bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the anatomic sinus after transcatheter aortic valve replacement
Authors: Moscarelli M , Prestera R , Fiore C , Pernice V , Milo S , Violante F , Cuffari F , Di Pasquale C , Ferlisi A , Speziale G , Angelini G D , Fattouch K
Published: November 2023

Background

Transcatheter aortic valve replacement (TAVR) determines the creation of outer area between the cage and the aortic wall named the ‘anatomic sinus’ (Figure 1 A-B). This newly formed space of the sinuses of Valsalva (SOV) might disrupt the physiological currents of Valsalva and contribute to the formation of subclinical leaflets thrombosis (SLT). The evaluation of the root geometry after TAVR is generally performed with multi detector computer tomography (MDCT), and the role of transthoracic echocardiography (TTE) needs further validation.

Purpose

The aim of this study was to test reproducibility of 2D TTE assessment of the anatomic sinus dimension with MDCT as reference. We also investigated predictors for SLT.

Methods

We enrolled 90 patients who underwent TAVR with self-expandable prosthesis. 2D TTE was performed using Philips EPIQ-7, and echocardiograms analysed offline with Philips QLAB cardiac analysis. Both SOV and prosthesis diameters were assessed in long and short-axis parasternal view (PLAX / PSAX) and the bidimensional area of the anatomic sinus was calculated (Figure 2 A-B). Inter-observer (observer 1 – 2) reproducibility was assessed by the means of interclass correlation coefficient (ICC). MDCT was performed in 50 individuals to evaluate concordance (Bland Altman test) with the 2D TTE anatomic sinus area and also to detect SLT (Figure 2 C-D). Multivariable model was built to assess predictors of SLT.

Results

Mean follow-up was 13.1 months. There was excellent and good correlation with regard to the diameter of the SOV and the prosthesis measured in PLAX view by observer 1 and 2: ICC: 0.93, 95% Confidence Interval (CI) (0.76–0.97), p< 0.001; ICC: 0.87(0.63,0.96), p<0.001, SOV and prosthesis respectively.

The correlation found with regard to the diameter of the SOV and the prosthesis measured in PSAX view was also excellent ICC: 0.90(0.68,0.97), p=0.001; and good ICC: 0.88(0.63,0.96), p <0.001, SOV and prosthesis respectively. The anatomic sinus areas assessed by 2D TTE were similar compared to areas derived by MDCT (4.1 ± 1.09 cm2 vs. 4.02 ± 1.55 cm2, respectively, p=0.57). Bland–Altman analysis of anatomic sinus area measured on 2D TTE and MDCT respectively, indicated high level of agreement and no fixed or proportional bias. Native bicuspid valve, but not the anatomic sinus area, was the only independent predictors for SLT.

Conclusions

Following TAVR, the newly formed anatomic sinus could be assessed with good reproducibility with 2D TTE. We found a significant association between native bicuspid valve and SLT diagnosed with MDCT.Figure 1A-BFigure 2A-D
Cardiac magnetic resonance correlates of staging algorithm in patients with asymptomatic severe aortic stenosis
Authors: Conte C , Martino M , Ferrer-Sistach E , Teis A , Junca G , Weerts J , Kasa G , Vallejo N , Perez C , Lopez-Ayerbe J , Bayes Genis A , Delgado V
Published: November 2023

Background

The staging algorithm recently proposed to risk stratify patients with severe aortic stenosis (AS) has not been largely applied to patients who are asymptomatic. While the presence of severe tricuspid regurgitation, pulmonary hypertension and right ventricular dysfunction (stages 3-4) is expected to be low, the prevalence of left ventricular damage (LV), mitral regurgitation, left atrial (LA) dilation and atrial fibrillation (stages 1-2) can be higher in patients with asymptomatic severe AS. The cardiac magnetic resonance (CMR) correlates of the staging algorithm have not been described.

Purpose

To investigate the distribution of patients with asymptomatic severe AS in the staging algorithm and its differences with CMR findings. In addition, differences in CMR data between patients presenting with AS-related adverse events at 1-year follow-up and patients free of events were compared.

Methods

Patients with asymptomatic severe AS (aortic valve area, AVA<1.0 cm2) and preserved LV ejection fraction (EF) (>50%) that were referred to CMR were included. Biomarkers, echocardiographic and CMR data were assessed retrospectively. CMR-derived parameters included LV and right ventricular (RV) volumes and systolic function, LA volumes and tissue characterization were reported at baseline and compared with AS-related events (a composite of all-cause mortality, symptoms onset, or need for aortic valve replacement) during 1-year follow-up.

Results

Of 97 patients included (73±9 years old; 36% males), 3 (%) patients were classified in Stage 0, 34 (35%) in Stage 1, 59 (61%) in Stage 2, and 1 (1%) in Stage 3 or 4. Compared to stage 1, patients in stage 2 were older (P=0.006) and had a higher prevalence of overweight (P=0.037), hypertension (P=0.018), NT-proBNP (P=0.030) and hsTnT (p=0.011) levels. On CMR, they showed higher LV volumes and mass index, larger LA volumes and reduced LA ejection fraction, but no differences on myocardial tissue characteristics (Table 1).

Regarding prognosis, 45 (46.5%) patients presented AS-related events at 1-year follow-up. Those with events were mainly in stage 2 (36%) and presented higher NT-proBNP levels despite showing no differences in AVA. On CMR, those with events had lower LVEF, greater LV to RV end-diastolic volume ratio, greater left atrio-ventricular coupling index, reduced LA function and a higher extension of late gadolinium enhancement (Table 2).

Conclusions

In our cohort, most patients with severe asymptomatic AS were in stage 2. Stage 2 patients presented a higher degree of left-chambers remodelling on CMR compared to patients in stage 1. Patients in stage 2 or with lower LVEF, LV remodelling or reduced LAEF on CMR were those with an increased risk for events at follow-up.
Advanced 3D-TEE tools for mitral annular calcification characterisation. Correlation with CT scan
Authors: Mahia P , Provencio A , Ferrandez M , Ramos N , Marcos-Alberca P , Gomez De Diego J J , Cobos M A , Luaces M , Pozo E , Nombela L , Cobiella J , Perez-Villacastin J , De Agustin A
Published: November 2023

Background

Mitral annular calcification (MAC) is a degenerative process that leads to development of mitral regurgitation (MR). Its presence is associated with worse therapeutic results, due to technical challenges and risk of complications. The precise characterization has gained special importance in recent years. Due to the accuracy of the CT to detect calcium compared to transesophageal echocardiography (TEE), different prognostic scores based on this technique have been proposed.

Purpose

Our objective was to assess the usefulness of new tools based on 3D-TEE to determine the severity of MAC compared to CT in patients with MR.

Methods

Between 2019 -2022, patients with severe MR with different degrees of MAC were selected and evaluated by 3D-TEE and CT. Two independent expert observers blindly performed a quantitative standardized characterization of severity (1-10), applying the score proposed by Guerrero et al. based on four parameters: Calcium thickness, radial extension, involvement of trigones and leaflets both by CT (Figure 1, A) and advanced 3D-TEE tools (transillumination/True-Vue (Figure 1, B-C) and multiplanar/iSlice reconstruction (Figure 1, D). The agreement and correlation of both techniques were compared for each of the categories, as well as for the final classification of severity (Mild: 0-3, Moderate: 4-7, Severe 8-10).

Results

38 patients were included (Mean age: 80±5.7 years), 76% women. The MAC score measured by TEE was 6.1±0.4 vs. 8±0.4 by CT (p=0.03) with a very good agreement between both techniques estimated by the ICC (r=0.9) with an average difference of 1.2±1.4. Regarding the qualitative estimation, the concordance was good except for the estimation of the of the leaflet’s calcification (Table 1).

Conclusions

The use of advanced 3D-TEE imaging tools provides an excellent estimation and extension of the severity of MAC compared to CT, slightly overestimating the severity. These tools not only bring qualitative but also quantitative information and could be a first approximation before performing CT. This result highlights the usefulness and necessity of using multimodality imaging in the evaluation of degenerative mitral regurgitation.Figure 1Table 1
Correlation of transesophageal echocardiography acquired 3D-multiplane reconstruction-planimetry of aortic valve area (AVA) with AVA determined by standard and modified continuity equation
Authors: Blaser I , De Marchi S , Buffle E
Published: November 2023

Background

Currently the most accepted method for measuring aortic valve area is the continuity equation. Planimetry is an alternative method that allows the direct measurement of the Aortic valve area (AVA). There are, however, pitfalls in this method, such as artifacts caused by valve calcification and difficulty with the correct alignment of the cusps. Furthermore, these measurements may not correlate linearly, as effective AVA may vary due to contraction of flow and specific 3-dimensional conformation of the aortic valve. The advent of new technology with three-dimensional multiplane reconstruction echocardiography (3D-MPR) could overcome some of those limitations.

Methods

Measurements were taken from 119 patients who underwent elective transesophageal echocardiography (TEE), encompassing the whole spectrum of aortic opening. AVA was first calculated with the standard continuity equation (CE) in which left ventricular outflow tract (LVOT) area was calculated from its 2D diameter (AVA-CEstd). Secondly, a modified CE (AVA-CEmod) was used, measuring the LVOT area with 3D-MPR. Thirdly, the AVA was directly measured by 3D-MPR planimetry using the maximal opening at mid-systole (AVA-3D). In a subset of 30 Patients in which right and retrograde left heart catheterization was clinically indicated and performed, cardiac output was estimated by the Fick formula and AVA was calculated by the Gorlin formula (AVAGorling). We determined the correlation and level of agreement of AVA-3D with AVA-CEstd, AVA-CEmod and AVAGorling. Lastly, inter-observer reproducibility was evaluated for AVA-3D.

Results

The mean AVA-3D, AVA-CEmod and CEstd were as wollows: 1.87cm2, 1.81cm2 and 1.69cm2 respectively. There was a strong correlation between AVA-3D and AVA-CEmod (r = 0.963, p < 0.001) with a mean difference of 0.056 cm2 ± 0.273. There was a strong correlation between AVA-3D and AVA-CEstd (r = 0.877, p < 0.001) with a mean difference of 0.179 cm2 ± 0.477. There was a moderate correlation between AVAGorling , AVA-3D (r = 0.40, p < 0.001), AVA-CEmod (r = 0.54, p < 0.001) and AVA-CEstd (r = 0.49, p < 0.001). Intra-observer (ICCs 0.991) and inter-observer (ICCs 0.983) agreement for AVA-3D measurements were excellent.

Conclusion

Comparison between AVA-3D, AVA-CEmod and CEstd showed a strong correlation and intra-observer and inter-observer variability for AVA-3D were excellent. The correlation of AVAGorling with the AVAs assessed by echocardiography was weaker. The mean differences and variability can be explained by the known hemodynamic and conceptual differences between the geometric AVA, effective AVA and AVA assessed by the Gorlin formula. We can therefore conclude that AVA-3D assessed by TEE is a useful tool in daily clinical practice as it overcomes some pitfalls of the planimetry method, although some of the limitations remain.
Prognostic impact of postprocedural pulmonary artery systolic pressure on late mortality after transcatheter aortic valve implantation
Authors: Karmpalioti M , Toutouzas K , Drakopoulou M , Oikonomou G , Simopoulou C , Apostolos A , Koliastasis L , Ktenopoulos N , Soulaidopoulos S , Latsios G , Synetos A , Tsioufis C
Published: November 2023

Background

Pulmonary hypertension is a common finding in patients with aortic stenosis. Although transcatheter aortic valve implantation (TAVI) is frequently associated with a reduction of pulmonary artery systolic pressure (PASP), data regarding the independent impact of postprocedural PASP (post PASP) on long-term clinical outcome are still contradictory.

Methods

Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into three groups according to PASP at 30 days: group 1 (≤ 35mmHg), group 2 (36-49mmHg), group 3 (≥50mmHg). Primary clinical endpoint was all-cause mortality at 8 years, as defined by the criteria proposed by the Valve Academic Research Consortium3.

Results

A total of 166 consecutive patients were enrolled in the study: 76 (45.8%) patients in group 1, 71 (42.8%) in group 2 and 19 (11.4%) in group 3. The primary clinical end point occurred in 76.8% of all patients. The Kaplan–Meier curves for 8 year mortality showed that the high value of post PASP was associated with poor survival. Interestingly, patients in group 3 had the highest rate of all-cause mortality compared to patients in group 1 and 2 ( group 1 : 69%, group 2: 78.5%, group 3: 100%, p=0.016). Performing a multivariable analysis demonstrated that post PASP could independently predict cumulative 8 year mortality [OR 1.151, (95% CI 1.051 – 1.260, p=0.002)]. Using ROC analysis for 8 year survival, PASP had 75% sensitivity, and 64% specificity (p<0.0001, AUC=0.730).

Conclusion

Patients with increased PASP at 30 days after TAVI are at higher risk of all cause mortality at 8 years. Moreover, post PASP is independent predictor of late mortality and should be performed to determine the best follow up strategy in TAVI patients.
Predicting aortic stenosis progression using a video-based deep learning model of aortic stenosis built for single-view two-dimensional echocardiography
Authors: Oikonomou E K , Holste G , Mcnamara R L , Velazquez E J , Nadkarni G N , Ouyang D , Krumholz H M , Wang Z , Khera R
Published: November 2023

Background

We have recently described a deep learning (DL) model that relies on 2-dimensional parasternal long axis (PLAX) videos from transthoracic echocardiography (TTE) without Doppler imaging to identify severe aortic stenosis (AS) at the point-of-care. However, the timely diagnosis of AS has traditionally required skilled examination with Doppler imaging at regular time intervals.

Purpose

To explore the role of a DL model previously trained to detect severe AS based on 2D-PLAX videos in predicting the rate of AS progression among patients with no, mild, or moderate AS.

Methods

In this retrospective cohort study, a random sample of 2354 individuals undergoing serial monitoring with at least two separate TTEs and available Doppler parameters of AS severity (peak aortic valve velocity, AV Vmax) between 2016 and 2021 in the Yale-New Haven Health system were included. Eligible participants had a left ventricular ejection fraction (LVEF) >=50% and no evidence of severe AS at baseline. After automated selection of PLAX videos using an automated view classifier, the baseline deep learning-based AS probability index (DL-ASi) was calculated for each patient. The absolute change in the AV Vmax was divided by the time difference between each pair of consecutive TTE studies, and then averaged to derive the mean rate of AS progression. The association between the baseline DL-ASi and the mean rate of AS progression was assessed using ordinary least squares regression with adjustment for the patient’s sex, age, and baseline LVEF and AV Vmax. To visualize the interaction between the baseline DL-ASi and AV Vmax in predicting the rate of AS progression, an interaction term was included and a contour plot was plotted for both men and women.

Results

We included 8473 TTE studies from 2354 unique individuals (mean age 70±14 years, n=1138 [48.3%] women) performed over a median 2.5 (IQR 1.4-3.7) years (A). Higher DL-ASi at baseline was independently associated with a more rapid rate of AS progression (βadj 0.27 [95% CI 0.20-0.33, P<0.001]). The rates of AV Vmax progression ranged from 0.06±0.01 m/sec/year in the <0.2 DL-ASi group, to 0.29±0.04 m/sec/year in the ≥0.8 DL-ASi group (B). Contour plots illustrate how, for a given AV Vmax value, DL-ASi stratified the risk of AS progression in women and men (C).

Conclusion

In individuals with mild to moderate AS or no AS, a DL model trained to detect features of severe AS identifies individuals with a higher rate of AS severity progression, as assessed by the mean rate of AV Vmax change. This represents a promising approach for the longitudinal, point-of-care monitoring of patients with non-severe AS outside specialized centers.
New method for quantification of atrial septum defect shunting by echocardiography
Authors: Helle-Valle T , Murbraech K , Gude E , Andreassen A , Broch K , Sarvaro S , Beitnes J O , Skulstad H
Published: November 2023

Background

Atrial septum defect (ASD) is a common congenital heart disease. Echocardiography is the preferred method for detection and characterization of ASD. Accurate quantification of shunting is pivotal, but often requires right heart catheterization (RHC). In the present study, we introduce a new non-invasive method for accurate quantification of the ASD shunt by combined transesophageal- (TEE) and transthoracic (TTE) echocardiography. Shunt by RHC was used as a reference method.

Method

In 22 adults with secundum ASD, left ventricular (LV) stroke volume (SV) was measured by the pulsed Doppler method using 2D TTE. The shunt volume passing through the ASD was quantified as the ASD area measured by planimetry from 3D TEE, multiplied with the time velocity integral (TVI) of the PW Doppler obtained at the center of the ASD by TEE. Finally, the ratio of the pulmonary to systemic shunt (Qp:Qs) was calculated as (LVSV+ASDvolume)/LVSV. Shunt by RHC was assessed by the Fick’s principle.

Results

Mean shunt was 2.2±0.7 (±SD) by echocardiography and 2.1±0.7 by RHC, with a mean difference of -0.1±0.4 (Figure 1). The correlation between shunt measured by RHC and echocardiography was strong (r=0.86, p<0.0001; Figure 2).

Conclusion

The present study demonstrates that ASD shunting can be quantified accurately by combining TTE and TEE, suggesting a new non-invasive approach in settings where RHC is not feasible or available.Figures
Cardioembolic events and death predictors in patients with intraventricular thrombus
Authors: Ortiz Lozada R , Ferrera Duran C , Pozo Osinalde E , Fernandez Vega A , Zulet Fraile P , Provencio Regidor A , Mahia Casado P , Noriega Sanz F J , Marcos Alberca P , Fernandez Jimenez R , Gomez De Diego J J , Fernandez Ortiz A , Perez Villacastin J , De Agustin Loeches A , Viana Tejedor A
Published: November 2023

Background

There is poor evidence about the optimal medical treatment and length of anticoagulation for the management of intraventricular thrombus (IVT). Current ESC guidelines recommend continuation of anticoagulation for up to 6 months.

Purpose

The objective of this study was to identify predictors of events during follow-up in patients with IVT in order to infer the best therapy in this clinical scenario.

Methods

All patients with IVT in our tertiary hospital between 2005 and 2021 were retrospectively analyzed. Patients were classified into 2 groups, according to whether they developed (group 1) or not (group 2) the combined event of death, myocardial infarction, stroke or embolism during the first 6 months. A multivariate logistic regression analysis was performed to identify independent risk factors of clinical events.

Results

195 patients were included, of whom 40 (24.1%) presented the combined event at 6 months. There were no differences in age (68.5±15.6 vs 65±13.7 years; p=0.167) or gender distribution (80% men vs 84.9%; p=0.463) between the groups. A history of peripheral vascular disease (22% vs 7.1%; p=0.007), atrial fibrillation (AF) (22% vs 6.3%; p= 0.004) and stroke (34.2% vs 11.8%; p=0.001) were more frequent in group 1. The echocardiogram showed more frequently a mobile thrombus (43.2% vs 23%; p=0.017) with the presence of outgrowths (19.4% vs 5.6%; p=0.012) in the group with events. In addition, these patients had worse ventricular function (LVEF 33.6% vs 40.4%; p=0.002). Regarding treatment, the use of P2Y12 inhibitors was lower in group 1 (36.6% vs. 58.3%, p=0.016). There were no differences in the use of anticoagulants (85.4% vs 87.4%, p=0.737) or in the time until the thrombus clearance (median 119 vs 147 days, p=0.152). The presence of outgrowths in the thrombus, the ejection fraction, and a history of stroke were independently associated with the development of events at 6 months (Table). Considering a cut-off point of one-year follow-up instead, only 7 patients more had events. The presence of outgrowths was the only factor that maintained the independent association with the development of events (OR 9.3 (95%CI 1.6-54.7); p=0.01) during this time frame.

Conclusions

Cardiovascular events after IVT diagnosis are concentrated in the first 6 months. The presence of outgrowths attached to the thrombus, the lower ejection fraction, and a history of stroke were independent predictors of events at 6 months. In addition, the presence of outgrowths maintained its strong association at one year. Therefore, a more aggressive antithrombotic treatment may be considered in the presence of these factors.
Right ventricular-pulmonary artery coupling in the early stages of infarction could optimize patient risk stratification over five years
Authors: Dekleva M , Martinovic M , Stevanovic A , Zivkovic M , Djordjevic A , Djuric T , Stankovic A
Published: November 2023

Background

Right ventricular (RV) dysfunction is recognized as a cardinal prognostic marker in heart failure (HF) patients. Myocardial infarction (MI) is often followed by unrecognized RV dysfunction, which can be associated with worse outcome. It is recently shown that the ratio between TAPSE and PASP (RV/PA) may depict cardiopulmonary hemodynamics better than the two parameters alone.

Aim

To evaluate the interactions between left ventricular (LV) and RV function in early phase of MI and to assess the prognostic significance of RV/PA coupling in patients with first MI during 5 years follow up.

Methods

The prospective study included 144 patients with the first MI treated with the primary percutaneous coronary intervention (p PCI) who underwent Doppler echocardiography within 2±1 days of MI. LV function analysis included: LV ejection fraction (EF), ratio between early diastolic velocity and tissue annular velocity (E/e) and global longitudinal strain (GLS). RV function and RV-PA interaction was expressed as ratio between TAPSE and PASP. During the five-year follow-up, major cardiovascular events and especially hospitalization for HF were analyzed.

Results

Progressive RV/PA uncoupling was associated with higher degree of LV impairment and dysfunction (EF p<0.001, E/e p=0.002, GLS p<0.001) and severity of mitral regurgitation (p=0.013). Lower baseline RV/PA coupling significantly reflects the frequency of hospitalizations for HF in the population of patients with first MI during five-year follow-up (0.62 v.s.0.51, p=0.021). After multivariate adjustment RV/PA remained an independent predictor of all major cardiac events (MACE) after five years (OR 14.0 [1.5–130.8], p=0.019).

Conclusion

A lower baseline RV-PA coupling, reflecting a higher degree of LV-induced pulmonary hypertension and secondary RV-dysfunction, is associated with decline of LV function in early phase of MI, and is independently associated with worse prognosis after five years. The value of RV-PA ratio as an prognstic marker warrants further investigation.
Real world application of left ventricular outflow tract diameter prediction and clinical implications
Authors: Matese C , Calogero Campo G , Venturoli E , Pangallo G , Zuin M , Pavasini R , Tonet E , Calvi S , Cimaglia P
Published: November 2023

Background

The Left Ventricular Outflow Tract diameter (LVOTd) measured with transthoracic echocardiogram is crucial for stroke volume, flow and effective orifice area (EOA) assessment in aortic stenosis (AS), but it’s also a source of error. A formula for its prediction has been proposed (Leye’s formula), based on body surface area (BSA). However, it has never been validated externally.

Purpose

The aim of study is to externally validate the equation by Leye et al. in a retrospective, single-center, large cohort of consecutive non-obese patients with severe symptomatic AS undergoing surgical aortic valve replacement.

Methods

A population of patients with severe symptomatic AS undergoing surgical aortic valve replacement was analyzed; three different LVOTd values were obtained for each patient: measured-LVOTd (m-LVOTd, from echo database), predicted-LVOTd (p-LVOTd, using Leye’s formula) and surgical-LVOTd (s-LVOTd, obtained by surgical reports). p-LVOTd was used to reevaluate stroke volume and EOA.

Results

Data from 735 patients were collected; mean age was 75±8 years and 417 patients (57%) were men, mean BMI was 25.6 kg/m2 and mean BSA was 1.8 m2. m-LVOTd was significantly lower than p-LVOTd (20.2±2.4mm and 22.4±1.0mm, respectively; bias 2.1mm; p < 0,001). Moreover the difference between p-LVOTd and s-LVOTd (23.2±1.7mm; bias 0.8 mm) was lower than the difference between m-LVOTd and s-LVOTd (bias 3.0 mm). When the stroke volume index (SVi) was calculated through p-LVOTd, its value increased significantly compared to SVi calculated with m-LVOTd (50.0±10.9 vs 40.9±10.2 mL/m2, p<0.001), leading to a significant decrease in patients classified as low-flow AS, from 216 (29%) to 73 (10%) (p<0.001). EOA calculated with p-LVOTd was significantly wider than that calculated using m-LVOTd, and correlation was weak (0.86±0.22 vs 0.70±0.16 cm2, p<0.001; r=0.599, p<0.001). Using the p-LVOTd instead of m-LVOTd has lead to the reclassification of 188 (26%) patients from EOA≤1 cm2 to EOA>1cm2.

Conclusion

We found that in non-obese patients with severe AS, LVOTd obtained from the simple formula proposed by Leye et al correlates better with the surgical annulus diameter compared with the echocardiographic measurement of LVOT, and this has relevant consequences on AS assessment.
Patent foramen ovale: high-risk echocardiographic features related to secondary stroke prevention
Authors: Cruz I , Campos I , Braganca B , Lopes R , Santos R , Andrade A
Published: November 2023

Introduction

Patent foramen ovale (PFO) closure has long been a matter of debate concerning the impact of such procedure on preventing ischemic events recurrence. Recent reports support this strategy raising the issue of optimal patient selection based on anatomical high-risk characteristics evaluated by transoesophageal echocardiography (TEE) that may be associated with an increased risk of recurrence.

Purpose

Characterize PFO-related echocardiographic findings and clinical features of a cohort of Embolic Stroke of Undetermined Source (ESUS) patients (pts).

Methods

Unicentric, retrospective analysis of pts with ESUS diagnosis who underwent TEE between 1/2014 and 11/2019. Excluded pts aged older than 70 years. Clinical stroke characteristics and echocardiographic PFO features were analysed.

Results

A total of 124 pts were included in the analysis, presenting a mean age of 50±1.6 [20;68] years and female gender predominance (58.9%). 48.4% of ESUS pts had PFO (53% female). Regarding PFO pts, 38 (62.3%) had significant right-to-left shunt on TEE, which was statistically associated with cortical infarcts (78.9 vs 56.5%,p=0.037). 35pts (58.3%) had shunt occurring at rest and during the Valsalva manoeuvre; when associated to significant shunt there was a correlation with cortical located infarcts (82.1 vs 60.0%, p<0.001). 33 PFOs (54.1%) had tunnel-like morphology. Tunnel-like PFOs were associated with significant right-to-left shunt (78.8 vs 42.9%, p<0.001), atrial septum aneurysm (ASA) presence (68.8 vs 50.0%, p<0.001) and with haemorrhagic transformation of ischemic stroke (15.2 vs 3.6%, p=0.031). 34 PFO pts (60.7%) had ASA. Mean PFO length was 6.42±5.0mm and mean height was 3.2±2.0mm.

Conclusion

In this cohort, there was a similar number of pts with and without PFO. Regarding ESUS pts with PFO, the majority had significant right-to-left shunt that occurred at rest and during Valsalva manoeuvre and were associated with cortical located infarcts. Tunnel-like morphology and ASA were also frequent. Tunnel-like morphology were associated with haemorrhagic transformation of ischemic strokes. These findings support the proposal that PFO characterization should have an additional role in stratifying pts with ESUS and selecting them for device closure.
Implementation of an electronic medical record order set with an opt-out rule increases utilization of ultrasound enhancing agents with transthoracic echocardiography
Authors: Khalil A , Al Badarin F , Manla Y , Bafadel A , Khalil M
Published: November 2023

Background

Use of ultrasound-enhancing agents (UEA) decreases the frequency of non-diagnostic transthoracic echocardiography (TTE) studies and improves accuracy for identification of potentially life-threatening conditions. However, several logistical barriers have led to UEA underutilization, including the need for a separate order for UEA in electronic medical records (EMR). We sought to determine the impact of implementing an EMR order set on utilization of UEA at the echocardiography laboratory of a tertiary care center.

Methods

EMR order for all TTE studies (complete, limited) was modified to include the use of UEA by default with an "opt-out" option for ordering physician when UEA is deemed unnecessary. During study performance, sonographers determined the need for UEA use and utilized existing order to dispense perflutren protein-type A microspheres to complete the examination. Internal policy for UEA use was developed in keeping with Intersocietal Accreditation Commission recommendations. We compared rates of UEA utilization 10 months before and after the implementation date (March 2022) for the new EMR rule.

Results

A total of 10,666 TTE studies were performed prior to, and 11,406 studies after the implementation of the new EMR rule. Of those, 54.3% were performed in outpatient setting, 12% in ICU, and the rest in non-ICU inpatient setting. Prior to the EMR rule implementation, UEA was used in 10% of total studies, 6.0% of outpatient studies, 11.2% of non-ICU inpatient studies, and 24.2% of ICU studies. Following the implementation of the new rule, UEA utilization increased significantly, including 89% increase in total use, 90% increase in outpatient setting, 129% in non-ICU inpatient setting, and 48% increased use in ICU (Figure). No adverse events were reported with UEA during the study period.

Conclusions

The implementation of a standing order in EMR, including default use of UEA with an "opt-out" option facilitates sonographer-driven use and administration of UEA across all patient care settings. While this approach was safe and significantly increased UEA utilization, whether it would translate to improvement in clinical outcomes or hospital length of stay requires further studies.Impact of EMR rule on UEA utilization
Treatment of ischemic heart failure through ultrasound-targeted microbubble destruction and it's mechanism
Authors: Wu J U E F E I , Cai Q Y , Li Q I N , Li S H A S H A , Li H A O Q I , Chen Y U A N Q I , Wang Y G
Published: November 2023

Background

The cavitation effect mediated by ultrasonic-targeted microbubble destruction (UTMD) can regulate the microenvironment and circulation of ischemic myocardium. The UTMD cavitation effect can rapidly enhance blood perfusion and improve cardiac function in patients with ischemic heart failure. However, the internal mechanism of this treatment has yet to be reported.

Objective

The objective of this study was to explore the underlying mechanism of UTMD-mediated cavitation effect to rapidly improve cardiac function in rats with ischemic heart failure.

Methods

In the first part of the study, the ischemic heart failure model was induced by ligation of the left anterior descending branch coronary in Sprague-Dawley rats, the rats were randomly divided into 7 groups: sham group, HF group, HF+MB(microbubble) group, HF+US(ultrasound) group, HF+UTMD group, HF+UTMD+LY294002(PI3K inhibitor) group, and HF+LY294002 group. Serum BNP level and echocardiographic parameters were measured to evaluate cardiac function. Thereafter, SD rats were treated with UTMD by specific ultrasonic parameters and microbubble concentration, cardiac function should be reassessed after treatment. Finally, the myocardial tissues were extracted for Western Blot and immunohistochemical analysis to detect the protein expression of the PI3K/Akt/eNOS signaling pathway, and the contents of serum nitric oxide(NO) and myocardial ATP were detected by Elisa.

Results

The application of UTMD resulted in significant improvements in ejection fraction (EF) and fractional shortening (FS) in rats with ischemic heart failure, as compared to the HF group (EF: 37.16 ± 1.21% vs. HF+UTMD: 46.31 ± 3.00%, P=0.0057; FS: 18.53 ± 0.58% vs. HF+UTMD: 24.05 ± 1.84%, P=0.0089). Additionally, UTMD treatment led to the activation of the PI3K/Akt/eNOS signaling pathway (HF vs. HF+UTMD, P < 0.01), and promoted the production of NO and ATP (HF vs. HF+UTMD, both, P< 0.05). However, when a PI3K inhibitor was used, the cardiac protective effects of UTMD treatment were largely eliminated. EF and FS deteriorated significantly (EF: HF+UTMD+LY294002: 42.84±2.88% vs. HF+LY294002: 32.73±3.05%, P<0.0001; FS: HF+UTMD+LY294002: 21.94±1.69% vs. HF+LY294002: 16.36±1.76%, P<0.0001), and the production of NO and ATP decreased significantly (HF+UTMD+LY294002 vs. HF+LY294002, both, P< 0.05).

Conclusion

The UTMD-mediated cavitation effect can rapidly improve the cardiac function of ischemic heart failure rats by activating PI3K/Akt/eNOS signaling pathway and promoting the release of NO and ATP.
Right atrial strain predicts collagen mRNA levels in human right atrium
Authors: Wester M , Hegner P H , Tafelmeier M T , Lebek S L , Provaznik Z P , Floerchinger B F , Schmid C S , Maier L S M , Arzt M A , Wagner S W
Published: November 2023

Background

Structural remodelling, which includes increased fibrosis and collagen production, is a hallmark of atrial cardiomyopathy. Echocardiographic strain measurements allow detailed assessment of atrial function. We investigated the association between right atrial (RA) strain and collagen mRNA levels in human RA.

Methods

RA biopsies were collected from 21 patients undergoing elective coronary artery bypass grafting in the prospective observational study CONSIDER-AF. Tissue mRNA levels of collagen type I (Col1A) and of collagen type III (Col3A) were quantified using real-time qPCR on ViiA 7 real-time PCR system. Echocardiographic RA strain (reservoir, conduit, and booster function) was measured in the four-chamber view using the designated software Philips QLAB. We performed uni- and multivariable linear regression analysis to elucidate the relationship between RA strain and collagen mRNA levels.

Results

There was a strong correlation between RA reservoir strain and Col1A mRNA levels (p=0.0152, r²=0.2608, Fig A) and Col3A mRNA levels (p=0.0058, r²=0.3374, Fig B) as well as between RA conduit strain and Col1A mRNA levels (p=0.0301, r²=0.2141, Fig C) and Col3A mRNA levels (p=0.0232, r²=0.2430, Fig D). However, there was no correlation between RA booster function and Col1A levels (p=0.5572, Fig E) or Col3A levels (p=0.3426, Fig F). Multivariate regression analysis revealed that RA conduit and RA reservoir function are predictors for Col1A and Col3A mRNA levels independent from clinical covariates (age, sex, body-mass index, systolic blood pressure).

Discussion

Our findings show that RA strain measurements are associated with RA collagen mRNA levels in humans and therefore highlight the potential of strain analysis to identify structural remodelling in atrial cardiomyopathy.FigureTable
Prognostic influence of left atrial strain in heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy
Authors: Sugahara M , Min K D , Mine T , Asakura M , Ishihara M
Published: November 2023

Background

Heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms is class I indication for cardiac resynchronization therapy (CRT), whereas it is still controversy to CRT response in HF with QRS width 120-149ms or non-LBBB as intermediate ECG criteria in routine echocardiography. Left atrial (LA) adverse remodeling is a prognostic marker in patients with heart failure. Nevertheless, the prognostic significance of LA strain (LAS) imaging in HF patients with intermediate ECG criteria is not well understood.

Purpose

The objective of this study was to determine the prognostic value of LA deformation analysis in patients undergoing CRT implantation who met the intermediate ECG criteria.

Methods

We studied 94 patients who were defined routine CRT indication by the clinical guidelines. LAS was calculated as the average strain using apical two- and four-chamber views. The predefined endpoint was death, hospitalization due to worsening HF for 5 years after CRT implantation.

Results

Of the 94 patients, LAS is feasible in 76 patients (81%) with aged 69 ± 11 years, 30±8% of LV ejection fraction. 46 patients (61%) fulfilled intermediate ECG criteria. The predefined endpoint occurred in 43 patients (57%). The median LAS was 15%. LAS below 15% were associated with a high probability of unfavorable outcomes over 5 years (Log-rank, p = 0.002). After adjusting for left ventricular ejection fraction, LAS remained significantly associated with poor outcomes (hazard ratio 0.92, 95% confidence interval 0.87-0.97, p<0.001). There is no difference in the probability of poor outcomes between LBBB with QRS width ≥150ms and intermediate ECG criteria. Patients with intermediate ECG criteria and LAS <15% had worse outcome than in those with LBBB with QRS width ≥150ms and in those with intermediate ECG criteria patients with LAS ≥15% (Log-rank: p = 0.046, p = 0.029, respectively).

Conclusion

Baseline LA functional deterioration by deformation analysis was significantly associated with poor outcome after CRT implantation regardless of the ECG criteria for CRT indication and has promise for clinical utility.
The assessment of left atrial and left atrial appendage mechanics in patients with different stages of atrial fibrillation
Authors: Mao Y K , Yang Y , Ma M M , Yu C , Jiang R H , Jiang C Y
Published: November 2023

Background

Atrial fibrillation (AF) is associated with left atrial (LA) mechanical dysfunction, which predisposes to stasis of blood within the LA and thus increases the risk of stroke. However, limited is known about the mechanical functional alterations of left atrial appendage (LAA) in relation to stages of AF. Here, we sought to analyse LA and LAA mechanics during different stages of AF in detail.

Methods

A total of 92 patients with AF referring for radiofrequency ablation were consecutively enrolled. Patients were categorized according to rhythm and stages of AF:sustained AF(SAF) (n=31), paroxysmal AF with sinus rhythm(PAF-SR)(n=30) andAF rhythm(PAF-AF)(n=31)at the time of echocardiography. Twenty-seven patients without a history of AF were included as controls. Using speckle-tracking echocardiography, LA and LAA global peak positive longitudinal strain (GLS) and mechanical dispersion (MD) were measured in all patients. Mechanical dispersion was defined as the standard deviation of the time to peak of the regional strain corrected by R-R interval.

Results

Patients with PAF-AF and SAF displayed prominently impaired LA and LAA mechanics(all P < 0.01 vs. PAF-SR and no AF). In the presence of SR, only LAA mechanical function were lower in PAF patients than patients without AF(LAA GLS 20.5±5.7%(no AF) vs 15.9±5.4%(PAF-SR); LAA MD 6.9±3.8%(no AF) vs 9.4±3.9(PAF-SR),both P<0.01). AF stages were independent determinants of LA and LAA mechanics after adjusting for age and comobidities.

Conclusions

AF affected mechanical function of LA and LAA on their own, and more so if stage of AF has advanced to more persistent forms. In addition, LAA mechanical dysfunction occurred earlier than that of LA.fig 1fig 2
Left atrial strain measurement to predict new-onset atrial fibrillation in ST-elevation myocardial infarction patients
Authors: Caunite L , Myagmarjdorj R , Galloo X , Laenens D , Stassen J , Nabeta T , Yedidya I , Meucci M C , Kuneman J H , Van Den Hoogen I J , Van Rosendael S E , Wu H W , Van Den Brand V , Ajmone Marsan N , Bax J J
Published: November 2023

Background/Introduction

ST-elevation myocardial infarction (STEMI) remains a healthcare burden not only through increased mortality risk, but also development of chronic cardiac pathologies like atrial fibrillation (AF). Left atrial (LA) reservoir strain is a known predictor of incident AF in the general population.

Purpose

Our aim was to explore the additional prognostic value of LA reservoir strain measured by transthoracic echocardiography (TTE) in STEMI patients for new-onset atrial fibrillation (NOAF).

Methods

Data were analyzed retrospectively from an ongoing STEMI registry. Patients with previous myocardial infarction, AF, known history of heart failure, severe valvular pathology, suboptimal image quality, AF during TTE or missing follow-up were excluded. TTE was performed within 48 hours of hospitalization. LA reservoir strain was measured in apical 4-chamber view. LA strain <23% was used as cut-off value for impaired LA function as previously established. The endpoint was NOAF. Follow-up was censored at last patient visit or at 5 years.

Results

In total 1238 patients (mean age 60±12 years; 930 (75%) men) were included. After median follow-up of 22 months (IQR 12; 60) 106 (8.6%) patients developed NOAF, most events (71 (67%)) taking place within the first year after STEMI. Mean LA reservoir strain was more impaired in patients who developed NOAF as compared to those who did not (19.3 ± 8.1% versus 24.3 ± 8.8% respectively (p<0.001). Clinical and echocardiographical characteristics are shown in the table. Cumulative event-free survival rates at 1, 3 and 5 years in patients with preserved versus decreased LA strain were 97%, 95% and 93% versus 91%, 89% and 83% respectively (Log-rank X2 = 21.1; p<0.001; Figure). Factors significant on univariable Cox regression analysis (age, presence of chronic obstructive pulmonary disease, troponin levels, left ventricular end-diastolic diameter, interventricular septum diameter, left ventricular global longitudinal strain, LA volume index, LA reservoir strain, E/E’ ratio and right ventricular fractional area change) were included in multivariable model, where LA reservoir strain remained significantly associated with NOAF (HR 0.96 (0.93 – 0.99); p=0.015). Addition of LA strain provided incremental prognostic value over baseline clinical risk factors, traditional TTE parameters and left ventricular global longitudinal strain (X2 84.5 vs 88.8; p=0.013).

Conclusion

LA reservoir strain was associated with new-onset atrial fibrillation in STEMI patients after adjusting for relevant clinical and echocardiographic risk factors.TableFigure
Postsystolic shortening by speckle tracking echocardiography predicts cardiovascular events and death in the general population
Authors: Lindhardt N , Lindhardt N B , Lassen M C H , Skaarup K G , Johansen N D , Jensen G B , Schnohr P , Moegelvang R , Biering-Soerensen T
Published: November 2023

Background

Postsystolic shortening (PSS) have demonstrated to be a valuable predictor of contractile dysfunction in the myocardium. Our objective was to investigate the prognostic value of PSS, assessed by two-dimensional speckle tracking echocardiography (2DSTE), in relation to cardiovascular morbidity and mortality in a large general population study.

Methods

This prospective longitudinal study consisted of 4466 participants of the general population. The postsystolic index (PSI) was defined as follows: [(maximum strain in cardiac cycle–peak systolic strain)/(maximum strain in cardiac cycle)]×100. The endpoints were heart failure, major adverse cardiovascular events (MACEs), and all-cause mortality.

Results

During a median follow-up of 3,5 years, 148 participants (3.8 %) experienced MACE, 85 participants (2.2 %) were diagnosed with heart failure, and 192 (4.9 %) died. In unadjusted models, PSS was significantly associated with both MACE, heart failure and all-cause mortality. Following multivariable adjustments, PSS remained significantly associated with MACE (HR: 1.54; [95% CI, 1.04 – 2.3]; P=0.033) and heart failure (HR: 1.28; [95% CI, 1.11 – 1.49]; P < 0.001). PSI provided incremental prognostic value in relation to MACE (SCORE risk chart with the addition of PSI: 0.86 (0.83-0.89), P < 0.001) and heart failure (SCORE risk chart with the addition of PSI: 0.86 (0.83-0.89), P = 0.014.

Conclusions

In the general population, PSS as assessed by two-dimensional speckle tracking echocardiography independently predict the occurrence of both MACE and heart failure.Postsystolic index cubic spline curves
Left atrial strain predicts stroke recurrence and death in patients with cryptogenic stroke
Authors: Vera Sainz A , Cecconi A , Ximenez Carrillo A , Ramos C , Martinez-Vives P , Lopez Melgar B , Sanz Garcia A , Ortega G , Aguirre C , Montes A , Vivancos J , Jimenez-Borreguero L J , Alfonso F
Published: November 2023

Background

Left atrial strain (LAS) has been widely studied as predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce.

Methods

From April 2019 to April 2022, 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome was the composite of stroke recurrence or death.

Results

Mean age was 77.5±7.7 and 58% of patient were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%; p=0.02), chronic kidney disease (33% vs 10%; p=0.034) and history of heart failure (13% vs 0%; p=0.025). LAS reservoir (LASr) and LAS conduct (LAScd) were lower in patients developing the primary outcome (21±7 vs 28.8±11%; p=0.017 and 7.7±3.9 vs 13.7±7%; p=0.007, respectively). On multivariate analysis, diabetes (HR 7.4, 95%CI 1.2-47; p=0.034)), LASr (HR 0.2, 95%CI 0.05-0.8; p=0.023), LAScd (HR 0.17, 95%CI 0.04-0.7; p=0.013) and LAS contraction (HR 0.2, 95%CI 0-05-0.8; p=0.025) were independent predictors of stroke recurrence or all-cause death after CS (Table). On long-rank test (using the discriminatory cut-off values of LASr <23% and LAScd <10%), LASr (p=0.009) (Figure 1) and LAScd (p=0.016) were associated with higher risk of the primary outcome.

Conclusion

Lower values of LAS reservoir, conduct and contraction are independently associated with higher risk of stroke recurrence or death after CS