bluuebunny/crossref_metadata_2025 huggingface dataset:
Use of artificial intelligence by novice users to enable accurate point-of-care echocardiographic assessment of left ventricular ejection fraction
Authors: Dadon Z , Orlev A , Steinmetz Y , Butnaru A , Rosenmann D , Wolak A , Glikson M , Gottlieb S , Alpert E A
Published: October 2022

Introduction

Point-of-care ultrasound (POCUS) is now universal in the hands of non-experts. However, the results are usually binary (normal/abnormal) but not necessarily specific. Artificial intelligence (AI) is currently used by non-experts in different imaging modalities including echocardiography to aid in diagnosis and decision making.

Aim

To prospectively evaluate whether medical students trained in POCUS and using an AI based assessment tool can accurately evaluate the left ventricular ejection fraction (LVEF) of patients hospitalized in the cardiology department.

Methods

Nine medical students were trained in a 6-hrs session that included lectures and hands-on practice. Participants used a hand-held ultrasound machine (VScan Extend) equipped with LVivoEF, an AI-based tool that automatically evaluates LVEF. The clips were assessed for LVEF by three methods: visually by the students, students plus the AI-based tool, and experienced cardiologists. All LVEF measurements were compared with the gold-standard (a formal echocardiogram completed within 24-hrs with the Simpson method and LVEF eyeball assessment by two blinded fellowship-trained echocardiographers).

Results

The study included 88 patients, (aged 58.3±16.3 yrs, mean BMI 28.3±4.4 kg/m2). Comparing LVEF (continuous values) reported by medical students' visual evaluation, medical students plus AI, and cardiologists vs. the echocardiographers values, revealed Pearson correlations of 0.32 (p=0.003), 0.67 (p<0.0001), and 0.73 (p<0.0001), respectively. The agreements between these three evaluation methods and the echocardiographers, assessed at different LVEF categorical thresholds (at 50% and 40%), using kappa coefficient are presented (Figure 1).

Conclusion

Medical student use of an AI-based tool with a hand-held ultrasound device can improve their LVEF visual assessment to a level of experienced cardiologists. In addition, the use of AI enabled achieving a moderate to substantial inter-rater reliability with echocardiographers' evaluation. This AI tool can be successfully utilized as a decision support tool for POCUS LVEF evaluation by non-experts.

Funding Acknowledgement

Type of funding sources: None.
Signals for reduced cognitive function are associated with subtle signs of atrial cardiomyopathy and left ventricular diastolic dysfunction – insights from a large population based study
Authors: Camen S , Nagel L , Bei Der Kellen R , Barow E , Schneider J N , Blankenberg S , Kirchhof P , Wenzel J P , Thomalla G , Schnabel R B
Published: October 2022

Background/Introduction

In recent years, it has been proposed that a thrombogenic atrial substrate due to various alterations in (left) atrial morphology and function could contribute to atrial thromboembolism even in the absence of (clinically overt) atrial fibrillation. This so-called atrial cardiomyopathy may pose a risk of stroke and cognitive decline beyond the presence of atrial fibrillation.

Purpose

To define the association of echocardiographic parameters of left atrial cardiomyopathy and left ventricular diastolic dysfunction with cognitive function in individuals free of clinically overt atrial fibrillation or stroke.

Methods

Data from the first 10,000 participants of a large German population-based cohort study were analysed. Of these, 8264 individuals underwent standardized transthoracic echocardiography and cognitive function testing at baseline. Parameters of left ventricular systolic and diastolic function as well as left atrial function were systematically assessed, including left atrial global peak strain. Cognitive function was quantified using the Animal Naming Test and the Trail Making Test A and B. We performed linear regression analyses with incremental adjustment to examine the association of echocardiographic parameters with the performance on the neuropsychological tests.

Results

After exclusion of 463 individuals with known AF and 309 individuals with prior/known stroke or severe depression, 7492 individuals were analysed (mean age 61.9±8.4 years, 52.3% women, median left ventricular ejection fraction 59% [25th/75th percentile 56/62%], median left atrial volume index 25.0 ml/m2 [25th/75th percentile 20/30 ml/m2]). In multivariable-adjusted analyses, E/e'-ratio was significantly associated with a worse performance on the Animal Naming Test (−0.24 per one standard deviation [SD] increase, 95% confidence interval [CI] −0.42 to −0.06), the Trail Making Test A (0.76 per one SD increase, 95% CI 0.35–1.17) and B (1.1 per one SD increase, 95% CI 0.09–2.11). Left atrial strain was associated with worse performance on Trail Making Test B (−1.39 per one SD increase, 95% CI −2.46 to −0.32). Increased left atrial volume index was associated with worse performance on the ANT (0.2, 95% CI 0.03–0.37).

Conclusions

Subtle echocardiographic signs of atrial cardiomyopathy and left ventricular diastolic dysfunction are associated with worse performance on cognitive function tests in a German middle-aged population.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Hamburg City Health Study (HCHS) is supported by the University Medical Center Hamburg-Eppendorf and by various grants from different institutions/organizations.
Correlation and prognostic ability of admission lung ultrasound and late peak atrial longitudinal strain in patients with ST-elevation myocardial infarction
Authors: Miglioranza M H M , Araujo G N D , Scolari F L S , Machado G P M , Menegazzo W R M , Rosa V F R , Niches M N , Silveira A D S , Camelli M C , Piediscalzi M P , Carrucola M C , Pastore C M P , Fuchs F C C , Rohde L E R , Wainstein M V W
Published: October 2022

Background

Acute heart failure is common after ST-elevation myocardial infarction (STEMI), leading to lung congestion. Speckle tracking echocardiography has increased sensitivity to detect subclinical myocardial compliance disorders and may help to better understand the physiopathology in this setting.

Purpose

This study sought to determine the correlation and prognostic ability of admission lung congestion evaluated by lung ultrasound (LUS) and peak atrial longitudinal strain (PALS) performed after the acute phase of STEMI.

Methods

This was a prospective cohort of STEMI patients treated in a tertiary care hospital. LUS was performed by two independent operators before primary percutaneous coronary intervention (PCI). Our protocol consisted of eight scanning sites, which were considered positive for congestion if there were three or more B-lines in at least one site. Echocardiography was performed in all patients 2–4 days after STEMI, and the images were interpreted offline by two operators blinded to LUS findings. PALS <30 was considered abnormally reduced atrial contraction. Major cardiovascular events (MACE) were considered as new myocardial infarction, stroke or death in 30 days.

Results

Of the 339 patients admitted with STEMI, 208 (61%) performed LUS and had interpretable PALS. The mean age was 61 (±12) years and 65% were male. Lung congestion was present in 48% patients. Mean left ventricular ejection fraction (LVEF) was 49%, 21% of patients had EF<40%. Pearson correlation between the number of positive LUS sites and PALS was 0.18 (P=0.029). A subanalysis including only patients with left ventricle ejection fraction >50% showed similar results (correlation 0.10, P=0.349). All 10 (5%) patients with unsuccessful primary PCI had PALS <30. No patients with PALS>30 experienced 30-day MACE, while patients with PALS <30 with and without lung congestion had 1.6% and 13.8% 30-day MACE, respectively.

Conclusion

In a cohort of STEMI patients, the correlation of positive LUS sites and the PALS was low. Impaired PALS was associated with unsuccessful primary PCI, while normal PALS was associated with uneventful follow-up. The PALS assessment in addition to LUS profile was able to identify patients at higher risk for MACE. Although timing difference between lung ultrasound and echocardiography is a limitation of this analysis, our findings are consistent with the “lung water cascade theory”.

Funding Acknowledgement

Type of funding sources: None.
Evaluation of myocardial work in patients recovered from the severe form of COVID-19
Authors: Sousa T L F , Alves M J N N , Melo M D T , Albuquerque A L P , Martins J G , Botelho L F B
Published: October 2022

Background/Introduction

The impact of COVID-19 goes beyond its acute form, and can lead to the persistence of symptoms and the emergence of systemic disorders, defined as Post-Covid or Long-Covid.

Purpose

Assess the late impact on the cardiorespiratory system of patients recovered from severe Covid.

Methods

We performed cross-sectional study that included patients over 18 years of age who recovered from the severe form of COVID-19 after at least 60 days of their discharge. Patients and healthy controls were enrolled to perform transthoracic echocardiography (TTE) and cardiopulmonary exercise testing (CPET).

Results

A total of 52 patients and 24 controls were enrolled. The standard TTE parameters (end diastolic diameters, left ventricular ejection fraction, diastolic function and right ventricular systolic function) showed no difference when compared to the control group. When analyzing the myocardial work, there was a higher Wasted MW (GWW): 135 mmHg% vs 84.5 mmHg% (p=0.002), with lower MW Efficiency (GWE): 94 vs. 96 (p=0.003); as well as lower values of global strain: cases = 18.6% vs. 20.1% (p=0.009). No differences were found in the Constructive MW (GWC) and MW Global Index (GWI). In the CPET data we found lower peak values for the VO2: 24 ml/kg/min vs. 32.75 ml/kg/min (p<0.001); for the Heart Rate: 162 bpm vs. 175 bpm (p<0.001); for the Ventilation: 79.3 L/min vs. 109.85 L/min (p<0.001) and Respiratory Exchange Ratio: 1.12 vs. 1.19 (p=0.004). There was no difference in the maximum load reached, neither in the oxygen pulse values and in the Ve/CO2 slope. In relation to the oxygen kinetics, there was a significant reduction in OUES%: 85% vs. 98% (p=0.03); as well as an extended T½: 112 s vs. 88.5 s (p<0.001); and a slowing of the fall in heart rate in recovery time, as measured by the Heart Rate decay: −17.32 bpm vs. −22.08 bpm (p=0.005).

Conclusion

Patients recovered from the severe form of COVID-19 had higher GWW with lower efficiency (GWE). Such findings, added to changes in oxygen kinetics during exercise, may point to a possible cardiocirculatory mechanism associated with decreased aerobic capacity.

Funding Acknowledgement

Type of funding sources: None.
Left ventricular mechanical dispersion by speckle tracking echocardiography is a predictor of atrioventricular block after transcatheter aortic valve implantation
Authors: Kaya E , Andresen K , Lie O H , Aaberge L , Haugaa K , Edvardsen T , Skulstad H
Published: October 2022

Background

Transcatheter Aortic Valve Implantation (TAVI) is an effective therapy for patients with severe aortic stenosis (AS). Complete atrioventricular block (AVB) that requires permanent pacemaker implantation is a common complication of TAVI. Direct mechanical effect of the prosthetic valve, QRS duration and underlying myocardial fibrosis are proposed mechanisms of AVB after TAVI. Left ventricular mechanical dispersion (LVMD) by Speckle Tracking Echocardiography (STE) is an index of contraction heterogeneity and a marker of myocardial fibrosis.

Purpose

We aimed to evaluate the association between LVMD, QRS duration and AVB to assess markers used to predict AVB after TAVI.

Methods

A total of 163 consecutive TAVI patients were enrolled in the study. Echocardiograms andelectrocardiograms were recorded the day before TAVI procedure to assess global longitudinal strain (GLS), LVMD and QRS duration. AVB and pacemaker (PM) implantation information was obtained by telephone interviews three months after TAVI.

Results

Ten patients were excluded due to poor image quality. Of the 153 patients analyzed, 45% were female. Mean age was 80±7 years. In our patient cohort 15.7% of the patients received PM within three months after TAVI. GLS and QRS duration was not different between AVB group and No-AVB group (−15.8±4.5% vs −16.9±4.4%, p=0.26 and 107±31ms vs 102±18ms, p=0.24 respectively). LVMD was prolonged in patients with subsequent AVB compared to patients with No-AVB (60±19ms vs 48±13ms, p<0.001) (Figure 1). LVMD predicted AVB after TAVI with area under the curve 0.71. LVMD predicted AVB independently of QRS duration (odds ratio 1.68; 95% confidence interval 1.23–2.3; p=0.001 by 10ms increments) (Table 1).

Conclusion

LVMD predicted AVB after TAVI independent of QRS duration. LVMD may be of added value as a myocardial functional echocardiographic predictor of this important and frequent complication of TAVI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): EACVI Research Grant 2020
Advanced echocardiography with left atrial strain and indexed left atrial 3D volume for predicting underlying atrial fibrillation after cryptogenic stroke
Authors: Vera Sainz A , Cecconi A , Ximenez Carrillo A , Ramos C , Martinez Vives P , Lopez Melgar B , Sanz Garcia A , Ortega G , Montes A , Aguirre C , Vivancos J , Alfonso F , Jimenez-Borreguero L J
Published: October 2022

Introduction

Cryptogenic stroke (CS) represents one-third of ischemic strokes. Atrial fibrillation (AF) can be detected in up to 30% of CS. Therefore, there is a clinical need for predicting AF to guide the optimal secondary prevention strategy. The evidence about the role of advanced echocardiography, including left atrial 3D index volume and left atrial strain (LAS) techniques, to predict underlying AF in this setting is lacking.

Methods

From April 2019 to November 2021 seventy-eight consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography was performed during admission. All patients underwent 15 days wearable Holter monitoring. The primary outcome measure was AF detection during follow-up.

Results

Twenty -two patients (28%) developed AF. Patients in the AF group were older (81±6.3 vs 76.5±7.8 years; p=0.012). Left atrial (LA) diastolic indexed volume was higher in AF group (37.2±12.8 vs 29.7±11 ml/m2 p=0.01). 3D LA indexed volume were also higher in patients with AF (41.4±14 vs 32.2±10 ml/m2 p=0.009). LAS reservoir, LAS conduct and LAS contraction (LASct) were significantly lower in patients with AF (19±5.6 vs 32±10.3%; 9±4.5 vs 15±7.6; 10±5.3 vs 17±6.4, respectively, all p<0.001). On multivariate analysis LASct <13.5% and LA 3D indexed volume >44.5 ml/m2 were independent predictors of AF (OR 10.9 [95% CI 1.09–108.2], p=0.042) (Table 1, Figure 1)

Conclusion

LASct <13.5% and LA 3D indexed volume >44.5 ml/m2 are independent predictors of underlying AF in patients with CS. Our results demonstrate the usefulness of advanced echocardiography in this challenging clinical setting.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Spanish Society of Cardiology
Impact of left ventricular ejection fraction on mortality and use of mechanical circulatory support in non-ischaemic cardiogenic shock
Authors: Sundermeyer J , Beer B N , Blankenberg S , Kirchhof P , Luedike P , Mangner N , Nordbeck P , Orban M , Pazdernik M , Proudfoot A , Schulze P C , Tavazzi G , Thiele H , Westermann D , Schrage B
Published: October 2022

Background

Evidence in non-ischaemic cardiogenic shock (CS), especially regarding prognostic markers and use of mechanical circulatory support (MCS), is scarce.

Aim

The aim of this study was to evaluate left ventricular ejection fraction (LVEF) as a prognostic marker as well as a factor to guide the use of MCS in non-ischaemic CS.

Methods

In this international observational study, patients with non-ischaemic CS (e.g. caused by severe de-novo or acute on chronic heart failure; but not by acute myocardial infarction) treated with or without MCS from 18 tertiary-care centers in five countries were enrolled. Cox regression models adjusted for age, sex, SCAI class, lactate, prior resuscitation, mechanical ventilation and pH were fitted to evaluate the association between LVEF and 30-day mortality as well as the interaction between MCS use, LVEF and 30-day mortality.

Results

A total of 807 patients were enrolled, of whom 387 (47,9%) were treated with and 418 (52.1%) without MCS; mean age was 63 [interquartile range (IQR) 51.5–72) years, 601 (74.5%) were male, 486 (60.2%) had acute on chronic heart failure, 221 (32.7%) had an ischaemic cardiomyopathy and 277 (34.5%) had prior cardiac arrest. The baseline LVEF was 20 (IQR 15–30) % and baseline lactate was 4.9 (IQR 2.6–8.5) mmol/l.

There was no significant association between LVEF and 30-day mortality risk [hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.74–1.22 if LVEF was considered as a continuous variable; HR 1.09, 95% CI 0.83–1.44 if LVEF was considered as a categorical variable with ≤20% vs. >20%]. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with a depressed LVEF (HR 0.74, 95% CI 0.52–1.05, interaction-p = 0.04).

Conclusion

In this retrospective, multicenter, international study of patients with non-ischaemic CS, LVEF was not a predictor of 30-day mortality risk. However, we observed a significant interaction between MCS use and LVEF, indicating a lower morality risk with MCS use only in patients with a depressed LVEF. This provides rationale to use LVEF as a parameter to guide MCS therapy in non-ischaemic CS, and calls for a randomized trial on this topic.

Funding Acknowledgement

Type of funding sources: None.
Impact of primary diagnosis on survival after heart transplant in female recipients of childbearing age: an analysis of the International Society for Heart and Lung Transplantation (ISHLT) Registry
Authors: Macera F , Cherikh W S , De Filippis E M , Ross H , Stehlik J , Bhagra C J
Published: October 2022

Background

Women undergoing heart transplantation (HT) for peripartum cardiomyopathy (PPCM) have been reported to have inferior post-transplant survival. Specific data on the impact of pre-transplant diagnosis on survival in female HT recipients of childbearing age are lacking, but important for pre-conception counseling of women considering a pregnancy.

Methods

Retrospective data analysis was conducted using the ISHLT Registry. The primary aim was to study the impact of pre-transplant diagnosis and alloimmunisation on post-transplant survival in women aged 15–45 yrs at time of HT. Secondary outcomes included the impact of primary diagnosis on conditional survival at 5, 10 and 15-yrs post HT.

Results

Of 121,501 HT recipients (Jan 1992–June 2018), 30,179 (24.8%) were women. 9,229 (7.6%) were 15–45 yrs at time of HT. Peripartum cardiomyopathy (PPCM) and congenital heart diseases (CHD) was the primary diagnosis in 8.9% and 9.3%, respectively. Overall median post-transplant survival was 15.2 yrs. Female with PPCM were associated with higher alloimmunisation (Figure 1). PPCM was associated with lower survival (median survival in PPCM vs CHD vs other: 9.1 years vs 15.2 years vs 15.5 years respectively, p<0.05). This was not entirely explained by higher alloimmunisation in this group (Figure 2A). Five-year conditional survival of recipients of childbearing age was significantly affected by primary diagnosis of PPCM, and by pediatric status at HT, defined as age <18-yrs (PPCM vs other diagnosis p<0.05; pediatric vs non-pediatric p 0.003), whilst 10- and 15-year conditional survival was not. The difference in 5-year conditional outcome between PPCM and other diagnosis, was not significant however when female recipients were grouped according to their level of alloimmunisation (Figure 2B).

Conclusion

PPCM as the primary indication for HT is associated with a worse post HT survival. Our data suggest that this is not entirely explained by alloimmunisation. The impact of previous PPCM appears to be greatest in the first 5 yrs post HT. Further research is needed to fully elucidate the mechanisms associated with worse survival in this group and help inform pre-conception counseling in those HT recipients considering a subsequent pregnancy.

Funding Acknowledgement

Type of funding sources: None.
Intracardiac echocardiography as transesophageal echocardiography replacement in percutaneous intervention imaging: a systematic review and meta-analysis
Authors: Pritazahra A , Hadwiono M R
Published: October 2022

Background

Intracardiac echocardiography (ICE) has become more popular as an alternative to transesophageal echocardiography (TEE), the current gold standard modality of intraoperative imaging in percutaneous closure of interatrial communications, despite the limited three-dimensional capabilities and operational learning curve. ICE's primary strength is the lack of general anaesthesia, thus reducing the risk from airway intervention. Studies have shown that the successful device deployment rate assisted with ICE was similar to TEE. In addition, the optimal use of ICE has been suggested to lower procedural and fluoroscopy time, leading to better outcomes. However, there is currently limited evidence in this area to support ICE as the better option for imaging in percutaneous atrial septal intervention.

Purpose

To compare the total procedural time and fluoroscopy exposure between ICE versus TEE for the guidance of percutaneous atrial septal intervention.

Methods

We performed a comprehensive literature search using PUBMED and Google Scholar from inception to December 2020. Publications that compared ICE and TEE in the atrial septal intervention in adult patients were screened according to our eligibility criteria. The primary outcome of the study was procedural time. Analysis was performed using Revman 5.4.

Results

Five studies were included in this study, providing a total of 332 (ICE=169 VS TEE=163) patients. The mean procedural time was shorter in the ICE group compared to the TEE group (mean differences −8.67 minutes, 95% CI: −10.48 to −6.86, p<0.0001, I2=95%). The mean fluoroscopy exposure was also shorter in the ICE group (mean differences −3.22 minutes, 95% CI: −3.73 to −2.71, p<0.0001, I2=87%). There was no difference in term of success rate of the closure nor significant complications during peri-procedural reported in all studies.

Conclusion

ICE-assisted intervention was shown to be more efficient and associated with statistically significant shorter procedure time and fluoroscopy time than TEE, reducing the possible risk for side effects. Therefore, our analysis suggested that ICE could replace TEE as primary guidance of percutaneous atrial septal intervention.

Funding Acknowledgement

Type of funding sources: None.
Outcomes in hospitalised diabetic ketoacidosis patients with underlying heart failure: a national inpatient sample analysis
Authors: Yalamanchili S , Khdeir O K , Atluri R T
Published: October 2022

Management of diabetic ketoacidosis (DKA) is challenging in patients with heart failure as they tend to be fluid sensitive. We conducted this study to assess the impact of heart failure (HF) on in-hospital outcomes in patients hospitalized with DKA.

We conducted this cohort study using the national inpatient sample database from 2017 and 2018. The International Classification of Diseases-10 codes were used to identify patients with DKA as the principal diagnosis and stratified them based on whether they had HF. The outcomes were in-patient mortality, length of stay, total hospital charges, and complications during the hospitalization. We used multivariate regression analysis to adjust for confounders.

Among the 446,339 total hospitalized for DKA, 20,210 had a secondary diagnosis of HF. The average age was 57 (HF) vs 38 (no HF) (p<0.001). In the HF group, 56% were male and 56% were caucasian. After adjusting for patient demographics, comorbidities, and hospital characteristics, patients with HF had higher odds of cardiogenic shock (aOR=3.77, p<0.001, CI: 1.89–7.49), pneumonia (aOR=1.37, p<0.001, CI: 1.18–1.60), Total hospital charges (coefficient= $5,894.20, p<0.001, CI: 3046–8741) and length of stay (coefficient 0.35 days, p=0.001, CI: 0.14–0.56). There was no statistically significant difference in mortality, cardiac arrest, and sepsis. Patients with HF had lower odds of developing acute kidney injury (aOR=0.66, p<0.001, 0.62–0.72).

Among hospitalized patients with DKA, those with HF had worse outcomes in terms of length of stay, total hospital charges, cardiogenic shock, and pneumonia. However, there was no statistically significant increase in inpatient mortality.

Funding Acknowledgement

Type of funding sources: None.
The predictive role of mean platelet volume to lymphocyte ratio and neutrophil-to-lymphocyte ratio for cardiovascular events in adult patients with acute heart failure
Authors: Angkananard T , Inthanoo T , Sricholwattana S , Rattanajaruskul N , Wongsoasu A , Rungsangmanoon W
Published: October 2022

Introduction

The inflammatory response plays a potential role for the pathogenesis and adverse outcomes of heart failure (HF).

Purpose

We aimed to explore the predictive role of neutrophil-to-lymphocyte ratio (NLR) and mean platelet volume to lymphocyte ratio (MPVLR) on cardiovascular events (CVEs) in patients hospitalized with acute HF.

Methods

A retrospective cohort study was conducted in 321 patients with HF between January 2017 and December 2019. The association between their NLR, MPVLR and combined NLR and MPVLR, and CVEs, HF re-hospitalization, in-hospital death, and a composite outcome were explored by survival analysis using a Cox proportional hazard model. They were separately investigated and compared with the area under the receiver operating characteristics curve (AUC).

Results

Up to the end of the 3-year follow-up, 96 (29.9%) had CVEs, 106 (33.0%) died, 62 (19.3%) were re-hospitalized with HF, and 21 (6.5%) died during admission. The NLR and MPVLR were significantly associated with CVEs (adjusted HR for NLR ≥3.29, 3.11; 95% CI, 1.98–4.89, MPVLR ≥8.57, 2.86; 95% CI, 1.87–4.39), HF readmission (adjusted HR for NLR ≥3.58, 2.70; 95% CI, 1.58–4.61, MPVLR ≥6.43, 2.84; 95% CI,1.59–5.07), in-hospital mortality (adjusted HR for NLR ≥3.29, 9.54; 95% CI, 2.19–41.40, MPVLR ≥8.57, 7.87; 95% CI, 2.56–24.19), and composite outcome (adjusted HR for NLR ≥3.32, 4.76; 95% CI, 3.29–6.89, MPVLR ≥7.07, 3.64; 95% CI, 2.58–5.15). The AUC of NLR and MPVLR for CVEs were 0.67 (95% CI, 0.61–0.72), and 0.63 (95% CI, 0.58–0.69). Combined NLR and MPVLR increased the AUC to 0.77 (95% CI, 0.72–0.83) with statistical significance.

Conclusion

The elevated NLR and MPVLR on admission in patients with acute HF were independently associated with worse CVEs, HF re-hospitalization, in-hospital death, and composite outcomes. These economical biomarkers should be considered in the management and follow-up care of patients with acute HF.

Funding Acknowledgement

Type of funding sources: None.
Relation of lymphopenia to comorbidity burden and its prognostic value in patients with acute decompensated heart failure with preserved left ventricular ejection fraction: a multicentre study
Authors: Tamaki S , Nagai Y , Shutta R , Masuda D , Yamashita S , Seo M , Yamada T , Yano M , Hayashi T , Yasumura Y , Hikoso S , Sotomi Y , Sakata Y
Published: October 2022

Background

Systemic inflammation resulting from comorbidities is postulated to play a central role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). Lymphopenia is a common manifestation of systemic inflammation and a prognostic factor in patients with HF. However, the association of lymphopenia with the comorbidity burden is unknown, and its prognostic value in patients with HFpEF admitted due to acute decompensated heart failure (ADHF) also remains elusive.

Purpose

We sought to clarify the relation of lymphopenia with the comorbidity burden, as well as its prognostic value and complementarity with the Get with the Guidelines-Heart Failure (GWTG-HF) risk score in ADHF patients with HFpEF.

Methods

Patients' data were extracted from the Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF), which is a prospective multicentre registry for patients with ADHF with a LVEF ≥50%. We analysed data of patients admitted between June 2016 and December 2020 who survived to discharge. The total lymphocyte count (per μL) and GWTG-HF risk score were obtained on admission, as previously reported. Comorbidity burden was defined as the number of comorbidities from the following: atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, anaemia, and obesity. The study endpoint was all-cause death.

Results

Over a median follow-up of 417 days, 181 of the 1013 included patients died. The proportion of patients with a total lymphocyte count in the lowest tertile was increasing with the increase in comorbidity burden (Figure 1). In the multivariate Cox analysis, a total lymphocyte count in the intermediate (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00–2.41, p=0.0486) and lowest tertile (HR 2.23, 95% CI 1.47–3.38, p=0.0002) was independently associated with all-cause death. There was a significant difference in the all-cause death rate among the groups stratified by total lymphocyte count tertile (Figure 2). The total lymphocyte count had a higher C-statistic value (0.627) for the prediction of all-cause death than the GWTG-HF risk score, and the C-statistic value of the GWTG-HF risk score was improved when the total lymphocyte count was added (0.613 to 0.636, p=0.0260).

Conclusions

Lymphopenia was significantly associated with comorbidity burden. Furthermore, it was a useful marker of poor prognosis in hospitalised patients with acute HFpEF and was shown to be complementary to the contemporary HF prognostic score.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics K.K.Fuji Film Toyama Chemical Co. Ltd.
The link between left atrial longitudinal reservoir strain and mitral apparatus geometry in patients with dilated cardiomyopathy
Authors: Toader D M , Mirea O , Craciun-Mirescu A , Magareata G , Florescu D , Iordache S , Iovanescu M , Cirstea I , Aniculesei A , Busu M , Istratoaie O , Militaru C
Published: October 2022

Background

4-Dimensional Automated Left Atrial Quantification (4D Auto LAQ) is a technique that uses 3D volume data to determine LA strain. 4-Dimensional Automated Mitral Valve Quantification (4D Auto MVQ) evaluates anatomical and functional mitral valve parameters. Our study evaluated patients with dilated cardiomyopathy and tried to find a correlation between LA strain and mitral apparatus geometry.

Methods

We enrolled 61 patients with dilated cardiomyopathy and 25 healthy volunteers. The evaluation consisted of clinical examination, laboratory tests, 12 leads electrocardiography. All participants underwent a complete transthoracic echocardiogram to determine cardiac structure and function according to the current guidelines. Measurement of LA strain and MV was performed using 4D Auto-quantification software. The study evaluated longitudinal strain during reservoir phase (LASr) and the parameters of the MV geometry that could interfere with left atrial function: annulus area, annulus perimeter, anteroposterior (A-P) diameter, posteromedial-anterolateral diameter (PM-AL), (the longest diameter of MV perpendicular to AP diameter); commissural diameter (CD), inter-trigonal distance, tenting height, tenting area, and tenting volume.

Results

1. The patients were divided in two groups: 26 with ischemic dilated cardiomyopathy and 35 with non-ischemic dilated cardiomyopathy. 2. Mean values of MV parameters in patients with dilated cardiomyopathy compare with healthy volunteers were: annulus area: 19.46 cm2 vs 11.85 cm2; annulus perimeter: 16.86 cm vs 12.71cm, A-P diameter 4.53 cm vs 3.45 cm, PM-AL diameter 4.84 cm vs 3.92 cm, CD 4.83 cm, vs 3.94 cm, inter-trigonal distance 3.9 cm vs 2.9 cm, tenting height 1.64 cm vs 1.05 cm, tenting area 4.82 cm2 vs 1.78 cm2, tenting volume 13.49 ml vs 4.27 ml. For LASr, mean values were 10.26 in patients with dilated cardiomyopathy vs 32.14 in healthy volunteers. Mean values of mitral valve parameters and LASr were comparable in ischemic vs non-ischemic cardiomyopathy patients. 3. LASr correlated with anatomical mitral valve parameters: annulus area: r=−0.6, annulus perimeter: r=−0.57, AP diameter: r=−0.58, PM-AL diameter: r=−0.58, commissural diameter: r=−0.66, inter-trigonal distance: r=−0.57, tenting height r=−0.53, tenting area r=−0.55 and tenting volume r=−0.54.

Conclusions

1. In patients with dilated cardiomyopathy phenotype, anatomical parameters of the mitral valve and LASr were altered. Results did not reveal significant differences between ischemic and non-ischemic etiology. 2. A correlation was found between the decrease in LASr and anatomical parameters of the mitral valve, suggesting a link between atrial function deterioration and deformity of mitral apparatus geometry in patients with dilated cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.
Right ventricular adaptation and subclinical damage by echocardiography in heart transplantation recipients: insights from myocardial work index
Authors: Sade L E , Colak A , Sezgin A , Donal E , Butcher S C , Pirat B , Eroglu S , Ozdemir H , Muderrisoglu H
Published: October 2022

Aim

Right ventricular (RV) dysfunction is an important cause of graft failure after heart transplantation (HTx) and a challenge for echocardiographic evaluation. We sought to evaluate the accuracy of the most novel echocardiographic tools for the assessment of RV remodelling and function in asymptomatic HTx recipients with and without rejection.

Methods

All patients underwent right heart catheterization with biopsy, cardiac magnetic resonance (CMR) and echocardiography in a row within the same day while fasting, irrespective of symptoms, as part of institutional follow up protocol dedicated to HTx recipients. Invasively measured systolic pulmonary artery pressure was used to calculate RV myocardial work index (MWI) from strain-pressure loops by using the custom software (EchoPAC BT204, Horten, Norway). Event timings were determined from pulmonic and tricuspid valve opening and closures. With the aim to generate full bull's eye map by automated function imaging, we computed RV LS data from the apical 4-chamber view 3 times, from 3 consecutive cycles substituting apical LV views. Other indices of RV function were measured according to the EACVI 2015 recommendations for chamber quantification. RV volumes and ejection fraction (EF) were quantified by CMR. Echocardiographic measurements were compared with CMR derived RV EF and biopsy findings as the reference for microstructural changes. We also evaluated by echocardiography organ donors as healthy controls.

Results

Sixty-one fully matching studies (echo, CMR, catheter, biopsy) were analyzed. Tricuspid systolic annular velocity (S'), peak systolic excursion (TAPSE) and longitudinal strain (LS) were significantly lower in healthy HTx recipients as compared to controls (p<0.001 for all). Whereas, RV volumes, EF and fractional area change (FAC) were not different between HTx recipients and healthy controls (Figure 1, EDV:end-diastolic volume). In the overall HTx recipients, only FAC (r=0.51, p<0.001) but not S', TAPSE, LS or MWI correlated with CMR derived EF. Biopsy defined subclinical rejections however were nicely mirrored by LS, and MWI (Figure 2), whereas other indices failed to reflect microstructural changes. In addition, MWI had higher accuracy than LS to discriminate biopsy findings. RV volumes, EF, FAC as well as TAPSE, S' were insensitive to subclinical myocardial damage.

Conclusion

RV adaptation in healthy HTx recipients is characterized by decreased longitudinal function but preserved overall RVFAC, EF, and volumes. MWI seems to be more reliable than other echocardiographic parameters to track subclinical RV myocardial damage due to rejection, while the RV EF remains preserved.

Funding Acknowledgement

Type of funding sources: None.
Circulating miRNAs as independent predictors of cardiovascular mortality in patients with type 2 diabetes mellitus
Authors: Jakubik D , Eyileten C , Nowak A , Wolska M , Keshwani D , Jarosz-Popek J , De Rosa S , Mirowska-Guzel D , Siller-Matula J , Postula M
Published: October 2022

Background

MicroRNAs (miRNAs, miR) are essential gene expression regulators involved in numerous biological processes and diseases including type 2 diabetes (DM).

Purpose

We aimed to determine the predictive value of selected circulating miRNAs for cardiovascular and all-cause mortality and their potential usefulness as biomarkers in DM patients.

Method

Two hundred fifty-two patients with diabetes were enrolled in the study. Among the patients included, 26 (10.3%) patients died during a median follow-up of 71 months (5.9 years). Plasma miR-191 and miR-16 expressions were assessed by quantitative real-time PCR and compared between the patients who survived and those who died.

Results

Patients who died from cardiovascular-related death had significantly higher expression of miR-191 and miR-16 as compared with patients who survived (p=0.003, p=0.001, respectively). The study population was divided into two subgroups by using ROC curve analysis for each miRNA, i.e., low or high value of single miRNAs. Kaplan Meier and Cox regression were performed for survival analysis. High expression levels of miRNAs were associated with cardiovascular mortality, when the models included one single miRNA and other covariates: miR-191 (HR = 4.793, 95% CI: 1.48–15.579; p=0.009) and miR-16 (HR = 4.66, 95% CI: 1.48–14.75; p=0.009). Furthermore, miRNAs expression between clopidogrel and the whole acetylsalicylic acid groups (i.e., 75 mg +150 mg), miR-191 expressions was significantly higher in the clopidogrel subgroup (p=0.010), whereas miR-16 did not differ (p=0.127).

Conclusion

To conclude, miR-191 and miR-16 expression are strong and independent predictors of cardiovascular and all-cause mortality in patients with T2DM. Moreover, miR-191 and miR-16 present significant interactions with antiplatelet treatment regimens and clinical outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Warsaw
Deep learning to detect significant coronary artery disease from plain chest radiographs
Authors: D'Ancona G , Massussi M , Savardi M , Signoroni A , Di Bacco L , Farina D , Metra M , Maroldi R , Muneretto C , Ince H , Marinoni F , Chizzola G , Curello S , Benussi S
Published: October 2022

Background

Coronary artery disease (CAD) is the single leading cause of mortality, premature death, and morbidity worldwide. Artificial intelligence (AI) could help identify markers present within first-line diagnostic imaging routinely performed in patients referred for suspected angina, such as chest radiographs.

Purpose

To train, test, and validate a deep learning (DL) algorithm for detecting the presence of significant CAD based on chest radiographs.

Methods

Data of patients undergoing chest radiography and coronary angiography were retrospectively analysed. A deep convolutional neural network (DCNN) was designed to detect significant CAD from the patient posteroanterior/anteroposterior chest radiograph. The DCNN was trained for binary classification of severe CAD absence/presence (at least one diseased coronary vessel with ≥70% stenosis). Coronary angiography reports were used as the ground truth. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of the DCNN were calculated. Multivariate analysis was performed to identify independent correlation among the presence of significant CAD (dependent variable), DCNN prediction, and CAD risk factors.

Results

Information of 7728 patients referred for suspected angina was reviewed. Severe CAD was present in 4482 patients (58%; 1% left main, 28% one vessel, 16% two vessels, and 12% 3 vessels). Patients were randomly divided for training (70%; n=5454) and fine-tuning/testing (10%; n=773) of the algorithm. Internal validation was performed with the remaining patients (20%; n=1501). At binary logistic regression, the DCNN prediction was the strongest independent determinant of severe CAD (p<0.0001; OR: 52.8; CI: 25.1–110.9). Age (p=0.008; OR: 1.01; CI: 1.0–1.02) and Diamond-Forrester score (p<0.0001; OR: 1.022; CI: 1.018–1.026) were also independently related to CAD, although with lower significance and odds-ratios. Using an operating cut-point with high sensitivity, the DCNN had a sensitivity of 0.90 and specificity of 0.31 to detect significant CAD in the internal validation group (AUC 0.73; 95% CI DeLong, 0.69–0.76). Adding to the AI chest radiograph interpretation, patient age and angina status improved the prediction (AUC 0.77; 95% CI DeLong, 0.74–0.80).

Conclusion

The chest radiograph is ubiquitous and carries a plethora of information concerning the patient's health status, including direct and indirect signs of CAD. Our DL algorithm can predict, with high sensitivity, the presence of severe CAD in patients referred for suspected angina. It could be used to pre-test significant CAD probability in outpatient clinics, emergency room settings, and CAD screening in more extensive settings. Further studies are required to externally validate the algorithm and develop a clinically applicable tool.

Funding Acknowledgement

Type of funding sources: None.
Characteristics and clinical implications of premature summation of early and late diastolic filling in patients without tachycardia
Authors: Kim K , Seo J , Cho I , Choi E Y , Hong G R , Ha J W , Rim S J , Shim C Y
Published: October 2022

Backgrounds

The summation of early (E) and late diastolic filling (A) on mitral inflow Doppler even in the absence of tachycardia is often found during assessments of left ventricular (LV) diastolic function. We evaluated the echocardiographic characteristics and clinical implications of premature E-A summation.

Methods

We identified 1,014 subjects who showed E-A summation and normal LV ejection fraction between January 2019 and June 2021 in two tertiary hospitals. Among these, 105 (10.4%) subjects showed premature E-A summation at heart rates less than 100 beats per minute (bpm). The conventional echocardiographic parameters and LV global longitudinal strain (GLS) were compared with 1:1 age, sex, and heart rate matched controls without E-A summation.

Results

The premature E-A summation group had a heart rate of 96.4±3.7 bpm. Only 4 (3.8%) subjects were classified as having LV diastolic dysfunction according to the current guidelines. That group showed prolonged isovolumic relaxation time (107.2±25.3 vs. 61.6±15.6 msec, p<0.001), increased Tei index (0.76±0.19 vs. 0.48±0.10, p<0.001), lower LVEF (63.8±7.0 vs. 67.3±5.6%, p<0.001) and lower absolute LV GLS (|LV GLS|) (17.0±4.2 vs. 19.7±3.3%, p<0.001) than controls. As the E-A summation occurred at lower heart rate, the |LV GLS| was also lower (p for trend=0.002).

Conclusions

The premature E-A summation at heart rates less than 100 bpm is associated with subclinical LV dysfunction. Time-based indices and LV GLS are helpful for evaluating this easily overlooked population.

Funding Acknowledgement

Type of funding sources: None.
Determinants of neointimal strut coverage in bio-degradable polymer coated ultrathin strut stent
Authors: Chattopadhyay S , Soman B , Taylor G , Choudhury A , Desilva R
Published: October 2022

Introduction

Incomplete strut coverage (ISC) is the most important morphometric determinant of stent thrombosis. Determinants of ISC have been studied in thick and thin strut stents.

Purpose

To identify morphometric factors causing ISC in the biodegradable polymer-coated ultra-thin strut drug eluting stent (BP-UTS-DES) that are designed to encourage better strut coverage.

Methods

Patients undergoing implantation of a 65μm BP-UTS-DES had opportunistic OCT during staged PCI to assess strut coverage at 90 days. Images were analysed offline by experienced operators blinded to patient and procedural data. Neointimal thickness (NIT, μm) was measured as the minimum endoluminal distant between the strut and lumen border. All malapposed struts were considered uncovered. ISC was defined as <100% covered struts in a frame. Stepwise logistic regression using multiple morphometric variables was used to identify independent determinants of ISC including markers of circumferential distribution of neointimal growth (CVS,NUS,RUS), symmetry of stent expansion (SEI, AVS, MAS) in each cross section and the geographical location of the frame along the axis of the stent.

Results

We analysed 11652 frames of 65 stents (1976 mm) in 46 arteries of 40 patients. All stents were post dilated. 95.6% arteries had >20mm stents, 39.1% were overlapped and 15.2% were chronic total occlusions. Malapposition was seen in 2.6% of all struts and 39.2% of uncovered struts. The proportion of covered struts decreased as indices of circumferential uniformity of distribution of neointimal hyperplasia increased (CVS: r=0.37, p<0.001; RUS: r=0.36, p<0.001; NUS: r=0.52, p<0.001). As uniformity of stent expansion improved (SEI increased) strut coverage and circumferential uniformity of neointimal hyperplasia increased (CVS, NUS and RUS decreased) suggesting that distribution of neointimal growth becomes homogeneous as uniformity of stent expansion improves (Fig. 1). Determinants ISC is shown in Table 1.

Conclusion

SEI but not AVS or MAS determines ISC. Compared to the distal third of the stent frames in the middle third had lower and the proximal third had high risk of ISC.

Funding Acknowledgement

Type of funding sources: None.