bluuebunny/crossref_metadata_2025 huggingface dataset:
The Risk of Resurgence in Vaccine-Preventable Infections Due to Coronavirus Disease 2019—Related Gaps in Immunization
Authors: Feldman Amy G , O’Leary Sean T , Danziger-Isakov Lara
Published: February 2021

Nationally, immunization delivery has decreased significantly during the coronavirus disease 2019 (COVID-19) pandemic. Internationally, >60 national vaccine programs have been disrupted or suspended. As a result of these immunization declines, the global community is at risk for a resurgence in vaccine-preventable infections including measles, pertussis, and polio—all highly contagious diseases that result in significant morbidity and mortality in children. Measles outbreaks have already occurred in many countries that suspended their vaccination programs. Outbreaks in the United States are likely to occur when social distancing stops and children return to school. Healthcare providers have acted quickly to institute multiple risk mitigation strategies to restore vaccine administration. However, childhood immunization rates remain below pre–COVID-19 levels. Partnerships between healthcare providers, community leaders, and local, state, regional, and national public health departments are needed to reassure families that vaccine delivery during COVID-19 is safe and to identify and catch up those children who are underimmunized.
Prenatal diagnosis of vascular ring: evaluation of fetal diagnosis and postnatal outcomes
Authors: Aly S , Papneja K , Mawad W , Jaeggi E , Yoo SJ
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The performance of fetal echocardiogram in diagnosing vascular ring (VR) and its impact on postnatal outcomes has not been well examined.

Methods

We reviewed all patients with VR diagnosis from 2000-2020.

Results

50 patients with antenatal diagnosis of VR; 42(84%) with right aortic arch aberrant left subclavian artery and left-sided ductus arteriosus ((RAA-ALS) and 8(16%) with double aortic arch (DAA) were compared to 120 patients with postnatal diagnosis; 90(75%) with DAA, 22(18%) with RAA-ALS (Table 1). Prenatal diagnosis of VR increased over study period; 4 vs 31, 10 vs 29, 14 vs 25, 22 vs 35 between 2000-2005, 2005-2010, 2010-2015, and 2015-2020 respectively, p< 0.01. Prenatal diagnosis of VR was associated with less symptoms [26(52%) vs 72(60%), p < 0.003] and less cross-sectional imaging [22(44%) vs 82(69%), p = 0.0001]. Postnatal diagnosis of VR was associated with more surgical interventions (102(85%) vs 28(56%), p = 0.002), later surgical repair (22.9 ± 35 vs 12.6 ± 10.2 months, p < 0.01), more postoperative complications [8/102 (7.8%) vs 1/28 (3.5%), p = 0.04] and more residual symptoms (2/28(7%) vs 30/102(29%), p = 0.001 respectively].

Conclusion

Prenatal diagnosis of VR has evolved over time. RAA-ALS versus DAA were dominant in the prenatally and postnatally diagnosed cohorts respectively. Prenatal diagnosis of VR was associated less symptoms, less cross-sectional imaging, earlier age of surgical intervention and less residual symptoms.

Table 1 Prenatal Diagnosis (N = 50) Postnatal Diagnosis (N = 120) p-value Gestational Age (weeks) 39 ± 3 38 ± 2 0.9 Male (%) 31 (62%) 69(58%) 0.8 Subtype of vascular ring: Double aortic arch RAA-ALSA Others 8 (16%) 42 (80 %) 0 (0 %) 90 (72%) 22 (17%) 8 (11%) 0.002 0.01 Associated intracardiac CHD: VSD TOF DORV AVSD Coarctation of aorta Others 11 (22%) 1 1 3 0 3 3 24 (20%) 5 7 2 2 3 5 0.8 Associated genetic diagnosis: 22q11 deletion Trisomy 21 Others 9 (18%) 6 3 0 32 (26%) 29 3 0 0.1 Symptomatic presentation: Respiratory Gastrointestinal 26 (52 %) 15 11 72 (60 %) 57 15 <0.03 Age at first symptoms (month) 3.2 ± 2.8 21.6 ± 37 0.01 Diagnostic modalities: Fetal echocardiogram Postnatal echocardiogram Barium swallow Bronchoscopy CT scan MRI 50 (100%) 50 (100%) 2 (4%) 3 (6%) 18 (36 %) 4 (8%) 0 (0%) 120 (100%) 23 (25 %) 18 (15 %) 65 (54%) 7 (14%) Surgical repair 28 (56%) 102 (85%) 0.02 Age at surgical repair (month) 12.6 ± 10.2 22.9 ± 35 <0.01 Postoperative complications 1 (3%) 8 (7%) 0.03 Residual symptoms 2 (1%) 30 (25%) 0.001 Age at most recent follow up (mo) 26 ± 7 60 ± 7 0.02 Table 1: Comparison of patients with prenatal versus postnatal diagnosis of vascular ring
Can the atrial septal defect size in newborn patient predict spontaneous closure?
Authors: Sawamura K , Afonso TR , Oliveira WAA , Lianza ACL , Tavares GMP , Vieira MLC , Fischer CH , Zacharias RSB , Morhy SS
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

onbehalf

Hospital Albert Eisntein"s pediatric echocardiogram team

Can atrial septal defect size in newborn predict spontaneous closure?

Introduction

Spontaneous closure of atrial septal defect (ASD) has been reported to occur in 33%-75% of patients. Factors that influence spontaneous closure are size of the ASD and age of the patients.

Purpose

We aimed to investigate if the diameter of ASD measured by echocardiogram in the newborn can anticipate clinical outcome and predict spontaneous closure.

Methods

We reviewed 1012 two-dimensional echocardiograms (2DE) performed in the first days of life of newborn at our hospital from January 2015 to December 2019 with ASD or patent foramen ovale (PFO) as initial diagnoses. The exclusion criteria were associated congenital heart disease, except ventricular septal defect and patent ductus arteriosus both without repercussion. 153 newborns with ASD or PFO in the first 2DE were included in this study. The individual data collected were age at the exam, birth weight, gestational age, height by birth, ASD diameter, total diameter of atrial septum and Septum/ASD ratio (Table 1). The results were expressed as mean ± SD, or percentage. Comparisons of continuous variables between groups of patients were performed using the Student T test. Statistical significance was determined by p <0,05. The newborn was grouped according to the observation or not of spontaneous closure.

Results

ASD or PFO was found in 153 newborns. 60 had PFO, spontaneous closure was reported in 38 (63%). 93 had ASD in the first 2DE, spontaneous closure was reported in 41 (44%). The mean age of diagnosis was 3,37 ±4,39 days of life. The diameter of the ASD in the first exam and the septum/ASD ratio were associated with spontaneous closure. There was no association between spontaneous closure of ASD and birth weight or gestational age in this studied group.

Conclusion

The ASD diameter obtained at the first 2DE in the first days of life was associated with spontaneous closure of the defect.

Table 1 Non-closure group (N = 52) Closure group (N= 41) P Age at the exam (days) 3,48 (±4,52) 3,2 (±4,27) 0,78 Birth weight (grams) 2459,85 (±1098,79) 2350,12 (±1247,70) 0,65 Gestational age (weeks) 34,88 (±5,17) 34,54 (±5,10) 0,75 Height by birth (cm) 44,46 (±6,81) 43,67 (±6,77) 0,57 ASD diameter (mm) 3,66 (± 2,66 (±0,57) <0,01 Septum diameter (mm) 18,74 (±3,9) 18,92(±4,51) 0,83 Septum/ ASD ratio 5,74 (±2,38) 7,28 (±1,96) <0,01 cm = centimeter, mm = millimeter, ASD = atrial septal defect. Unit: Mean and standard deviation.
How common is aortic dilatation?
Authors: Babu A , Meng Z , Oji O , Bowker TJ , Xiao HB
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic dilatation is most commonly associated with hypertension, bicuspid aortic valve and connective tissue diseases such as Marfan’s. It is a precursor to life threatening complications such as rupture or dissection of the aorta. The current ESC Guidelines recommend surgical intervention once the aortic diameter is >50 mm in patients with Marfan syndrome (Ic) and >55 mm in patients with a bicuspid or normal aortic valve morphology (IIb). There is currently a lack of literature on the prevalence of aortic dilatation in the general or even hospital population although there is historical data suggesting the incidence of thoracic aortic aneurysm to be 5.9 cases per 100,000.

Purpose

The aim is to investigate the prevalence of aortic dilatation by echocardiography in our hospital population which may help lay the foundation for population studies and identify prognostic factors which may determine the time of surgical intervention.

Methods

We carried out a retrospective survey using the digital echocardiogram archive and the electronic patient record system at our hospital. This survey covered the period between 1st October 2016 and 1st November 2018. For randomisation  purposes, all transthoracic echocardiograms (TTE) performed on every Thursday during this period were included. All patients with an echocardiographic report of aortic root or ascending aorta dilatation were enrolled. Other information including echocardiographic dimensions along with demographics and past medical history was collected.

Results

During this 24-month period, we analysed a total of 3019 TTEs. 209 patients (6.9%) were reported to have aortic dilatation. 137 (66%) were male and the median age was 67 years. The mean height and weight were 169cm and 80kg, respectively.  A bicuspid aortic valve was confirmed in 10 (4.8%) patients. 132 (63%) patients had a history of hypertension. On echocardiogram, 75 (36%) patients had septal hypertrophy and 26 (12.4%) had a dilated left ventricle.  

Conclusion

Our findings are unique and for the first time, to our knowledge, we report the echocardiographic prevalence of aortic dilatation in the hospital population (6.9%). It is a staggering 40-fold increase when compared to the the prevalence of aortic aneurysm, the most likely end point of aortic dilatation. Based on our figures, there would be at least 400 patients with a dilated aorta in a year in our hospital alone. The prevalence of bicuspid aortic valve in our cohort (4.8%) was nearly three times higher than the general population where it is quoted as 1-2%. Our study also emphasised the established link between hypertension and aortic dilatation with an increased frequency in our cohort (63%) compared to the global prevalence (31%). Given the devastating sequelae of aortic dilatation and its increased prevalence in our patient population, it will be very important to keep these patients under routine surveillance and particularly those with hypertension.
Metformin in non-diabetic patients with metabolic syndrome and diastolic dysfunction: the MET-DIME randomized trial
Authors: Ladeiras-Lopes R , Sampaio F , Leite S , Santos-Ferreira D , Vilela E , Leite-Moreira A , Bettencourt N , Gama V , Braga P , Fontes-Carvalho R
Published: February 2021

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Merck

Background

Metabolic syndrome (MetS) affects one out of 3 adults in the western world and is associated with preclinical diastolic dysfunction that impairs functional capacity and quality of life (QoL).

Purpose

This randomized trial was designed to evaluate if the addition of metformin to the standard treatment of non-diabetic patients with MetS improves diastolic dysfunction.

Methods

Prospective, randomized, open-label, blinded-endpoint trial. Fifty-four non-diabetic adults with MetS and diastolic dysfunction were randomized to lifestyle counseling or lifestyle counseling plus metformin (target dose 1000 mg bid). The primary endpoint was the change in mean e’ velocity (assessed at baseline, 6, 12 and 24 months). Secondary endpoints were improvements in insulin resistance, functional capacity and QoL. Linear mixed effects modelling was used for longitudinal data analysis using modified intention-to-treat (mITT) and per-protocol (PP) approaches.

Results

Forty-nine patients were included in the mITT analysis (mean age = 51.8 ± 6.4; 55% males). Metformin treatment was associated with a significant decrease in HOMA-IR. There was a significantly different mean change in e’ velocity during the study period between trial arms, both in the mITT (at 24 months, change of +0.67 ± 1.90cm/s in metformin arm vs. -0.33 ± 1.50cm/s in control arm) and PP populations (+0.80 ± 1.99cm/s in metformin arm vs. -0.37 ± 1.52cm/s in control arm), using a random intercept linear mixed model. There were no significant differences in peak oxygen uptake and SF-36 scores between trial arms.

Conclusion

Treatment with metformin of non-diabetic MetS patients with diastolic dysfunction, on top of lifestyle counseling, is associated with improved diastolic function.

Abstract Figure.
Echocardiographic systolic and diastolic function alterations in multiple myeloma patients treated with Carfilzomib
Authors: Mingrone G , Astarita A , Maffei I , Cesareo M , Airale L , Bruno G , Vallelonga F , Catarinella C , Salvini M , Bringhen S , Gay F , Veglio F , Milan A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Carfilzomib improves the prognosis of multiple myeloma (MM) patients, but significantly increases cardiovascular toxicity. The timing and effect of carfilzomib therapy on left ventricular function is still under investigation.

Purpose

We sought to assess the echocardiographic systo-diastolic changes, including global longitudinal strain (GLS), in patients treated with carfilzomib and to identify predictors of increased risk of cardiovascular adverse events (CVAEs) during therapy.

Methods

88 patients with MM performed a baseline cardiovascular evaluation comprehensive of transthoracic echocardiogram (TTE) before the start of Carfilzomib therapy and after about 6 months. All patients were clinically followed-up to early identify the occurrence of CVAEs for the whole therapy duration.

Results

After Carfilzomib treatment, mean GLS slightly decreased (-22.2% ± 2.6 vs -21.3% ± 2.5; p < 0.001). 58% of patients experienced CVAEs during therapy: 71% of them had uncontrolled hypertension, 29% had major CVAEs or CV events not related to arterial hypertension. GLS variation during therapy was not related to an increased risk of CVAEs; however, patients with baseline GLS ≥ -21% and/or left ventricular ejection fraction (LVEF) ≤ 60% had an increased risk of major CVAEs (OR = 6.2, p = 0.004;  OR = 3.7, p = 0.04, respectively). Carfilzomib led to an increased risk of diastolic dysfunction (5.6% vs 13.4% p = 0.04) and to a rise in E/e’ (8.9 ± 2.7 vs 9.7 ± 3.7; p = 0.006).

Conclusions

Carfilzomib leads to early LV function impairment early demonstrated by GLS changes and diastolic dysfunction. Baseline echocardiographic parameters, especially GLS and LVEF, might improve cardiovascular risk stratification before treatment.
Left atrial function in heart failure with preserved ejection fraction vs. aortic stenosis: evidence for atrial myopathy?
Authors: Jin X , Melle JV , Voors AA , Sim DKL , Jaufeerally FR , Lee SSG , Soon D , Loh SY , Ding ZP , Richard MA , Lam CSP , Ling LH
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background and Aim

Left atrial (LA) enlargement and impaired LA function are frequently found in patients with heart failure with preserved ejection fraction (HFpEF). Whether these structural and functional LA abnormalities are a consequence of increased LA pressure or whether HFpEF patients have an intrinsic LA myopathy is unknown. We compared LA pressure, size and function between patients with HFpEF and aortic stenosis, as a comparator with LA pressure overload, as well as community-dwelling control subjects.

Methods

Extensive echocardiographic assessments were performed in 219 patients with HFpEF (age 68 ± 11, 48% female), 173 patients with moderate to severe AS (age 69 ± 11, 55% female, aortic valve area index 0.55 ± 0.15 cm2/m2), and 219 controls (age 65 ± 9, 48% female, 42.2% hypertensive)

Results

Compared to controls, both patients with HFpEF and AS had larger LV and LA size and worse LV systolic, diastolic and LA function. Compared with AS patients, HFpEF patients had smaller LA volume index (40.2 ± 19.4 vs. 44.5 ± 11.9 ml/m2 p = 0.01) but similar LV filling pressure estimated by E/e’ (13.4 ± 4.8  13.4 ± 4.8 , p = 0.12). Despite smaller LA volume index and similar LV filling pressure, HFpEF patients had remarkably poorer LA function compared to AS [reservoir GLS, 22.6 ± 10% vs 31.4 ± 10.1 (p < 0.001); contractile GLS, 15.8 ± 6.1% vs 17.5 ± 6.9 (p < 0.05); LASrs, 0.92 ± 0.35% vs 1.27 ± 0.41 (p < 0.001); LASre, -1.49 ± 0.65 vs -1.86 ± 0.67 (p < 0.001)]. The differences in  LA reservoir GLS and LASrs remained significant  after adjustment for atrial fibrillation, diabetes, coronary artery disease, LV ejection fraction and LV mass index.

Conclusion

Patients with HFpEF had significantly worse LA function than patients with AS, despite similar LA pressure overload. These findings support the concept of an intrinsic LA myopathy in patients with HFpEF, beyond LA pressure overload.

Abstract Figure.
Different effects on right ventricular function in different etiology of secondary tricuspid regurgitation
Authors: Tsai WC , Lee WY , Huang MS , Lee WH
Published: February 2021

Funding Acknowledgements

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

Background

Tricuspid regurgitation (TR) is traditionally classified as primary or secondary TR. The effects of TR on right ventricular (RV) function were not consistent. We hypothesized that secondary TR is not a unique group, sophisticated sub-grouping can be useful for studying effects of TR on RV function.

Methods

207 consecutive patients identified as significant TR (moderate and severe) by echocardiography were recruited. Standard measurements for right heart were done according to guideline. Lateral tricuspid annulus systolic tissue velocity (S’) and RV fractional area change (FAC) were used for RV function. We classified these patients into primary TR and 6 subgroups of secondary TR according to a new systemic approach.

Results

Mean age of subjects was 71.2 ± 14.7 years, and there were 84 (40.6%) male. There were 29 (14%) primary TR. Secondary TR was further classified into 6 groups included 18 (8.7%) pacemaker related, 81 (39.1 %) left heart diseases, 6 (2.9%) congenital heart diseases, 3 (1.4%) RV myopathy, 27 (13.0%) pulmonary hypertension, and 43 (20.8%) idiopathic TR. Among 4 major groups (congenital heart disease and RV myopathy were not included in analysis due to low numbers) of secondary TR, S’ was significant higher in idiopathic TR and RV FAC were higher in pacemaker related and idiopathic TR. RV dysfunction was defined as FAC < 35%. RV dysfunction presented mostly in pulmonary hypertension related TR and leastly in idiopathic TR (59.3% vs. 14%, p <0.001). Multivariate analysis using idiopathic TR as reference and controlled TR maximal velocity, RV end-diastolic area, right atrial area, and severity of TR, left heart disease related TR had higher risk of RV dysfunction (OR 4.178, 95% CI 1.490-11.703, p = 0.007).

Conclusions

Effects of TR on RV function were different among different subgroups of secondary TR. Left heart disease related TR had highest risk for RV dysfunction. Secondary TR should not be regarded as a single disease.
prognostic evaluation of patients benefiting from a trans aortic valve replacement according to the type of aortic stenosis
Authors: Lacout M , David C , Bernard A , Saint Etienne C , Clerc JM , Quilliet L , Dion F , Caze C
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic Stenosis (AS) is a common condition in patients over 75 years.  Latest ESC recommendations differentiate 4 types of AS according to: Indexed Stroke Volume (SVi), mean gradient and left ventricular ejection fraction (LVEF). The aim of our study is to evaluate prognosis of patients who have had a transcatheter aortic valve replacement (TAVR), in terms of mortality, according  to the 4 types of AS.

Methods

This study compares prognosis of 620 patients who had TAVR between January 1, 2015 and December 31, 2018. Patients were classified into 4 groups according to AS type: high gradient; low gradient, low flow, low LVEF; low gradient, low flow, normal LVEF; low gradient, normal flow.

Results

69 patients (11.1%) died within 12 months of the procedure: 49 in the high gradient group (9.4%); 13 in the low gradient, low flow, low LVEF group (47.1%); 1 in the low gradient, low flow, normal LVEF group (5%); 6 in the low gradient, normal flow, normal LVEF group (18.2%). All-cause mortality at one year follow-up is higher in low-gradient, low-flow, altered LVEF group (p = 0.0004) than in other groups. Patients in this group were significantly more often admitted for heart failure than patients in high-gradient group (p = 0.009).

Conclusion

A complete echocardiography evaluation is needed to evaluate AS, its severity and type. Patients in the low gradient, low flow, low LVEF group have an independent risk of mortality at 12 months higher than other groups and are more hospitalized than patients in the high gradient group.
Prospective validation of a non-invasive method to estimate myocardial work in aortic stenosis
Authors: Hubert A , Owashi KP , Le Rolle V , Hernandez A , Galli E , Donal E
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): ANR - Maestro project

Background

Stratification of aortic stenosis patients remains challenging and robust indices are required. Myocardial work assessment is a new afterload independent alternative to evaluate left ventricular function. Although, this method was developed in patients with normal aortic valve. We previously developed an integrated cardiovascular system simulated by a computational model to estimate non-invasively myocardial work in aortic stenosis patients* (figure 1A). In the present study, we tested our model in a prospective population of AS patients.

Method and results

9 patients with severe AS (aortic valve area < 1cm2) were included. A complete trans-thoracic echocardiography with a non-invasive blood pressure by brachial artery cuff were realized immediately before a left heart catheterization to have an invasive left ventricular pressure. Myocardial work is then calculated with non-invasive and invasive LV pressure combined to LV strain curves. For constructive and wasted work, root mean squared between invasive and estimated measures were respectively r2 = 0.92 and r2 = 0.94 (figure 1B)

Conclusion

The proposed model is efficient to estimate non-invasively myocardial work indices in AS-patients. These afterload independent indices could permit in future to better stratify this population. 

*Owashi KP, Hubert A and al. Model-based estimation of left ventricular pressure and myocardial work in aortic stenosis. PlosOne 2020. Mar 3;15(3):e0229609

Abstract Figure 1
Principal morphomic components of secondary mitral regurgitation
Authors: Heitzinger G , Bartko PE , Spinka G , Pavo N , Prausmueller S , Arfsten H , Gebhard C , Mascherbauer J , Hengstenberg C , Strunk G , Huelsmann M , Goliasch G
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund (FWF – identification number: KLI-818B).

Background

Secondary mitral regurgitation in patients with heart failure and reduced ejection fraction (sMR) results from distortion of the physiologic cardiac architecture. Underlying morphological components might account for the clinical impact of sMR but have not yet been assessed systematically or related to outcome. 

Objectives

To investigate the morphologic features of sMR and their prognostic impact on outcome. 

Methods

This study used morphomic network profiling in patients with stable heart failure under guideline directed medical therapy. Principal component analysis was applied and three factors extracted, of which Factor 1 and 2 were strongly related to sMR and outcome. Based on the factors, four morphologically distinct clusters were derived. 

Results

Morphomic data from 383 patients were profiled. Factor 1 consists of high loadings of left atrial morphological information, factor 2 high loadings of left ventricular morphology. Cluster analysis revealed four morphologically distinct phenotypes. sMR was most prominent in cluster 3 and 4. The morphological difference was left ventricular size (enddiastolic volume 188ml (160-224) versus 315ml (264-408), P < 0.001). Clusters were associated with mortality (P < 0.001), however, sMR remained independently associated with mortality after adjusting for the clusters (adj.HR 1.42, 95% CI 1.14–1.77; P < 0.01) (Figure 1/ Panel B). The detrimental association of sMR with mortality was mainly driven by cluster 3 (HR 2.18, 95% CI 1.32-3.60; P = 0.002), the "small LV cavity" phenotype (Figure 1/ Panel A).

Conclusions

These results challenge the current perception of sMR resulting exclusively from global or local LV remodeling and, supported by previous concepts, emphasize the role of the atrial component as a pathophysiologic mechanism. The association of sMR with mortality cannot be purely attributed to cardiac morphology alone. Additionally, other key aspects such as balance of closing and tethering forces contribute to mitral valve closure. The association of sMR with mortality mainly driven by the small LV cavity phenotype refines the prognostic impact of sMR in relation to the underlying anatomic variability.

Abstract Figure. Survival for clusters and adj. sMR
Atrial coupling index by standard echocardiography in degenerative mitral regurgitation: incremental determinant of survival
Authors: Essayagh B , Benfari G , Antoine C , Batista R , Maalouf J , Michelena H , Enriquez-Sarano M
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Mayo Clinic Foundation

Background

Left atrial (LA) volume is linked to outcome in degenerative mitral regurgitation (DMR) but does not encompass LA function assessment. Thus, we ought to determine the prognostic role of left atrial coupling-index (LACI), as left atrial volume-index (LAVI) by Tissue-Doppler-Imaging a’ (TDI-a’), in a large cohort of DMR.

Methods

All consecutive 4792 patients (61 ± 16 years, 48% women) with isolated degenerative mitral valve disease diagnosed at Mayo Clinic 2003-2011, comprehensively characterized, in whom LAVI and TDI-a’ in sinus rhythm was prospectively measured in routine practice, was enrolled and their long-term survival analyzed.

Results

LACI (5.8 ± 3.7–T1 < 3.8; T2 3.8-6.3; T3 > 6.3) was significantly higher through different DMR grades (no, mild, moderate, severe DMR: 3.77 ± 2.26, 5.08 ± 2.95, 6.54 ± 3.74 and 7.84 ±4.29 respectively; p < 0.0001). Independent determinants of LA dysfunction assessed by LACI were age, E/e’, left-ventricle (LV) end-systolic-diameter, mitral-regurgitation (MR) grade, and LV ejection-fraction (all P ≤ 0.0001). LACI > 6 was independently associated with dyspnea, edema, more severe functional tricuspid-regurgitation and elevated pulmonary artery pressure, irrespective of age, sex, Charlson-comorbidity-index, ventricular function and MR severity. Total follow-up was 7.03 ± 3.0 years, during which 1146 (24%) underwent mitral-valve surgery (94% repair-6% replacement) and 880 (18%) died, 780 under medical treatment and 100 after surgery. Overall survival throughout follow-up (10-year 76 ± 1%) was strongly associated with LACI (88 ± 1% vs. 78 ± 1% and 62 ± 2% for LACI <3.8, 3.8-6.3 and ≥6.3, P < 0.0001) even adjusting comprehensively, including for DMR severity (adjusted-hazard-ratio 1.23[1.07-1.43] for LACI > 5.79, P = 0.005). Mortality under medical management was profoundly affected by LACI (adjusted-hazard-ratio 1.11[1.05-1.18] per 3 unit increment; 1.35[1.15-1.58] for LACI > 5.79 vs. ≤5.79, both P = 0.0002). Survival improved after mitral surgery (time-dependent adjusted-hazard-ratio 0.40[0.28-0.65], P < 0.0001) but remained humbly linked to LACI (10-year 93 ± 3% vs. 90 ± 2% and 80 ± 3% for LACI tertiles, P = 0.0008). Most importantly, LACI provided incremental prognostic information over LAVI and other conventional determinants of survival (P < 0.0001) with Net-reclassification-improvement vs. LAVI of 0.21 ± 0.02, P < 0.0001.

Conclusion

LA function assessed by LACI in routine practice, by conventional echocardiographic measurements, displays incremental and independent link to excess-mortality, considerable under medical management and partially alleviated by mitral surgery. Thus, LACI is a simple tool of crucial interest in DMR risk-stratification.

Abstract Figure. LACI in DMR
Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction
Authors: Vilardell P , Moral S , Albert X , Bosch D , Morales M , Frigola JM , Robles R , Pla R , Ramos R , Aboal J , Brugada R
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose

Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods

An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding <5mm inside the cavity.

Results

Of 1.215 anterior STEMI patients, 121 (10%) cases presented LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323 ± 116 days. No differences in baseline clinical and echocardiographic characteristics were detected between both groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p < 0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P = 0.042) and embolism-related rate (3% vs 19%; p = 0.024) than protruding LVT cases (see Figure). Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (OR = 0.11; 95% CI,0.12-0.94; p = 0.045). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p = 0.400).

Conclusions

Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.

Abstract Figure.
Comparison of pulmonary vein sizing by transesophageal echocardiogram and by direct angiogram
Authors: Bachani N , Vadivelu R , Bagchi A , Jadwani JP , Panicker GK , Shah H , Dhirawani B , Rathi C , Lokhandwala Y
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein (PV) anatomy and sizing is important to know before performing PV isolation. This information is conventionally obtained by angiography or by CT scan.

Aim

We undertook this study to identify and measure the PVs during TEE studies and validate these against angiography.

Method

17 consecutive patients due to undergo PV isolation for paroxysmal atrial fibrillation were analysed. Using TEE, the PVs were visualised (Upper panel) as follows:  i) From the mid-esophageal four chamber view, the chamber probe was turned to the right at 110-130º for the bicaval view, where the RSPV was seen entering the left atrium adjacent to the SVC. ii) At 0º the SVC was imaged in its short axis, and the probe advanced till the interatrial septum was seen. The angle was changed to 30º to visualise the right inferior PV (RIPV). iii) From the two chamber view (70-90º), the probe was turned to the left and withdrawn to display the left superior PV (LSPV) entering the left atrium parallel to the appendage.iv) Keeping the LSPV in focus, the angle was changed to 135º and the probe advanced till the AV groove, where the left inferior PV (LIPV) was visualised. After transseptal puncture, each PV was cannulated. The PV angiograms were performed in several projections to obtain the best PV profile (lower panel). Using electronic callipers, each PV was measured within 1 cm of its entry into the left atrium, after having received all tributaries. Those PVs were considered for analysis which were measured by both TEE and angiography. The paired ‘T’ test was used to compare the PV diameters by TEE and angiography and the Bland Altman analysis was done to see the level of agreement.

Results

Of a total of 68 PVs, 62 could be adequately visualised by TEE and 50 by angiography. These 50 PVs were measured using both methods. The diameters of the PVs measured by TEE and angiography were not statistically different by the paired t test; LSPV14 ± 1.8 mm v/s 14.4 ± 2.1 mm; RSPV 13 ± 1.8 mm v/s 14.6 ± 3.5 mm; LIPV 11.9 ± 2.1 vs 13.2 ± 2.8 mm and RIPV 10.5 ± 2.7 vs 12.1 ± 2.9 mm. Bland Altman analysis showed most PV sizes estimated by TEE and angiography lay within limits of agreement.

Conclusions

A majority of PVs can be visualised by TEE using a defined protocol. TEE is a good technique to visualise and assess the size of PVs, avoiding the need for contrast medium and radiation.

Abstract Figure. TEE and angiographic images of PVs
Left atrial strain and outcome in heart failure with preserved ejection fraction
Authors: Bekki N , Hayama H , Nagai R , Miyake W , Yamamoto J , Torii S , Kubota S , Nakagawa T , Okazaki T , Yamamoto M , Okazaki O , Hara H , Hiroi Y
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function is impaired in heart failure with preserved ejection fraction (HFpEF). However, the association between LA longitudinal strain and heart failure (HF) events in patients with HFpEF is still unknown. We evaluated whether LA strain measurements would be useful to predict hospitalizations for worsening HF in this study.

Methods

This study included 121 patients (Male 73, Female 48) with HFpEF who had echocardiogram at our institute (Age = 76 ± 14y, Left ventricular ejection fraction; LVEF = 63 ± 8%). Patients with atrial fibrillation were excluded. LA longitudinal strain was measured by speckle-tracking echocardiography, using TOMTEC imaging system. The endpoints were hospitalizations for worsening HF.

Results

During follow-up period of 319 ± 269 days, 33 patients (27%) experienced hospitalizations for worsening HF. LA strain was markedly lower in patients with HF events at 11.3 ± 5.6, whereas LA strain was higher at 20.3 ± 10.1 in patients without HF events. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by median value of LA strain (Figure).

Conclusions

LA dysfunction in HFpEF is associated with a higher risk of HF hospitalization, and LA strain measurements would be useful to predict HF events.

Abstract Figure
Predictors of atrial fibrillation in patients with cryptogenic stroke and fifteen-days electrocardiographic monitoring. Preliminary results of the DECRYPTORING study
Authors: Vera Sainz A , Cecconi A , Martinez Vives P , Ximenez Carrillo A , Aguirre C , Ramos C , Benedicto A , Diego G , Dominguez L , Lopez B , Rojas A , Gamarra A , Vivancos J , Jimenez Borreguero LJ , Alfonso F
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

onbehalf

DECRYPTORING study

Introduction

Cryptogenic stroke (CS) represents up to 30% of all stroke types.  In one third of CS, atrial fibrillation (AF) is identified as the underlying cause. Predictors of AF in the setting of CS have been described, however these findings were based on retrospective studies and with maximum ECG monitoring of 72 hours. To overcome these limitations, we designed the prospective Decryptoring study whose objective is to create a comprehensive predictive model for AF in patients with CS.

Methods

From April 2019, 41 consecutive patients with a CS and age > 60 years were included. On admission, a transthoracic echocardiogram with 3D volume and left atrial (LA) strain was performed. All patients were monitored with a 15-day ECG-Holter after discharge. Patients were classified according to AF detection.

Results

AF was detected in 9 patients (22%). Patients with AF were older (75.9 ± 8 vs. 81.9 ± 4.3 years, p = 0.041). There was no difference in T-troponin levels. NTproBNP was higher in the group with AF (350 ± 586 pg / ml vs. 1084 ± 1416 pg / ml, p = 0.018). Regarding LA strain, patients with AF presented reservoir LA strain (25.5 ± 8.2% vs 17.4 ± 4.3%; p = 0.006) and conduct LA strain (12 ± 5.2% vs 7.2 ± 1.5%; p = 0.01) lower than patients without AF. There were no differences in contraction LA strain or other echocardiographic variables. The risk of developing AF was higher in patients with NTproBNP> 165 pg / ml (OR 11.3 [95% CI 1.2-102.9] p = 0.031), LA reservoir strain <19.1% (OR 7.7 [IC 95 % 1.5-40.0] p = 0.016) and LA conduct strain <9.1% (OR 7.8 [95% CI 1.3-45.0] p = 0.022) (Table).

Conclusions

This prospective study, demonstrates that high NTproBNP, low reservoir LA strain and low conduct LA strain are associated with underlying AF in patients with cryptogenic stroke.

No AF (n = 32) AF (n = 9) P value Age (years) 75.9 ± 8 81.9 ± 4.3 p = 0.041 NTPROBNP (pg/ml) 350 ± 586 1084 ± 1416 P = 0.018 LA indexed diastolic volume (ml/m2) 30 ± 11.8 33.8 ± 9.8 P = 0.35 LA EF (%) 45 ± 16.7 45 ± 12.8 P = 1 Reservoir LA strain (%) 25.5± 8.2 17.4± 4.3 P = 0.006 Conduct LA strain (%) 12 ± 5.2 7.2 ± 1.5 P = 0.01 Contraction LA strain (%) 13.5 ±5.3 10.2± 3.9 P = 0.10 NTPROBNP > 165 pg/ml 12 (41%) 8 (89%) OR 11.3 [IC 95% 1.2-102.9]; p = 0.031 Reservoir LA strain <19.1% 6 (20%) 6 (67%) OR 7.7 [IC 95% 1.5-40.0]; p = 0.016 Conduct LA strain <9.1% 9 (31%) 7 (78%) OR 7.8 [IC 95% 1.3-45.1]; p = 0.022
Value of TAPSE normalized to right ventricular length as a substitute to speckle tracking-derived right ventricular free wall longitudinal strain assessment
Authors: Unger P , Paesmans M , Amzulescu M , David-Cojocariu A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The diagnostic and prognostic value of right ventricular strain assessed by speckle-tracking imaging (STI-RV) has recently emerged in various clinical situations and this parameter has been incorporated into echocardiographic guidelines. However, it suffers from several limitations including the fundamental but often unmet requirement of good image quality and from the need for dedicated software with inter-vendor variability.

Purpose

We hypothesized that RV free wall (fw) longitudinal shortening, i.e. the ratio of tricuspid annular plane systolic excursion (TAPSE) to end-diastolic RV longitudinal length (RVDL) could be used as a surrogate of RVfw strain, without suffering from the abovementioned limitations. We therefore compared -(TAPSE/RVDL) to STI-RVfw strain in a series of non-selected patients undergoing echocardiography.

Patients and methods

144 consecutive ≥18 y-o patients in sinus rhythm referred to our echocardiographic laboratory underwent transthoracic echocardiography using a Vivid E9 platform (GE Vingmed, Horten, Norway). STI-RVfw strain was obtained using a RV focused apical four chamber view and -(TAPSE/RVDL) was obtained from the apical four-chamber view.  Images and loop were stored digitally and analyzed offline using EchoPac 2.02 software (GE Vingmed).

Results

Poor image quality precluded the assessment of STI-RVfw strain - but not of -(TAPSE/RVDL) - in 27 patients (18.8%) and of both parameters in 4 patients (2.8%); the study group consisted in the remaining 113 patients. Among all tested RV function indices, -(TAPSE/RVDL) best correlated with STI-RVfw strain (Panel A), without significant bias between the two methods (Panel B). The area under the ROC-curve for -(TAPSE/RVDL) to detect abnormal STI-RVfw strain (using a threshold of -20.2%) was 0.97 [IC 95% 0.94-1], and sensitivity, specificity, negative and positive predictive value were 83%, 96%, 96%, and 83%, respectively.

Conclusion

In this unselected series of patients, the assessment of -(TAPSE/RVDL) performed reasonably well to predict abnormal STI-RVfw strain and was more often feasible than the latter. Its prognostic value should be prospectively tested.

Abstract Figure 1
Left atrial function assessed by speckle tracking echocardiography predicts atrial fibrillation burden after catheter ablation independently of reconduction: a RACE-AF echocardiographic sub-study
Authors: Nielsen A , Soerensen S , Skaarup K , Djernaes K , Estepar R , Hansen M , Worck R , Johannesen A , Hansen J , Biering-Soerensen T
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial (LA) function assessed by 2D speckle tracking echocardiography (STE) has demonstrated to be a useful predictor of recurrence of atrial fibrillation (AF) following catheter ablation (CA). Pulmonary vein reconduction (PVR) is one of the most important causes of recurrent paroxysmal AF (PAF) after ablation. The purpose of this study was to evaluate the association between AF burden (% of time in AF) following CA and LA strain measurements independently of PVR.

Methods

This prospective study included 66 patients with PAF who underwent CA (mean age 60 ± 8 years, 65% male). STE was performed during sinus rhythm prior to CA. AF burden was recorded by continuous rhythm monitoring using implantable loop recorders during a follow-up period of 4-6 months, excluding a blanking period of 3 months. After follow-up, all patients underwent an invasive assessment of pulmonary vein isolation to test for PVR. Multivariable linear regression analysis was used to assess the association between AF burden and peak atrial longitudinal reservoir strain (PALS), peak atrial contraction strain (PACS) and peak atrial conduit strain (PCS).

Results

Prior to CA, median AF burden was 3.8% (IQR: 0.5, 17). During follow-up, 37 patients (56%) were free of AF while median AF burden was 0.7% (IQR: 0.2, 1.6) in patients with an AF burden of more than 0%. A total of 35 patients (54%) were found to have PVR after ablation. Patients with AF recurrence had significantly lower PACS compared to patients with no AF during follow-up (10% ± 6% vs. 14% ± 5%, p = 0.004). No differences in PALS and PCS were observed. Increased PACS remained independently associated with low AF burden following CA after multivariable adjustments for clinical characteristics, comorbidities, and PVR (β=-0.262, p = 0.049) (Figure 1). PALS and PCS did not remain significantly associated with AF burden.

Conclusion

Increased PACS is strongly associated with low AF burden after CA even after adjusting for PVR. This suggests that an analysis of LA function could be useful to stratify patients prior to CA and improve treatment strategies.

Abstract Figure.
Does global longitudinal strain predict long-term outcome in patients presenting to the emergency department with chest pain?
Authors: Fuks A , Liel-Cohen N , Blondheim DS , Shimoni S , Jabaren M , Leitman M , Adawi S , Asmer I , Ganaeem M , Lavi I , Saliba W , Shiran A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

 Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) was a prospective multicenter study designed to determine whether 2D longitudinal strain (2DLS) can assist in triage of patients with chest pain in the emergency department (ED). In that study 2DLS was not useful to rule out acute coronary syndromes (ACS) in the ED, partly because many patients without ACS had abnormal 2DLS. The prognostic significance of 2DLS in these patients is unclear.

The aim of the current study was to determine whether global longitudinal strain (GLS), measured using 2D echocardiography in the ED, can predict long-term outcome.

Methods

 Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure or atrial fibrillation) was available in 525 of 605 patients (87%) enrolled in the 2DSPER study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. Global longitudinal strain (GLS) was computed from echocardiograms performed within 24 hours of chest pain using a dedicated 2DLS software (EchoPAC SW; GE Vingmed Ultrasound AS). MACE of patients with worse GLS (>median) was compared to those with better GLS (≤median).

Results

 Median GLS was -18.8%. MACE occurred in 43/249 (17.3%) of patients with worse GLS (-16.8 ± 1.5) as compared with 49/276 (17.8%) with better GLS (-20.8 ± 1.6), HR 0.98 (95%CI 0.65-1.4, p = 0.9) (Figure). Similarly, there was no significant difference in total mortality (6% vs. 4.7%, p = 0.5), cardiac death (0.4% vs. 0.7%, p = 0.6), ACS (8% vs. 8.3%, p = 1), revascularization (10% vs. 10.9%, p = 0.8), hospitalization for heart failure (0.8% vs. 2.2%, p = 0.2) or atrial fibrillation (3.6% vs. 4.3%, p = 0.7) between groups. Predictors of MACE were male gender (HR 2.5, 1.4-4.3, p = 0.02), history of coronary artery disease (HR 3.3, 2-5.4, p < 0.0001) and hypertension (HR 1.8, 1.2-2.8, p = 0.005), but not GLS (HR 0.98, 0.7-1.5, p = 0.9).

Conclusions

 GLS did not predict long term outcome in patients presenting to the ED with chest pain. Long-term outcome was favorable in the group of patients with worse GLS, similar to better GLS.

Abstract Figure.