bluuebunny/crossref_metadata_2025 huggingface dataset:
Prognostic value of left atrial function in patients with severe primary mitral regurgitation undergoing mitral valve repair
Authors: Stassen J , Van Wijngaarden A L , Butcher S C , Palmen M , Bax J J , Delgado V , Marsan N A
Published: October 2021

Background

Timing of mitral valve surgery for primary mitral regurgitation (MR) remains challenging. Since MR has a significant hemodynamic impact on the left atrium (LA), assessment of LA function may have prognostic value in these patients which is incremental to LA volume and left ventricular (LV) remodeling parameters.

Purpose

This study sought to investigate whether preoperative assessment of LA reservoir strain (LASr) by speckle tracking echocardiography is associated with long-term outcome in patients undergoing mitral valve repair for severe primary MR.

Methods

Echocardiography was performed prior to mitral valve surgery in 566 patients (age 64±12 years, 66% men) with severe primary MR. Complete clinical information was collected and the endpoint was all-cause mortality after operation. The study population was divided based on a cut-off value of LASr (22%) derived from a spline curve analysis (hazard ratio for all-cause mortality >1).

Results

Patients with LASr ≤22% (n=277) were significantly older, had more impaired renal function and were more symptomatic (NYHA functional class III to IV) compared to patients with LASr >22% (n=289). In terms of echocardiographic data, patients with LASr ≤22% had significantly lower LV ejection fraction and LV global longitudinal strain (LV-GLS) and significantly higher systolic pulmonary artery pressures and LA volume index compared with patients with LASr >22%.

During a median follow-up of 95 (56 – 147) months, 129 patients (22.8%) died. Patients with LASr ≤22% experienced significantly higher mortality rates compared to patients with LASr >22% (log rank chi-square 35.1; p<0.001) (Figure). On multivariable analysis, age (hazard ratio (HR): 1.06; 95% confidence interval (CI): 1.03 to 1.09; p<0.001), LV-GLS (HR: 1.08; 95% CI: 1.02 to 1.15; p=0.014) and LASr (HR: 0.96; 95% CI: 0.93 to 0.99; p=0.014) were independently associated with all-cause mortality. The addition of LASr to a clinical model (including: age, coronary artery disease, estimated glomerular filtration rate, NYHA class III-IV, atrial fibrillation, LV end-diastolic volume index, LV ejection fraction, LV-GLS, LA volume index and systolic pulmonary artery pressure) showed a significant increase in the chi-square value (chi-square differences = 6.9; p=0.011), demonstrating the incremental prognostic value of LASr in patients with primary MR.

Conclusions

Preoperative LASr is independently associated with all-cause mortality in patients undergoing mitral valve repair for primary MR, has incremental prognostic value over LA volume and LVEF and might therefore be helpful to guide surgical timing.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Jan Stassen has received an ESC training grant (Appehab724.011364741) Association of LASr and outcome
Correlation of intraprocedural and follow up parameters for mitral regurgitation grading after percutaneous edge-to-edge repair
Authors: Salinas Gallegos A , Pozo Osinalde E , Gordillo X , Jimenez Quevedo P , Marcos-Alberca P , Mahia P , Tirado G , Gomez De Diego J J , Macaya C , Perez-Villacastin J , Fernandez-Ortiz A , Nombela-Franco L , De Agustin J A
Published: October 2021

Background

Percutaneous edge-to-edge mitral repair has merged as an effective therapy for moderate-to-severe mitral regurgitation (MR) in high surgical risk patients. Transesophageal echocardiogram (TEE) is crucial for procedure guiding and immediate result evaluation, whereas transthoracic echocardiogram (TTE) is largely used in follow up. However, there is no consensus on the best intraprocedural parameter to evaluate residual MR.

Purpose

To evaluate the predictive value of different MR parameters from intraprocedural TEE with grading in consecutive TTE during the follow up.

Methods

All the consecutive patients who underwent percutaneous mitral repair with the MitraClip system between 2010 and 2020 in our tertiary university hospital were considered for this study. Immediate posprocedural MR parameters (number of jets, summatory and maximum vena contracta (VC), summatory and maximum 3D effective regurgitation orifice (ERO) and pulmonary vein (PV) flow parameters) were reassessed when possible blindly to the follow up MR grading in sequential TTE.

Results

We included 88 patients (64.8% males) with a mean age of 76±10 years. Baseline MR was graded as moderate-to-severe in 13 (14.8%) and severe in 75 (85.2%). The most frequent MR etiology was secondary (44.3%) followed by primary (35.2%) and mixed (20.5%). Patients presented with mild left ventricular systolic dysfunction (LVEF 44.5±15.3%) and dilatation (LVEDVi 71.8 [51.5–102.8] mL/m2). MR grading distribution remained stable at 1 and 6 months follow up TTE. Among all the aforementioned criteria only summatory and maximum VC remained significant for different MR grade prediction. Thus, these values were able to identify MR ≥3 at 1 and 6 months (Table). Moreover, on ROC analysis maximum VC demonstrated an excellent discriminatory power to identify significant MR at 6 months (Figure). Thereby, a cut-off point of 0.45 cm was able to predict MR ≥3 with 88% sensitivity and 89% specificity.

Conclusion

Among intraprocedural TEE parameters to evaluate residual MR in percutaneous edge-to-edge mitral repair, maximum and summatory VC appeared to be the more reliable to predict significant insufficiency in the follow up.

Funding Acknowledgement

Type of funding sources: None. Table 1. Differences in intraprocedural TEE VC in relation with significant MR in follow-up TTEFigure 1. ROC curve of maximum VC for prediction of significant MR at 6 months
Analysis of right ventricle echocardiographic function parameters for the prediction of outcomes in significant functional tricuspid regurgitation
Authors: Romero Delgado T , Travieso Gonzalez A , Luque Diaz T , Vivas Balcones D , Mahia Casado P , Vilacosta I
Published: October 2021

Introduction

Functional tricuspid regurgitation is a common disease that significantly impairs survival and quality of life. The role of echocardiographic right ventricular (RV) function parameters to detect patients with worse prognosis that may benefit from invasive treatment is still under debate.

Methods

121 consecutive patients with grade III and IV functional tricuspid regurgitation were evaluated. RV function parameters and clinical variables were assessed at baseline, and then patients were prospectively followed-up. The primary endpoint was the combination of death or heart failure (HF) admissions. Comparison of imaging parameters was done using receiver-operating characteristics (ROC) curves. Multivariate logistic regression analysis was preformed to establish independent predictors of outcomes.

Results

Median follow up was 27.3 months. 73.6% of the patients were female, and mean age was 80.4 years. 63.6% were grade IV tricuspid regurgitation.

In the univariate analysis using the area under the ROC curve (AUC), RV-free wall strain (RVS, AUC=0.633) and pulmonary artery systolic pressure (PASP, AUC=0.605) were the best predictors of death and HF admissions, although the individual diagnostic performance was weak.

In the multivariate analysis including either clinical and echocardiographic variables, independent predictors of death and HF admissions were Age (OR 1.07, p=0.029), RVS >−16 (OR 5.0, p=0.001), Diabetes mellitus (OR 3.0, p=0.011), eGFR (ml/min, OR 0.96, p=0.001) and Hemoglobin (g/dL, OR=0.74, p=0.048). The model including these variables was superior than RVS and PASP alone (AUC 0.884, p<0.001) (graph 1), showing high sensitivity (78.8%) and specificity (67.3%).

Conclusions

In patients with significant functional tricuspid regurgitation, RVS and PASP show the best performance for the detection of death and HF admissions. A multivariate model including age, diabetes, eGFR, hemoglobin and RVS was superior than the individual imaging parameters.

Funding Acknowledgement

Type of funding sources: None. Table 1Graph 1
Multimodality imaging and systemic biomarkers in classical low-flow low-gradient aortic stenosis: key findings for cardiac remodeling evaluation
Authors: Lopes M.A.A.A.M.L , Campos C M , Rosa V E E , Sampaio R O , Morais T C , Brito F S , Vieira M L C , Mathias W , Medeiros H N A A , Santis A S A L , Rochitte C E , Ribeiro M H , Santos L M , Abizaid A , Tarasoutchi F
Published: October 2021

Background

Elevated levels of troponin I (hsTnT) and B-type natriuretic peptide (BNP) have been related with poor prognosis in patients with LFLG-AS. Biomarkers are less expensive, more practical and more accessible than imaging tests, so their use can be an alternative to imaging in the evaluation of patients with LFLG-AS.

Purpose

The aim of the present study is to assess multimodality imaging findings according to systemic biomarkers (i.e. hsTnT and BNP) in Low-Flow, Low-Gradient Aortic Stenosis (LFLG-AS) and reduced left ventricular ejection fraction (LVEF) patients.

Methods

Prospective study with LFLG-AS patients (LVEF <50%, aortic valve area ≤1,0 cm2 and mean gradient <40 mmHg) that underwent hsTNnT, BNP, cardiac magnetic resonance (CMR) with T1 mapping and 2 dimensional echocardiogram (2DEcho). All patients also underwent dobutamine stress echocardiogram to define aortic stenosis severity. Patients were divided into 3 groups according to BNP and hsTnT levels: Group 1: BNP and hsTnT levels below median (BNP <395 pg/ml and TnI-Ultra <0.042 ng/ml); Group 2: BNP or hsTnT higher than median; and Group 3: both hsTnT and BNP higher than median.

Results

49 patients with LFLG-AS were included (Group 1: 17 patients, Group 2: 14 patients and Group 3: 18 patients). Clinical characteristics (including risk scores) were not able to stratify these groups. Patients with elevation of both biomarkers had lower valvuloarterial impedance (P=0.03), lower LVEF (P=0.02), less moderate/severe mitral (P=0.01) and tricuspid regurgitation (P<0.01) by 2DEcho. CMR identified a progressive increase (from Group 1 to 3) of right and left chamber volumes; reduction in right and left ejection fraction and a marked increase in myocardial fibrosis assessed by extracellular volume (ECV) and indexed extracellular volume (iECV) (Figure 1).

Conclusion

Higher levels of BNP and hsTnT in LFLG-AS patients were associated with worse multi-modality imaging parameters and can be a surrogate of cardiac remodeling.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): No funding
Imaging and circulating biomarkers: a united approach for secondary tricuspid regurgitation
Authors: Spinka G , Bartko P E , Heitzinger G , Teo E , Prausmueller S , Arfsten H , Pavo N , Winter M P , Mascherbauer J , Hengstenberg C , Huelsmann M , Goliasch G
Published: October 2021

Background

Secondary tricuspid regurgitation (STR) is frequent among patients with heart failure with reduced ejection fraction (HFrEF), however inheres considerable diagnostic challenges. The assessment of circulating biomarkers reflecting neurohumoral activation may constitute a valuable supplement to the currently imaging-based diagnostic process. This study therefore sought to investigate (i) the expression of a set of complementary biomarkers in STR, (ii) to evaluate their association with STR severity, and (iii) to analyse whether the combination of neurohormone measurement and echocardiographic grading improves the individual patient risk assessment.

Methods

We included 576 HFrEF patients under guideline-directed therapy recording functional, echocardiographic, invasive hemodynamic and biochemical measurements, i.e. N-terminal pro-B-type natriuretic peptide, mid-regional pro-atrial natriuretic peptide (MR-proANP), mid-regional pro-adrenomedullin, C-terminal pro-endothelin-1 (CT-pro-ET1) and copeptin.

Results

Plasma levels of aforementioned neurohormones were significantly rising with increasing STR severity (for all P<0.001). Among all measured biomarkers, CT-pro-ET1 and MR-proANP were closest related to severe STR, even after multivariate adjustment for established clinical confounders (adj. OR 1.46; 95% CI 1.11–1.91, P=0.006 and adj. OR 1.45, 95% CI 1.13–1.87, P=0.004, respectively). By means of individual outcome in patients with moderate to severe STR, adding the selected biomarkers (i.e. CT-pro-ET1 and MR-proANP) resulted in a substantial improvement in the discriminatory power regarding long-term mortality (C-statistic: 0.54 vs. 0.65, P<0.001; continuous NRI 57%, P<0.001).

Conclusions

Circulating biomarkers closely relate to STR severity and correlate with hemodynamic and morphologic mechanisms of STR. Specifically, MR-proANP and CT-pro-ET1 are closely linked to the presence of severe STR and a combined assessment with the guideline recommended echocardiographic grading leads to a significant improvement of individual risk stratification.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): FWF - Austrian Science Fund Graphical AbstractNeurohumoral profiles of STR
Myocardial deformation techniques as potential tools to detect arrhythmogenic cardiomyopathy in early stages of the disease
Authors: Segura Rodriguez D , Bermudez-Jimenez F J , Gonzalez Camacho L , Oyonarte-Ramirez J M , Moreno Escobar E , Bautista-Paves A , Macias Ruiz M R , Alvarez Lopez M , Tercedor Sanchez L , Jimenez-Jaimez J
Published: October 2021

Introduction

Arrhythmogenic Cardiomyopathy (ACM) is a life-threatening entity which predispose to malignant arrhythmias and sudden cardiac death even in early stages of the disease. Deformation techniques obtained by echocardiography are promising tools which can identify subtle pathologic changes in the myocardial wall. Our aim is to investigate how myocardial deformation parameters may be affected throughout ACM spectrum.

Methods

A cohort of ACM 45 subjects, was characterized using advanced transthoracic echocardiography and divided into groups according to left ventricle ejection fraction (LVEF). Twenty-three healthy volunteers were also included as control group (CG). We analyzed regional wall motion abnormalities and left ventricular myocardial deformation parameters by 2D Speckle Tracking, such as global longitudinal strain (GLS), mechanical dispersion (MD) [standard deviation (SD) and range (delta)].

Results

23 (51,1%) of the ACM cohort were men, with a mean age of 43,13±16,55 years. Next-generation sequencing identified a potential pathogenic mutation in 37 (82,2%) of the patients. Those ACM subjects with low LVEF (ACM-L) presented lower GLS values when compared to those with normal LVEF (ACM-N) (−16,17±2,68% vs. ACM-N −19,39±2,97%; p<0.001) with no significant differences in MD parameters. ACM-N showed no differences in GLS regarding to CG, but significant differences were found when analyzing MD values, with pathological dispersion times in the ACM-N group (ACM-N DMSD 50,50±20,39ms vs. CG 37,35±17,15ms; p=0,016; ACM-N DMDelta 167,4583±75,07ms vs CG 125±49,13ms; p=0,033).

Conclusions

MD may be an additive tool for identifying ACM patients in early stages of the disease when LVEF is still preserved.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic characteristics of cardiac myxoma
Authors: Koritnik P , Pavsic N , Bervar M , Prokselj K
Published: October 2021

Background

Accurate imaging differentiation of various cardiac masses is pivotal due to differences in clinical management and treatment. The most common primary cardiac tumor is cardiac myxoma (CM), which is typically located in the left atrium attached to the interatrial septum. Although benign, serious clinical manifestations may occur and surgical treatment of CM is warranted in most cases. Echocardiography is the most common imaging modality, with a reported sensitivity of 90–96%, however accurate diagnosis can be challenging due to the heterogeneous morphological presentation of CM.

Purpose

The aim of this study was to determine the utility of echocardiography in CM diagnosis.

Methods

We retrospectively analyzed the echocardiographic and pathohistological findings of all consecutive patients admitted to our cardiology department for possible CM between 2005 and 2020.

Results

During the 15-year period, 73 patients were admitted for diagnostic evaluation of a possible CM. Subsequently, 54 patients (74%) were diagnosed with CM or another non-myxomal (NM) cardiac tumor, while in others cardiac masses of other etiologies (thrombus, infective endocarditis, etc.) were diagnosed (Figure 1). All but one patient with CM or NM cardiac tumor were treated surgically at our institution and pathohistological specimens were obtained from the resected tumor. There was a significant female preponderance (n=34, 63%) and the mean age at the time of surgery was 64±14 years. Based on the preoperative echocardiographic findings, 45 (85%) tumors were diagnosed as CM and 8 as NM cardiac tumors (Figure 1). Evaluation of pathohistological specimens revealed CM in 39 of 53 (74%) operated patients. Patohistiologically, a NM cardiac tumor was diagnosed in 7 patients who were preoperatively classified as CM. The sensitivity and specificity of preoperative echocardiography for the detection of CM were 97% and 50%, respectively (Figure 1). The echocardiographic characteristics of pathohistologically confirmed CM were compared to cases of NM cardiac tumors. The comparison between the two groups revealed statistically significant differences in localization and tumor size. All NM cardiac tumors were located in an atypical position and 72% of CM were found in a typical position within the left atrium (p<0.001). NM cardiac tumors were also significantly smaller than CM (25.1±12.6 mm vs. 37.5±18.5 mm, p=0.029).

Conclusion

Our single-center study confirms the excellent sensitivity of echocardiography for CM diagnosis. The specificity of echocardiography was modest, thus caution is warranted due to a wide differential diagnosis of CM. The diagnosis of CM seems to be less likely with atypical tumor location and small tumor size. Other non-invasive imaging modalities such as cardiac computed tomography or magnetic resonance imaging should be considered in such cases.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Flow chart showing the number of patients diagnosed with CM on preoperative echocardiography.
A modified Dabestani-Mahan formula estimates a normal pulmonary artery systolic pressure: a single-center retrospective study
Authors: Sunder V , Cha R , Hunter K , Dolan R ,   Cooper Heart Institute
Published: October 2021

Background

Pulmonary artery systolic pressure (PASP) is increasingly used as an important datapoint in clinical decision-making and prognostication even in specialties outside of cardiology. Estimation of PASP by Doppler quantification using tricuspid regurgitation (TR) peak velocity is commonly used and correlates well with invasive measurement by right heart catheterization. Further study of transthoracic echocardiogram (TTE) techniques to estimate PASP is needed to provide this datapoint in the absence of sufficient Doppler data for the TR peak velocity method. One technique using right ventricular outflow tract acceleration time (AT) to estimate mean pulmonary artery pressure (MPAP) has been proposed by Dabestani Et al. by the equation MPAP=90-(0.62x AT). Assuming a linear relationship between MPAP and PASP, as suggested by Chemla Et al. by MPAP=(0.61xPASP)+2, a modified formula PASP=145-AT could possibly estimate a normal PASP ≤25 mmHg.

Purpose

To examine if a modified Dabestani-Mahan formula PASP=145-AT can estimate a normal PASP ≤25 mmHg as calculated by the TR peak velocity method.

Methods

We queried the electronic medical record at our institution for a sample of 300 patients who had a TTE performed between 2017 and 2020. Each TTE was reviewed and PASP was estimated for each using the TR peak velocity method. A right atrial pressure of 3 mmHg, 8 mmHg, or 15 mmHg was used in the estimation based on inferior vena cava diameter and collapsibility in keeping with the 2015 American Society of Echocardiography guidelines. A short axis view of pulmonary flow using the pulse-waved Doppler sample volume over the transpulmonary valve jet was then reviewed. The time from onset of ejection to peak flow velocity was measured manually as AT in milliseconds using Change Healthcare Cardiology Web Software Package 14.1.1. The measured AT was averaged over three cardiac cycles. Patients with a heart rate between 60 and 100 beats per minute at time of TTE and with sufficient Doppler data to estimate PASP by TR peak velocity and to measure AT were included in a logistic regression analysis.

Results

154 patients were included in the statistical analysis. Patients who had a right ventricular outflow tract acceleration time greater than 120 milliseconds, giving a PASP ≤25 mmHg by the modified formula PASP=145-AT, had a 36 times greater odds of having a PASP ≤25 mmHg by the TR peak velocity method (OR=36.0, 95% CI=10.36–125.12, p<0.001).

Conclusion(s)

Based on a single-center sample, a right ventricular outflow tract acceleration time greater than 120 milliseconds could be used to estimate a normal pulmonary artery systolic pressure less than or equal to 25 mmHg in the absence of sufficient Doppler data for the commonly used TR peak velocity method.

Funding Acknowledgement

Type of funding sources: None.
Clinical significance of aortic arch plaques simultaneously assessed with coronary atherosclerosis on cardiovascular outcomes in patients undergoing coronary CT angiography
Authors: Otsuka K , Ishikawa H , Kono Y , Shirasawa K , Hirata K , Kasayuki N
Published: October 2021

Aims

Computed tomography (CT) coronary angiography is a useful diagnostic imaging modality in assessing presence, severity, and extent of coronary artery disease (CAD). Aortic arch plaques have been shown to be an underlying cause of embolic stroke and also related to increased risk of cardiovascular events. Yet, conventional CTCA imaging protocol does not include aortic arch for the reduction of radiation exposure. This study aimed to investigate prevalence of aortic arch plaques simultaneously assessed by CTCA and their clinical significance in combination with the presence of obstructive CAD for prediction of CVD events in patients with suspected CAD.

Methods

This study consisted of 310 (mean age, 66 years old, 42% female) patients with suspected CAD undergoing CTCA between 2017 and 2019. All CTCA examination was performed with 320-row detector scanner using ECG-triggered prospective gating method. Aortic arch images were simultaneously acquired during CTCA scanning without an increase of contrast media. Using Agatston method, coronary artery calcium score (CACS) was categorized into either of the groups having CACS of 0, 0–99, 100–299, or more than 300. The presence of CAD was reported as non-obstructive or obstructive CAD. High-risk featured aortic plaque was defined as large plaques >4 mm in thickness showing ulceration or protrusion. A composite event of cardiovascular disease, including all-cause mortality, non-fatal myocardial infarction, unplanned hospitalization requiring revascularization or stroke was defined as the primary endpoint.

Results

Patients having CACS of 0, 0–99, 100–299, and >300 were found in 41%, 24%, 15%, 20%%, respectively, where obstructive CAD was diagnosed in 11%. Aortic HRPs in ascending aorta, aortic arch, and thoracic descending aorta were observed in 1.6%, 6.9%, and 15%, respectively. During a mean follow-up period of 2.2 years, the primary endpoint was observed in 27 patients (8.7%). Cox regression hazard model demonstrated an independent association of aortic arch high-risk plaques (HR; 3.2, 95% CI; 1.20–8.64, p=0.02) and obstructive CAD (HR; 3.3, 95% CI; 1.45–7.92, P=0.005) when adjusted by age, CACS, and chronic kidney disease. Kaplan-Meier curve analysis showed a worse outcome of patients with aortic HRP and obstructive CAD compared to those without aortic plaques and obstructive CAD (p<0.001).

Conclusion

This study demonstrated an independent association of aortic arch high-risk featured plaques with CVD events. Further study is warranted whether pharmacological interventional therapies can reduce future CVD risks in patients with CAD and aortic arch plaques.

Funding Acknowledgement

Type of funding sources: None.
Calcified versus non-calcified plaque volume fraction in patients with coronary artery disease and their association with outcome
Authors: Kuneman J H , Van Den Hoogen I J , Schultz J , Maaniiity T , El Mahdiui M , Kamperidis V , De Graaf M A , Broersen A , Jukema J W , Bax J J , Saraste A , Knuuti J
Published: October 2021

Background

The amount of coronary artery calcification is a general marker of coronary atherosclerosis and has been associated with increased risk of adverse cardiac events. On the other hand, calcification of coronary artery plaques has also been considered as a marker of plaque stabilization.

Purpose

We hypothesized that the fraction of the non-calcified volume of the total plaque volume in patients with coronary artery disease (CAD) is associated with abnormal myocardial perfusion and increased risk of future cardiac events.

Methods

Consecutive patients with suspected CAD undergoing sequential coronary computed tomography angiography (CCTA) with selective positron emission tomography (PET) perfusion imaging between 2007 and 2011 were selected. The total, calcified and non-calcified plaque volume (PV) were defined at patient-level. The non-calcified plaque volume fraction was calculated by dividing the non-calcified PV by the total PV, and expressed as percentage. Patients were divided into three groups: patients with 1) non-obstructive CAD (<50% diameter stenosis), 2) suspected coronary stenosis but normal PET perfusion and 3) suspected stenosis and abnormal regional PET perfusion. Difference between high vs. low PV was based on the median value. Clinical outcomes including all-cause mortality and myocardial infarction were recorded for 6.1 [SD 5.3–7.5] years.

Results

In total, 494 patients (age 63±9 years, 55% male) with documented atherosclerosis on CCTA were included. Total PV, calcified PV and non-calcified PV were all significantly larger in patients with abnormal myocardial perfusion compared to patients with non-obstructive CAD (370 [197–739] mm3 vs. 108 [59–177] mm3, 84 [23–220] mm3 vs. 9 [1–34] mm3 and 274 [157–500] mm3 vs. 94 [53–140] mm3, respectively, p<0.001 for all). However, the non-calcified fraction was smaller in patients with reduced myocardial perfusion (75 [63–86]% vs. 89 [76–98]%, p<0.001, Figure 1). During follow-up 35 events occurred. Patients with higher total PV, calcified PV and non-calcified PV showed worse outcome compared to patients with lower PV (log-rank p<0.001, Figure 2). In contrast, patients with a lower non-calcified plaque volume fraction showed poorer outcome (log-rank χ2=5.54; p=0.019) even after adjusting for statin therapy or revascularization.

Conclusion

We observed that higher volumes of any plaque component in general are associated with abnormal perfusion and increased risk of future cardiac events. In contrast, patients with a lower non-calcified plaque volume fraction showed poorer outcome.

Funding Acknowledgement

Type of funding sources: None. Non-calcified plaque volume fractionKaplan-Meier survival analysis
Effect of diabetes mellitus on coronary plaque characteristics and progression by serial Coronary Computed Tomography Angiography (CCTA)
Authors: Lakshmanan S , Kinninger A , Nakanishi R , Shekar C , Shaikh K , Dahal S , Nezarat N , Roy S K , Budoff M J
Published: October 2021

Background

Diabetes Mellitus (DM) is a major risk factor for coronary artery disease (CAD) and associated poor outcomes. There is a higher incidence of major adverse cardiac events in patients with DM than those without DM. Coronary plaque characteristics measured by CCTA are correlated with adverse cardiovascular (CV) outcomes.

Purpose

We sought to evaluate coronary plaque characteristics as well as rates of progression of coronary plaque burden as measured by serial CCTA in patients with DM and those without DM.

Methods

The study population included a total of 403 participants (mean age 61.4±11.4 years, 53% men; median scan interval 1.5 years) who were prospectively enrolled in serial CCTA trials. We identified 212 participants with DM and 191 participants without DM, who had undergone serial CCTA. Coronary Plaque volumes were measured and characterized as low attenuation plaque (LAP), total non-calcified plaque (TNCP) and total plaque (TP) using semi-automated plaque analysis software (Qangio medis). Multivariate linear regression was used to examine the effect of DM on coronary plaque progression.

Results

Patients with DM had greater rates of progression of normalized TP volume (median change in annualized plaque (IQR): 39.1 (9.9–114.4) in DM vs 23.5 (4.1–63.8) mm3 in non-DM, p=0.001), TNCP volume (21.6 (3.3–60.8) in DM vs 8.7 (0.1–35.6) mm3 in non-DM, p=0.003) and LAP volumes (0.7 (−0.6 to 7.8) in DM vs 0.1 (−0.4 to 1.9) mm3 in non-DM, p=0.04). After adjusting for relevant risk factors and baseline plaque, the annualized rates of progression were higher in patients with DM by 28% for TP (p=0.004), 27% for TNCP (p=0.011), 23% for fibrous plaque (p=0.026) and by 42% LAP (p=0.050), compared to those without DM.

Conclusion

Patients with DM have significantly higher rates of coronary plaque progression, including vulnerable LAP, than those without DM. Our findings reveal differences in rates, burden and characteristics of coronary plaque progression in patients with DM vs those without DM. These results provide mechanistic understanding of natural history of coronary atherosclerosis in this vulnerable population, that could explain the increased risk of CV events among patients with DM. Coronary atherosclerotic phenotyping by CCTA could serve as a potential surrogate measure for risk stratification and evaluation in clinical trials to examine therapeutic strategies in this vulnerable population.

Funding Acknowledgement

Type of funding sources: None.
Left atrial appendage perimeter ostium evaluation by cardiac CT utilizing 3mensio technology for watchman implantation
Authors: Loli A , Rodriguez J
Published: October 2021

Background

Left atrial appendage occlusion (LAAO) with Watchman device traditionally relies on accurate left atrial appendage ostium diameter measurement by 2D or 3D transesophageal echocardiogram (TEE). Alternate methods of ostium measurement including area-derived diameter and perimeter-derived diameter using cardiac computed tomography (CT) have been proposed.

Methods

We performed a retrospective analysis of 92 patients with atrial fibrillation (Afib) who underwent LAAO with WATCHMAN implantation with pre-procedural TEE and CT between May 2015 and December 2018. LAA characteristics including ostial or landing zone perimeter, minimum and maximum diameters were acquired utilizing 3mensio Structural Heart Imaging Program. Proposed device size was estimated utilizing ostium perimeter by CT and compared to the current standard utilizing ostium diameter by 2D-TEE. Both measurements were then compared to actual final device size that satisfying release criteria.

Results

CT had a very high correlation with the actual implanted device size (Pearson coefficient r=0.94, p<0.001), while TEE based sizing had a lower correlation (Pearson coefficient r=0.66, p<0.001). CT predicted size had a significantly higher agreement compared to standard TEE based sizing (93.4% vs 47.8%), and higher interrater agreement (Cohen's kappa = 0.91 vs Cohen's kappa = 0.32, p<0.001, p<0.001 respectively). Bland-Altman analysis also showed better correlation with CT-based sizing. Procedural complications were 0, and 0 patients had a leak recorded at 45-days post implant.

Conclusion

CCT LAA perimeter sizing is superior to the current standard TEE based Watchman sizing. Larger, multi-center studies may be necessary to further validate results.

Funding Acknowledgement

Type of funding sources: None. 3mensio after CT upload
Deep learning for automatic calcium scoring in population based cardiovascular screening
Authors: Vonder M , Zheng S , Dorrius M D , Van Der Aalst C M , De Koning H J , Yi J , Yu D , Gratama J W C , Kuijpers D , Oudkerk M
Published: October 2021

Background

High volumes of standardized coronary artery calcium (CAC) scans are generated in screening that need to be scored accurately and efficiently to risk stratify individuals.

Purpose

To evaluate the performance of deep learning based software for automatic coronary calcium scoring in a screening setting.

Methods

Participants from the Robinsca trial that underwent low-dose ECG-triggered cardiac CT for calcium scoring were included. CAC was measured with fully automated deep learning prototype and compared to the original manual assessment of the Robinsca trial. Detection rate, positive Agatston score and risk categorization (0–99, 100–399, ≥400) were compared using McNemar test, ICC, and Cohen's kappa. False negative (FN), false positive (FP) rate and diagnostic accuracy were determined for preventive treatment initiation (cut-off ≥100 AU).

Results

In total, 997 participants were included between December 2015 and June 2016. Median age was 61.0 y (IQR: 11.0) and 54.4% was male. A high agreement for detection was found between deep learning based and manual scoring, κ=0.87 (95% CI 0.85–0.89). Median Agatston score was 58.4 (IQR: 12.3–200.2) and 61.2 (IQR: 13.9–212.9) for deep learning based and manual assessment respectively, ICC was 0.958 (95% CI 0.951–0.964). Reclassification rate was 2.0%, with a very high agreement with κ=0.960 (95% CI: 0.943–0.997), p<0.001. FN rate was 0.7% and FP rate was 0.1% and diagnostic accuracy was 99.2% for initiation of preventive treatment.

Conclusion

Deep learning based software for automatic CAC scoring can be used in a cardiovascular CT screening setting with high accuracy for risk categorization and initiation of preventive treatment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Robinsca trial was supported by advanced grant of European Research Council
Positive predictive value of CT coronary angiography vs. CT fractional flow reserve in a real-world population
Authors: Sinclair H , Yongli R L , Beattie A , Farag M , Egred M
Published: October 2021

Background

Computerised tomography coronary angiography and fractional flow reserve (CTCA and CT-FFR) are non-invasive diagnostic tools for the detection of flow limiting coronary artery stenoses. Although their negative predictive values are well established, there is a concern that the high sensitivity of these tests may lead to overestimation of coronary artery disease (CAD) and unnecessary invasive coronary angiography (ICA). We compared the positive predictive value (PPV) of CT-FFR with computerised tomography coronary angiography (CTCA) against the gold standard of ICA in different real-world patient groups.

Methods

We conducted a retrospective study of 477 patients referred for CTCA or CT-FFR for investigation of possible coronary ischaemia. Patients were excluded if the image quality was poor or inconclusive. Patient-based PPV was calculated to detect or rule out significant CAD, defined as more than 70% stenosis on ICA. A sub-analysis of PPV by indication for scan was also performed. Patients that underwent invasive non-hyperaemic pressure wire measurements had their iFR or RFR compared with their CT-FFR values.

Results

In a patient-based analysis, the overall PPV was 59.3% for CTCA and 76.2% for CT-FFR. This increased to 81.0% and 86.7% respectively for patients with stable angina symptoms. In patients with atypical angina symptoms, CT-FFR considerably outperformed CTCA with a PPV of 61.3% vs. 37.5%. There was not a linear relationship between invasive pressure wire measurement and CT-FFR value (r=0.23, p=0.265).

Conclusion

The PPV of CTCA and CT-FFR is lower in the real-world than in previously published trials, partly due to the heterogeneity of indication for the scan. However, in patients with typical angina symptoms, both are reliable diagnostic tools to determine the presence of clinically significant coronary stenoses. CT-FFR significantly outperforms CTCA in patients with more atypical symptoms and the targeted use of CT-FFR in this group may help to avoid unnecessary invasive procedures.

Funding Acknowledgement

Type of funding sources: None.
Effect of Sacubitril/Valsartan on left ventricular longitudinal strain in patients with hematologic malignancies after bone marrow transplantation
Authors: Katogiannis K , Ikonomidis I , Stamouli M , Makavos G , Tsilivarakis D , Koliou G , Vythoulkas D , Tsirigotis P
Published: October 2021

Background and aims

Chemotherapy is known for its potential adverse effects on myocardium. Optimal medical treatment for heart failure may reverse myocardial dysfunction in the early stages of toxicity development. We hypothesized that early initiation of treatment with sacubitril valsartan could prevent cardiotoxicity.

Patients and methods

40 patients (mean age 45,3±13,1 years old, 23 male) with preserved ejection fraction, who suffered from hematologic malignancies (lymphoma, leukemia) and underwent bone marrow transplantation and were randomized to receive sacubitril/valsartan 24/26 mg bid daily or placebo. We measured at baseline, before transplantation, and after three months: i) Global Longitudinal Strain of left ventricle (LV) (GLS), ii) Left Ventricular Epicardial Strain (GLSepi), iii) Left Ventricular Endocardial Strain GLSendo), by speckle tracking imagind iv) Left Ventricular End Diastolic Volume, Left Ventricular End Systolic Volume and Left Ventricular Ejection Fraction (LVEF-Simpson's Method).

Results

The two treatment groups had similar age, sex atherosclerotic risk factors and cardiotoxic medication before and after bone marrow transplantation. Compared to baseline, patients treated with sacubitril/valsartan did not show a deterioration of LV GLS and GLSepi [(GLS = −20,2±3,1% vs −19,8±3,1%, p=0,551), (GLSepi = −17,9±2,8% vs −17,8±3,1%, p=0,855), (GLSendo = −23,02±3,6% vs −22,6±3,5%, p=0,572)], Conversely, patients treated with placebo group, presented a significant impairment of LV GLS and GLSepi [(GLS = −20,5±1,9% vs 18,5±2,3%, p=0,006, GLSepi = −18,1±1,5% vs −16,1±2,1%, p=0,003), (GLSendo = −23,4±2,2% vs −21,4±2,6%, p=0,008)] six months after bone marrow transplantation. No significant changes were found in LVEF after treatment with sacubitril/valsartan (57,9±5,6% vs 57,6±6,1%, p=0,733) or the placebo (60,1±5,6% vs 57,8±6,6%, p=0,166). However, in the sacubitril valsartan group, we noticed a significant reduction of left ventricular end diastolic and end-systolic volume [(103,1±27,01 ml vs 89,2±21,1 ml, p=0,012), (44,65±15,83 ml vs 36.4±8.3 ml, p=0,003), respectively].

Conclusions

Treatment with sacubitril/valsartan prevented deterioration of myocardial deformation three months after bone marrow transplantation in patients with hematologic malignancies and preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.
Rising utilization of coronary CT angiography across Europe over the last decade: insights from a large prospective European registry
Authors: Foldyna B , Uhlig J , Mayrhofer T , Natale L , Vliegenthart R , Lotz J , Salgado R , Francone M , Nikolaou K , Bamberg F , Maintz D , Maurovich-Horvat P , Thiele H , Hoffmann U , Gutberlet M
Published: October 2021

Background/Introduction

The recently updated 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes endorse the use of coronary computed tomography angiography (CCTA) for exclusion of obstructive coronary artery disease in patients with a low clinical likelihood (Class I, LOE B). Higher demand for CCTA requires broad availability, inevitably involving smaller healthcare providers, such as non-academic hospitals and private practices. Nevertheless, most published data on CCTA image quality and safety rely on exams performed in high-volume academic centers, and little is known about CCTA in non-academic settings.

Purpose

To investigate the utilization of CCTA across Europe over the last decade, focusing on differences between academic and non-academic centers.

Methods

We included patients with stable chest pain and suspected coronary artery disease (CAD) who received CCTA and were included in the European Society of Cardiovascular Radiology MR/CT registry 01/2010–01/2020. We compared CT equipment, image quality, radiation dose, the incidence of periprocedural adverse events, patient characteristics, and CCTA findings between academic (high volume university hospitals) and non-academic centers (non-academic hospitals and private practices).

Results

Overall, 64,317 patients (41.2% women; age 60±13 years) from 212 sites across 19 European countries were included. Academic centers submitted most cases in 2010—2014 (51.6%), whereas non-academic centers accounted for 71.3% of records in 2015–2020. While non-academic centers used less advanced technology, radiation dose remained low (4.54 [interquartile range (IQR) 2.28–6.76] mSv) with a 30% decline of high-dose scans (>7 mSv) over time. Diagnostic image quality was reported in 97.7% of cases, and the rate of acute scan-related events was low (0.4%) (Figure 1). From 2010–2014 to 2015–2020, CCTA nearly doubled in patients with low to intermediate pretest-probability, women >50, and 40–60 years old men (Figure 2). CAD presence and extent decreased slightly over time (prevalence: 2010–2014: 41.5% vs. 2015–2020: 40.6%), (multi-vessel disease in those with CAD: 2010–2014: 61.9% vs. 2015–2020: 55.9%; all p<0.01).

Conclusion

CCTA expands rapidly to non-academic centers across Europe, increasing availability while maintaining relatively low radiation dose, high diagnostic image quality, and safety. Broad availability of high-quality CCTA is essential for a successfully implementation of the recently updated guidelines for the diagnosis and management of chronic coronary syndromes.

Funding Acknowledgement

Type of funding sources: None. Changes in CCTA utilizationChanges in patient characteristics
Epicardial adipose tissue volume is associated with low-attenuation plaque volume in subjects with or without increased visceral fat: a 3-vessel coronary artery analysis with CT angiography
Authors: Otsuka K , Ishikawa H , Yamaura H , Shirasawa K , Kasayuki N
Published: October 2021

Background

Low-attenuation plaque (LAP) with a CT value of less than or equal 30 HU on coronary CT angiography (CCTA) is a marker of high-risk plaque features that leads to future acute coronary syndromes. Perivascular and epicardial adipose tissue (EAT) have been shown to be associated with progression of high-risk coronary plaques through metabolic and inflammatory mechanisms. However, association of EAT with LAP volume in three coronary arteries in subjects with or without visceral obesity remain unclear.

Aims

This study aimed to investigate the association of EAT volume (EAV) and coronary 3-vessel LAP volume in subjects with or without visceral obesity who underwent CCTA.

Methods

Patients who underwent CCTA without known coronary artery disease were included in the study (525 patients). Study subjects were classified as having non-obstructive or obstructive coronary artery disease according to the degree of coronary artery stenosis on CCTA. The plaque volume and EAV of the main vessel of the left anterior descending artery, left circumflex artery, and right coronary artery were measured with VINCENT software. Coronary plaque composition was classified as calcified plaque (CP, >150HU), noncalcified plaque (NCP, 30–150HU), and Lap (<30HU). The %LAP volume of the three coronary arteries was classified into quartiles. Multiple logistic regression analysis was used to analyze the factors associated with the %LAP volume.

Results

Compared with subjects without increase visceral fat, subjects with increased visceral fat had a significantly higher BMI, a greater total plaque volume, a greater total %LAP volume, a greater EAV, and a lower mean CT value of EAT. A significant correlation was observed between EAV and %LAP volume (R=0.24, p<0.001). EAV (odds ratio; 1.83, 95% confidence interval 1.071–3.141, p-value 0.027) and type 2 diabetes mellitus (odds ratio 1.76, 95%confidence interval 1.042–3.000, p-value 0.034) appeared to be independent predictors of %LAP volume (Q4), when adjusted by age, gender, BMI>25 kg/m2, visceral fat >100cm2, LogCRP, coronary artery calcium score>300, and obstructive coronary artery disease requiring revascularization.

Conclusion

This study suggests that LAP volume, which reflects the high-risk plaques in the three coronary arteries, is associated with EAV in subjects with or without increased visceral fat. Further research is needed whether pharmacological therapeutic intervention enables the prevention of coronary plaque progression and destabilization through the reduction of EAV in patients.

Funding Acknowledgement

Type of funding sources: None.
C-reactive protein velocity predicts microvascular pathology after acute ST-elevation myocardial infarction
Authors: Holzknecht M , Tiller C , Reindl M , Lechner I , Troger F , Mayr A , Brenner C , Klug G , Bauer A , Metzler B , Reinstadler S
Published: October 2021

Background

The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood.

Purpose

The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology.

Methods

This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24±8h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2–4] days after PCI.

Results

After adjustment for cardiac troponin T (cTnT), culprit lesion location and TIMI-flow post-PCI, CRPv (odds ratio 3.36, 95% confidence interval (CI) 1.72–6.57; p<0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71–0.81; p<0.001) was a better predictor for MVO compared to 24h CRP (AUC difference: 0.03, p=0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82–0.90; p<0.001 vs. AUC 0.84, 95% CI 0.79–0.88; p<0.001. AUC difference: 0.02, p=0.042).

Conclusions

In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.

Funding Acknowledgement

Type of funding sources: None. ROC analysis for the prediction of MVO.CRPv (median) and clinical outcome.