in 100% of patients (median 13.9% [IQR 9.2-19.0%]). Patients with LARS ≤13.9% experienced worse outcomes (log-rank p<0.001).

Conclusion

H2PEFF-score and LARS might be used for risk-prediction post TAVR with LARS being applicable for more patients in our cohort.
Exercise echocardiography in octogenarian patients: a valid and feasible tool for diagnostic and prognostic assessment in ischemic heart disease
Authors: Casanova Rodriguez C , Cano Carrizal R , Velez Salas A , Rodriguez Alcudia D , Martin Penato Molina A , De La Cruz Berlanga E , Cadenas Chamorro R , Iglesias Del Valle D , Paredes Gonzalez B , Martinez Dosantos V , Aguilera Martinez M C , Lareo Vicente A , Garcia Garcia A
Published: January 2025

Background

The increase in life expectancy in general population is leading to a rise in the number of elderly patients visiting cardiology clinics. Often, the reason for these visits is the diagnostic suspicion or follow-up of patients with ischemic heart disease. Furthermore, elderly patients are often underdiagnosed and undertreated and they are a population poorly represented in clinical trials for coronary artery disease (CAD). Exercise echocardiography (EE) is a fundamental test in the evaluation of patients with diagnostic suspicion or prognostic assessment of CAD. However, there is limited evidence in the literature regarding its usefulness in elderly patients.

Purpose

The aim of our study is to analyze the usefulness of EE in octogenarian patients referred for diagnostic or prognostic assessment of CAD.

Methods

Retrospective analysis of consecutive patients aged 80-89 years referred for treadmill EE for diagnostic suspicion or prognostic assessment of CAD between January 2021 and December 2023.

Results

Ninety three octogenarian patients (aged 80-89 years) were included, representing 5.3% of the total patients who underwent EE during the analyzed period. The average age was 83.1 years, 40% were women and 41.9% had a previous history of CAD. Bruce protocol was performed in 87.1% of the cases. A mean METs level significantly higher than predicted by age and sex was achieved (6.6 vs. 4.9 METs, p<0.001). The test was negative for ischemia in 48.4%, positive in 24.7%, and inconclusive in 26.9%. 5.4% of the studies were considered non-assessable. There were no complications resulting from the test.

Conclusions

EE is an appropriate and feasible diagnostic and evaluative test that is valid and safe for octogenarian patients who do not have a limitation in walking on a treadmill. The vast majority of the studies (95%) were considered assessable.
changes in coronary disease management in real world practice in the united kingdom: insights from the multi-centre EVAREST/BSE-NSTEP study
Authors: Johnson C , Krasner S , Woodward W , Mao E , Mccourt A , Dockerill C , Senior R , Augustine D , Paton M , O'driscoll J , Oxborough D , Pearce K , Robinson S , Willis J , Leeson P
Published: January 2025

Background/Introduction

Recent guidelines and randomised controlled trials have proposed less frequent use of invasive strategies for patients with stable chest pain, and demonstrated the non-inferiority of an initial medical management strategy. However, the impact of these updates on clinical practice in the United Kingdom has not been previously reported.

Purpose

We aimed to identify if recent guidelines and literature have changed the management of patients being referred for stress echocardiography to assess inducible ischaemia in a real-world, multi-centre national healthcare system, and determine if this has significantly impacted patient outcomes.

Methods

Patients were recruited to the EVAREST/BSE-NSTEP prospective cohort study between 2015 and 2023 across the UK as part of two phases (phase 1: Mar 2015-Sep 2020; phase 2: Oct 2020-Sep 2023). Patient demographics, and stress echocardiogram procedural details were collected by study team members at each participating hospital, and 1 year medical outcome data was collected via the Data Access Request Service from NHS England. Patient management decisions and outcomes including referral for invasive coronary angiography, mortality, and cardiovascular events were compared between recruitment phases using Kaplan-Meier analysis and Cox proportional hazard ratios.

Results

5,082 participants were included in this analysis of patient management and outcomes (2,613 in phase 1, and 2,469 in phase 2), with a consistent age, sex, and BMI between recruitment cohorts. There was a higher rate of smoking and hypercholesterolaemia in phase 2 participants, but a decrease in hypertension and peripheral vascular disease (Table 1). There was a decrease in referral rate for invasive angiography for participants with a positive stress echocardiogram in phase 2 (p<0.05; Fig. 1B). Overall, participants in phase 2 had a higher rate of mortality (p<0.01) than those in phase 1, but there was no difference in cardiac event rate between phases (Fig. 1C-F). These results remained consistent after adjusting for covariates, with a reduced hazard ratio for invasive angiography in phase 2 participants who had a positive stress echocardiogram (HR 0.78, 95% CI 0.66-0.92, p<0.01). Additionally, phase 2 participants had an increased hazard ratio for mortality (HR 1.93, 95% CI 1.05-3.55, p<0.05), but no significant increase in risk of cardiac event (HR 0.69, 95% CI 0.43-1.12, p=0.13).

Conclusions

Since 2020, participants are being less frequently referred for invasive coronary angiography after stress echocardiography possibly in favour of an initial medical management strategy. However, this reduction in referral to coronary angiography does not appear to have a negative impact on patient health as measured by cardiac event rate.
Septum displacement implications in the limited cardiac reserve, RV to pc uncoupling and oxygen uptake during exercise in heart failure
Authors: Serrantoni V , Crisci G , Losito M , Ginelli D , Bursi F , Guazzi M
Published: January 2025

Background

Exertional dyspnea is crucial in heart failure (HF) and may be determined by an unfavorable dynamic of ventricular interaction. This concept has been poorly addressed over time and we hypothesized that a careful study of the interventricular septum adaptations during maximal exercise in HF might be implicated in the limited cardiac reserve, uncoupling of right ventricular (RV) to pulmonary circulation (Pc), both yielding to a limited O2 uptake.

Aim

To address the pathophysiology behind biventricular interaction during exercise in HF, studying the role of l septum displacement during exercise and how and whether it would affect peak exercise oxygen consumption (VO2 peak). Through a limited cardiac output (CO) increase and some degrees of RV to PC uncoupling assessed by TAPSE/PASP.

Methods

22 HF underwent a combined cardiopulmonary exercise testing imaging (CPET imaging) with RV 3D-imaging analysis and were compared with a control population.

3D imaging of the RV chamber was examined off-line using the 4D RV TomTec software and obtained 3D mesh of the RV model using custom software to obtain the mean curvature value of IVS in 4 regions of: inflow tract (RVIT), outflow tract (RVOT), apical and body. We acquired measurements of curvature during end-diastole (ED) and at end systole (ES) phases and obtained a parametric curvature map.

Results

HF patients (mean age 72±12, 27% female) typically exhibited an abnormal septal curve, with a more leftward configuration either at rest and under exercise (rest =−0.01±0.007 at ED, and −0.01±0.009 at ES; peak exercise= −0.01±0.006 at ED, and −0.01±0.007 at ES) compared to controls (rest =−0.02±0.002 at ED, and −0.02±0.006 at ES; peak exercise −0.02±0.0.006 at ED, and −0.02±0.01 at ES, Figure). Notably, the degree of the IVS curvature was found to linearly correlate with an impaired gas exchange performance as showed by a lower peak VO2, a limited CO and impairment of TAPSE/PASP in HF (respectively, r=0.64, p<0.001, r=0.5, p<0.001, r=0.53, p<0.001 at ED during exercise; r=0.61, p<0.001 at ES during exercise; Figure).

Conclusions

In HF, the occurrence of right to left IVS displacement appears worth of investigation, tightly contributing to a reduced CO response, and RV-PA uncoupling during exercise. These findings clearly point to the utility of assessing how therapeutic strategies may modulate the negative septum displacement and overall cardiac mechanics.

RV colorimetric curvature map

Septal curvature correlations
Simultaneously assessed left ventricular strains and right ventricular longitudinal shortening are associated in healthy adults - a three-dimensional speckle-tracking echocardiographic study
Authors: Nemes A , Kormanyos A , Ambrus N , Lengyel C
Published: January 2025

Introduction

The right ventricle (RV) lies on the left ventricle (LV), their shape and function are characteristic and significantly different. To better understand the interaction between the LV and the RV in clinical settings even in healthy circumstances, imaging studies now available may help.

Purpose

The aim of the present study was to investigate the relationship between three-dimensional speckle-tracking echocardiography (3DSTE)-derived LV strains, which represent LV contractility as quantitative features, and tricuspid annular plane systolic excursion (TAPSE) as determined by M-mode echocardiography, which represents the longitudinal movement of the RV, in healthy adults.

Methods

Seventy-nine healthy adults (mean age 28.1±6.3 years, 33 men) were enrolled in the present study. After two-dimensional Doppler echocardiography, 3DSTE-derived data acquisition was carried out in all cases, and detailed 3DSTE-based analysis was performed offline at a later date.

Results

Subjects with reduced TAPSE (mean - standard deviation≤21 mm) had increased global (29.6±13.0% vs. 22.7±8.5%, p<0.05) and basal (35.3± 14.9% vs. 27.5±12.1%, p<0.05) LV radial strain (RS) as compared to cases with normal (mean) TAPSE (21 mm≤TAPSE≤27 mm). Increased TAPSE (mean+standard deviation≥27 mm) was also associated not only with increased basal LV-RS (34.2±10.4% vs. 27.5±12.1%, p<0.05), but also with increased global LV longitudinal strain (LS)(-17.5±1.7% vs. 15.5±2.4%, p<0.05). Increase of global LV-RS and LV circumferential strain (CS) showed associations with other strains except for global LV-LS. Increase of LV-LS did not show associations with other strains. If global LV-RS was less than mean - standard deviation (≤14.9%) TAPSE was 23.8±2.4 mm, when global LV-RS larger than mean + standard deviation (≥35.5%) TAPSE proved to be 22.2±3.2 with a significant difference in between (p<0.05). Degree of global LV-LS and global LV-CS did not show associations with TAPSE.

Conclusions

3DSTE-derived LV-RS and LV-LS are associated with RV longitudinal shortening represented by TAPSE in healthy adults.
(Un)natural history of right ventricular function and exercise tolerance during adolescence following tetralogy of fallot repair
Authors: Bitterman Y , Bulic A , Friedberg M K
Published: January 2025

Introduction

Patients with repaired tetralogy of Fallot (rTOF) develop progressive right ventricular (RV) dilatation and dysfunction in adulthood, which may have origins in childhood. Cohorts from previous eras studied patients who underwent primary repair at an older age with frequent use of palliative shunts. The trajectory of RV functional decline and its relation to exercise capacity and outcomes over childhood is poorly characterized.

Purpose

We sought to delineate changes in RV size, function, and exercise tolerance and occurrence of ventricular arrhythmia in a contemporary cohort of pediatric and adolescent rTOF.

Methods

We retrospectively reviewed serial echo, cardiac magnetic resonance (CMR) and clinical data from all rTOF patients between 2010-2020. We excluded patients with significant residual lesions, RV pressure overload (RVSP> half systemic) or without CMR data. Clinical data was recorded at 2-year intervals. We then compared CMR data and exercise tolerance at 10 to 16 years of age. Ventricular arrhythmias were defined based on Holter monitoring.

Results

We studied 95 rTOF patients (61% male). Pulmonary insufficiency fraction (31% vs 32%, p=0.8), RV size (RV end diastolic indexed volume 130 ml/m2 (117 – 167) vs. 140 ml/m2 (124 – 166), p=0.6) and RV free wall longitudinal strain (19.4±4.3% vs. 19.3±4.7%, p=0.86) remained stable at 10 and 16 years of age. CMR RVEF (51±6% vs. 47±5.3%, p=0.01) and exercise tolerance (95±17% vs. 81±14.4%, % predicted VO2, p=0.002, figure B) decreased with the advent of incident ventricular arrhythmias (figure A). There were no deaths.

Conclusions

Despite excellent survival in childhood, patients with rTOF develop worsening RV function, exercise intolerance and ventricular arrhythmias during adolescence. These are worrisome findings given the known increase in sudden death in the 3-4th decades of life that warrant further investigation into the underlying causes, their temporal development and therapeutic approaches.

Figure 1: A-Kaplan-Meier curve of incident ventricular and atrial arrhythmias. B- percentage of predicted VO2 during childhood.
Myocardial work analysis of aortic stenosis parients with right ventricular pacing: interaction of afterload and mechanical dyssynchrony?
Authors: Lakatos B K , Ladanyi Z , Turschl T , Fabian A , Tolvaj M , Balint T , Nagy D , Zima E , Molnar L , Nagy A , Kovacs A , Ruppert M , Merkely B
Published: January 2025

It is well known that left ventricular (LV) performance is substantially influenced by the corresponding loading conditions and LV synchrony. Notably, data are scarce about the interaction of these factors: previous studies suggest that patients with left bundle branch block (LBBB) has increased afterload sensitivity. This phenomenon may have special importance in certain clinical situations, such as aortic stenosis (AS) patients with concomitant right ventricular pacing (RVP).

Accordingly, our aim was to investigate the effects of RVP on LV function in patients with severe AS before and after transcatheter aortic valve replacement (TAVR).

Patients with a previously implanted pacemaker and significant AS undergoing TAVR in our Institute were screened. Only subjects with intrinsic non-LBBB QRS were enrolled (n=31). Detailed echocardiographic protocol suitable for speckle-tracking and myocardial work analysis was obtained. Myocardial work measures were calculated by estimating LV pressure as the sum of the systolic blood pressure and the mean aortic gradient. The patients underwent two sets of echocardiographic examinations: one with their narrow QRS rhythm and one with RVP. Those patients (n=19), who did not develop LBBB or complete AV-block also underwent a post-TAVI protocol. We measured LV ejection fraction (EF), global longitudinal strain (GLS) and also global work index (GWI) and global wasted work (GWW).

Preoperatively, RVP resulted in significantly lower LV EF (55±9 vs. 49±10%, p≤0.001), GLS (-14.2±3.6 vs. -11.9±3.5%, p≤0.001) and GWI (1830±502 vs. 1322±546 mmHg%, p≤0.001) compared to narrow QRS rhythm, while GWW was markedly higher (222±129 vs. 344±146 mmHg%, p≤0.001). After TAVR, LV EF was comparable (55±9 vs. 52±8%, p=0.11), while GLS (-13.8±.3.8 vs. -11.4±3.8%, p≤0.001) and GWI (1360±403 vs. 1018±385 mmHg%, p≤0.01) was lower in RVP. Notably, the relative change in GWI in response to RVP was significantly lower after TAVR (-31±21 vs. -22±20%, p≤0.05).

In patients with severe AS, LV dyssynchrony associated with RVP results in markedly lower LV functional measures. TAVR alleviates LV pressure overload, and the detrimental effect of RVP may dampen with the afterload reduction. Significant AS and RVP may have a highly unfavorable interaction raising the need for early interventions in this population.
Myocardial stiffness decreases in decompensated heart failure patients after recompensation
Authors: Wouters L , Papangelopoulou K , Youssef A , D'hooge J , Voigt J U
Published: January 2025

Background

Cardiac shear wave elastography (SWE) allows for the non-invasive assessment of myocardial stiffness via the detection of shear waves (SW) travelling through the heart after e.g. mitral valve closure (MVC). The propagation speed of these waves is directly related to myocardial stiffness. Myocardial operational stiffness depends on the intrinsic properties of the myocardium as well as the loading conditions of the heart. Therefore, changing loading conditions, for example volume unloading under diuretics, could influence SW speed.

Purpose

To evaluate the effect of volume unloading on shear wave speed in patients with decompensated heart failure before and after intravenous diuretics.

Methods

Eleven patients with decompensated heart failure were included. SWE was performed in the first hours after they presented at the emergency room and a few days later before discharge of the hospital. In between, all patients had received intravenous diuretics. For SWE, tissue doppler imaging of the LV parasternal long axis view was acquired at a high frame rate (1048±97 fps) using a research ultrasound scanner. SWs after mitral valve closure were visualized in M-modes of the septum, colour coded for tissue acceleration (fig A). The slope of the shear waves in the M-mode represents their propagation speed. SW speeds were measured in a semi-automatic manner.

Results

Patient characteristics are described in table 1. There was a significant decrease in weight (80.6±17.6kg vs 76.7±15.9kg, p<0.001) and tricuspid regurgitant velocity (3.4±0.5m/s vs 2.8±0.7m/s) before discharge, indicating a decrease in volume overload. Ejection fraction, global longitudinal strain and E/e’ did not significantly change between admittance and discharge. E/A ratio is not described, as most patients had atrial fibrillation. SW speed was significantly higher in the decompensated state upon admission than right before discharge (7.3±1.8m/s vs 5.4±1.4m/s, p<0.001; Fig B). A borderline correlation was observed between the difference in shear wave speed and weight loss between admission and discharge (r=0.53; p=0.09; Fig C). Although this was not significant, likely due to the limited size of the study population, it seems that SW speed decreases with decreasing volume overload. Furthermore, a borderline correlation was seen between shear wave speed and pro-BNP at admittance (r=0.60; p=0.085; Fig D), possibly indicating that there is a link between increased shear wave speed and increased filling pressures.

Conclusion

SW speed at mitral valve closure significantly decreased with decreasing volume overload in patients with decompensated heart failure. We hypothesize, that unloading the LV causes a leftward shift on the end-diastolic pressure-volume-relation and with this a decrease in in end-diastolic myocardial stiffness. SWE might become an interesting tool to non-invasively evaluate diastolic properties of the LV.

Table 1

Figure 1
Reevaluating heart failure risk: integrating echocardiography with unconventional holter ECG parameters
Authors: Duca S , Costache Enache I I
Published: January 2025

Background

Chronic heart failure (CHF) constitutes a multifaceted clinical syndrome arising from structural or functional abnormalities within the myocardium. Echocardiography serves as an indispensable diagnostic modality for identifying cardiac anomalies, facilitating comprehensive evaluation of disease severity, and informing therapeutic strategies. Additionally, Holter electrocardiography (ECG) offers a robust technique for the analysis of heart rate variability (HRV), thereby elucidating the autonomic nervous system's impact on cardiac function.

Purpose

Our research undertook a comparative analysis of echocardiographic parameters and HRV metrics derived from 24-hour Holter ECG, incorporating non-traditional measures such as acceleration capacity, deceleration capacity, and the triangular index. The objective was to ascertain whether a diminished triangular index or alterations in acceleration and deceleration capacities, in contrast to conventional HRV parameters, are associated with an elevated risk of cardiovascular mortality.

Methods

We enrolled 140 consecutive patients diagnosed with CHF, all of whom exhibited a left ventricular ejection fraction below 50%. Each participant underwent thorough echocardiographic examination alongside 24-hour Holter ECG monitoring.

Results

Our analysis of the correlation between the E/A ratio and HRV parameters identified significant associations with the Triangular Index (Spearman’s ρ = −0.233, p = 0.037), acceleration capacity (Spearman’s ρ = 0.226, p = 0.044), and deceleration capacity (Spearman’s ρ = −0.381, p < 0.001). These HRV parameters also demonstrated statistically significant relationships with the E/E' ratio: Triangular Index (Spearman’s ρ = −0.241, p = 0.031) and deceleration capacity (Spearman’s ρ = −0.230, p = 0.033), as well as with the E/E' septal ratio. Moreover, the mitral valve deceleration time showed notable associations with the Triangular Index (Spearman’s ρ = 0.251, p = 0.025), acceleration capacity (Spearman’s ρ = −0.293, p = 0.008), and deceleration capacity (Spearman’s ρ = 0.309, p = 0.005). A positive correlation was observed between estimated pulmonary artery systolic pressure and deceleration capacity. In contrast, no statistically significant relationships were found between the commonly used HRV parameters (SDNN, SDANN, and SDNN index) and echocardiographic parameters.

Conclusions

Less commonly utilized Holter ECG parameters, such as acceleration and deceleration capacity, along with the triangular index, demonstrated significant diagnostic efficacy, especially in scenarios where traditional HRV parameters remained within normal ranges. These findings underscore the importance of integrating non-traditional HRV metrics into the risk stratification processes for CHF patients. To substantiate their long-term prognostic value, further extensive multicenter studies are warranted.
Prognostic predictors in constrictive pericarditis, 19-year experience at a tertiary care hospital
Authors: Ayduk Govdeli E , Yavuz M L , Ercan C C , Bilge A K , Dursun M , Karaca Ozer P
Published: January 2025

Introduction

Constrictive pericarditis is a chronic inflammatory entity that may progress with thickening and calcification in the pericardial tissue, resulting in decreased pericardial elasticity and subsequent increase in ventricular filling pressures1,2. This rare treatable cause of HFpEF, is associated with various aetiologies, depending on the development level of the countries. Several algorithms have been developed for the diagnosis, whereas studies evaluating the prognostic factors are limited3–6. Our study aimed to examine the clinical, laboratory, electrocardiographic, imaging and catheterization parameters that determine the prognosis of constrictive pericarditis.

Methods

60 patients diagnosed with constrictive pericarditis based on echocardiography, computed tomography and right heart catheterization parameters were included retrospectively in the study. Clinical presentation, laboratory, and electrocardiographic findings were assessed. Volumetric measurement, tissue Doppler, mitral inflow velocity analysis, and pericardial evaluation were made via 2D echocardiography. Pericardial thickness, effusion, and calcium score were obtained via thorax CT, while right-sided pressure measurements were acquired via catheterization. The primary clinical outcome was determined as mortality, and the effect of these parameters was evaluated by Cox regression analysis.

Results

Median follow-up was 3.5 years (0-19) and mean age was 52.7 ±17.5 years. 38 of the patients (63.3%) were male, the most common aetiologies were malignancy (21.4%) and other systemic diseases (21.4%). 7 patients were lost to follow-up and 18 (31.6%) patients died during the process. When different models were evaluated with Cox regression analysis, ascites, hemoglobin and elevated proBNP values were prognostic predictors (HR 10.991 p-value 0.006, HR 0.513 p-value 0.010 and HR 3.904 p-value 0.045, respectively). ROC analysis indicated the highest AUC value for the model that included hemoglobin (AUC 0.953).

Conclusion

Constrictive pericarditis is one of the treatable causes of HFpEF. While imaging and catheterization parameters play a crucial role in the diagnosis, clinical and laboratory parameters affect the prognosis.