bluuebunny/crossref_metadata_2025 huggingface dataset:
Incidence trends and management of severe aortic valve stenosis in the community over 20 years of practice
Authors: Benfari G , Essayagh B , Michelena H , Zi Y , Medina Inojosa J , Ribichini F , Crestanello J , Messika-Zeitoun D , Prendergast B , Wong B , Thapa P , Enriquez-Sarano M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Severe aortic-stenosis (AS) is the guideline-based indication for aortic-valve-replacement (AVR) performance, which has markedly increased with transcatheter approaches, suggesting possible increasing AS incidence. However, reported secular trends of AS incidence remain contradictory, uncertain and lacking quantitative Doppler-Echocardiographic ascertainment. Thus, population-based trends in presentation, treatment and outcome are unknown.

Methods

All adults residents our County (MN,USA) diagnosed with incident (first-diagnosis) severe AS based on quantitative Doppler-Echocardiography (aortic-valve-area≤1cm2, aortic-valve-area-index≤0.6cm2/m2, mean-gradient≥40mmHg, peak-velocity≥4m/s, Doppler-velocity-index≤0.25) between 1997–2016, were accounted for and trends for incidence, presentation, treatment and outcome analysed.

Results

Incident severe-AS was diagnosed in 1069 community-residents over 20-years. Incidence-rate was 52.5[49.4–55.8] per 100.000 patient/year, slightly higher in male vs. female and was almost unchanged after age and sex adjustment for the US population 53.8[50.6–57.0] per-100000 residents/year. Over 20-years severe AS-incidence remained stable (p = 0.20) but absolute-burden of incident-cases markedly increased (p = 0.0004) due to population growth. Incidence-trend differed by sex, stable in men (incidence-rate-ratio 0.99, p = 0.72) but declining in women: (incidence-rate-ratio 0.93, p = 0.024). AS clinical-presentation, age, symptoms, comorbidity, ventricular size/function, valve-area-index, low-flow or low-ejection-fraction AS, remained stable. Over the study 20 years, AVR performance grew (1997–2001 to 2012–2016, at 3-month:14% to 21%, p = 0.02; at 1-year 19% to 33%,p<0.0001), and was more prompt (from 1.3[0.11–3.3]years in 1997–2001 to 0.48[0.15–2.11]years in 2013–2016, p = 0.001) but severe AS undertreatment remained prominent (>40%). Early-AVR (within 3-months) was associated with survival benefit (adjusted-hazard-ratio 0.55[0.42–0.71], p<0.0001) stable throughout the 20-years. Despite these improvements, overall mortality, 8.3% within 3-months, 17.8% within 1-year, 36% within 3-years, was swift, considerable and unabated (all p≥0.44) throughout the 20-year study.

Conclusion

Over 20 years, the population incidence of severe-AS remained stable with increased absolute case-burden purely related to population growth. Despite stable severe-AS presentation, AVR performance grew notably, but while declining, undertreatment remained substantial and disease-lethality did not decline. These findings have important population-health management implications.
Normal values of left atrial strain in 62–65 year old men and women from the general population
Authors: Solberg M , Enger S , Berge T , Ronningen P S , Aagaard E N , Pervez O , Orstad E B , Kvisvik B A , Lyngbakken M N , Rosjo H , Steine K , Tveit A
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): South-Eastern Norway Regional Health Authority

Background

Left atrial (LA) function is divided in a reservoir, a conduit and a contractile phase. LA reservoir and contractile function can be quantified through echocardiographic speckle tracking strain analysis and provide prognostic information in cardiovascular disease. Normal values are still not fully established for all age groups.

Purpose

To provide normal values of LA reservoir (LASr) and contractile (LASct) strain in men and women in their sixties.

Methods

We included 3,706 men and women, all born in 1950, from the general population in a prospective observational study. Study inclusion and baseline examination including echocardiorgraphy took place between 2012 and 2015. The echocardiographic images were assessed for LA strain analysis, and only participants with sinus rhythm during echocardiography, good image quality without LA foreshortening, and frame rates > 40/second were included. We further defined a healthy group without cardiovascular, cerebrovascular, pulmonary or renal disease. Values of LASr and LASct are presented as median and interquartile range (IQR), and the lower limits of normality (LLN) for LASr and LASct were defined as the 2,5th percentile value in the healthy group. We used Mann Whitney U-test to compare groups.

Results

Of 3,229 participants with available LA strain analyses, median age was 63.9 years and 50.0% were women. Healthy individuals (n=758) had a median LASr of 35.5% (IQR 29.6%-42.2%), which was significantly higher than the LASr of 33.1% (IQR 27.9%-39.4%) in non-healthy individuals (p<0.001). LASct was similar between the healthy and non-healthy individuals. Men and women of the healthy group had similar measures of LASr and LASct. The LLN of LASr was 21.9%, whereas LASct had a LLN of 9.0%, both similar for males and females.

Conclusion

We present normal values and limits of normality of LASr and LASct, similar between men and women, in 758 healthy individuals aged 62–65. We found LASr to be significantly higher in healthy compared to non-healthy individuals, whereas LASct was similar between the groups.
Ratio of aortic to left ventricle SSFP blood signal in a single 3-chamber view correlates with aortic stenosis severity
Authors: Vimalesvaran K , Zaman S , Howard J P , Zehra F , Ariff B , Bharath A , Cole G D
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): UK research and Innovation [UKRI Centre for Doctoral Training in AI for Healthcare].

Background

Aortic stenosis (AS) is the most common valvular heart disease in developed countries with prevalence increasing with age. CMR is an important tool for the evaluation of AS, co-existing aortic disease and concurrent myocardial abnormalities. Whilst a 3-chamber aortic valve view is standard for most cardiac protocols, a full evaluation of the aortic valve including short-axis cine imaging of the valve and flow imaging in the ascending aorta incurs additional time penalty and is not necessary for all patients. We noted that the SSFP signal of blood in the ascending aorta on a standard 3-chamber view was often reduced in those with aortic stenosis. Our aim was to compare the aortic to left ventricular (LV) blood ratio of SSFP signal with existing gold-standard imaging biomarkers of aortic stenosis.

Methods

Retrospective analysis of 53 patients with varying aortic stenosis severity. We manually measured a 1–2cm2 region of interest (ROI) in the aorta and LV in end-systole (Figure 1). We compared the signal intensity in the aorta ROI to the LV ROI (Ao:LV) with echocardiography parameters including dimensionless index (DI) and aortic valve maximum velocity (Vmax). Pearson correlation coefficient (R) was used to compare methods.

Results

Patients (n=53, median age 67 [24–91], 33/53 male) included none or trace AS (n=14), mild AS (n=12), moderate AS (n=8) and severe AS (n=19) according to echocardiography. Median time between CMR and echocardiography was 43 days [1–917]. There was a reasonable correlation (R=0.785, −0.771 respectively) between blood Ao:LV ratio of SSFP signal with DI and Vmax (Figure 2).

Conclusion

The ratio of blood signal seen in SSFP 3-chamber cine images gives a reasonable approximation to aortic stenosis severity measured using gold-standard echocardiography strategies. It is potentially automatable and may allow identification of the subset of patients whose scans would be enhanced by need of dedicated aortic valve imaging.
Optimal timing of late gadolinium enhancement imaging in patients undergoing CMR for suspected pericarditis: the later the better?
Authors: Moutzoukis G , Oberli L , Bekeredjian R , Mahrholdt H , Seitz A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pericarditis is frequently encountered in daily clinical practice and accounts for about 5% of chest pain hospital admissions [1]. Although the diagnosis of pericarditis can be established by clinical criteria, cardiovascular magnetic resonance (CMR) imaging is increasingly used to evaluate concomitant myocardial involvement and/or to exclude other disease entities. Besides well-known morphologic findings like pericardial effusion, thickening or adhesion, pericardial late gadolinium enhancement (LGE) imaging has been demonstrated to be the most sensitive surrogate of pericarditis [2].

Purpose

While there is a lot of data regarding the optimal timing of LGE for the detection of myocardial damage, optimal timing of LGE for the detection of pericarditis is unknown. In the recent advent of rapid high-throughput CMR protocols, high diagnostic accuracy needs to be maintained not only for myocardial diseases, but also for the assessment of the pericardium.

Methods

We present a case series comparing pericardial contrast enhancement in rapid routine LGE images versus LGE images acquired following a longer waiting time after Gadolinium injection (gadoteridol).

Results

After a longer than rapid clinical routine waiting time, we observed more prominent pericardial signal enhancement in the setting of pericarditis. This effect is most likely explained by different pericardial Gadolinium distribution kinetics compared to the myocardium.

Conclusion

Consequently, this observation should be taken into account when imaging patients with suspected pericarditis and may warrant further evaluation.

Figure: Routine LGE timing (top row) versus delayed LGE timing (bottom row) in 4 patients with pericarditis undergoing CMR

Exemplary LGE images in the top row were acquired routinely after ∼10 min. from contrast administration (0,15mmol/Kg), whereas same LGE slices in the bottom row were additionally acquired after a delayed waiting time (∼20 min.) from contrast injection (0,15mmol/Kg). Pericardial LGE was more prominent in delayed LGE imaging compared to routine LGE imaging.
Are artificial intelligence derived coronary atherosclerotic characteristics associated with subsequent development of acute coronary syndrome (ACS)
Authors: Rodriguez Ruiz C , Hermel M , Miller G , Chang C W , Salerno M , Van Rosendael A , Epstein E , Joye C , Spierling Bagsic S R , Newlander S , Bhavnani S , Robinson A , Gonzalez J , Wesbey G E
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Scripps Health Krueger Wyeth Grant

Background

ACS results from unstable atherosclerotic plaques. Current measures to assess risk do not consider the patient’s coronary atherosclerotic composition. This was a case control study using a prospective single-center registry of patients undergoing CCTA (N=2,700) from 2017–2020 to assess the association between plaque characterization and the occurrence of ACS.

Methods

ACS cases were adjudicated independently by two cardiologists using data from the EMR. Patients with prior ACS prior to CCTA, were excluded. Controls were selected 1:1 by nearest neighbor propensity matching (R. v. 4.0.3.) based on age, sex, smoking, HTN, HLD, and DM. Plaque burden and stenosis features were calculated by a commercially available artificial intelligence (AI) coronary analysis (Figure 1).

Results

There were 21 cases and 21 controls. Mean age of 68, 43% women, 5% Hispanic, 29% smoking hx, 76% HTN, 81% HLD, 24% DM, CAD-RADS score 2.3, and CAC of 487. Median time from CT to ACS for cases was 329 days. Presence of total non-calcified plaque, calcified plaque, fibro-fatty plaque, maximum stenosis diameter percentage and total plaque were each associated with greater risk of ACS (Table 1).

Conclusion

AI assessment of CCTA plaque characteristics were associated with ACS. This study shows the association between AI derived coronary atherosclerotic features and development of ACS in patients undergoing CCTA and highlights the potential utility of using AI-driven plaque characterization to predict ACS.
Clinical and prognostic implications of cardiopulmonary exercise stress echocardiography in asymptomatic degenerative mitral regurgitation
Authors: Althunayyan A , Alborikan S , Badiani S , Wong K , Uppal R , Patel P , Petersen S , Lloyd G , Bhattacharyya S
Published: June 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Saudi Arabian Cultural Bureau.

Background

Current guidelines recommend intervention in severe degenerative mitral regurgitation (MR) in symptomatic patients or asymptomatic patients with left ventricular dilatation or dysfunction. The insidious onset of symptoms may mean patients do not report symptoms. The role of systematic exercise testing for symptoms in MR is not clearly defined.

Methods

97 patients with moderate to severe, asymptomatic MR underwent exercise echocardiography combined with cardiopulmonary exercise testing. Predictors of exercise-induced dyspnoea, symptom-free survival and mitral valve intervention were identified.

Results

18 (19%) patients developed limiting dyspnoea on exercise. Spontaneous symptom free survival at 24 months was significantly higher in those without exercise-induced symptoms compared to those with exercise-induced symptoms, p <0.0001. The only independent predictors of spontaneous symptoms at 2 years were effective regurgitant orifice area (odds ratio 27.45 (95% CI 1.43 – 528.40), p = 0.03) and exercise-induced symptoms (odds ratio 11.56 (95% CI 1.71 – 78.09), p = 0.01). The only independent predictor of surgery was indexed left ventricular systolic volumes (Odds ratio 1.17 (95% CI 1.04 – 1.30), p = 0.006). Where only patients undergoing surgery due to symptoms were included, the only independent predictor was exercise-induced symptoms (Odds ratio 13.94 (95% CI 1.39 – 140.27), p = 0.025).

Conclusion

In patients with primary asymptomatic degenerative MR, one fifth develop symptoms on exercise. This predicts subsequent development of spontaneous symptoms and mitral valve intervention due to symptoms.
Echocardiographic parameters analysis in acute pulmonary embolism: what is the prognostic value in the real-world setting?
Authors: Duarte F , Oliveira L , Coutinho I , Barradas M I , Monteiro A , Machado C , Dourado R , Martins D
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transthoracic echocardiogram performed after the diagnosis of acute pulmonary embolism is used for risk stratification. The individual prognostic value of the echocardiographic parameters and its association with the clinical data is still being studied.

Objective

To determine the impact of echocardiographic parameters (TAPSE, PSAP e TAPSE/PSAP), as well as its association with the clinical evaluation in the patient’s prognosis.

Methods

Single centre retrospective study, evaluating 131 patients admitted by acute pulmonary embolism between January 2017 and December 2020. Mean age was 67.6 ± 15.3 years, 38 patients were male (29.0%). The patients were stratified according to the European Cardiology Association (ESC) early mortality risk classification in high or intermediate-high risk (group A) and low or intermediate low risk (group B). The correlation with echocardiographic parameters was evaluated. In-hospital mortality at 30 days and 1 year was determined.

Results

Group A included 27 patients (20.6%) and group B 104 patients (79.4%), with no difference regarding demographic and clinic characteristics between both groups. In group A the mean PSAP was 49.4 ± 22.8 mmHg, TAPSE 14.7 ± 5.2 mm and TAPSE/PSAP 0.3. In group B the mean PSAP was 34.6 ± 16.8 mmHg, TAPSE 20.9 ± 4.5 mm and TAPSE/PSAP 0.7. The ROC analysis shows PSAP has good discriminative power for risk stratification (AUC 0.716; p = 0.017 95% CI 0.56 – 0.87), with a cut-off point at 35 mmHg. The TAPSE/PSAP ratio has an excellent discriminative power (AUC 0.873, p value 0.001, CI 95% 0.767 – 0.978), with a cut-off point of 0.3.

In-hospital mortality was 8.4% (11 patients), 30-day mortality was 12.2% (16 patients) and 1-year mortality was 19.8% (26 patients). There was no difference regarding mortality between groups A and B. Comparing PSAP and TAPSE/PSAP ≤ 0.3, only the latter was correlated with mortality at 1 year (p = 0.021).

The addition of TAPSE/PSAP ≤ 0.3 to ESC classification for each group had a significant impact on mortality at 1 year (p = 0.004).

Conclusion

The addition of TAPSE/PSAP ≤ 0.3 to risk scores in groups A and B confers relevant prognostic information on long-term mortality. When available, the addition of echocardiographic parameters to the clinical data could add relevant prognostic value.
Left ventricular ejection fraction and functional capacity: insights from cardiopulmonary exercise testing
Authors: Duarte F , Ricardo I , Faria C , Silva P , Cunha N , Miguel S , Pinto R , Pinto F , Abreu A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac rehabilitation program (CRP) is a multidisciplinary intervention tailored to improve functional fitness in different cardiovascular conditions. Patients with reduced left ventricular ejection fraction (LVEF) are commonly unrepresented hence the impact of LVEF on functional fitness is uncertain.

Purpose

To evaluate changes on functional capacity in a cohort of patients referred to a CRP, according to baseline LVEF.

Methods

Tertiary-center retrospective analysis of patients referred to an exercise-based phase II CRP. To be enrolled patients had to complete a 12-weeks CRP and to perform a symptom-limiting cardiopulmonary exercise test (CPET), at the beginning and at the end of the program. Patients were stratified into a reduced (LVEF < 45%) or preserved (LVEF ≥ 45%) group. Four CPET parameters were evaluate: peak oxygen uptake (pVO2), predicted-pVO2 (ppVO2), O2 pulse and VE/VCO2 slope.

Results

127 patients (mean age 57.8 ± 11.2 years; males 79.5%) were eligible for CRP, of which 86.6% were referred following an acute coronary event. Patients included in the reduced LVEF group (38.6%; mean LVEF 31% ± 8.1) had more dyslipidemia (48.8% vs 22.8%, p = 0.013), atrial fibrillation (24.5% vs 7.7%, p = 0.008) and implanted electronic devices with defibrillator (30.6% vs 2.6%, p<0.001).

Regarding CPET parameters, reduced LVEF patients had a lower pVO2 (mean dif 2, p = 0.048), ppVO2 (mean dif 12.1%, p<0.001) and O2 pulse value (mean dif 2, p = 0.049) vs higher values of VE/VCO2 slope (mean dif 2.9, p = 0.036). The Weber and ARENA classifications analysis revealed similar distribution between groups: 24.4% of reduced vs 27.5% of preserved patients entering CRP had a low Weber class (C or D). Higher ARENA class (III-IV) included 28.5% of patients with reduced and 14.1% with preserved LVEF.

At the end of the rehabilitation program, changes on CPET parameters were similar between reduced and preserved groups: ppVO2 increased by 4% vs 3.2% (p = 0.808), O2 pulse increased about 0.7 vs 0.5 mL/beat (p = 0.509) and VE/VCO2 slope reduces 1.7 vs 0.3 (p = 0.232). As a continuous variable, LVEF did not predict Weber´s (p = 0.546) or ARENA (p = 0.393) class changes. Yet, those with a reduced baseline LVEF derived a greater LVEF improvement after CRP (Δ 10.2 ± 9.8 vs Δ 2.2 ± 7.9; p<0.001)

Conclusions

All patients enrolled in CRP show improvement of exercise capacity irrespective of baseline LVEF. Thus, patients with reduced LVEF should not be denied for cardiac rehabilitation and a significant LVEF improvement is expected.
Association of AI derived right ventricular function with all-cause mortality in patients referred for routine cardiovascular magnetic resonance
Authors: Rizvi M , Ruijsink B , Puyol-Anton E , Mariscal-Harana J , King A , Carr-White G , Razavi R
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering at King’s College London (WT 203148/Z/16/Z), the National Institute for Health Research (NIHR) Cardiovascular MedTech Co-operative award to the Guy’s and St Thomas’ NHS Foundation Trust, and the London AI Center, funded through the UK Research and Innovation (UKRI) and the Department of Health and Social Care (DHSC), Office of Life Sciences, delivered through Innovate UK.

Background

Right ventricular (RV) function is an important prognostic marker in assessment of cardiovascular disease. Artificial Intelligence (AI) based quantification of RV function has been validated against ground truth metrics however their relationship to outcomes is not yet well defined.

Purpose

To evaluate the relationship between RV biomarkers obtained using our validated AI tool, AI-CMRQC with all-cause mortality in patients who underwent routine cardiovascular magnetic resonance (CMR).

Methods

3,108 routine clinical CMR scans, performed between 2016 and 2020 were retrospectively analysed using AI-CMRQC (1) to obtain RV function parameters of end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV) and ejection fraction (EF). All-cause mortality and date of death were obtained from hospital electronic records and Personal Demographics Service from the Office for National Statistics (ONS). Cox proportional hazard risk models were used to derive hazard ratios for measuring association between RV function and all-cause mortality. All variables were stratified based on upper or lower limits of reference values (2), RVEF <50% or >50%, EDV >217ml males, >175ml females, ESV >91ml males, >75ml females, SV <71ml males, <56ml females.

Results

The distribution of mean values (±SD) of RV parameters were EDV 166.14 ± 0.83ml, ESV 77.83 ± 0.57ml, SV 88.3 ± 0.45ml and EF 55.9 ± 0.17%. The median follow up duration was 3.4 years. On univariate analysis, ejection fraction [Hazard Ratio (HR) 2.903 (95% Confidence Interval [CI] 2.197 to 3.834] and stroke volume [HR 3.385 (95% CI 2.534 to 4.522)] were significant predictors of mortality. After adjustment for covariates of left ventricular function (LVEF, LVEDV, LVESV) RVEF remained an independent predictor of mortality.

Conclusions

Automated RV ejection fraction is significantly associated with all-cause mortality in patients undergoing routine CMR.
The role of novel echocardiographic indices in the identification of myocardial injury in patients with NSTEMI
Authors: Karakosta M , Ntiloudi D , Miaris N , Katsillis N , Mitsiadis S , Maritsa D , Arnas N , Vasileiadou A , Destounis A , Kalesi A E , Zachos P , Theodosis-Georgilas A , Pisimisis E , Kasinos N
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction / Purpose

Early detection of myocardial injury in patients with myocardial infarction presenting without persistent ST elevation (NSTEMI) is crucial for prognosis estimation. The purpose of this study is the assessment of novel echocardiographic indices in the detection of myocardial injury in patients with NSTEMI and normal left ventricular ejection fraction (LVEF).

Methods

In this case-control study, patients with NSTEMI (18 to 80 years old) who were examined at the echocardiography laboratory of our general hospital, from May 2021 until August 2022, and controls were enrolled. All patients had no former history of cardiac disease or other significant comorbidities, and they all had LVEF ≥55% and normal wall motion score index. After coronography all of them were diagnosed with significant coronary artery disease. Among the novel echocardiographic indices, global longitudinal strain (GLS), and the parameters of myocardial work, global work index (GWI), global constructive work (GCW), global wasted work (GWW) και global work efficiency (GWE) were examined. Τ - test was used to compare the means of the variables, since the distributions were normal, and a p value <0.05 was considered statistically significant.

Results

The participants of the study were 34 patients with NSTEMI (26 males), of mean age 60.1 years (SD 10.5 years) and 25 healthy volunteers (19 males), of mean age 52.5 years (SD 7.5 years). For the patients, mean |GLS| was 17.9% (SD 2.2), GWI 1957.7mmHg% (SD 368.2), GCW 2231.0mmHg% (SD 380.5), GWW 141.7mmHg% (SD 79.4) and GWE 92.2% (SD 3.8) (Table 1). As for the volunteers mean |GLS| was 20,6% (SD 2.2), GWI 2179.4mmHg% (SD 407.4), GCW 2409.9mmHg% (SD 406.1), GWW 93.2mmHg% (SD 64.4) and GWE 95.5% (SD 2.7). Patients with NSTEMI showed significantly lower values of GLS (p<0.01), GWI (p = 0.033) and GWE (p = 0.01) compared to healthy volunteers (Diagrams). Also, their GWW values were higher (p = 0.015) compared to volunteers. No statistically significant difference was found in the GCW values.

Conclusion

Novel echocardiographic indices were able to identify myocardial injury, even in patients presenting with NSTEMI and normal LVEF.
Left atrial deformation discloses atrial amyloid infiltration among patients with increased myocardial thickness
Authors: Edbom F , Lindqvist P , Anan I , Pilebro B , Arvidsson S
Published: June 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Swedish research council

Swedish heart and lung foundation

Background

Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative disease with thickening and stiffening of the heart walls as a result. Amyloid deposits are found not only in the ventricular walls, but in the atriums as well. Atrial function is known to play an integral part in the overall function of the heart.

Purpose

We aimed to evaluate left atrial deformation including left ventricular-atrial strain loop (LV-LA loop). The latter to test LA deformation and its dependence of LV deformation in ATTR CA and compare it to left ventricular hypertrophy (LVH).

Methods

Retrospective analysis was performed on available echocardiographic data, obtained between years 2004–2022. The study population was divided into three groups: healthy controls with no identified cardiac disease; ATTR-CA patients with verified ATTR-CA diagnosis and interventricular septal thickness end diastole (IVSd) of ≥14mm; LVH including IVSd ≥14mm and no CA diagnosis. Left heart strain measurements, including LV global longitudinal strain (LV GLS) and LA peak atrial longitudinal strain (LA PALS), were acquired from apical 4-chamber view during same single heart cycle. Strain coordinates throughout the heart cycle were plotted using MATHLAB, combining LV GLS and LA PALS to compute a strain-strain loop. A slope was determined using regression line to index relative function of the left ventricle to left atrium (GLS-PALS-slope).

Results

Data was gathered in total of 90 patients (67.8±1.2 years, 55,6% male) divided into three groups containing 30 patients each: ATTR-CA including 24 hereditary ATTR (including mutations; 19 Val30Met, one The60Ala, one Val122Ile, one Ala45Glys, one Ala97Ser and one His88Arg) and six wild type ATTR, LVH with increased myocardial thickness believed caused by aortic stenosis (n=13; one grade I, three grade II-III and eight grade III), essential hypertension (n=10) and hypertrophic cardiomyopathy (n=7, four of which had outflow obstruction). The lowest PALS and PALS-GLS slope was detected in ATTR-CA (p-value 0.005 respectively 0.003 between ATTR-CA compared to LVH). No significant statistical difference could be verified in GLS between ATTR-CA and LVH (p-value 0.114). A ROC curve of ATTR-CA demonstrated similar results between PALS and GLS-PALS slope (AUC 0.79 resp. 0.78) which was slightly higher than GLS (AUC 0.69). Slightly higher AUC was generated when slope was indexed with LAVI (AUC 0.80).

Conclusions

LA deformation demonstrates a strong ability to differentiate ATTR-CA from LV hypertrophy. Adding LV strain in relation to LA deformation showcases the mechanical dissociation of LA to LV in ATTR-CA, potentially unmasking atrial infiltration. Its use in prognostic evaluation needs further studies.
Quantification of extracellular volume with cardiac computed tomography in patients with left ventricle dysfunction
Authors: Baggiano A , Fusini L , Mushtaq S , Annoni A , Formenti A , Mancini E , Fazzari F , Volpe A , Tassetti L , Maragna R , Junod D , Gaudenzi M , Conte E , Guaricci A I , Pontone G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial fibrosis (MF) is a common endpoint in the majority of pathological mechanisms affecting cardiac muscle, ultimately resulting in cardiac failure. Cardiovascular magnetic resonance (CMR) with gadolinium-based contrast agent and T1 mapping technique is able to deliver a non-invasive quantification of the extracellular volume (ECV) expansion. Recently, ECV estimation with cardiac computed tomography (ECV-CCT) has been validated in the setting of cardiac amyloidosis, showing good agreement with ECV-CMR. However, no evidence is available with last generation single source single energy CT scanner in the clinical context of newly diagnosed left ventricular dysfunction. Therefore, the aim of this study is to test the diagnostic accuracy of ECV-CCT for the detection of MF in patients with recent diagnosis of reduced left ventricle ejection fraction (LVEF), having ECV-CMR as reference technique.

Methods

A consecutive cohort of 41 patients with newly diagnosed left ventricle dysfunction (LVEF < 50%) was enrolled. Time interval of maximum 30 days was present between CCT and CMR. Myocardial segment evaluability with each technique, agreement between ECV-CMR and ECV-CCT, regression analysis and Bland-Altman analysis were performed.

Results

Age of enrolled patients was 62 ± 11 years, and mean LVEF at CMR was 35.2 ± 10.7%. Mean total amount of administrated iodinated contrast was 112.6 ± 22.2 ml, while overall radiation exposure for ECV estimation was 2.1 ± 1.1 mSv. Out of 656 myocardial segments available, 656 (100%) segments were evaluable at CCT while 640 (97.6%) were evaluable at CMR. ECV-CCT demonstrated slightly lower values compared to ECV-CMR both at global and region-based comparison (all segments, 33.1 ± 8.5% vs 35.5 ± 10.7%, p < 0.001). At regression analysis, strong correlations were described both at global and region-based analysis (all segments, r = 0.877, 95%CI: 0.840 to 0.914). On Bland-Altman analysis, bias between ECV-CMR and ECV-CCT for global analysis was 2.4 (95%CI: −7.8 to 12.7).

Conclusions

ECV estimation with last-generation single source single energy CT scanner is feasible and accurate. Integration of ECV measurement in comprehensive CCT evaluation of patients with newly diagnosed left ventricular dysfunction can be performed with a small increase in overall radiation exposure.
Choosing between coronary CT angiography and functional tests in patients with suspected coronary artery disease - mind the (gender) gap
Authors: Paiva M , Presume J , Freitas P , Lopes P M , Gomes D A , Santos R R , Guerreiro S , Abecasis J , Santos A C , Saraiva C , Mendes M , Ferreira A M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

There is a need for a simple method to choose between a functional vs. anatomical test as first line approach to patients with suspected coronary artery disease (CAD). While European Guidelines base the decision on pretest probability (PTP) without a clear threshold, American Guidelines rely uniquely on age, with a 65-year-old cut-off for both genders.

The aims of this study were: 1) to assess the proportion of patients undergoing coronary CT angiography (CCTA) in whom a functional test could have been more suitable due to extensive coronary artery calcification (CAC) and/or inconclusive CCTA results; 2) compare PTP vs. age to predict the presence of these suboptimal conditions for CCTA.

Methods

Individuals 40–80 years old were identified in a single center registry of patients with stable chest pain or dyspnea who underwent CCTA. Patients with known CAD, severe valvular disease, or irregular heart rhythms were excluded. PTP of obstructive CAD was calculated using age, sex, and symptom typicality.

Patients were considered to have suboptimal conditions for CCTA if extensive CAC was present (defined conservatively as an Agatston score >400) or if one or more segments >2mm were deemed non-evaluable despite CAC score ≤ 400.

Results

A total of 884 patients (57% women, mean age 62±10 years) were included. Symptoms consisted of chest pain in 705 patients (80%). The median PTP of obstructive CAD was 22% (IQR 14–32).

Overall, 162 patients (18%) had suboptimal conditions for CCTA due to CAC score >400 (n=140), or ≥1 non-evaluable segments (n=22). The proportion of patients with suboptimal conditions for CCTA was significantly higher in men than in women (27% vs. 12%, respectively; p<0.001). For both genders, the discriminative power to predict suboptimal CCTA conditions was significantly higher for age than for PTP (c-statistic in men 0.74 vs. 0.64, p<0.001; in women 0.71 vs. 0.62, p = 0.012). In every age group, the proportion of patients with suboptimal conditions for CCTA was at least 2 times higher in men than in women, with a 10–15 year gap between genders - Figure 1.

Conclusion

Suboptimal conditions for a fully diagnostic CCTA were found in 18% of patients, were more strongly associated with age than with PTP, and were at least 2 times more frequent in men than in women across all age groups. These findings support the use of an age cut-off for anatomical vs. functional testing in men, and the use of CCTA as first line test in most women regardless of age.
Evolution and prognostic value of left ventricular deformation and myocardial work parameters in Transthyretin Amyloid Cardiomyopathy
Authors: Antonelli J , Curtis E , L'official G , Kosmala W , Donal E
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Wild-type transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized condition. Prognosis is related to early diagnosis and treatment. It remains clinically challenging to estimate the risk for many patients at the time of the diagnosis. Myocardial work is a novel echocardiographic tool that improves the characterization myocardial impairment.

Objective

We sought to investigate the evolution in time and prognostic value of myocardial deformation and myocardial work parameters, in ATTR-CM patients.

Method

We analyzed clinical, electrocardiographic, biological, and echocardiographic characteristics in 113 consecutive patients (median age 82 [77–85], 90,4 % men) diagnosed for a wild-type ATTR-CM based on international consensus. Baseline and 18-months follow-up evaluations were taken into account. All the data came from a single center and all the images were recorded on the same platform (Ve95, GE-healthcare).

Results

Thirty-four patients died and twelve were hospitalized for heart failure at a median follow-up of 935 days (IQR 691–1159 days). Eighty-six patients were treated with Tafamidis.

Left ventricular end-diastolic diameter and thickness, left atrial strain during reservoir phase (LASr), Global, Apical and Basal Longitudinal Strain, Global Work Index (GWI), Global Constructive Work, and TAPSE significantly decreased from baseline to 18 months. Left ventricular Ejection Fraction (LVEF), Right Ventricular Free Wall Strain, Global Wasted Work (GWW) and Global Work Efficiency (GWE) did not alter significantly.

Using a multivariate analysis, two parameters could be highlighted for their prognostic value on baseline evaluation: GWW and Global Longitudinal Strain (GLS) were significantly associated with the risk of death and/or hospitalization for heart failure. Patients treated with Tafamidis had a significantly better survival.

Conclusion

GLS and Myocardial Work parameters, particularly GWW, might be used to improve the risk assessment of major events in ATTR-CM patients. The LV strain and myocardial work-based echocardiographic follow-up might be useful in this condition.
Routine 4D Cardiac Computed Tomography to Identify Concomitant Transthyretin Amyloid Cardiomyopathy in TAVI candidates with Severe Aortic Stenosis
Authors: Graeni C , Bernhard B , Leib Z , Dobner S , Caglayan D , Caobelli F , Rominger A , Grogg H , Pilgrim T , Windecker S , Stortecky S
Published: June 2023

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Bangerter-Rhyner Foundation, Pfizer, GAMBIT foundation.

Background

Transthyretin amyloid cardiomyopathy (ATTR-CM) may coexist in patients with severe aortic stenosis (AS) considered for transcatheter aortic valve implantation (TAVI). The diagnosis of ATTR-CM by 99mTechnetium-3,3-diphosphono-1,2-propanodicarboxylic-acid (DPD)-scintigraphy is costly, whereas endomyocardial biopsy is associated with relevant procedural risks and sampling error.

Objectives

To evaluate whether ATTR-CM may be diagnosed by routine 4D cardiac computed tomography (4DCCT).

Methods

In a prospective screening study for ATTR-CM, the diagnostic performance of 4DCCT-based left- (LV), right ventricular (RV) and left atrial (LA) dimensions, ejection fraction (EF) and myocardial strain was evaluated against DPD-scintigraphy to identify ATTR-CM. Diagnostic predictors and a newly developed 4DCCT-score were validated by internal bootstrapping.

Results

Among 263 patients considered for TAVI (57% males,age 83±4.6 years) undergoing 4DCCT, DPD-scintigraphy (Perugini grade 2–3) confirmed co-existing ATTR-CM in 27 (10.3%) patients. Patients with ATTR-CM had impaired 4DCCT-based LVEF, LV global longitudinal strain (GLS), and LA-GLS. LV mass index, LV-GLS, LA-GLS and relative apical longitudinal strain (ratio of apical to basal/midventricular strain), each predicted the presence of ATTR-CM with an area under the curve (AUC) of >0.7. Implementing these parameters with cutoff-values of ≥81g/m2, ≥-14.9%, <11.5% and ≥1.7 in an unweighted score yielded high prognostic accuracy (AUC=0.89; 95%CI:0.81–0.94;p<0.001), robust to internal bootstrapping validation (AUC=0.88;95%CI:0.82–0.94). If two criteria were fulfilled, sensitivity and specificity to detect ATTR-CM were 96.3 and 58.9%, respectively.

Conclusions

Clinically indicated, routine 4DCCT in patients considered for TAVI provides high diagnostic yield to detect concomitant ATTR-CM, by assessing LV- and LA-GLS, LV relative apical longitudinal strain and LV mass index.
Prognostic value of coronary CT angiography derived fractional flow reserve in patients with myocardial infarction
Authors: Boussoussou M , Edes I , Nowotta F , Vattay B , Vecsey-Nagy M , Drobni Z S , Simon J , Kolossvary M , Nemeth B , Jermendy A , Becker D , Leipsic J , Maurovich-Horvat P , Merkely B , Szilveszter B
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

We sought to analyze whether invasive fractional flow reserve (FFRi) values of non-infarction related (non-IRA) lesions change over time in ST Elevation Myocardial Infarction (STEMI) patients and to evaluate the diagnostic performance of coronary CT angiography derived FFR (FFRCT) close to the index event for defining follow-up FFRi.

Methods

We prospectively enrolled 38 multi-vessel STEMI patients (mean age 61.6±9 years, mean body mass index 28.8±4.8 kg/m2, 23.1 % female) who underwent non-IRA baseline and follow-up FFRi measurement and during the 10-day period after the index event FFRCT measurement. Follow-up FFRi was performed in 45–60 days after the index event and staged percutaneous coronary intervention (PCI) was carried out if FFRi was ≤0.8 at follow-up.

Results

Mean FFRi values showed significant difference between baseline and follow-up (0.83±0.11 vs. 0.80±0.13 p = 0.04, respectively). Mean FFR-CT was 0.79±0.14. Stronger correlation and smaller mean bias was found between FFR-CT and follow-up FFRi (ρ=0.86, p<0.001, bias: 0.01) as compared with baseline FFRi (ρ=0.68, p<0.001, bias: 0.04). The overall accuracy was 94.7% with 100.0% sensitivity and 90.0% specificity for identifying lesions ≤0.8 on follow-up FFRi. Accuracy, sensitivity and specificity were 81.5%, 93.3% 73.9%, respectively for identifying lesions on baseline FFRi using FFR-CT.

Conclusion

Non-invasive assessment of FFR at hospital discharge after the acute event lead to a better diagnostic performance for the identification of hemodynamically relevant non-IRA lesions as compared with baseline FFRi. FFRCT might improve decision making by selecting the patients for staged PCI in patients with multi-vessel STEMI.
Sex-specific differences in cardiac damage among patients undergoing TAVI
Authors: Myagmardorj R , Nabeta T , Galloo X , Meucci C M , Butcher S , Van Der Kley F , Ajmone Marsan N , Bax J J
Published: June 2023

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): EACVI Training Grant App000073275.

Background

Aortic stenosis (AS) is the most common valvular heart disease in developed countries and when indicated can be treated with transcatheter aortic valve implantation (TAVI). Recently, a cardiac damage staging (including the left ventricle, the left atrium and mitral regurgitation, the pulmonary pressures and tricuspid regurgitation, and finally the right ventricle, Figure 1) has been proposed in severe AS to optimize risk stratification, but there is still paucity of data about potential sex-differences for this classification.

Purpose

to identify differences between men and women in cardiac damage before and after TAVI, and evaluate the potential prognostic value.

Methods

A total of 734 patients with severe AS undergoing TAVI were included. Demographic and clinical data were collected before TAVI. Echocardiography was performed before and 6 months after TAVI, and patients were hierarchically classified in a given cardiac damage stage (worst stage) if at least one of the proposed criteria was met (Figure 1). The primary endpoint was all-cause mortality at long-term follow-up (3.2 years ± 1.3 starting from the 6 months follow-up echocardiography).

Results

At baseline women (n=334, 45%) were older (81.3 ± 6.7 years vs 78.5 ± 7.7 years, p<0.0001), had fewer cardiovascular risk factors but higher heart rate and blood pressure compared to men. By echocardiography before TAVI, cardiac damage distribution was overall comparable (p = 0.056) between men and women although women showed higher percentage of patients in stage 3 (p<0.05, Figure 2). After TAVI, an improvement in cardiac damage staging was observed with less patients in stage 3 and 4, but a significant difference (p<0.0001) was observed between men and women, having women still more patients in stage 3 (p<0.05) and men more patients in stage 4 (p<0.05) (Figure 2). During long-term follow-up, 206 events occurred (n=79 in women and n=127 in men) and Kaplan-Meier curve analysis illustrated that women had better survival than men (Log-rank p = 0.018; Chi-square 5.642) after TAVI. However, in the multivariate cox regression analysis, at each increment of cardiac damage stage women had higher increased risk for all-cause mortality (HR 1.480, CI 1.143–1.914, p = 0.003) as compared to men (HR 1.206, CI 1.002–1.451, p = 0.003) after adjusting for significant clinical covariates.

Conclusions

Women and men with severe AS present different cardiac damage staging namely after treatment with TAVI. Although women show better survival after TAVI, cardiac damage staging is of important prognostic value in both sex.
Complex myocardial mechanics in adult patients with repaired TOF- A novel study assessing myocardial work and mechanical dispersion at rest and during exercise
Authors: Alborikan S A , Vonklemperer K V , Badian S B , Prista Monteiro R M , Vonklemperer K V , Althunyyan A T , Bhattacharyya S B , Lloyd G L
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Assessment of LV myocardial work (MW) and biventricular mechanical dispersion (MD) in patient with repaired TOF (rTOF) is novel. We sought to investigate the LV MW and biventricular MD response during stress echocardiography.

Methods

We analysed MW and MD at baseline and at low exercise intensity for 100 adult patients with repaired TOF, 60 patients with severe pulmonary regurgitation (SPR), and 40 patients with negligible PR (NPR). MW was derived as the area of pressure strain loop using speckle tracking echocardiography and blood pressure. MD was derived as the SD of time Q/R wave on ECG to peak longitudinal strain and expressed in millisecond.

Results

Reduced MW indices were observed in the entire population with mean global work efficiency (MWE) was 85±7%. Overall mean of global work index (GWI) was 1198±312mmHg%, 1701±303mmHg% for global constructive work (GCW), and 293±194mmHg% for global wasted work (GWW). The SPR group had lower MWE, lower GCW and higher GWW. During exercise, overall ΔMWE decreased by −2±10%, ΔGWI increased by 36±43%, ΔGCW increased by 68±40%, and ΔGWW increased by 120±110%. Overall resting mean value of RVMD was 46±18,ms, while 64±11,ms for LVMD, and higher values were observed during exercise. Changes in MWE, MWW, and LV and RVMD were closely associated with peak oxygen uptake (r=.33, r=.41, r=.36, r=.47, p<0.001).

Conclusions

LV MW indices are reduced and biventricular MD are pronounced in rTOF patients. Augmentation of MW parameters and timing were associated with objective exercise ability, suggesting that they are potential determinants of cardiopulmonary capability.
Cardiac phenotype of propionic acidemia in the Amysh community
Authors: Lopez Sainz A , Snyder C , Rozema T , Wenger O , Smith B , Morton D H , Ammous Z , Smith J , Bijnens B , Chowdhury D
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Propionic acidemia (PA) is an organic acid disorder with poorly described cardiac phenotype despite progressive important cardiac remodeling and causes of death including congestive heart failure and sudden cardiac death, often in a setting of vigorous exercise or stress. Cardiac modifications begin at cellular level, both metabolic and lipid depositions, resulting in overall changes in shape, size, geometry and function, with ventricular dysfunction and risk for arrhythmias at young age.

Purpose

Echocardiographic assessment of left ventricular (LV) shape and timing (especially the Isovolumic contraction time (IVCT)) can help us understand the pathophysiology during the remodeling process in this rare disease.

Methods

We included all the PA patients from the Amish plain Community seen in our center. Clinical data, including demographics, ECG and echo measurements were recorded.

Results

We included 22 patients, who were homozygous for the pathogenic variant for PA, (59% males, 20.3± 13.3 years old). ECG analysis showed mild tachycardia (92 ± 30bpm) with normal QRS (84± 18 msec) and QTc segments duration (424± 31 msec). Echocardiography demonstrated a globular LV with dilated base and apical segments, normal systolic function, and normal diastolic function. The Global Longitudinal Strain was mildly decreased (GLS −17±3.08) with a dispersion of the regional strain with apical sparing. (Figure 1). The mean LV IVCT (75 msec) was longer compared to mean RV IVCT (69 msec, Figure 1).

Conclusion

Patients with PA present with very specific remodeling, including an increase in sphericity of the heart and slightly decreased GLS with normal EF. The very long LV IVCT suggests a problem with pressure generation, potentially as a marker of decreased LV contractility, either at cellular level or with activation-contraction coupling. Together with the difference in timings between the LV and RV this might become a substrate for life-threatening arrhythmias. A contractility problem, together with the exercise induced arrhythmias suggest that PA patients might benefit from afterload reduction.