bluuebunny/crossref_metadata_2025 huggingface dataset:
Reproducibility and repeatability of biventricular function/volume and strain parameters by 2D and 4D stress echocardiography in adult patients with repaired TOF
Authors: Alborikan S A , Pandya B P , Vonklemperer K V , Badian S B , Encarnacion D E , Bhattacharyya S B , Lloyd G L
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

The use of 2D and 4D during stress echocardiography to undertake complex measures in complex patients like patients with repaired TOF is challenging and the validity of these measures is not known yet.

Methods

For test-retest variability, 20 patients with repaired TOF with no or mild pulmonary regurgitation were selected randomly and underwent a cardiopulmonary exercise test (CPET) with echocardiography. Intra-observer variability study was performed for all 20 patients by the same observer. Interobserver variability study was performed for 5 patients by different experienced observer. Intraclass correlation coefficient (ICC), and coefficients of variation (COV) were used to quantify reproducibility and variability.

Results

For 2D measures, better reproducibility was observed for semiautomated 2D strain measures than 2D functional measures for biventricular systolic function at baseline and during the stress (ICC>.90 vs >.70, p<0.001), with least COV was observed (COV<10%). 4D semiautomated volumetric measures demonstrated less reproducibility during stress with highest COV was observed for 4D RV volume parameters (COV, 35%), followed by 4D LV volume parameters (COV, 27%). CPET had an excellent agreement of all measures (ICC >.90). with very low COV (<10%).

Conclusions

Semiautomated echo measures outperformed manual measures during stress echocardiography and can be performed with acceptable reproducibility. Variability is at highest for 4D semiautomated measures despite good reproducibility, while lowest variability was observed for 2D semiautomated measures of myocardial deformation.
Cardiac MRI safety assessment of patients with congenital heart disease and cardiac implantable electronic devices with abdominal pulse generators and epicardial leads
Authors: Schlesinger-Irsch U , Hart C , Zartner P , Pieper C , Attenberger U , Luetkens J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Reports about cardiac MRI safety and utility in pediatric and adult patients with non-MR-conditional cardiac implantable electronic devices with abdominal pulse generator and epicardial leads remain underreported.

Purpose

To retrospectively assess safety of cardiac MRI with non-MR-conditional abdominal pulse generators and epicardial leads in pediatric and adult patients with congenital heart disease.

Methods

Between 04/2020 and 01/2023 25 patients aged 2–32 years (mean 12.7±8.3 years) with abdominal pulse generators and up to three epicardial leads underwent cardiac MRI at 1,5T. SAR was limited to 2W/kg. 19/25 (76%) patients carried pacemakers, 1/25 (4%) ICD, 4/25 (16%) CRTs. 12/25 (48%) of the examinations were performed under general anesthesia. Patients were continuously monitored during cardiac MRI. Results of thresholds, sensing and impedances of the devices were assessed before and after MRI examination.

Results

In 24/25 (96%) the examination could be finished without significant changes in thresholds, sensing and impedances of the abdominally placed devices. One examination was terminated early because of a major adverse event of heating/abdominal discomfort. Three minor adverse events in three different patients were inability to program back to previous setting (patient 1), alert that the elective replacement indicator (ERI) was reached (patient 2), and significantly elevated impedance (patient 3). Patient 1 and 2 remained in MRI mode and had to be monitored after the MRI examination. Reconfiguration was possible in both patients after 24 hours. Patient 3 had normal results for impedances in the pacemaker query 24 hours after the cardiac MRI examination.

Conclusion

Our data suggest that cardiac MRI in patients with non-MR-conditional abdominal pulse generators and epicardial leads in pediatric and adult patients with congenital heart disease can be imaged safely in an experienced and multidisciplinary environment. The potential increased risks of MRI in these patients should be balanced against the value of the diagnostic information that can be obtained.
The relationship between troponin T and plaque burden in patients with stable chest pain
Authors: Borzsak S , Vecsey-Nagy M , Boussoussou M , Vattay B , Kolossvary M , Merkely B , Szilveszter B
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Certain laboratory parameters of patients presenting with stable chest pain may also have clinical utility in estimating individual cardiovascular (CV) risk in addition to ruling out acute myocardial infarction. Therefore, it is plausible that they provide valuable information on the overall plaque burden in patients with low to intermediate CV risk who are examined due to suspected coronary artery disease (CAD).

Purpose

Our purpose was to investigate the potential association of certain laboratory parameters of potential cardiological relevance and the extent and severity of CAD, as assessed by coronary CT angiography (CCTA).

Methods

In our present study, 307 consecutive patients referred to CCTA due to suspected CAD were enrolled. A comprehensive laboratory panel (including a complete blood count, comprehensive metabolic panel, lipid panel, cardiac biomarkers, and C-reactive protein) was performed immediately before the CCTA for all patients. Segment stenosis score (SSS) was calculated on CCTA images to characterize overall plaque burden. A score was assigned to each coronary segment according to the most severe stenosis present: <25%: 1 point, 25–49%: 2 points, 50–69%: 3 points, ≥70: 4 points. The patient's SSS score was calculated as the sum of each score. Predictors of SSS were determined by linear regression analysis incorporating traditional CV risk factors and laboratory parameters.

Results

The mean age of the patients was 57.1 ± 11.5 years, 65% (200/307) had CAD. The independent predictors of SSS were female sex (ß = −1.63 [95%CI: −2.28–−0.98], p<0.001), age (ß = 0.08 [95%CI: 0.05–0.16], p<0.001), alcohol consumption (ß = 0.26 [95%CI: 0.06–0.47], p = 0.01), hypertension (ß = 0.70 [95%CI: 0.07–1.33], p = 0.03), blood glucose level (ß = 0.40 [95%CI: 0.05–0.75], p = 0.03), and troponin T level (ß = 0.08 [95%CI: 0.006–0.16], p = 0.03).

Conclusions

The elevation of troponin T in patients with stable angina was independently associated with SSS, which might be due to subclinical plaque ruptures causing myocardial injury. The measurement of troponin T may allow more precise risk stratification of patients with stable angina.
Use of an echocardiographic-based, artificial intelligence system to improve racial disparities in care of patients with valvular heart disease
Authors: Horde G , Sotelo M , D Amico A , Brouner M , Shields A , Wagner L , Rogers C , Booker O J , Andrikopoulou E
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Referral for valvular interventions is frequently delayed, and racial disparities in access to care are prominent in the United States.

Purpose

To assess the effectiveness of an echocardiographic (Echo) – based, artificial intelligence (AI) driven protocol in improving management of patients with severe aortic stenosis (SAS) and severe mitral regurgitation (SMR).

Methods

From 10/2019 to 11/2022, 126,678 Echo’s (73,453 patients) were screened using a proprietary natural language processing (NLP) system to detect SAS and SMR based on the ACC/AHA guidelines. Aggregated zip code-derived census data and the area deprivation index (ADI) were merged based on each patient’s recorded address at the time of their index Echo. The control group comprised of Echo’s performed 10/2019–2/2020 (prior to implementation of our NLP system) and the intervention group of those between 2/2020–11/2022 (following implementation of NLP). Our AI system uses NLP to detect SAS/SMR from Echo reports and automatically sends a notification to the referring clinician’s inbox with recommendation for referral to appropriate specialist. The endpoint was follow-up defined as the combination of (a) follow-up Echo, (b) follow-up clinic visit with the heart valve (for SAS) or the advanced heart failure clinic (for those with SMR), or (c) follow-up valvular intervention.

Results

Figure 1 summarizes the sociodemographic and Echo characteristics of the patients, as well as outcomes. Notifications were more likely to be sent out for black patients (OR 2, 1.69–2.34, p<0.001), and those with a lower mean national ADI rank (39.29 vs 42.33, p = 0.001). Time to the combined follow up was improved (74 days vs. 43 days, pre vs. post AI/NLP, p< 0.001) (Figure 1, 2A). Both white and black patients saw an improvement in time to combined endpoint (57 vs 36 days, p = 0.015 for whites, 120 vs 64 days, p = 0.035 for blacks), the improvement being more significant in black patients (Figure 2B).

Conclusions

An Echo - based, AI/NLP system was helpful in improving overall management of patients with SAS and SMR and in bridging racial disparities. More diverse, multi-site studies are needed to confirm our single-site findings.
Evolution and prognostic impact of right ventricular to pulmonary artery coupling after transcatheter aortic valve implantation
Authors: Meucci M C , Malara S , Butcher S C , Hirasawa K , Van Der Kley F , Lombardo A , Aurigemma C , Romagnoli E , Trani C , Massetti M , Burzotta F , Bax J J , Crea F , Ajmone Marsan N , Graziani F
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

there is limited evidence regarding the association between right ventricular-to-pulmonary artery (RV-PA) coupling and outcomes after transcatheter aortic valve implantation (TAVI). Particularly, the prognostic value of post-TAVI RV-PA coupling has not been investigated so far.

Purpose

We aimed to explore the evolution of RV-PA coupling in patients with severe aortic stenosis (AS) undergoing TAVI and its prognostic impact.

Methods

A total of 900 patients who underwent TAVI in two tertiary centers and with echocardiographic analysis performed within 3 months before and after the procedure were included. RV-PA coupling was measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). On the basis of current evidence, RV-PA uncoupling was defined by TAPSE/PASP<0.55, whereas a TAPSE//PAS<0.32 identified a severe uncoupling. Primary endpoint was all-cause mortality.

Results

A total of 520 (58%) patients showed RV-PA uncoupling before TAVI, whereas post-TAVI RV-PA uncoupling was observed in 407 (45%) patients. During a median follow-up of 40 months, 250 (28%) deaths occurred. In multivariable Cox regression analyses adjusted for significant clinical, procedural and echocardiographic variables, post-TAVI RV-PA uncoupling was independently associated with an increased risk of mortality (adjusted hazard ratio [HR]:1.450, 95% Confidence interval [CI]:1.094–1.921, p = 0.010), while pre-TAVI uncoupling did not. Among patients with post-TAVI RV-PA uncoupling, the presence of severe uncoupling identified a subgroup with the worst survival (adjusted HR: 1.907, 95%CI:1.160–2.815, p = 0.009) (Figure 1). Notably, post-TAVI RV-PA uncoupling provided better risk stratification for all-cause mortality, than its components considered separately (i.e. TAPSE and PASP).

Patients with RV-PA coupling recovery after TAVI (n=173, 33% of patients with pre-TAVI uncoupling) showed similar outcomes as compared to patients with normal coupling. Conversely, the presence of either persistent or new-onset RV-PA uncoupling following TAVI (n=347 and n=67) was associated with an increased risk of death (adjusted HR:1.422, 95%CI:1.025–1.974, p = 0.035 and adjusted HR: 2.247, 95%CI:1.403–3.599, p = 0.001, respectively) (Figure 2).

Conclusions

Post-TAVI RV-PA uncoupling is an independent predictor of long-term mortality, irrespective from coupling before intervention. Assessment of TAPSE/PASP response after TAVI may be helpful to improve patients’ risk stratification.
Incremental prognostic value of fully-automatic LVEF by stress CMR using machine learning
Authors: Pezel T , Toupin S , Hovasse T , Sanguineti F , Champagne S , Unterseeh T , Chitiboi T , Jacob A , Borgohain I , Sharma P , Garot P , Garot J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Although some recent reports showed that fully automated artificial intelligence (AI)-based left ventricular ejection fraction (LVEF) measured at stress has good performance, its prognostic value during a stress CMR exam to predict outcomes is not well established.

Aim

To determine in patients undergoing stress CMR whether fully automated AI-based LVEF (LVEF-AI) measured at stress can provide incremental prognostic value to predict death.

Methods

Between 2016 and 2018, we conducted a longitudinal study including all consecutive patients referred for vasodilator stress CMR. LVEF-AI was assessed using AI-algorithm combines multiple deep learning networks for LV segmentation. The primary outcome was all-cause death defined by the French National Registry of Death. Cox regression was used to evaluate the association of stress LVEF-AI with death after adjustment for traditional risk factors.

Results

In 9,712 patients (66±15 years, 67% men), there was an excellent correlation between stress LVEF-AI measurement and LVEF measured by expert (LVEF-expert) (r=0.94, p<0.001). Using Bland–Altman analysis, we found that the difference between the mean LVEF-expert and the LVEF-AI group was −0.1% (−0.066–0.067), that was not statistically significant (p = 0.46).

Stress LVEF-AI was associated with death (median [IQR] follow-up 4.5 [3.7–5.2] years) before and after adjustment for risk factors (adjusted hazard ratio [HR], 0.84 [95% CI, 0.82–0.87] per 5% increment, p<0.001). Stress LVEF-AI had similar significant association with death occurrence compared with LVEF-expert. After adjustment, a lower stress LVEF-AI showed the greatest improvement in model discrimination and reclassification over and above traditional risk factors and stress CMR findings (C-statistic improvement: 0.11; NRI=0.250; IDI=0.049, all p<0.001; LR-test p<0.001), with a superior additional prognostic value than the LVEF-AI measured at rest.

Conclusion

AI-based fully automated LVEF measured at stress is independently associated with the occurrence of death in patients undergoing stress CMR, with an additional prognostic value above traditional risk factors, inducible ischemia and LGE.
A deep learning approach to predict myocardial fibrosis in early contrast-enhanced CCT images
Authors: Penso M , Carerj M L , Moccia S , Babbaro M , Baggiano A , Guglielmo M , Fusini L , Mushtaq S , Andreini A , Pepi M , Caiani E , Pontone G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Late gadolinium enhancement (LGE) derived from cardiac magnetic resonance (CMR) has become a method of choice for the evaluation of myocardial tissue composition and detection of myocardial fibrosis. Advances in cardiac computed tomography (CCT) imaging have led to its growing role as possible alternative to CMR, because of its wider availability and suitability for patients with contraindication.

Purpose

To develop a myocardial fibrosis detection method from early contrast-enhanced CCT (CE-CCT) imaging using a deep learning (DL) approach.

Methods

Fifty consecutive patients (age: 62±10 y, male 84%) with known left ventricular dysfunction were enrolled. All patients underwent both LGE-CMR and early and delayed CE-CCT. According to the LGE-CMR patterns, patients were classified as ischemic (n=15, 30%) or non-ischemic (n=35, 70%). Scar regions were manually traced on delayed CE-CCT using LGE-CMR as reference. On early CE-CCT images, segments were extracted according to American Heart Association (AHA) 16-segment model and labeled (scar/no scar) based on the delayed CE-CCT manual tracing. A DL model was developed for automatic segmental classification.

Results

Based on 44187 segments analyzed, 71% of accuracy (ischemic: 66%; non-ischemic: 74%) for detecting scar on early CE-CCT images was achieved (Picture 1). In a per-segment analysis of the 16-segment AHA model, an accuracy of 91% (ischemic: 87%; non-ischemic: 93%) was obtained from early CE-CCT compared to the LGE-CMR.

Conclusions

DL on early CE-CCT acquisition may allow the detection of myocardial fibrosis without additional contrast-agent administration or radiation exposure, thus reducing the user interaction and visual inspection with benefit in both efforts and time.
Exploring pericoronary adipose tissue differences between calcified and non-calcified plaques on coronary CT angiography with fat attenuation index and radiomics analysis
Authors: Shieh A , Tsai Y T , Sun Y T , Chang C H , Yan J Y , Lee W J , Wang T D
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Science and Technology.

Introduction

Coronary CT angiography (CCTA)-derived pericoronary adipose tissue (PCAT) is a novel marker for coronary inflammation. The relationship between the extravascular PCAT and the vascular lesion itself is particularly important to establish its use in monitoring the disease status. Past studies investigated lesion-level PCAT differences in vessels with acute myocardial infarction. However, lesion-level PCAT differences between calcified and non-calcified plaques in patients with stable coronary artery disease were not well understood.

Purpose

To investigate the differences between PCAT adjacent to calcified and PCAT adjacent to non-calcified plaques using fat attenuation index (FAI) and radiomics analysis.

Material and Methods

In a cohort of 100 consecutive patients who underwent CCTA, 446 plaques were identified in 89 patients. Among these plaques, 213 were calcified plaques and 49 were non-calcified plaques, with the rest classified as mixed by our expert cardiologist and radiologist. The PCAT of these 262 plaques were then extracted. Following prior literature, adipose tissue was defined as voxels with attenuation ranging −190 to −30 HU. PCAT was extracted within 3 mm distance from the vessel wall, along the middle 10 mm of each plaque. FAI was defined as the mean attenuation of the PCAT volume. For radiomics analysis, we used PyRadiomics to calculate the radiomic features and the random forest classifier from Scikit-Learn to distinguish PCAT volumes of calcified and non-calcified plaques. Patient-level 5-fold cross validation was used to develop the classifier.

Result

FAI were higher in PCAT adjacent to non-calcified plaques compared to PCAT adjacent to calcified plaques (−81.4 [IQR: −91.8 to −73.5] vs −86.7 [IQR: −94.1 to −78.4], p = 0.008). The classifier using radiomics features achieved better discrimination (AUROC=0.738 [0.715–0.761]) than FAI alone (AUROC=0.607 [0.605–0.609]).

Conclusion

Significant differences in PCAT characteristics were found between calcified and non-calcified plaques either with direct comparison of FAI or radiomics analysis. Radiomics analysis revealed further discrimination between PCAT characteristics other than FAI may exist between calcified and non-calcified plaques. It is also important to note that the FAI of calcified plaques could be affected by beam hardening. Further investigation is needed to explore the underlying cause of such differences and their clinical implications.
Association between coronary inflammation measured by FAT attenuation index and CT features of atheromatous plaque vulnerability
Authors: Parajko Z S , Benedek I , Kovacs I , Bordi L , Opincariu D , Rat N , Halatiu B , Rodean I , Blindu E , Rosca A , Matyas B , Gerculy R , Benedek T
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This research has been funded by the research grant Intel-FAT, proposal registration code PN-III-P4-ID-PCE-2020-2861, contract number PCE 206/2021, Project funded by the European Union and the Government of Romania through the Ministry of European Funds, and the Doctoral School of the “George Emil Palade” University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania.

Background

Coronary computed tomography angiography (CCTA) is a rapidly evolving tool for the assessment of coronary artery disease (CAD), being able to characterise not only the degree of coronary artery stenosis but also the presence and severity of coronary plaque vulnerability. Fat attenuation index (FAI) is a recently developed marker of coronary inflammation, based on the gradient of CT density at the level of pericoronary fat.

Purpose

The aim of our study is to investigate the correlation between (1) coronary inflammation as assessed by FAI score, and (2) vulnerability degree of atheromatous coronary plaques, as assesses by presence and severity of CT features of vulnerability at the level of coronary plaques.

Methods

A total of 54 patients who underwent 128-slice CCTA for chest pain, and having at least one vulnerable coronary plaque, were enrolled in the study. Vulnerable plaques were defined as plaques showing at least one of the following on CT scan: low attenuation plaque, napkin-ring sign, spotty calcifications, or positive remodeling. In total, 114 vulnerable plaques were identified and analyzed using the advanced via Syngo.via Frontier software. FAI score was determined using the FAI technology patented by Caristo.

Results

The FAI score of coronary inflamamtion was significantly correlated with the total plaque volume at the level of left anterior descendent artery (LAD) (p = 0,01), respectively with the calcified plaque volume at the level of the circumflex artery (p = 0,02). Receiver operating characteristic (ROC) analysis for the correlation between the FAI score and the presence of the Napkin Ring Sign (NRS) showed a significant correlation for plaques located on LAD (AUC 0,729; 95%CI 0,585 – 0,845; p = 0,01), and lefty circumflex artery (AUC 0,745; 95%CI 0,601–0,859; p = 0,032), but not for the right coronary artery (AUC 0,636; 95%CI 0,487–0,767; p = 0,25). Furthermore, the ROC analysis identified a good correlation between the FAI score and the presence of spotty calcification or positive coronary remodeling (AUC 0,777, p = 0,0004, respectively AUC 0,717, p = 0,0081).

Conclusion

Coronary inflammation measured by FAT attenuation index is significantly correlated with the presence of CT vulnerability features in the coronary tree.
Development of cardiac amyloidosis: potential early indicators from a retrospective longitudinal CMR pilot study
Authors: Moutzoukis G , Oberli L , Bekeredjian R , Mahrholdt H , Seitz A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

While early diagnosis and treatment initiation is crucial in cardiac amyloidosis (CA), the diagnosis is currently mostly established in advanced stages of the disease. Cardiac magnetic resonance imaging (CMR) with late gadolinium enhancement (LGE) provides excellent sensitivity for the diagnosis of CA. A diffuse subendocardial or transmural LGE pattern independent from coronary perfusion areas is considered characteristic of CA.

Purpose

While there is a distinct LGE pattern in later stages of CA, CMR characteristics during early stages are not established. In this retrospective study, we sought to identify potential early CMR indicators of CA.

Methods

Patients undergoing CMR at our center between 2012 and 2022 were retrospectively screened. Those with at least two CMR studies, of which only the latter demonstrated LGE characteristic for CA, were included. All patients underwent CINE and LGE imaging.

Results

Fifteen patient (80% male; median age 76 [73–79] at first CMR) were included in this analysis. Median time interval between the two CMR studies was 4 years. We observed differences in left ventricular morphology between the initial and follow-up CMR (IVS 15±3 vs. 17±3 mm, p = 0.003; EDV 128±40 vs. 139±39, p = 0.02). LV function was preserved and did not differ between the two CMR (EF 65±10 vs. 62±9 %, p = 0.14). While an LGE pattern characteristic for CA was present in all patients on follow-up CMR, severe left ventricular hypertrophy (IVS >14 mm in 60%), atrial LGE (67%) and focal non-ischemic LGE of the posterolateral basal LV wall (87%) were identified as highly prevalent findings during the initial CMR already.

Conclusions

Based on these observations, we hypothesize that the combination of certain CMR characteristics (severe septal hypertrophy, atrial LGE and LGE of the basal posterolateral LV) may help to identify CA at an early stage. Prospective studies are needed to further investigate this hypothesis.
The prognostic significance of right ventricular basal diameter in addition to tricuspid annulus diameter in patients underwent to tricuspid valve surgery
Authors: Tukenmez Karakurt S , Karakurt H , Akbas A , Tanboga I H , Guler A , Onan B , Iyigun T , Aydin U , Kalkan A K , Birant A , Erturk M , Babur Guler G
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Functional tricuspid valve regurgitation occurs as a result of enlargement of the tricuspid annulus (TA) despite the normal valve structure (1). However, the tendency of the tricuspid annulus to enlarge in the posterior annular part suggests that the mediolateral diameter measurement measured by 2-dimensional (2-D) echocardiography does not provide an accurate anatomical evaluation (2). Inaccuracies in these measurements also affect the selection of the tricuspid ring in patients undergoing surgery and thus affect the short- and long-term outcomes (3). Therefore, new methods and reference points have developed in the measurement of the tricuspid annulus.

Purpose

In this study, we aimed to investigate the importance of apical 4-chamber tricuspid annulus diameter and right ventricular basal diameter measurements in choosing a surgical tricuspid ring size.

Methods

The records of 359 patients who underwent tricuspid ring annuloplasty for functional tricuspid valve regurgitation between 2018 and 2022 were retrospectively reviewed. Tricuspide anulus and right ventricular basal diameter measurements were re-evaluated echocardiographically, and surgical tricuspid ring sizes were recorded.

Results

There was no significant relationship between 2-D measurement of tricuspid annulus diameter and choosing surgical ring sizes (OR 0.74, 95% CI 0.51 – 1.09, p = 0.257), however, the increase in RV basal diameter size was associated with larger ring size selection (OR 2.63, 95%). CI 1.72 – 4.02, p<0.0001). Among the 5 models that predicted the surgical ring size according to the ordinal regression analysis, the models that most accurately predicted the surgical ring size were model-4, which included RV basal diameter, and model-5, which included RV basal diameter and TA diameter. (Table 1). Also, in model-5, RV basal diameter was superior to TA-diameter in showing variation in surgical ring size. Also, when the TA diameter is < 40 mm and the RV basal diameter is < 45 mm, the large ring selection rate (34 or 36) is 36.2%, but this rate is 70.9% when the TA diameter is < 40 mm and the RV basal diameter is ≥ 45.

Conclusions

In conclusion, when the measurements in the apical 4-chamber were compared, the effectiveness of the measurement of the tricuspid annulus in determining the surgical ring size was lower than the RV basal diameter. During pre-operative evaluation, RV basal measurement in addition to the tricuspid annulus may help in the selection of patients who require tricuspid valve annuloplasty and in determining the ring sizes.
automatic detection of aortic valve pathology using 3-chamber cine MRI
Authors: On Y , Vimalesvaran K , Galazis C , Zaman S , Howard J , Linton N , Peters N , Cole G , Bharath A A , Varela M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

The assessment of aortic valve pathology using magnetic resonance imaging (MRI) typically relies on blood velocity estimates acquired using phase contrast (PC) MRI. However, abnormalities in blood flow through the aortic valve often manifest by the dephasing of blood signal in gated balanced steady-state free precession (bSSFP) scans (cine MRI) [1]. This suggests cine MRI may be used to identify patients with blood flow abnormalities who would benefit from additional detailed PC-MRI scans. Nevertheless, there are currently no tools to automatically identify abnormalities in blood flow through the aortic root in cine MRI which can be used to improve diagnosis and optimise clinical CMR protocols.

Aim

To determine whether a classification neural network (NN) can automatically detect aortic valve pathology from 3-chamber cine MRI, without the need for dedicated additional imaging or manual annotation.

Data We train and test our approach on a retrospective clinical dataset from three UK hospitals, using single-slice bSSFP 3-chamber cine MRI (cardiac frames: 31 ± 15, spatial resolution: 1.17–1.56 x 1.17–1.56 x 8 mm3) from n = 577 patients. Using information from clinical assessments, each image was labelled as: aortic regurgitation (AR) (13%), aortic stenosis (AS) (11%), mixed valve disease (MVD) (9%), or showing no relevant pathology (67%). 322 randomly selected images were used for training, 81 for validation and 174 for testing.

Methods

We trained a 3D classification NN (DenseNet201 model [2] with 4 dense blocks which include 3D (i.e., spatiotemporal) convolutional layers; Adam optimisation and a cross-entropy loss function) to classify the time-resolved cine MR images. We used binary labels: "pathology" (corresponding to AR, AS or MVD) or "no pathology". As a pre-processing step, we automatically identified the heart in all cine MRI frames using an in-house algorithm that detected motion in the image across the cardiac cycle, and cropped the images to remove non-cardiac anatomical structures. After the classification, we used gradient-weighted class activation mapping (Grad-CAM) [3] to gain confidence that the classification was most dependent on voxels close to the aortic root. Fig 1 shows an overview of the image processing pipeline.

Results

Our classification model accurately predicts aortic valve pathology using 3-chamber cine MRI: Fig 2 shows the confusion matrix and the evaluation metrics of the study. The Grad-CAM heatmaps showed the aortic region contributed the most to the classification, as seen in Fig 1.

Conclusion

Convolutional NNs can identify aortic valve pathology automatically from 3-chamber cine MRI, without the need for manual annotations. This can be used to improve diagnosis and optimise clinical CMR protocols, namely as a triage tool to identify the patients most likely to benefit from additional PC-MRI sequences.
Tracking treatment response in cardiac AL amyloidosis with native-T1 mapping
Authors: Ioannou A , Patel R K , Razvi Y , Porcari A , Martinez-Naharro A , Rauf M U , Bolhuis R E , Fernando-Sayers J , Venneri L , Lachmann H , Whelan C , Hawkins P N , Gillmore J D , Wechalekar A , Fontana M
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) derived extracellular volume (ECV) mapping has demonstrated utility in determining the cardiac response to chemotherapy in systemic AL amyloidosis, but concomitant renal dysfunction is a common contraindication for the required gadolinium contrast.

Objectives

To assess the ability of native-T1 mapping to measure the cardiac response to treatment, and assess the association between changes in native-T1 and prognosis.

Methods

We studied 221 patients who underwent cardiac magnetic resonance (CMR) scans at diagnosis and a repeat scan following chemotherapy.

Results

At 6-months a reduced native-T1 of ≥50ms occurred in 8(4%) patients, all of whom had a good haematological response; by contrast an increased native-T1 of ≥50ms occurred in 42(23%) patients, most of whom had a poor haematological response (n=27,68%). At 12-months, a reduced native-T1 occurred in 24(15%) patients, all of whom had a good haematological response, and was associated with a reduction in median N-terminal pro-brain natriuretic peptide (NT-proBNP) (2638ng/L vs 432ng/L,P<0.001) and E/e’ (14.9±6.8 vs 12.0±5.2, P=0.007), improved longitudinal strain (−14.8±4.0 vs −16.7±4.0, P=0.004) and reduction in both T2 (52.3±2.9 vs 49.4±2.0, P<0.001) and ECV (0.47±0.07 vs 0.42±0.08, P<0.001); increased native-T1 occurred in 24(15%) patients, most of whom had a poor haematological response (n=17,71%) and was associated with an increased median NT-proBNP (1622ng/L vs 3150ng/L, P=0.007), reduced ejection fraction (65.8±11.4% vs 61.5±12.4%, P=0.009) and both increased T2 (52.5±2.7 vs 55.3±4.2, P<0.001) and ECV (0.48±0.09 vs 0.56±0.09, P<0.001). Change in native-T1 at 6-months predicted mortality even after adjusting for haematological response and NT-proBNP response (HR=2.41,95%CI[1.36–4.27],P=0.003).

Conclusion

Changes in myocardial native-T1 in response to treatment, are reflected in changes in the traditional markers of the cardiac response provide a powerful independent predictor of mortality. Change in native-T1 represents an important addition to the standard armamentarium of amyloid assessment, and provides an alternative measure of the cardiac treatment response, that not only limits exposure of patients to contrast but could also have implications on clinical workflow by reducing scan time.
The evolution of hemodynamic force parameters after cardiac resynchronization
Authors: Laenens D , Galloo X , Rossi A C , Tonti G , Reiber J H , Pedrizzetti G , Ajmone Marsan N , Bax J J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

A new mathematical model allows calculation of hemodynamic forces (HDF) from routine transthoracic echocardiographic images. In large cohorts, the evolution of HDF parameters in patients after onset of cardiac resynchronization therapy (CRT) has not been investigated.

Purpose

To compare HDF parameters at baseline versus six months follow-up after CRT implantation in patients with non-ischemic cardiomyopathy.

Methods

Patients with LV ejection fraction (LVEF) ≤35%, QRS duration ≥130 ms and left bundle branch block were included. In the complete heart cycle, the following HDF parameters were calculated: apical-basal strength (AB strength), lateral-septal strength (LS strength), the ratio of LS strength to AB strength (LS-AB ratio) and the dominant angle of HDF (angle) (Figure 1). In the systolic thrust, apical-basal impulse (AB impulse) and the angle were measured (Figure 1). The measurements are presented as percentages, normalized for left ventricular volume and adjusted for fluid density and gravity acceleration. The measurements were acquired at baseline and six months after CRT implantation.

Results

196 patients were included (mean age 64 ± 11 years, 62% male). Clinical and echocardiographic characteristics were acquired, as well as HDF parameters at baseline and after six months (Table 1). After six months a significant improvement occurred in clinical parameters (New York Heart Association class, Quality of Life and 6-minute walking distance) with significant reverse LV remodeling (reduction in left ventricular and left atrial volumes with increased LVEF and global longitudinal strain). Moreover, a significant change in the magnitude of apical-basal force, represented in the AB strength and AB impulse and in the orientation of force, represented as the ratio and the angle of HDF were observed.

Conclusion

The evaluation of HDF parameters after CRT implantation shows an increase in magnitude of force and a change in orientation of force. This new tool provides insight in changes of fluid dynamics after CRT implantation and may contribute to better understand the benefit of CRT.
Impact of aortic stenosis progression rate on prognosis
Authors: Teixeira R , Ribeiro D R , Nunes F S N , Almeida M C A , Lobo A L , Leite M L , Neves I N , Santos D S , Brandao M B , Diaz S D , Saraiva F S , Barros A B , Sampaio F S , Fontes-Carvalho R F C
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis (AoS) is a progressive disease of the aortic valve (AoV) and, ultimately, of the myocardium, potentially fatal. Most studies considerthat the rate of AoS progression is time-invariant while recognizing wide variability between patients (pts) and among the same patient.

Aim

1) evaluate the rate of AoS progression, 2) cluster pts into rapid progressors (RP) and slow progressors (SP) and explore possible predictors, and 3) evaluate the impact of progression rate on cardiac damage and survival.

Methods

We retrospectively identified 914 pts (age 76 ± 8 years, 52% female, median follow-up time 6.8 years) with mild to severe AoS who had undergone > 1 echocardiogram from 2012 to 2020. Seriated echocardiograms, biomarkers, and clinical records were consulted, providing a multiparametric data frame for modeling AoS progression and outcomes. Bayesian hierarchical models were trained using machine learning algorithms (MLA) to predict aortic peak velocity (APV) as a function of time. After selecting the best model, individual AoS acceleration rates were estimated from the posterior distribution, and pts were clustered in RP and SP using MLA.

Results

APV was best modeled by a logistic function of time. 483 pts were clustered as RP (53%) and 431 as SP (47%), with acceleration rates estimated at 0.14 ± 0.02 years-1 and 0.09 ± 0.02 years-1, respectively (p< 0.01). There was no association between progression rate and clinical variables. RP had a higher incidence of cardiac damage at eight years than SP (p = 0.01). Rapid progression was associated with higher mortality (Hazard Ratio (HR) 1.28, p = 0.02), persisting after adjustment for demographics, comorbidities, AoS severity, and time-dependent AoV replacement (HR 1.36, p<0.01). A 5-year mortality prediction model incorporating AoS progression rate to age, gender, and AoS severity displayed higher performance (C-statistic= 0.82, change in C-statistic= 0.02, p<0.01, Brier score= 0.11). RP consistently displayed a higher risk of excess mortality across all ranges of aortic peak velocities, such that a velocity threshold of 3.2 m/s in RP carried the same risk of death as 4 m/s in SP.

Conclusions

A nonlinear model of AoS progression and two clusters of progressors were identified. Rapid progression was associated with earlier cardiac damage and higher mortality, independent of baseline AoS severity. Incorporating AS acceleration rate in clinical practice can improve AoS stratification and provide a proactive time frame for follow-up and intervention.
Cardiac magnetic resonance in suspected MINOCA patients, clinical and imaging profile, diagnostic performance and 1 year clinical follow up
Authors: Rodriguez Perez A , Parada Barcia J A , Barreiro Perez M , Pazos Lopez P , Matajira Chia T , Calvo Iglesias F , Iniguez Romo A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance (CMR) is fundamental at the evaluation of patients with differential diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) due to its tissue characterization potential to exclude non-ischaemic causes such as myocarditis and Takotsubo syndrome and better stratify ischaemic disease in acute and chronic disease.

Purpose

To describe the clinical profile, cardiac magnetic resonance findings, final clinical and CMR diagnosis and clinical 1-year follow-up in patients with a working diagnosis of MINOCA evaluated with a CMR.

Methods

All patients who underwent a CMR for suspected MINOCA during a period of 1 year from June 2021 to June 2022 were retrospectively evaluated, past medical history, clinical characteristics, CMR reports and 1 year follow up were obtained. Myocarditis was defined by modified Lake Louise criteria. Patients were stratified following CMR diagnosis, accurate CMR diagnosis was considered when matched clinical final diagnosis.

Results

A total of 107 patients were evaluated with a CMR for a suspected MINOCA from June 2021 to June 2022, of whom CMR classified 51 (47.7%) as myocarditis, 11 (10.3%) as Takotsubo syndromes, 13 (12.2%) as acute ischaemic etiology, 3 (2.8%) as chronic ischaemic etiology, 24 (22.4%) as normal CMR and 5 (4.7%) had other diagnoses (cardiomyopathies and type II myocardial infarctions). Myocarditis patients were younger and more frequently males, ischaemic etiologies were older, had more comorbidities and were more frequently males, Takotsubo syndromes were more frequently females and were frequently hypertense. (Table 1) The final clinical diagnosis corresponded to the diagnosis provided by CMR in 92.2% of myocarditis, 100% of Takotsubo syndromes, 84.6% in acute ischaemic etiologies and 100% of chronic ischaemic etiologies. Patients with a normal CMR or other diagnosis had significantly lower correspondence between final and CMR diagnosis, in this setting CMR was still useful to rule out ischaemic etiology, myocarditis and Takotsubo syndrome. During follow-up there were no clinical differences between groups in terms of deaths, readmissions myocardial infarction and visits for recurrent chest pain. Patients with myocarditis CMR diagnosis were more likely to be followed up with CMR than other groups. (Table 2).

Conclusions

The final diagnosis of the patient studied for suspected MINOCA was given or facilitated by CMR in most cases, being of clinical use in the diagnostic and the follow up strategy of patients.
Measuring integrated backscatter in patients undergoing transcatheter aortic valve implantation
Authors: Ferreira A , Carvalheiro R , Rio P , Timoteo A T , Branco L , Leal A , Varela F , Cacela D , Galrinho A , Ferreira R C
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Calibrated integrated backscatter (cIB) derived by 2D echocardiography quantifies myocardial ultrasound reflectivity, and it has been used in previous studies as a surrogate for myocardial fibrosis. Before the advent of other cardiac imaging techniques, it was a major focus of tissue characterization research.

Purpose

We examined whether cIB may help identify patients undergoing transcatheter aortic valve implantation (TAVI) at risk of procedure-related complications.

Methods

Consecutive patients submitted to transfemoral TAVI between January and December 2021 were routinely imaged by echocardiography in the five days peri-procedure. Calibrated integrated backscatter was obtained from the parasternal long-axis view (PLAX) by subtracting pericardial cIB intensity from myocardial septal and posterior wall average cIB. Patients with poor PLAX views were excluded from the study. Measurements of cIB, expressed in decibels, were performed at end-diastole. The primary endpoint was the occurrence of major TAVI-related complications.

Results

Of 149 patients that underwent TAVI during the study period, 131 had a reasonable acoustic window for cIB measurement and were included in the study. Patient mean age was 82.1±6.9 years, and 62% were female. At baseline, 84% of patients had preserved left ventricle function, the mean aortic mean gradient was 47.3±14.8 mmHg, and the mean Euroscore II was 5.34±3.24. The global mean cIB measured was 19.74±7.56 dB. No significant differences were found in the myocardial wall ultrasound reflectivity in patients with TAVI-related major complications (20.63±10.8 vs 19.6±6.9 dB, p = 0.587), which were defined according to the Valve Academic Research Consortium-2 consensus. However, cIB was significantly higher in patients who had post-TAVI conduction disturbances (21.09±7.72 vs 18.11±7.06 dB, p = 0.026), including left bundle branch block and atrioventricular block. There was also a negative correlation of cIB with aortic annulus area as measured by computed tomography (r(129)= −0.19, p = 0.032), and cIB was also significantly higher in patients who had a pre-TAVI estimated glomerular filtration rate of less than 30 mL/min/1.73m2 (22.42±7.17 vs 19.56±6.88 dB, p = 0.043).

Conclusion

Our data disfavors the use of cIB as a predictor of major TAVI-related complications, but it suggests that cIB assessment could add value in identifying patients at risk of conduction disturbances in post-TAVI procedures.
Global longitudinal strain during stress echocardiography predicts hospitalization for heart failure or acute coronary syndrome
Authors: Cruz-Mendoza J R , Lopez-Alferez R , Rodriguez-Zanella H , Fritche-Salazar J F , Posada-Martinez L , Ortiz-Leon X , Hernandez-Madinabetia O , Ruiz-Esparza-Duenas M E , Lopez-Romero L E F , Arias-Godinez J A
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology of Mexico “Ignacio Chávez”.

Background

Global longitudinal strain (GLS) has important prognostic value in different clinical scenarios. However, evidence regarding the value of GLS use during stress echocardiography is currently limited.

Purpose

To evaluate the prognostic value of GLS during stress echocardiography to predict hospitalization for heart failure or acute coronary syndrome.

Methods

We prospectively studied 62 patients with suspected ischemic heart disease referred for dipyridamole stress echocardiography with good images for GLS quantification. Datasets with at least 50 frames per second were obtained.

Results

Overall, 60 patients with baseline and stress GLS were included. 56% were men, BMI was 27.9 (18.5–47.7), age 60 ± 13 years, 31% had diabetes and 71.7% hypertension, ejection fraction was 59.97 (±9.83). Baseline GLS was 20.3 ± 3.7, and stress GLS 23.4 ± 4. Patients with hospitalization for heart failure or ACS had lower GLS values during stress 21.7 ± 3 vs 24.6 ± 4 (p = 0.022). Baseline GLS was non statistically significant in patients with hospitalization for heart failure or ACS 19 ± 2.7 vs 21.2 ± 3.8 (p = 0.06). A cut off value of GLS < 22.1 during stress echocardiography was useful to identify patients with increased risk of hospitalization for heart failure or ACS. AUC 0.75, sensibility 69.3%, specificity 82.4%, +LR 3.9, -LR0.37, Youden index 0.56.

Conclusions

GLS during stress echocardiography is related to increased risk of hospitalization for heart failure or ACS. A cut of value of < 22.1% during stress echocardiography might be useful to identify patients with higher risk.