bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of mortality by echocardiographic parameters: human vs. fully-automated AI-based analysis
Authors: Merin R , Gvili Perelman M , Merin H , Tzuberi M , Topilsky Y , Ziv-Baran T , Flint N
Published: January 2025

Background

The use of artificial intelligence (AI) for echocardiography analysis has been rapidly advancing and integrating into clinical practice. AI applications have demonstrated good accuracy in validation models compared to human experts. It is unclear how fully automated echocardiographic measures correlate with clinical outcomes, as compare to human readers.

Purpose

We aim to compare the performance of AI-based vs human expert-based analysis of echocardiographic measurements in prediction of mortality.

Methods

We retrospectively analyzed 889 consecutive hospitalized patients who underwent a clinically indicated transthoracic echocardiographic study. Each study was performed by experienced cardiac sonographers and reviewed by expert echocardiologists. All studies were also analyzed by a commercial, fully automated AI software (Us2.AI). For both human and AI measurements, we constructed multivariable models to predict 1-year all-cause mortality. Variables included in the models were selected based on their significance in univariate analysis. Cut-offs values were identified using a decision tree and the Chi-squared Automatic Interaction Detector (CHAID) algorithm. We used receiver operating characteristic (ROC) curves to determine which model provided stronger predictive power for mortality.

Results

Of the 889 patients, 731 (82%) patients (mean age 68±16, 46% Female) had sufficient echocardiographic data to be included in the analysis. One-year mortality was 13% (95 patients). Table 1 shows univariate analysis of human and AI measurements for 1-year all-cause mortality. 15 parameters automatically obtained by the AI system were found to be correlated with mortality, while 9 parameters from the human-based analysis were significant. In the multivariable regression model for 1-year mortality (Figure 1), the AI model showed superior predictive value (ROC area under the curve =0.758 vs. 0.709, P=0.041).

Conclusion

In this cohort of hospitalized patients, fully automated AI-based echocardiographic analysis was superior to human expert analysis in prediction of 1-year mortality.

Univariate analysis for mortality

Multivariable regression model
Right ventricular volumes and function indices by automated 3D speckle tracking echocardiography with artificial intelligence software
Authors: Koutsogiannaki E , Siama A , Ritsatos K , Tsoukas A , Ikonomidis I
Published: January 2025

Introduction

Normal values of three dimensional right ventricular (RV) volumes, ejection fraction (EF) and systolic function indices by three - dimensional speckle tracking echcardiography (3D - STE) are not well established. All measurements relied on older 3D RV software analysis and most of these are operator - depended with a wide variability in measured values. The gold standard method for evaluation of RV volumes and EF remains the Magnetic Resonance Imaging (MRI)despite the rapid improvement in echocardiography softwares for RV evaluation.

Purpose

Aim of the study was to assess the feasibility of modern advanced technology echocardiographic software based on 3D imaging powered by Artificial Intelligence (AI) in measurement of RV volumes, RV EF and systolic function indices by 3D - STE in normal subjects.

Methods

Healthy subjects without any cardiovascular, pulmonary and renal disease, underwent complete echocardiographic evaluation including the 3D datasets from each of the parasternal, apical and subcostal views. 3D RV datasets were obtained and analyzed using RV software powered by AI, to measure Global RV Volumes, End - Diastolic volume (EDV), End - Systolic volume (ESV), RV EF and Tricuspid Annular Plane Systolic Excursion (TAPSE). Additionally 3D Free Wall Longitudinal Strain (FWLS) and 3D Global Strain (3D GS) were obtained. Three or more datasets obtained from the apical view were available for comprehensive analysis in each subject.

Results

Of the 54 healthy subjects, 40 (50% male and 50% female, mean age 51 +/- 15 years old) had adequate image quality for measurements. Mean indexed 3D EDV, ESV and RV EF were measured at 48.5 +/- 10.3 mL/m2, 16.7 +/- 5.8 mL/m2, 56,1 +/- 5.9 % respectively. in addition 3D FWLS and 3D GS were measured at - 27.9 +/- 4.5 % and - 24.7 +/- 3.6 % respectively. TAPSE was measured at 22.4 +/- 5.1 mm.

Conclusions

Modern softwares based on AI are a new era in Cardiology and Echocardiography. A rapid increase of AI contribution in cardiovascular imaging techiniques is expected in the near future. 3D RV acquisition is feasible in the majority of subjects, although the quality of imaging and appropriate echocardiographic views remains operator - depended. Reference values of 3D RV volumes and 3D - STE systolic function indices were obtained by advanced technology AI software. Larger studies are required to establish normal values for the above indices.
Impact of mitraclip on diastolic inflow dynamics and energy loss in severe mitral regurgitation: a topological flow data analysis
Authors: Kayama K , Itatani K , Kikuchi S , Seo Y
Published: January 2025

Background

The MitraClip is a transcatheter edge-to-edge repair device whose efficacy in treating mitral regurgitation (MR) has been increasingly established in recent years. A unique aspect of this procedure is that, during diastole, the mitral valve orifice can be divided into two or more openings, a feature not seen in traditional surgical mitral valve repair. However, the impact of this division on diastolic inflow dynamics and left ventricular workload remains unclear.

Methods

We performed topological flow data analysis based on echocardiography vector flow mapping (iTEcho, Cardio Flow Design Inc.) to compare left ventricular flow vortex, streamlines, and energy loss in patients with severe MR before and after MitraClip. The patients examined in this study had severe atrial functional MR due to long-standing atrial fibrillation and underwent MitraClip with the placement of one clip at the A2-P2 leaflets of the mitral valve. Post-procedure, the severity of MR improved to a mild degree. Additionally, these parameters were compared with data from healthy individuals.

Results

In a healthy patient, during the diastolic filling phase, a unidirectional vortex is observed beneath the anterior leaflet, accompanied by a straightforward flow stream (Figure 1-A). Conversely, in severe MR, vortices form beneath both the anterior and posterior mitral leaflets, resulting in highly distorted, curved trans-mitral flows (Figure 1-B). Post-MitraClip intervention, unlike in healthy patients, a twin vortex structure with oppositely directed swirling flows is seen beneath the anterior leaflet. However, compared to the pre-MitraClip state, a straightforward trans-mitral flow is restored (Figure 1-C).

Analysis of energy loss reveals that the maximum energy loss before MitraClip treatment was 18.4 mW/m², which was associated with the distorted, curved blood flow in mid-diastole (Figure 2-B). In contrast, post-MitraClip treatment, the energy loss significantly improved to 5.9 mW/m², which was attributed to the improvement in diastolic inflow blood flow (Figure 2-C).

Conclusion

Although the vortex structure in diastole after the clip is different from that in healthy cases, successfully reduced energy loss with straight streamlines is obtained, indicating feasible inflow dynamics despite the double orifice.
Diabetes duration over the adult life course and associations with cardiac structure in later life
Authors: Al Saikhan L , Chaturvedi N , Wong A , Ghosh A , Hughes A
Published: January 2025

Background

Type 2 diabetes mellitus (T2DM) is associated with adverse left ventricular (LV) remodelling including an increase in LV mass. With falling global age of onset of T2DM, knowing the impact of T2DM duration over the adult life course on future cardiac structure is increasingly important.

Purpose

We studied the association of T2DM duration over the adult life course with cardiac structure in a British birth cohort.

Methods

Participants in the MRC National Survey of Health and Development, (the 1946 British birth cohort) underwent comprehensive investigations including echocardiography at 60-64y. The diagnosis of T2DM and age of onset was established from self-report, doctor diagnosis and/or glycated haemoglobin. The relationship between T2DM duration (3-year intervals) and LV structure (LV mass indexed to height1.7 (LVMi), LV end-diastolic volume indexed to height1.7 (LVEDVi) and LV remodelling index (LVRI)) measured at 60-64y was investigated using multivariable linear regression models.

Results

Age at echocardiography was 63.2±1.10 years and 701 (47.4%) were men (Table-1). Longer T2DM duration was associated with higher LVMi (1.09 (95% CI [0.364, 1.81], g/m1.7 per 3-year; p=0.003) and was independent of confounders (model-2) (Table-2). The was no relationships with LVEDVi and LVRI. The association of T2DM with LVMi was also independent of glycaemia estimated by HbA1c at 60-64y (model-3) (Table-2).

Conclusions

Longer duration of T2DM is associated with elevated LVMi in later life independent of current glycaemia. Preventing or delaying the onset of T2DM may have beneficial effects on the subsequent risk of cardiovascular disease.
Validation of a fully automated AI system for accurate left ventricular mass measurement in echocardiography
Authors: Sveric K , Platzek I , Haussig S , Linke A
Published: January 2025

Background

Accurate measurement of left ventricular mass (LVM) with 2D transthoracic echocardiography (Echo) provides prognostic information, and aids in tailoring treatment plans.

Purpose

We sought to validate a fully automated artificial intelligence (AI) system for LVM measurement in Echo against human measurements and computed tomography (CT), considered the gold standard.

Methods

101 patients with symptomatic aortic valve stenosis (AS), 48 with mitral valve regurgitation (MR), and 41 with tricuspid valve regurgitation (TR) underwent both Echo and cardiac spiral CT on the same day, the latter for planning interventional valve repair. End-diastolic septal and posterior wall thickness (IVSD, PW), along with end-diastolic diameter (EDD) from LV parasternal long axis views in Echo, were independently measured for 1-dimensional LVM calculation by both an AI and an experienced cardiologist (>10 years) (Figure 1A). Notably, the AI performed fully automated view selection from the entire Echo exam and measured LV diameter and wall thickness on appropriate LV views without operator involvement. LVM results from CT were supervised by an experienced radiologist (>10 years) (Figure 1B). Pearson’s correlation coefficient (r), regression analysis, and mean absolute error (MAE) were used to assess agreement of measurement values between methods.

Results

The final cohort consisted of 164 patients, with complete LVM calculations by AI, human, and CT (feasibility: 91%, 95%, and 99%, respectively). LVM from AI and human correlated strongly (r=0.83, MAE=22 g), but AI exhibited higher agreement with CT (r=0.69, MAE=28 g) than human LVM measurement (r=0.62, MAE=37 g) (Figures 1C and 1D). AI and human measurements showed good correlation for IVSD (r=0.74, MAE=0.18 cm) and EDD (r=0.73, MAE=0.54 cm), but low correlation for PWD (r=0.48, MAE=0.23 cm).

Conclusion

The findings highlight the potential use of an AI-based application for fully automated view selection and measurement of LV wall thickness and diameter, demonstrating strong agreement of LV mass with CT and human measurements.
Improvement of right and left ventricular echocardiographic parameters in obese patients after bariatric surgery
Authors: Polewczyk A , Siudak Z , Cecha P , Bryk P , Nawacki Ł , Bociek A
Published: January 2025

Background

Severe obesity causes hemodynamic changes in the circulatory system, which leads to the development of heart failure with either preserved or reduced ejection fraction. Weight loss achieved through bariatric surgery is likely to possibly reverse many of hemodynamic and structural abnormalities caused by obesity.

Purpose

Assessment of left and right ventricular function in patients undergoing bariatric surgery.

Methods

Detailed echocardiographic parameters assessing left and right ventricular function in severely obese patients undergoing bariatric surgery were analyzed. The following parameters of left and right ventricular function were compared in the examinations performed before, 3 and 6 months after surgery: left ventricular ejection fraction (LVEF), LV and RV global longitudinal strain (GLS), peak early (e’) and late (a’) diastolic annular velocities (lateral and septal) with calculation of E/e’ ratios, left atrium volumeindex ( LAVI), TRV (tricuspid regurgitation velocity), tricuspid annular plane systolic excursion (TAPSE), maximum systolic velocity of the lateral part of the tricuspid annulus-s’ and accelerated pulmonary time (AcT).

Results

Forty obese patients (76% women) with mean BMI 40.3 (SD 5.6) and mean age of 42.4 (SD 11.9) years were enrolled. BMI as 6 months was 31.2 (SD 5.1). Baseline and follow-up results of echocardiography are presented for both left and right ventricular parameters in Table 1 and Table 2.

Conclusions

Only GLS for right and left ventricle, FWS and TRV improve significantly within 6 months from bariatric surgery. On the other hand, these changes are significant as early as 3 months after bariatric surgery.

Left ventricular parameters

Right ventricular parameters
Cardiac systolic and diastolic function in relation to cardiovascular risk factor distribution: a comparison of strain-rate imaging in Russian and Norwegian populations
Authors: Roesner A , Kornev M , Caglayan H A , Malyutina S , Ryabikov A , Schirmer H , Kudryavtsev A V
Published: January 2025

Background and Purpose

Cardiovascular morbidity and mortality rates are high in Russia and it is likely that this reflects a similar impact on the general cardiac health of the population. The current study seeks to compare standard echocardiography and strain-based measurements between Russian and Norwegian populations, while also exploring their links to hemodynamic and risk factors.

Methods

This study included echocardiographic measurements of 1,192 participants from Russia, and 917 from the Study population, Norway. The sample included men and women aged 40–69 years. Normalcy, defined as the absence of hypertension or indicators of CVD, was observed in 840 individuals. We performed conventional echocardiography and analysed two-dimensional speckle-tracking longitudinal strains, including systolic, early-, and late-diastolic SR values. The study population was divided into four groups: normal, controlled hypertension, hypertensive blood pressure, and cardiac disease. Echocardiographic parameters were compared between the Russian and Norwegian populations, adjusted for age, sex, height, body mass index, blood pressure, heart rate (HR), atrial fibrillation (AF), smoking, pulmonary hypertension, and serum values for total, LDL (low density lipoprotein), and HDL (high density lipoprotein) cholesterol; triglycerides; creatinine; high-sensitivity C-reactive protein; and HbA1C.

Results

Russians showed a tendency towards lower longitudinal systolic functional parameters, which were most prominent in the normotensive group. However, these differences became insignificant after adjusting for parameters that influence pre- and after-loads. Russians also had a lower stroke volume, higher HR, higher left atrial volume, lower A, and higher E/A ratio, indicating a higher incidence of diastolic dysfunction in the Russian population that persisted after adjustments.

Conclusion

After adjusting for factors that influence cardiac function, there were no differences in systolic functional parameters between the Norwegian and Russian populations. However, differences in diastolic parameters, which persisted after adjusting for conventionally influential factors, indicated unexplained underlying causes of diastolic dysfunction in the Russian population.

Figure 1

Table 1
Prognostic significance of predischarge echocardiography in acute decompensated heart failure
Authors: Krawczyk M , Brzostowicz M , Ponikowski P , Kosmala W
Published: January 2025

Introduction

Current guidelines do not specify the timing of echocardiography during acute decompensation of heart failure (HF). In particular, the question of the usefulness of an echocardiographic imaging immediately before discharge from the hospital, i.e. after achieving hemodynamic stabilization, remains unresolved.

Aim

To compare the prognostic value of echocardiography performed on admission and discharge in patients hospitalized due to acute HF decompensation, and to identify which echocardiographic markers may predict a poor early outcome after discharge.

Methods

A complete echocardiogram, comprising assessment of myocardial deformation and myocardial work: global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) was performed twice- upon admission and upon discharge from the hospital in 130 patients (67±15 years of age, mean EF 35±15%) with decompensated HF (NYHA class III or IV). HFpEF was diagnosed in 26, HFmrEF in 19, and HFrEF in 85 enrollees. Participants were followed over 6 weeks after discharge for death and HF hospitalization (composite end-point).

Results

HF hospitalization or death occurred in 18 patients (13 and 5, respectively). Among echocardiographic parameters of left ventricular (LV), left atrial and right ventricular (RV) function, only E/e’ and GWW measured at pre-discharge were associated with the composite end-point, and the significance of these associations was retained when both predictors were included in the bivariable model. (Table). No associations with the study endpoint were found for any of the echo parameters measured at admission.

Conclusions

In patients with acute decompensated HF: 1) predischarge echocardiography after achieving hemodynamic stabilization can provide more short-term prognostic information than admission echocardiography during hemodynamic worsening; 2) in addition to LV filling pressure estimation (E/e’), measurement of LV myocardial work may improve the prediction of early mortality and HF readmission after hospital discharge.

Table
Double-blind comparison study on the reliability of binary assessment of left ventricular systolic function and dimensions between standard echocardiogram and handheld echocardiogram
Authors: Bia E , Cristiano E , Ignatiuk B , Graniero A , Pedrigi C , Previtali I , Marvelli A , Nudi A , Poloni C L , Passaretti B , Toscano O , Gad A , Brscic E , Licastro M , Celentano E
Published: January 2025

Rationale

Left ventricular systolic function parameters have considerable prognostic importance, but demand for echocardiographic examinations is greater than supply. The market availability of handheld echographs provides greater access to low-cost summary echocardiographic evaluation.

Purpose of the study

The purpose of the study is to compare in a double-blind manner the binary concordance ( yes/no) of an examination done with a handheld ultrasound and a standard echocardiographic examination on four parameters referred to the left ventricle ( LV) on the same patient 4 days apart.

Method

Thirteen volunteer cardiologists who had performed at least 1000 echocardiograms blindly performed on patients not known to them an evaluation with a handheld ultrasound machine and reported the result on a card stating the presence or absence in an eye-based manner of 4 conditions: LV dilatation, reduced LV systolic function ( left ventricular ejection fraction LVEF< 55%), presence of left ventricular segmental kinetics alterations. The two echocardiographic examinations were performed at a maximum time interval of two days and in the absence of any new procedures on the patient between the two examinations.

The time taken for each examination was timed.

A statistical analysis with Choen’s Kappa test was performed.

Results

A total of 107 examinations were performed on 86 patients, whose characteristics are shown in Table Number 1. The average number of examinations per cardiologist was 8.9 with a minimum of 5 examinations and a maximum of 10. There was excellent concordance on the VS dilatation parameter ( kappa 0.85, SE 0.05, 95% CI 0.77 to 0.99), with a number of 4 false positives and 0 false negatives; the ability to detect the presence of reduced global left ventricular systolic function was also excellent ( kappa 0.9 SE 0.04 95% CI 0.82 to 0.99). Concerning left ventricular hypertrophy there was a high percentage ( 22%9 of false negatives), referring to mild degree of LV hypertrophy, with concordance however ( kappa 0.42 SE 0.08 CI 95% 0.26 to 0.59); on segmental kinetics there was 9% false positives and no false negatives with fair concordance ( kappa 0.55 SE 0.09 95% CI 0.37 to 0.73). Results are summarized in table 2.

Conclusions

Qualitative assessment on left ventricular systolic function parameters with a handheld ultrasound machine compared with a standard echocardiographic examination is reliable for the recognition of left ventricular dilatation and dysfunction. This may have considerable use of the examination as a filter or screening for the recognition of relevant heart disease.
Sex-related effect of exercise on RV-PC coupling in asymptomatic patients with significant primary mitral regurgitation
Authors: Koukos M , Ververeli C L , Sakalidis A , Dimitroglou Y , Beneki E , Dritsa P , Kouremeti M , Tsartsalis D , Patsourakos D , Tolis E , Kalompatsou A , Gialeli F , Tsioufis K , Aggeli C
Published: January 2025

Background

Right ventricular–pulmonary circulation (RV-PC coupling) serves as an index to evaluate RV function in relation to underlying RV afterload. Although impaired RV-PC coupling has been proposed as a predictor of adverse outcomes in heart failure (HF) patients with secondary mitral regurgitation (MR), there is limited data available for patients with primary MR and moreover, if there is a sex-related trend.

Purpose

This study aimed to assess RV-PC coupling at rest and during exercise with bicycle stress echocardiography in patients with asymptomatic moderate to severe primary MR and compare these alterations between men and women.

Methods

All patients and controls underwent stress echocardiography with a supine bicycle. RV systolic function was evaluated with TAPSE and S’. The non-invasively measured RV-PC coupling was evaluated by indexing TAPSE to right ventricular systolic pressure (RVSP) during baseline echocardiogram and peak workload stages of bicycle SE.

Results

Among the 48 patients, 28 (58%) were women and 20 (42%) were men (mean age 54.07+14.16 and 52.7±16.81 years, p. NS, respectively). 39 patients had moderate MR (81.3%), 5 patients had moderate-to-severe MR(10.4%), and 4 patients had severe MR(8.3%). The duration of stress echocardiogram was significantly longer in the male MR group (9.32+1.62 min vs 7.22+2.50 min, respectively; p .001). Left Ventricular Ejection Fraction (LVEF) was within normal limits in both groups {67.59+13.71 % vs 72.93+10.21 %(p=NS)} and the dimensions of left ventricular cavity (end-diastolic and end-systolic diameters) were significantly larger in the male group compared to female group (51.5+5.10 mm vs 47.64+4.73mm (p .011) and 34.00+4.06mm vs 30.25+3.74mm (p .002) respectively}.

TAPSE and RVSP increased from baseline to peak dose for both men [Rest: 22.95±2.93mm and 14.13±1.99cm/sec (p. NS) respectively, Peak exercise: 29.55 ±3.41mm and 20.84±2.00cm/sec (p. NS) respectively] and women [Rest: 23.86±3.13 and 14.54±1.88cm/sec (p.NS), Peak: 30.21±3.56mm and 20.07±2.60cm/sec (p. NS) respectively].

Moreover, a steady decrease was observed in TAPSE/RVSP from baseline to peak workload both in men (0.81±0,13mm/mmHg to 0.75±0.21mm/mmHg) and women (0.86±0.16mm/mmHg to 0.69±0.16mm/mmHg, respectively). Interestingly, a significant change was observed between men and women in TAPSE/RVSP (-0.05±0.17 and -0.16±0.17, p .029 respectively).

Conclusions

RV-PC coupling decreases during exercise in asymptomatic men and women with moderate to severe MR. Therefore, future studies should aim to evaluate the incremental role of this novel index not only in the assessment and evaluation of men and women with MR but also as a potential prognostic marker between them.

TAPSE/RVSP change Graph
Impact of right ventricular function on outcome in low-risk secondary tricuspid regurgitation according to effective regurgitant orifice area
Authors: Pece C , Tomaselli M , Penso M , Badano L P , Clement A , Radu N , Heilbron F , Gavazzoni M , Springhetti P , Oliverio G , Caravita S , Baratto C , Buta A , Parati G , Muraru D
Published: January 2025

Background

The threshold value of the effective regurgitant orifice area (EROA) that identifies patients with secondary tricuspid regurgitation (STR) at high risk of events during follow-up remains unclear.

Purpose

Our study aimed to identify the threshold value of the EROA defining patients with STR at high-risk of events during follow-up and to evaluate the impact of right ventricular (RV) remodeling in modulating the outcome of low-risk STR patients according to EROA.

Methods

513 consecutive outpatients with STR were included. Using the threshold value derived by spline curves, we divided our cohort into two groups: low- (EROA≤ 0.47cm2) and high- (EROA> 0.47cm2) risk STR patients. The endpoint was a composite of heart failure hospitalization and death.

Results

At 18±15 months from enrolment, 195 patients (38%) reached the endpoint. The Kaplan-Meier curves demonstrated a higher rate of events for high-risk patients (54±6% vs 30±7%, p <0.0001). EROA> 0.47 cm2 was associated with a 2-fold increased risk of experiencing the outcome (Hazard Ratio [HR]: 2.08, 95% Confidence Interval [CI] 1.56-2.77, p<0.0001). Patients with atrial STR had a significantly lower threshold value (0.44 cm²) than patients with ventricular STR (0.49 cm²). In multivariate Cox regression analysis, EROA remained independently associated with the composite endpoint (adjusted HR: 1.01, 95% CI 1.00-1.02, p<0.0001) both in the entire cohort and in high-risk patients. Patients with low-risk STR were associated with a dismal prognosis only if they had dilated or dysfunctioning RV. In patients with EROA≤ 0.47cm2, the event rate at two years for RV end-diastolic volume >90 mL/m2, RV end-systolic volume (RV ESV) >46 mL/m2, RV ejection fraction <45% and RV forward stroke volume/RV ESV< 0.40 were respectively: 42±4%, 51±4%, 44±4%, and 47±4%).

Conclusions

Our results refine the independent association between STR severity assessed by EROA and outcomes. In patients with low-risk STR, the assessment of RV function and RV-PA coupling may improve the patient’s risk prediction, demonstrating a clinically relevant link between STR severity and RV geometry and function.
Comparison of quantitative echocardiographic parameters for grading of mitral regurgitation severity for prediction of clinical outcome
Authors: Ambrozic J , Prodanova D , Starc A , Cvijic M
Published: January 2025

Introduction

Current recommendations favour the use of quantitative parameters for the assessment of mitral regurgitation (MR) severity and the effective regurgitant orifice area (EROA) derived from the proximal isovelocity surface area (PISA) method has been demonstrated as a predictor of outcome.

Purpose

The aim of our study was to compare the long-term predictive value of quantitative echocardiographic parameters, derived from the PISA method and volumetric method on clinical endpoints.

Methods

We retrospectively analysed 298 patients who consecutively underwent echocardiographic examination at out department in 2018 and had been diagnosed with more than mild MR. From the echocardiographic measurements we calculated the quantitative parameters (EROA, regurgitant volume (Rvol) and regurgitant fraction (RF)) by the PISA method and volumetric method (based on the Rvol calculated as a difference between total left ventricular stroke volume derived from the Simpson’s biplane planimetry and forward stroke volume assessed by the pulsed-wave Doppler left ventricular outflow tract method). The clinical outcome was death from any cause, hospitalization due to heart failure or mitral valve intervention in the period from the echocardiographic examination to the end of 2022.

Results

The study cohort comprised 169 (56%) patients with secondary MR, 103 (35%) with primary MR and 26 (9%) with combined etiology. Clinical endpoints were observed in 198 (66%) patients. Median time to the event was 732 (121-1578) days. Quantitative parameters by the PISA method better predicted the clinical outcome compared to quantitative parameters by the volumetric method (Figure A). RF-PISA had the biggest area under the curve (AUC 0.633, p < 0.001), followed by the EROA-PISA (AUC 0.626, p < 0.001), while the predictive values of quantitative parameters by the volumetric method were not significant (EROA: p= 0.109, Rvol: p=0.153, RF: p=0.156). By the PISA method, patients with RF≥50% had more adverse outcome compared to those with RF<50% (Figure B). By the volumetric method, however, the outcome was similar for both patients with RF≥50% or <50% (Figure B). In our cohort, the best cut-off value for the prediction of the clinical event was RF-PISA >46% (sensitivity 48%, specificity 76%) and EROA-PISA > 0.24 cm2 (sensitivity 41%, specificity 78%).

Conclusions

Quantitative parameters for grading MR severity by the PISA method provide better diagnostic accuracy for predicting the clinical outcome in comparison to quantitative parameters by the volumetric method. RF-PISA turned out as a good predictor for clinical outcome. Our results show that the fraction of regurgitation better defines the clinical significance of MR than the absolute values of quantitative parameters. Therefore, the RF should be reported as part of the quantitative assessment of MR severity.
The impact of severe tricuspid regurgitation on quality of life among patients with atrial fibrillation
Authors: Vijan A , Ablachim T , Daha I , Delcea C , Iliesiu A M
Published: January 2025

Introduction

Atrial fibrillation (AF) is a widespread arrhythmia that influences the quality of life (QOL) and tricuspid regurgitation (TR) frequently occurs alongside AF in these patients.

Aim

The goal of the study was to assess the quality of life in patients with AF and severe TR.

Material and methods

In this prospective study AF patients admitted consecutively to a tertiary clinical hospital, between January 2021 and July 2022, were included irrespective of the cause of hospitalization. QOL was measured using the validated AFEQT questionnaire with the cutoff value set by the mean value. The severe TR at echocardiography was defined according to current european guidelines. Patients with AF were divided into four categories: patients with paroxysmal, persistent, long-standing persistent, and permanent AF. Right ventricular dysfunction was defined using the tricuspid annular plane systolic excursion (TAPSE) less than 17mm, peak systolic velocity of the tricuspid annulus (s'RV) less than 10cm/s, with cutoff values in accordance with the EACVI-ASE guidelines. High arrhythmic burden was determined by the number of AF episodes (more than 5 episodes per month) and by the type of AF (long-standing persistent or permanent AF).

Results

117 patients with AF and TR, 57.26% women, mean age 71±10 years , were included in the study. 41.03% patients had a poor QOL and were significantly older (p 0.002). Severe TR was present in 13.68% AF patients. Mean AFEQT score was significantly lower in patients with severe TR (42.88±12.68 vs 35.45±18.08, p 0.02).

Right atrial volume index (HR 6.72, 95%CI 1.63-27.63, p 0.008) and systolic pulmonary artery pressure (HR 1.1, 95%CI 1.03-1.20, p 0.001) were independent predictors for severe TR.

AFEQT score was directly correlated with left ventricle ejection fraction (r 0.508, p 0.001), TAPSE (r 0.456, p 0.001), S’RV (r 0.486, p 0.001) and inversely correlated with NTproBNP values (r -0.570, p 0.001), age (r -0.462, p0.001), CHA2DS2-VASC score (r -0.493, p 0.001), right atrial volume index (r -0.405, p 0.001) and left atrial volume index (r -0.428, p 0.001)

In multivariable analysis, after adjusting for age and sex, severe TR was an independent predictor of poor QOL (HR 3.83, 95%CI 1.09-13.46, p 0.035), alongside high arrhythmic burden (HR 3.06, 95%CI 1.15-8.14, p 0.025), CHA2DS2-VASC score (HR 1.37, 95%CI 1.07-1.75, p 0.01), increased NTproBNP (HR 1.83, 95%CI 1.10-3.05, p 0.020), non-paroxysmal AF (HR 4.01, 95%CI 1.34-11.90, p 0.012) and right ventricle dysfunction (HR 6.41, 95% CI 2.66-15.42, p<0.001)

Conclusion

In patients with atrial fibrillation the association of severe tricuspid regurgitation was an independent predictor for reduced quality of life.
A new perspective on mixed moderate aortic valve disease
Authors: Son J H , Kim O Y , Park S J , Kim J H , Kim D R , Kim E K , Chang S A , Lee S C , Park S W
Published: January 2025

Background

Mixed aortic valve disease (MAVD) is common in patients with aortic valve disease. Some studies suggest that outcomes of mixed moderate aortic stenosis and regurgitation (ASR) are similar to severe aortic stenosis (AS). However, there is limited data on moderate ASR in the Asian population. This study aims to analyze the characteristics and outcomes of MAVD at our center and compare them with isolated moderate AS and severe AS to determine the prognosis of MAVD.

Methods

This retrospective study collected MAVD patients from a single tertiary center from January 2000 to January 2023 (n=1452). Patients with severe aortic valve stenosis and/or regurgitation, left ventricular ejection fraction (LVEF) ≤40%, other significant valve disease, previous valve surgery, and age <18 years were excluded. Eventually, we identified 55 patients with moderate ASR (mean aortic peak velocity 3.7 ± 0.6 m/s, mean pressure gradient 31.0 ± 11.0 mmHg, aortic valve area 1.3 ± 0.2 cm², AR vena contracta width 0.4 ± 0.1 cm). We compared them with the isolated moderate AS group (n=648) and severe AS group (n=749). We analyzed the outcomes of AVR and mortality across the three groups. In a sub-analysis, AVR rates were compared between the moderate ASR and moderate AS groups.

Results

Mean age was the lowest in the moderate ASR group (63.7±13.2 years) compared to the moderate AS group (72.2±10.8 years) and severe AS group (72.6±10.5 years, p<0.001). The proportion of males was similar among the three groups. In moderate ASR group, the etiology of valve was identified as 21.8% of bicuspid valve (12/55), 25.5% of rheumatic valve (14/55) and 50.9% of degenerative trileaflet valve (28/55). (Table1) Mean follow-up duration was 4.15 ± 4.02 years.

In outcome, the mortality showed similar between the moderate ASR group and moderate AS group, but significant higher in severe AS group in time-varying adjusted cox regression analysis. The cumulative incidence of AVR was higher in the moderate ASR group by the Kaplan-Meier curve (p=0.025, Figure). Freedom from AVR in the moderate ASR group was 71% at 3 years, 61% at 5 years and 54% at 7 years, indicating more slow progression than previous study.

Conclusions

In this study, mortality rates between the moderate ASR and the moderate AS groups were similar, but the AVR rates were higher in the moderate ASR group. Compared to previous studies, differences in etiology of the valve and ethnicity may affect the slow progression rate of moderate ASR. Further studies with larger cohorts are needed in the future.
Echocardiographic evaluation of mechanical abnormalities to predict significant ventricular arrhythmias in mitral valve prolapse: a systematic review and meta-analysis
Authors: Viva T , Sperlongano S , Bruno V D , Glauber M , Lancellotti P
Published: January 2025

Background

A subset of patients with MVP (mitral valve prolapse) is at high risk of malignant ventricular arrhythmias (VAs). Recently, a role of strain echocardiographic parameters has emerged in the risk prediction of these events.

Purpose

This systematic review and meta-analysis aimed to analyze the association between strain parameters and VAs and sudden cardiac death in MVP.

Methods

A systematic review and meta-analysis were performed for studies including patients with MVP, in which strain parameters were analyzed and an history of significant VAs was reported. The aim was to evaluate the association between strain parameters and the occurrence of significant VAs and to compare these parameters between patients with significant VAs ("Arrhythmogenic mitral valve prolapse", AMVP) vs No VAs ("Non-arrhythmogenic mitral valve prolapse", NAMVP).

Results

Seven observational studies1–7 (six retrospective and one prospective) were included and a total of 1065 patients with MVP were part of the analysis. GLS (global longitudinal strain), mechanical dispersion (MD), and post-systolic index (PSI) demonstrated to be associated with significant VAs in our analysis (GLS: OR = 1.16, 95% CI 1.02 - 1.33, p = 0.03, MD: OR = 1.05, 95% CI 1.01 - 1.09, p < 0.01, PSI: OR = 1.13, 95% CI 1.03 - 1.23, p < 0.01, Fig.1), although some conflicting data exist in literature. A "double-peak pattern" in the LV infero-lateral basal wall was also associated with the occurrence of VAs (HR 4.81, 95% CI 2.22 – 10.4, p < 0.001). GLS was significantly lower in patients with AMVP compared with NAMVP (mean difference = 1.24%, 95% CI 0.33 - 2.15, p < 0.01, I2 = 52%, Fig.2); MD and PSI were found significantly higher (MD: mean difference = 7.78 ms, 95% CI 2.81 – 12.75, p <0.01, I2 = 61% difference = 1.12%, 95% CI 0.53 – 1.72, p <0.01, I2 = 0%, Fig.2) in AMVP patients.

Conclusions

Three echocardiographic strain parameters (GLS, MD, PSI) were significantly different between patients with AMVP vs NAMVP and predict the risk of VAs. Further studies are required to confirm the utility of these parameters in patients with MVP.
Performance of effective regurgitant orifice and 3D vena contracta area for the diagnosis of severe mitral regurgitation in patients with localized and diffuse mitral valve prolapse.
Authors: Auberson D , Soylemez N , Tzimas G , Arangalage D , Antiochos P , Rutz T , Hugelshofer S , Monney P
Published: January 2025

Background

Mitral valve prolapse (MVP) is heterogenous, ranging from localized disease to diffuse bi-leaflet involvement in Barlow myxoid degeneration. Mitral regurgitation (MR) may be localized or diffuse, holosystolic or end-systolic, depending on the valve morphology. We aimed to compare the diagnostic accuracy of effective regurgitant orifice by conventional 2D PISA (ERO) on transthoracic echocardiography (TTE) with 3D vena contracta area (3D-VCA) on transoesophageal echocardiography (TOE) in patients with localized and diffuse MVP.

Methods

Patients with MVP assessed with TTE, 3D-TOE and cardiac magnetic resonance (CMR) for moderate to severe MR were included. MR was considered severe when the regurgitant fraction (RF) by CMR was ≥40%.1 3D-VCA was acquired in multi-beat mode during breath-hold and 3D-VCA was measured at end-systole. The diagnostic accuracy of 3D-VCA and ERO were compared using ROC analysis in patients with diffuse (6 prolapsing scallops) versus localized prolapse

Results

77 patients had undergone all three exams. Diffuse bi-leaflet prolapse was present in 24 patients (31%, Barlow). In the group with localized prolapse (69%, non-Barlow), 90% had a single scallop prolapse, and 85% had a flail leaflet. 53 of the patients (70%) had severe MR by CMR, and severe MR was less frequent in Barlow (46%, versus 79% in non-Barlow).

ERO could not be calculated accurately by TTE in 10 patients (8 with non-Barlow, 2 with Barlow). Hence, 67 patients were included in the comparative analysis. On average, 3D-VCA overestimated ERO by 20mm2 in non-Barlow and by 24mm2 in Barlow (Figure 1). Diagnostic accuracy of 3D-VCA and ERO was comparable in non-Barlow (AUC 0.79 vs 0.84, p=0.45), but 3D-VCA tended to perform poorly in Barlow (AUC 0.66 vs 0.84, p=0.2) (Figure 2).

Conclusion

3D-VCA measured in end-systole consistently overestimated ERO as determined by the conventional 2D PISA method on TTE. While its diagnostic performance was comparable to ERO in the case of localized prolapse, it seems to demonstrate low performance in the context of Barlow disease.

Figure 1

Figure 2
Dapagliflozin improves ejection fraction, radial/longitudinal strain and reduces systemic H-FABP and pro-inflammatory cytokines in models of dororubicin/trastuzumab induced cardiotoxicity
Authors: Maurea N , Palma G , Luciano A , Maurea F , Bruzzese F , Paccone A , Izzo F , Barbato M , Arianna R , Giacobbe I , Giordano V , Di Mauro A , Ferrara G , Berretta M , Quagliariello V
Published: January 2025

Background

The use of anthracyclines as a standard cancer therapy is limited by the potential for the development of cardiac dysfunction, arrhythmias, and clinical heart failure. The incidence of cardiac dysfunction or heart failure post-trastuzumab plus anthracycline therapy is higher compared to monotherapy regimen, exposing cancer patients to cardiotoxic risk. Dapagliflozin exerts several cardiometabolic benefits in patients with and wthout T2DM through SGLT2-NLRP3 mediated pathways. In this study, we highlighted on new beneficial properties of Dapagliflozin in preclinical models of doxorubicin-HER-2 blocking agent induced cardiotoxicity.

Methods

Female C57Bl/6 mice were untreated (Sham, n=6) or treated for 10 days with doxorubicin i.p at 2.17 mg/kg associated to HER-2 blocking agent i.p at 2,25 mg/kg (DOXO/TRA, n=6), DAPA at 12 mg/kg (DAPA, n=6) or doxorubicin-HER-2 blocking agent combined to DAPA (DOXO/TRA–DAPA, n=6). Cardiac function studies, including EF, FS and radial/longitudinal strain were analysed through transthoracic echocardiography (Vevo 2100) . Systemic levels of ferroptosis-related biomarkers, galectin-3, high-sensitivity C-reactive protein (hs-CRP), and pro-inflammatory chemokines (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-10, IL-12, IL17-α, IL-18, IFN-γ, TNF-α, G-CSF, and GM-CSF) were quantified.

Results

Dapagliflozin increased EF and FS compared to DOXO groups (p < 0.01), prevented the reduction of radial and longitudinal strain after 10 days of treatment with DOXO-TRA (RS) 40.2% in EMPA-DOXO vs 14.9% in DOXO-TRA mice; LS – 26,8 % in DOXO/TRA-DAPA vs – 9,7.3% in DOXO/TRA mice (p < 0.001 for both). Dapagliflozin associated to Doxorubicin reduces of 53,8 % plasma levels of H-FABP compared to DOXO group (p<0.001). Myocardial expression of H-FABP were also reduced, indicating cardioprotective properties of SGLT2i. Significant reductions in ferroptosis, xanthine oxidase expression, cardiac fibrosis and apoptosis in DAPA associated to DOXO/TRA were also seen. A reduced expression of systemic pro-inflammatory cytokines and NLRP3 was also seen in in DOXO/TRA-DAPA group compared to DOXO/TRA (p < 0.001).

Conclusion

For the first time, Dapagliflozin demonstrated significant improvements in cardiac functions and reductions of systemic H-FABP and troponin levels during doxorubicin associated to HER- blocking agent therapy, indicating new potential pathways of cardioprotection in cancer patients.
Distinct phenotypic groups and related clinical outcomes in patients with hypertrophic cardiomyopathy
Authors: Kwak S , Kim J , Kim H K , Lee S C
Published: January 2025

Background

Hypertrophic cardiomyopathy (HCM) is a heterogeneous disorder with varying risks of clinical outcomes, including sudden cardiac death (SCD).

Purpose

We aimed to identify distinct phenotypes among patients with HCM in relation to SCD risk factors, interpret their clinical characteristics, and examine their outcomes.

Methods

This retrospective study analyzed 1,231 consecutive patients with HCM from two tertiary hospitals. We performed latent class analysis (LCA) to categorize patients into phenotypic groups, which is a probabilistic modeling technique that reveals hidden patterns and subgroups within a dataset.

Results

Three distinct phenotypic groups were identified using LCA. Group 1 (n=554) consisted of young patients with HCM with minimal SCD risk factors and favorable cardiac remodeling. Group 2 (n=114) comprised young patients with HCM and a high prevalence of SCD risk factors, whereas Group 3 (n=563) included older patients (median age, 68 years). Over a median 6.5-year follow-up, 34 SCD-related events, 131 cardiovascular (CV) events, 133 all-cause mortality, and 70 non-CV mortality were observed. Group 2 exhibited the highest rate of SCD-related events (5-year SCD rate: Group 1 vs. 2 vs. 3: 0.8% vs. 8.2% vs. 4.0%, respectively, p<0.001), and CV events were more frequent in Group 2 and 3 compared to Group 1 (Figure 1). All-cause and non-CV mortality were the most frequent in Group 3. A simplified decision tree was developed for the straightforward assignment of phenotypic group membership, demonstrating fair concordance. The phenotypic categorization and the decision tree is shown in Figure 2.

Conclusions

This study identified three distinct clinical phenotypes in patients with HCM, each associated with different SCD risks and outcomes. Data-driven phenotyping of patients with HCM offers effective risk stratification and may optimize patient management.
Abnormal right ventricular strain predicts poor prognosis in transthyretin amyloidosis
Authors: Istratoaie S , Bourg C , Lee K C , Al Wazzan A , Marut B , Antonelli J , L'official G , Donal E
Published: January 2025

Background

The diagnosis of transthyretin amyloidosis (ATTR) significantly impacts the management and prognosis of patients initially presenting with heart failure (HF). Despite recent advances in treatment, defining the prognosis of ATTR remains challenging. Biological staging systems have been used to stratify disease severity. Valuable insights have emerged from echocardiography parameters.

Purpose

We aimed to assess echocardiographic parameters associated with mid-term prognosis in patients with wild-type ATTR using a biomarker staging system as a reference point.

Methods

Consecutive wild-type ATTR patients referred to a referral center were identified between 2016 and 2022.

The staging system was based on NT-proBNP and eGFR, with cut-offs set at 3000 pg/mL and 45 mL/min/1.73 m², respectively. Echocardiographic indices including all-chamber strains were compared across the staging system. Patients were all treated by Tafamidis 61mg on top of the management of signs and symptoms of HF. Primary endpoint was a composite of death or hospitalization for HF.

Results

182 patients were enrolled (91% male, median age 82 years). Using NT-proBNP and eGFR cutoffs, we divided patients into stage I (101 patients, 55.5%), stage II (53, 29.0%), and stage III disease (28, 15.5%). Patients in a higher ATTR stage were older, with lower body-mass-index and higher NYHA-functional class and more likely to develop AF. Patients classified in stage I presented with subtle signs of left ventricle(LV) and right ventricle(RV) systolic dysfunction, as well as diastolic dysfunction, evident by a reduced global longitudinal strain, right ventricular free-wall-strain (RVFWS) and left atrial strain, respectively. Higher ATTR stage was associated with worse LV and RV systolic functions, worse diastolic function and increase in pulmonary pressures. Over a fixed follow-up of 18 months, 48 patients (26.4%) experienced the composite outcome of death or HF hospitalization. When compared with stage I ATTR, the hazard ratio for death or hospitalization was 1.55 (95% CI 0.62–3.86) for stage II ATTR and 4.53 (95% CI 1.66–12.4, p = 0.0116) for stage III ATTR. Among echocardiographic parameters, reduced RV FWS was independently associated with all-cause mortality or HF hospitalization after adjustment for the staging system (HR 2.03, 95% CI 1.07-3.85, p < 0.05).

Conclusion

RV FWS should be routinely assessed for all patients with ATTR. It is an independent predictor of poor prognosis and provides additional value beyond biomarker staging system.