bluuebunny/crossref_metadata_2025 huggingface dataset:
Microvascular and mechanical improvements following bariatric surgery in the obese; mechanistic insights from advanced & automated quantitative perfusion cardiac MRI
Authors: Joy G , Crane JD , Augusto JB , Lau C , Seraphim A , Bhuva A , Moon JC , Xue H , Kellman P , Cruickshank JK , Mcgowan BM , Manisty C
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Guy"s and St Thomas" Charity University College London Hospital Biomedical Research Centre

Background

  In people with obesity, bariatric surgery reduces mortality, heart failure and coronary disease, improving metabolic (blood sugar, lipid profile, inflammation) and cardiovascular (diastolic/systolic function, filling pressure, cardiac remodelling) parameters. Myocardial microvascular function is a candidate causal link of metabolic to structural cardiac abnormalities.

Purpose

We hypothesised that bariatric surgery could improve myocardial microvascular and mechanical function in both those with and without diabetes. 

Methods Before and six months after bariatric surgery, 24 subjects with obesity were assessed with haematology, biochemistry and advanced CMR (cines, vasodilator adenosine stress and rest fully-automated quantitative perfusion mapping, tissue-tracking (CVI42, post processing). 

Results. Mean age was 49± 12 years, 35%(8) were male, 63%(15), had hypertension, 17 (71%) had diabetes. Surgery resulted in decreases in BMI (44 ± 7 to 34 ± 6 kg/m2 p = 0.0001) and HbA1c (57 ± 16 to 42 ± 9mmol/mol p = 0.0001). EF% and absolute LV end-diastolic volumes remained unchanged, but mass regressed and myocardial contraction fraction (ratio of stroke volume and LV volume) increased (see Table).  There were also strain improvements (radial 35 ± 8.8 to 37.3 ± 8.7 %p = 0.029) (circumferential -19.8 ± 2.3 vs -20.7 ± 3% p = 0.017), although longitudinal did not improve (-16.3 ± 3.2 to -15.9 ± 3% p = 0.25).

Myocardial perfusion significantly improved (stress myocardial blood flow, MBF 2.35 ± 0.71 to 2.80 ± 0.98 ml/g/min p = 0.008; myocardial perfusion reserve MPR 2.47 ± 0.78 to 2.97 ± 0.95 p = 0.005).  Improvement in stress MBF and MPR from pre-operative to post-operative was higher in the non-diabetics (n = 7 (29%)) than the diabetics (n = 17 (71%)) (stress MBF: 1.15 ± 1.00 vs 0.16 ± 0.39ml/g/min p = 0.002) MPR: (1.09 ± 0.73 vs 0.25 ± 0.66 p = 0.011).

Conclusion

At 6 months, bariatric surgery results in beneficial myocardial remodelling and substantial improvements in myocardial microvascular function. These improvements occur most in those without diabetes suggesting that there may be reversible and irreversible components to microvascular dysfunction.

Perfusion and strain variables Variable Pre-op (n = 24) Post-op (n = 24) p-value LVEDV (ml) 163 ± 28 161 ± 29 0.64 EF (%) 70 ± 8 70 ± 7 0.78 Stroke volume (ml) 113 ± 19 111 ± 21 0.6 LV Mass (g) 117 ± 25 103 ± 21 0.001 Myocardial contraction fraction 94 ± 14 105 ± 14 0.001 LVEDV - left ventricular end-diastolic volume, EF - ejection fraction Abstract Figure.
Septal scar predicts non-response to cardiac resynchronization therapy
Authors: Kjellstad Larsen C , Duchenne J , Galli E , Aalen JM , Bogaert J , Lederlin M , Kongsgaard E , Linde C , Penicka M , Donal E , Voigt J-U , Smiseth OA , Hopp E
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority Norwegian Health Association

Background

Scar in the left ventricular (LV) posterolateral wall is associated with poor response to cardiac resynchronization therapy (CRT). The impact of septal scar, however, has been less thoroughly investigated. As recovery of septal function seems to be an important effect of CRT, we hypothesized that CRT response depends on septal viability.

Aim

The aim of the present study was to investigate the association between septal scar and volumetric response to CRT, and to compare the impact of scar located in septum to scar located in the posterolateral wall.

Methods

128 patients with symptomatic heart failure undergoing CRT implantation based on current guidelines (ejection fraction 30 ± 8%, QRS-width 164 ± 17 ms) were included in the study. Volumes and ejection fraction were measured by echocardiography using the biplane Simpson’s method at baseline and six months follow up. Non-response was defined as less than 15% reduction in end-systolic volume. Scar was assessed by late gadolinium enhancement cardiac magnetic resonance, and reported as percentage scar per regional myocardial volume. Numbers are given in [median ;10-90% percentile].

Results

Scar was present in 62 patients (48%). Scar burden was equal in septum [0% ;0-34%] and the posterolateral wall [0% ;0-36%], p = 0.10. 31 patients (24%) did not respond to CRT. The non-responders had higher scar burden than the responders in both septum [16% ;0-57% vs 0% ;0-23%, p < 0.001] and the posterolateral wall [6% ;0-74% vs 0% ;0-22%, p < 0.001].

In univariate regression analysis both septal and posterolateral scars correlated with non-response to CRT (r = 0.51 and r = 0.33, respectively). However, combined in a multivariate model only septal scar remained a significant marker of non-response (p < 0.001), while posterolateral scar did not (p = 0.23).

Septal scar ≥ 7.1% predicted non-response with a specificity of 81% and a sensitivity of 70% by receiver operating characteristic curve analyses. The area under the curve was 0.79 (95% confidence interval 0.70 – 0.89) (Figure).

Conclusions

Septal scar is more closely associated with volumetric non-response to CRT than posterolateral scar. Future studies should explore the correlation between regional scar burden and different functional parameters, and how they relate to CRT response.

Abstract Figure. Septal scar predicts non-response to CRT
Myocardial native T1 mapping and cardiac outcomes in thalassemia major
Authors: Meloni A , Martini N , De Luca A , Positano V , Pistoia L , Gerardi C , Sanna PMG , Bitti PP , Benni M , Sorrentino F , Sinagra G , Pepe A
Published: February 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The E-MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and ApoPharma Inc. and Bayer).

Background. The T2* cardiovascular magnetic resonance (CMR) is the gold standard for the non invasive detection of myocardial iron overload (MIO). The native myocardial T1 mapping has been proposed as a complementary tool, thanks to its higher sensitivity in presence of small amounts of iron, but no data are available in literature about its clinical impact.

Objective

To explore the clinical impact of T1 mapping for detecting cardiac complications in thalassemia major (TM).

Methods. We considered 146 TM patients (87 females, 38.7 ± 11.1 years) consecutively enrolled in the Extension-Myocardial Iron Overload in Thalassemia Network. Three parallel short-axis slices of the left ventricle (LV) were acquired with the Modified Look-Locker Inversion recovery (MOLLI) sequence. The native T1 values in all 16 myocardial segments were obtained and the global value was the mean.

Results. Twenty-one patients had an history of cardiac complications: 11 heart failure,  8 arrhythmias (7 supraventricular and 1 ventricular), and 2 pulmonary hyperthension.

Patients with cardiac complications had significantly lower global heart T1 values (879.3 ± 121.9 ms vs 963.2 ± 98.5 ms; P < 0.0001) (Figure) but comparable T2* values (33.32 ± 11.66 ms vs 37.17 ± 9.15 ms; P = 0.116). Cardiac complications were more frequent in the group of patients with reduced global heart T1 value (<928 ms for males and <989 ms for females) compared to the group with normal global heart T1 value (71.4% vs 39.5%; P = 0.009). Odds ratio (OR) for cardiac complications was 3.8 (95%CI = 1.3-10.9) for patients with reduced global heart T1 value versus patients with normal global heart T1 value.

Conclusion

We found out a significant association between decreased native global heart T1 values and a history of cardiac complications, suggesting that an early detection of myocardial iron  burden by  native T1 can support the clinicians in modifing chelation therapy earlier.

Abstract Figure.
Risk stratification and prognostic value of CMR in DCM; parametric mapping and GLS- value beyond EF and LGE?
Authors: Brown P , Dimarco A , Bradley J , Nucifora G , Miller C , Schmitt M
Published: February 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dr Pamela Brown was suppoerted by funding from Alliance Medical.

Background; Arrhythmia risk stratification and device implantation in dilated cardiomyopathy (DCM) poses significant challenges and as demonstrated by the DANISH trial appears to have reached the asymptote of clinical efficacy. A body of evidence now demonstrates that risk stratification of and device selection for DCM patients may be enhanced by inclusion of patients" LGE-status. Furthermore, it has been suggested that CMR based parametric mapping and strain analysis may further advance risk stratification.

Methods; 703 patients with DCM undergoing clinically indicated CMR scans and prospectively enrolled into the UHSM-CMR study (NCT02326324) between 03/2015-12/2018 were analysed. Multivariable Cox proportional hazard models and Youden index driven C-statistics were used to assess additive prognostic value of GLS, T1 and ECV mapping on the combined endpoint of cardiovascular death, cardiac transplantation, LVAD  insertion  or hospitalisation for heart failure in models incorporating NHYA class, EF and LGE status. Additionally. the value of GLS, T1, and ECV on predicting significant arrhythmic events (SAV) (ventricular arrhythmia (VA), resuscitated cardiac arrest (rCA) or sudden cardiac death (SCD)) was assessed.

Results; Patients (mean age 59, 66% male, 60% ≥NYHA II, mean EF 42%, mean GLS -12%, mean ECV 27%) were on good medical therapy (beta blocker 74%%, ACE 79%, MRA 38%, Entresto 5%, CRT 23%). Mean follow-up was 21 months; the combined endpoint occurred in 34 patients (5%). On univariate analysis NYHA class (HR 2.44 (1.67-3.57), p < 0.001), ECV (HR 1.14 (1.05-1.22), p < 0.001), GLS% (HR 1.14 (1.07-1.21) p < 0.001,) T1 (HR 1.06 (1.005-1.1), p = 0.03), RVEF (HR 0.95 (0.93-0.98), p < 0.001), LVEF (HR 0.92 (0.9-0.95), p < 0.001) were all significantly associated with outcome. On multivariate analysis only EF and NYHA class was associated with outcome.

SAV occurred as the first manifestation of disease or during follow up in 27 patients (4%). At univariate analysis LGE, ECV, GLS, EF and NYHA class were all associated with SAV. However, on multivariable analysis only EF, LGE  and ECV (HR 1.11 (1.01-1.22), p = 0.03) but not GLS remained independently predictive in a model already incorporating EF, NYHA and LGE.

Conclusion

Optimally treated DCM populations have very low event rates. CMR based assessment of fibrosis status/burden with both LGE and ECV assessment has the potential to enhance patient selection for ICD therapy. Whilst GLS is increasingly recognised as a sensitive imaging biomarker of early disease detection it provides no additive value,  likely because of it’s high co-linearity with EF, in models already containing EF, NYHA class and LGE status.
Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping
Authors: Vago H , Dohy Z , Szabo L , Czimbalmos CS , Suhai FI , Toth A , Sydo N , Kiss O , Csulak E , Juhasz V , Hirschberg K , Becker D , Merkely B
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary

Background

Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema.

Purpose

The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM).

Methods

A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age >18 years,  in the athlete group >7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated.

Results

Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15  ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p < 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p < 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p < 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p < 0.01).

Conclusion

Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy.

Abstract Figure. T1 mapping in HCM and athlete
Left ventricular hypertrabeculation - an unanswered question
Authors: Gregor Z , Kiss A , Horvath M , Deak N , Szabo L , Suhai F , Merkely B , Vago H , Szucs A
Published: February 2021

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Supported by the ÚNKP-19-3-II New National Excellence Program of the Ministry for Innovation and Technology

Left ventricular (LV) hypertrabeculation (H-TRAB) is a morphological description when the LV is highly trabeculated, but it remains below the diagnostic criterion of  noncompaction cardiomyopathy (NCMP). Although, it is a frequent finding on cardiac MRI scans its diagnostic and prognostic relevance remains controversial.  

In this cardiac MRI study, we aimed to describe the LV functional and feature-tracking strain values of healthy subjects with LV H-TRAB to decide whether it is a normal variant or an NCMP-like pattern.

We included 189 adult participants with good LV ejection fraction (EF), and without co-morbidities. 63 of them had a morphology of LV H-TRAB (H-TRAB, age: 37.1 ± 14.4 years; EF: 66.4 ± 5.1%), 63 patients were diagnosed with NCMP (age: 36.3 ± 14.0 years, EF: 65.8 ± 5.5%) and the remaining 63 people were healthy controls (38.3 ± 14.0 years, EF: 69.0 ± 4.9%). MR examinations were performed with 1,5T Philips Achieva and Siemens Aera devices. The  Medis Suite software was used for post-processing analysis, the MedCalc software for statistics, p < 0.05 was considered statistically significant. No significant differences were found between the functional parameters of the H-TRAB and NCMP groups. However, the EF was decreased, the end-diastolic (EDVi),  and end-systolic volume (ESVi), the myocardial mass (LV-massi), and trabeculated muscle mass (LV-trabi) values were increased in both groups compared to controls (H-TRAB vs. control: EF: 6.4 ± 5.4 vs. 69.0 ± 5.0%, EDVi: 74.4 ± 14.3 vs. 69.7 ± 12.8 ml/m2, ESVi: 25.1 ± 6.7 vs. 21.7 ± 5.8 ml/m2, LV-massi: 77.0 ± 15.1 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.0 ± 5.1 vs. 20.1 ± 4.0 g/m2; NCMP vs. control: EF: 65.8 ± 5.5 vs. 69.0 ± 5.0%, EDVi: 77.8 ± 15.0 vs. 69.7 ± 12.8 ml/m2, ESVi: 26.7 ± 7.9 vs. 21.7 ± 5.8 ml/m2, LV-massi: 76.8 ± 18.0 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.9 ± 7.5 vs.

20.1 ± 4.0 g/m2; p ≤ 0.05). The global circumferential strain (GCS) differed significantly between these groups: its absolute value was the lowest in the NCMP and the highest in the control group (NCMP vs. H-TRAB vs. control: -30.2% vs. -34.3% vs. -35.9%; p < 0.05). Similar results were found in the comparison of the mean segmental circumferential strain values of the apical-, mid- and basal-parts between the three groups. The absolute values of these parameters were the lowest in the NCMP patients, followed by the H-TRAB, and were the highest in the control group.

These results suggest that the LV functional and strain values of the H-TRAB population are more similar to NCMP patients than healthy controls. Further studies are necessary to determine the pathological implications and consequences of this morphology.
Interatrial septal aneurysm mimicking an atrial myxoma on multiparametric cardiovascular magnetic resonance imaging
Authors: Fang CC , Lim VG , Codispoti M , Khan J
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Interatrial septal aneurysm (IASA) appears as a localised saccular deformity usually detected during routine echocardiography or stroke evaluation. Imaging hallmarks are >15mm prolapsing motion across the interatrial septum (IAS) and identical content to blood-pool, which are in contrast to this patient.

Clinical case

An 81-year-old asymptomatic man underwent transesophageal echocardiographic (TEE) right atrial mass assessment revealing a well-circumscribed, mobile mass attached to the interatrial septum suggestive of myxoma. Given previously-excised renal cell carcinoma, gadolinium contrast-enhanced cardiovascular magnetic resonance (CMR) imaging was performed for mass characterisation. Mass signal intensity (SI) was distinct to blood-pool, in keeping with mass content not being blood. Cine imaging revealed an isointense, mobile mass (Figure 1, Video 1) attached to the fossa ovalis. The mass was of intermediate SI isointense to myocardium on T1-weighted, and bright and hyperintense on T2-weighted imaging. First-pass perfusion (Video 2) and early enhancement imaging demonstrated a hypointense, non-perfusing mass. The mass hyperenhanced on late enhancement imaging excluding the differential of thrombus. Imaging findings were entirely consistent with atrial myxoma. Intraoperatively, the excised mass was actually confirmed as an IASA with exquisitely tight neck.

Discussion

This is the first case of IASA mimicking atrial myxoma on CMR imaging. We postulate that it behaved like a non-perfusing mass as its uniquely narrow neck resulted in extremely slow flow in and out. This permitted minimal blood with contrast entry which remained ‘trapped’ within, resulting in distinct SI to blood pool, and late hyperenhancement. Left atrial pressures forced the mass into the right atrium, preventing typical lateral IASA motion.

Conclusion

The diagnosis of IASA is best established with TEE while CMR imaging is the reference standard imaging modality for tissue characterization. It is vital to be able to identify and differentiate such entities to avoid misdiagnosis of an IASA as a cardiac myxoma or a malignant cardiac tumour.  Nevertheless, we recognize the presence of limitation of imaging in this extraordinary case.

Abstract Figure 1
A wall based regional innervation/perfusion mismatch assessed by cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT to predict arrhythmic events in ischemic heart failure patients
Authors: Verschure DO , Poel E , Jacobson AF , Verberne HJ
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiac 123I-mIBG SPECT imaging provides information on regional myocardial innervation. However, there is no consensus on how to use a, 17-segment based score to assess prognosis. The present study examined whether a simpler regional scoring approach for evaluation of 123I-mIBG SPECT combined with rest 99mTc-tetrofosmin SPECT myocardial perfusion imaging could be used for the prediction of arrhythmic events (AEs) in ischemic heart failure (HF).

Methods

261 ischemic HF subjects (NYHA II/III, LVEF ≤35% on gated SPECT) of the ADMIRE-HF study cohort with complete cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT studies were enrolled. Both SPECT image sets were read together by 2 experienced nuclear imagers and scored by consensus. In addition to standard 17 segments scoring, the readers classified walls (i.e. anterior, lateral, inferior, septum and apex) as normal, matched defect of innervation and perfusion, mismatched (i.e., innervation defect lager than perfusion defect) or reverse mismatched (i.e., innervation defect smaller than perfusion defect). Cox proportional hazards ratios (HR) were used to determine if the visual segmental wall classification innervation/perfusion mismatch score, 123I-mIBG summed defect scores (SDS), 99mTc-tetrofosmin SDS and innervation/perfusion mismatch SDS, age, LVEF, NYHA class, B-type natriuretic peptide (BNP) and norepinephrine (NE) plasma levels were associated with occurrence of AEs (i.e. sudden cardiac death, sustained VT, resuscitated cardiac arrest, appropriate ICD therapy).

Results

At 2-year median follow-up, 38 subjects (14.6%) had AEs. Subjects with 1 or 2 mismatched walls were more than twice as likely to have AEs compared with subjects with either 0 or 3-5 mismatched walls (24.0% vs 10.8%, p = 0.006). Cox regression analyses showed that the combination of the presence of visual mismatch in 1-2 walls and BNP and were the only independent predictors of AEs (HR 2.583 [1.261-5.107],p = 0.001) However, compared to the visual mismatch, the contribution of BNP is relatively small (i.e., HR 1.001 [1.000-1.001]).

Conclusion

In ischemic HF with LVEF ≤35 the highest risk of AEs occurs in subjects with intermediate levels of visual wall-level innervation/perfusion mismatches. Therefore, a simple visual wall-level based assessment of combined cardiac 123I-mIBG and rest 99mTc-tetrofosmin SPECT can be used to differentiate those HF patients at higher AE risk from those with relatively low AE risk.

Table 1. Cox regression analysis Variable HR (95% CI) X2 change X2 p-value AE’s 1-2 mismatched segments 2.412 (1.204-4.830) 6.581 5.880 0.010 BNP 1-2 mismatched segments 1.001 (1.000-1.001) 2.538 (1.261-5.107) 13.434 4.129 0.001 Abstract Figure. Kaplan Meier curves for AEs
Left atrial volumes evaluation by cardiac magnetic resonance - time to revise the grading severity cut off values
Authors: Rimbas RC , Nicula AI , Marinescu AV , Visoiu SI , Mihaila-Baldea S , Magda LS , Balanescu P , Chitroceanu AM , Velcea AA , Balinisteanu A , Vinereanu D
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number grant 5/2018 and 83/2018 and PN-III-P1-1-TE-2016-0669, within PNCDI III

Background

Left atrial maximal volume (LAVmax) assessed by 2D echocardiography (2DE) is incorporated in new scoring system (2019) of heart failure with preserved ejection fraction (HFpEF), using well established cut-off values for grading severity. These values have strong evidence for diagnosis and prognosis. Moreover, cardiac magnetic resonance (CMR) is also included in the structural evaluation of HFpEF. However, cut-off values for LAVmax evaluated by CMR are higher. This might generate a different classification for LA dilation by CMR, potentially including patients in another risk class. We aimed to evaluate LAVi by 2DE and CMR in a group of HFpEF patients, in order to test the agreement between these two methods, regarding severity grading.

Methods.  We prospectively enrolled 74 HFpEF patients (68 ± 9 yrs), and evaluate them by 2DE and CMR. Conventional 2DE was used to define anatomy and function of the left ventricle (LV). NTproBNP was done in all patients. We assessed biplane LAVmax index (LAVimax) and LA minimal volume index (LAVimin), from 4C and 2C views, and reported as a mean value, by eco and CMR (area–length method). Cohen"s k of agreement was evaluated to determine if there was an agreement between eco and CMR, using the cut off values for LAVimax by CMR and eco, provided by the guidelines (Figure)

Results. Feasibility of the complete analysis was 95% (70 pts). LVEF was 60 ± 5.7%. LAVimax and LAVimin by eco and CMR were highly correlated (all R > 0.7, p < 0.001) (Table). However, CMR diagnosed a high percent of patients as having normal LAVimax values, by comparison with echo (59 vs. 5.7 %, p < 0.001) (Figure). There was no agreement between these two evaluation methods (Cohen"s k of agreement = 0.000), suggesting that CMR evaluation provides completely  different severity grading. NTproBNP significantly correlated only with LAVimin by CMR (R = 0.4, p = 0.04).

Conclusions. We suggest that there is need for a future update of the grading cut-offs for LAV by CMR with larger reference range studies, and also with prognosis studies, as 2DE already provided. The present CMR grading severity might generate misclassification in certain pathological condition, such as HFpEF. We also suggest that LAVi min, instead of LAVi max should be used in the future study for assessment of prognosis.

LA volumes evaluation by CMR and 2D echo LAVimax LAVimin ECO (ml/m2) 47 ± 11 23 ± 9 CMR (ml/m2) 51 ± 15 26 ± 12 R coefficient 0.7 0.74 P value <0.001 <0.001 Abstract Figure.
Predictors of survival in patients with precapillary pulmonary hypertension
Authors: Fontes Oliveira M , Oliveira MI , Costa R , Dias Frias A , Silveira I , Cabral S , Santos M , Torres S , Reis A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although the perceived prognosis of patients with precapillary pulmonary hypertension (PH) is poor, the natural history of this condition is very heterogeneous. In this study we sought to identify predictors of poor outcomes which could help refine prognosis.

Methods

We studied consecutive patients referred to our centre from 12/2016 to 11/2018 with confirmed precapillary PH. A range of clinical, laboratory, echocardiographic and right heart catheterization (RHC) data variables were collected to assess predictors of survival. Outcome was defined as mortality from any cause.

Results

Of the 80 included patients, 51 (64%) were female and mean age was 60.5 ± 16.0 years. The majority of patients (45%) had pulmonary arterial hypertension (group 1) and 41% were chronic thromboembolic pulmonary hypertensive disease patients (group 4). During a median follow-up of 18.7 [IQR 12.3 – 26.7] months, 10 patients (12.5%) died. New York Heart Association (NYHA) functional class (HR 19.4 [95% CI 2.56 - 147.5], p = 0.004) was the strongest predictor of mortality, whereas higher haemoglobin (HR 0.70 [0.49 - 0.99], p= 0.047) and 6-minute walking distance (6MWD) expressed as percentage of predicted (HR 0.96 [0.93 - 0.99], p = 0.004) were associated with better survival overall. Echocardiographic parameters such as eccentricity index (HR 3.35 (95% CI 1.11 - 10.0), p = 0.031), short pulmonary acceleration time (HR 0.98 [95% CI 0.96 - 0.99], p = 0.008), the presence of moderate to severe tricuspid regurgitation (HR 6.46 [95% CI 1.67 - 25.0], p = 0.007) and pericardial effusion (HR 3.86 [95% CI 1.12 - 13.4], p = 0.033) were also associated with death. Traditional right ventricular function parameters such as fractional area change, tricuspid annular plane systolic excursion (TAPSE) and S velocity of the lateral annular tricuspid annulus did not predict mortality in these patients. Invasive pressures and pulmonary vascular resistance measured by RHC were also not associated with mortality. In multivariable analysis, NYHA functional class was the only independent predictor of mortality in patients with precapillary PH (HR 14.5 [95% CI 2.3 - 146.8], p = 0.006).

Conclusion

Eccentricity index, short pulmonary acceleration time, moderate to severe tricuspid regurgitation and pericardial effusion were associated with poor survival. Functional class was the strongest independent predictor of mortality in precapillary PH patients. These parameters may help stratify the risk of death in this heterogenous population.
The prognostic value of lung ultrasound in aortic stenosis
Authors: Agoston G , Szabo I , Gargani L , Nemeth N , Morvai-Illes B , Frigy A , Varga A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Aortic stenosis (AS) is a progressive disease and once symptomatic and heart failure (HF) develops is associated with poor prognosis. The degree of the pathophysiological and structural changes in AS are associated with poor survival. Pulmonary congestion is an almost universal finding in patients with HF. Lung ultrasound (LUS) evaluation of B-lines has been proposed as a simple, non-invasive tool to assess pulmonary congestion.

Aim

To assess pulmonary congestion with LUS in patients with AS and to define the prognostic value of B-lines.

Methods

84 consecutive patients (43 women, mean age 74 ± 9 years) with moderate or severe AS were enrolled. Exclusion criteria were as follows:  moderate or severe aortic regurgitation, moderate or severe mitral regurgitation, cardiomyopathies, pulmonary disease, renal failure. At baseline, all patients underwent comprehensive echocardiography examination and LUS according to 28 scanning-site assessment. Patients were followed-up after enrollment to establish the prognostic value of LUS. A composite endpoint was considered, including: aortic valve replacement due to deterioration of patient condition or progression of AS from moderate to severe, death (any cause), hospitalization due to acute heart failure or progression of chronic heart failure which required hospitalization.

Results

We found a  severe number of B-lines (total B-lines ≥30) in 31% of AS patients. The number of B-lines was correlated with estimated pulmonary artery systolic pressure (p < 0,005, r= 0,52) and increased along with NYHA class (p < 0,001) Figure 1. Patients with ≥30 B-lines had more events during the 13,4 ± 6 months follow-up  (p < 0,001, Log-rank: 10,7; Figure 2).

Conclusion

Assessing B-lines in AS is a simple, feasible method to detect pulmonary congestion. The number of B-lines correlates with hemodynamic changes caused by AS and with the functional status of the patients. A severe degree of sonographic pulmonary congestion is associated with an increased risk of adverse events.

Abstract Figure. FC class vs. Blines and prognostic value
Prognostic value of mitral regurgitation in patients with asymmetric hypertrophic cardiomyopathy
Authors: Tesic M , Travica L , Giga V , Trifunovic D , Jovanovic I , Boskovic N , Dobric M , Aleksandric S , Juricic S , Radomirovic M , Petrovic O , Vratonjic J , Stankovic G , Beleslin B , Djordjevic-Dikic A
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since mitral regurgitation (MR) is a very common finding in patients with hypertrophic cardiomyopathy (HCM), the evaluation of the mitral valve anatomy and the degree of MR is of utmost importance in this population. However, data regarding the prognostic value of different degrees of MR in HCM remains scarce.

Purpose

The aim of this study was to determine whether the presence of a higher degree of MR affects: 1) long term prognosis; 2) clinical and echocardiographic presentation of HCM patients.

Material and Methods

We included prospectively 102 patients, diagnosed with primary asymmetric HCM. The degree of MR was determined echocardiographicaly according to current recommendations of the American Association of Echocardiography. According to the MR severity, patients were divided into 2 groups: Group 1 (n = 52) with no/trace or mild MR and Group 2 with moderate or moderate to severe MR. All patients had clinical and echocardiographic examination, 24-hour Holter ECG and NT pro BNP analysis performed. The primary outcome was a composite of: 1) HCM related death or sudden death; 2) hospitalization due to acute heart failure; 3) sustained ventricular tachycardia; 4) ischemic stroke.

Results

Patients with higher MR degree had more frequent chest pain (p = 0.039), syncope (p = 0.041) and NYHA II functional class (p < 0.001). Group 2 patients had mostly obstructive form of HCM (p < 0.001) with more frequent presence of previous atrial fibrillation (AF) (p = 0.032), as well as the new onset of AF (p = 0.014) compared to patients in Group 1. Patients with higher MR degree had significantly more SAM (p < 0.001) resulting in a more frequent eccentric MR jet (p < 0.001), along with calcified mitral annulus (p = 0.007), enlarged left atrial volume index (p < 0.001), and elevated right ventricular pressure (p = 0.001). As a result of higher MR grade, Group 2 had higher E/e" values (p < 0.001), elevated LV filling pressure (lateral E/e’ >10), as well as higher levels of NT pro BNP (p = 0.001). By Kaplan-Meier analysis we demonstrated that the event free survival rate during follow up of median 75 (IQR 48-103) months was significantly higher in Group 1 compared to the Group 2 (79% vs. 46%, p < 0.001), Figure 1. After adjustment for relevant confounders, moderate/moderate to severe MR remained as an independent predictor of adverse outcome (hazard ratio 2.58, 95% CI: 1.08-6.13, p < 0.001).

Conclusion

Presence of moderate, or moderate to severe MR was associated with poor long-term outcome of HCM patients. These results indicate the importance of an adequate MR assessment and detailed evaluation of the mitral valve anatomy in the prediction of complications and adequate treatment of patients with HCM.

Abstract Figure.
Cardiovascular magnetic resonance (CMR) normal values for pulmonary arteries in healthy children and adolescents
Authors: Boll C , Voges I , Caliebe A , Gati S , Puricelli F , Wage R , Krupickova S
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Changes in the right ventricular outflow tract (RVOT) and pulmonary arteries (PAs) are often seen in paediatric patients with congenital heart disease (CHD), pulmonary hypertension or genetic disorders (e.g. Marfan syndrome, Loeys-Dietz syndrome, Williams syndrome, DiGeorge syndrome). Cardiovascular magnetic resonance (CMR) imaging is an excellent method to visualize the RVOT and PAs without the use of ionizing radiation and contrast media but for the interpretation of CMR data in the paediatric population the knowledge of normal values is crucial. However, normal values for pulmonary arteries from contrast-free cine CMR images are lacking.

Purpose

The aim of this retrospective multicentre study was to establish reference ranges for the diameters of the mean PA (MPA), right PA (RPA) and left PA (LPA).

Methods

163 CMR scans of healthy children and adolescents (mean age 13.8 ± 2.9 years; range 5-18 years) from two centres in the UK and Germany were included. The diameter of the MPA was measured in sagittal-oblique RVOT cine images and transaxial cine stacks, whereas the diameter of the RPA and LPA were measured from transaxial stacks and specific pulmonary artery branch cine images.

Results

Mean systolic and diastolic diameters for the MPA were 22.1 ± 2.8 mm (14.4 ± 2.2 mm/m²)/ 17.2 ± 2.3 mm (11.3 ± 1.9 mm/m²) measured in RVOT cine stacks. Mean systolic and diastolic diameters for the RPA and LPA were:  1) RPA, 12.4 ± 1.7 mm (7,9 ± 1,6 mm/m²)/ 9.8 ± 1.6 mm (5.9 ± 1.8 mm/m²) and 2) LPA, 13.3 ± 1.5 mm (8.3 ± 2.1 mm/m²)/ 10.8 ± 1.5 mm (6.8 ± 1.8 mm/m²). Separate centile charts for boys and girls for the MPA were created.

Conclusions

We established CMR normal values for the MPA, RPA and LPA for children and adolescents. Our data might be useful for the detection of PA stenosis and dilatation and may serve as a reference in future studies.
Impact of pregnancy and risk factors for ventricular arrhythmias in women operated for tetralogy of Fallot
Authors: Quattrone A , Lie ØH , Nestaas E , De Lange C , Try K , Lindberg HL , Skulstad H , Erikssen G , Edvardsen T , Haugaa KH , Estensen ME
Published: February 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority

Background

Patients with tetralogy of Fallot (TOF) have a high survival rate 30 years after surgical repair, and generally enjoy a satisfactory quality of life. Many female patients experience pregnancy during adulthood, however the effects of pregnancy on the long-term cardiovascular outcome in this group of patients are not well known.

Purpose

We aimed to investigate the association of pregnancy and cardiac function with occurrence of ventricular arrhythmia (VA) in women operated for TOF.

Methods

We included 80 patients recruited from the national database for patients diagnosed for TOF. All were examined with echocardiography, including strain echocardiography. We assessed mechanical dispersion of right ventricle (RV) as measure of heterogeneous contraction. Holter monitoring or implanted devices detected ventricular arrhythmias (VA), defined as non-sustained or sustained ventricular tachycardia or aborted cardiac arrest. Blood tests included N-terminal pro-brain natriuretic peptide (NT-proBNP).

Results

In all, 55 (69%) women had experienced pregnancy (age 40 ± 9 years, parity median 1, range 1-4), while 25 (31%) women were nulliparous. The mean age was lower in nulliparous compared to those with children (30 ± 9 vs 40 ± 9, p < 0.01).

VA was more prevalent in women who had experienced pregnancy (n = 16, 94%) compared to nulliparous (n = 1, 6%) (p = 0.02), and importantly also when adjusted for age [adjusted OR 9.8 (95% CI 1.2-79.1), p = 0.02].

RV mechanical dispersion was more pronounced in patients with VA [39.2 ± 14 ms vs. 49.6 ± 8 ms, p = 0.009, adjusted OR 2.1 (95% CI 1.3 - 7.5), p = 0.01 adjusted for age]. Higher NT-proBNP was also a marker of VA [211 ng/L (127-836) vs. 139 ng/L (30-465), p = 0.007, adjusted OR 1.4 (95% CI 1.1 - 1.8) p = 0.017 adjusted for age]. NT-proBNP >182 ng/L (normal values < 170 ng/L) optimally detected women with VA (p = 0.019), also independent of age [OR 7.2 (95% CI 1.7-30.1), p = 0.007].

Conclusion

History of pregnancy was associated with higher prevalence of VA among women with surgically corrected TOF. Right ventricular mechanical dispersion and NT-proBNP were age independent markers of VA. These findings may have importance for risk stratification and preconception counselling of these patients.
2D cine vs. 3D free-breathing self-navigated whole heart for aortic root measurements in congenital heart disease
Authors: Nussbaumer C , Bouchardy J , Blanche C , Piccini D , Pavon AG , Hugelshofer S , Monney P , Stuber M , Schwitter J , Rutz T
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance is considered the method of choice for determination of aortic root diameters in congenital heart disease. Usually, a cross-sectional 2D cine stack is acquired perpendicular to the vessel’s axis. However, this method requires a considerable patient collaboration and precise planning of image planes. This study compares a recently introduced free-breathing high-resolution 3D self-navigating whole heart sequence (3D self nav) to the 2D cine technique for determination of aortic root diameters.

Methods

Two observers measured on 2D cine and 3D self nav cross-sectional planes of the aortic root (figure A and B), acquired on a 1.5T scanner, cusp-commissure (CuCo) and cusp-cusp (CuCu) enddiastolic diameters (figure B and C). Asymmetry of the aortic root was evaluated by the ratio of the minimal to maximum CuCu diameter. CuCu diameters were compared to transthoracic echocardiographic (TTE) aortic root diameters.

Results

65 exams in 58 patients (mean age 32 ± 15y) were included. 2D cine and 3D self nav spatial resolution was 1.4x4.5-6mm and 1.1³mm, respectively. 3D self nav and CuCu yielded larger diameters than 2D cine and CuCo, respectively (table). Intra- and interobserver variabilities were excellent for both techniques ( bias -0.5 to 1.0 mm). Intra-observer variability of the experienced observer was better for 3D self nav (F-test p < 0.05). Aortic root asymmetry was more pronounced in patients with bicuspid aortic valve (BAV: 0.73 (0.69; 0.78) vs. 0.93 (0.9; 0.96), p < 0.001), which was associated with a larger difference of maximum CuCu to TTE diameters: 5.5 ± 3.3 vs. 3.3 ± 3.8 mm, p = 0.03.

Conclusion

Both, the 3D self nav and 2D cine techniques allow reliable determination of aortic root diameters. However, the 3D self nav technique and measurement of the CuCu diameters should be privileged to avoid underestimation of the maximum diameter, particularly in patients with asymmetric aortic roots and/or BAV

2D cine vs. 3D self nav CuCo min CuCo mid CuCo max CuCu min CuCu mid CuCu max Mean diameter 2D cine (mm) 33.5 34.8 36.2 33.4 37.6 38.5 Mean diameter 3D self nav (mm) 34.5 35.9 37.2 34.3 38.5 39.7 Mean difference (mm) -1.0 -1.1 -1.0 -0.8 -1.3 -1.2 95% Limits of agreement (mm) -5.1 to 3.2 -5.3 to 3.1 -5.5 to 3.5 -5.5 to 3.8 -4.7 to 2.0 -4.7 to 2.3 Standard deviation (mm) 3.2 2.1 2.3 2.4 1.7 1.8 Variance (mm2) 4.5 4.5 5.2 5.6 2.9 3.2 Pearson’s correlation (r) 0.952 0.954 0.945 0.944 0.972 0.951 P value (t-test) 0.003 0.001 0.006 0.005 <0.001 <0.001 Abstract Figure.
Ross procedure and aortic valve repair: long-term echocardiographic outcomes, quality of life and physical activity of different aortic valve surgery procedures
Authors: Bianco F , Colaneri M , Bucciarelli V , Surace FC , Iezzi FC , Primavera M , Biasi AC , Berton E , Baldoni M , Baldinelli A , Pozzi M , Gallina S
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background

 To compare long-term outcomes of aortic valve repair (AVr) and pulmonary autograft replacement (Ross procedure) in terms of echocardiographic parameters, quality of life (QoL), physical activity (PA).

Methods

 In 2005-19, 129 patients (median age 22 [13, 33 IQR], 75% males) underwent aortic surgery in our Department: 40 were Ross (22 years [19, 51 IQR]), 67 AVr (17 years [1, 50 IQR]) and 22 aortic valve replacements (52 years [30, 80 IQR]). We focused on Ross and AVr. Retrospectively, relevant data were collected from medical records and phone re-calls. Physical activity (spontaneous and active) and QoL were assessed utilizing the IPAQ and SF-36 questionnaires. All patients underwent echocardiography pre/post-surgery and the follow-up lasted 12 ± 4 years.

Results

 At the baseline, Ross patients had more aortic stenosis than insufficiency (P = 0.045). At the follow-up, Ross procedures presented more right-ventricle and aortic annulus dilatation (P = 0.002 and P = 0.030, respectively), but higher left-ventricular global longitudinal strain (LV GLS: 18 ± 3.2 % vs. 16 ± 3.3, P = 0.0027). Conversely, AVr experienced more re-do operations (Log-rank P = 0.005). Ross reported better QoL (SF-36: 0.8 ± 0.07 vs. 19 ± 0.4, P-0.045) and were also more active in daily PA (IPAQ ≥ 2500 Mets: 63.8% vs. 6%; P = 0.006). Ross patients practiced more sports activities than AVr (P = 0.011).

Conclusions

 In a relatively small cohort of young and adults post aortic surgery patients, Ross procedures had better prognosis in terms of re-do operations; presented better ventricular function, as assessed by LV GLS. Ross patients had better long-term QoL and showed more spontaneous PA and involvement in sports activity.
The interplay of systemic atrial and ventricular function in patients with transposition of the great arteries after arterial switch operation
Authors: Schoeber A , Jerosch-Herold M , Wegner P , Voges I , Gabbert D , Pham HM , Scheewe J , Kramer HH , Rickers C
Published: February 2021

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: The role of systemic atrial (LA) function and its interplay with the systemic ventricle (LV) in patients with transposition of the great arteries (TGA) after arterial switch operation (ASO) is currently not well defined.

Purpose

Investigate the role of LA function and its interplay with the LV.

Methods

Between 2007 and 2018 patients with TGA corrected by ASO and control patients of comparable age, sex, height but without known cardiovascular disease were included in this prospective single centre analysis of 3 Tesla cardiac magnetic resonance cine imaging studies of atrial and ventricular function. Additionally, in TGA patients extracellular volume fraction (ECV) was assessed by T1 mapping and global longitudinal strain (GLS) by feature tracking.

Results

Overall, 81 TGA (16.3 [IQR 10.5-21.2] years, 32% female) and 30 control patients (11.9 [IQR 8.7-22.5] years, 63% female) were included in the current analysis. TGA patients had smaller LA maximum volume index, and reduced total atrial and conduit volume emptying. This resulted in a reduced LA reservoir and conduit function compared to controls. In TGA, a higher LA active/conduit and active/total ratio indicated impaired passive filling of the LV. (Table 1)

The median ECV was 28.3% (IQR 25.8-33.9) and the median GLS -24.2% (IQR -28.6- -20.4) in TGA patients. LA reservoir (Fig. 1A), conduit and contractile function showed a negative correlation with GLS (r=-0.470, p < 0.001, r=-0.270, p = 0.022 and r=-0.257, p = 0.030, respectively). Interestingly, the LA active/conduit ratio (Fig. 1B) and the active/total ratio showed a positive correlation with ECV (r = 0.418, p = 0.002 and r = 0.339, p = 0.013, respectively).

Conclusion

Impaired LA function is frequent among patients with TGA following ASO. The impairment of LA function is linked to both LV dysfunction and fibrosis.

Table 1 Variable TGA (n = 81) Control (n = 30) p-value LAVI max.[ml/m²] 37.8 (29.9-42.9) 42.02 (38.3-51.6) 0.002 LAVI total emptying [ml/m²] 16.8 (13.7-20.8) 24.3 (20.6-29.4) <0.001 LAVI conduit emptying [ml/m²] 10.3 (8.1-13.9) 17.5 (15.2-20.8) <0.001 LAVI active [ml/m²] 6.7 (4.1-8.6) 6.4 (5.0-7.9) 0.984 LA-EF-reservoir [%] 46.6 (42.0-50.5) 57.2 (51.2-60.1) <0.001 LA-EF-conduit [%] 28.1 (23.4-34.3) 42.5 (35.4-45.8) <0.001 LA-EF-active [%] 24.11 (17.9-29.1) 25.7 (21.5-29.7) 0.339 LA active/conduit ratio 0.60 (0.41-0.90) 0.37 (0.28-0.44) <0.001 LA active/total ratio 0.38 (0.29-0.47) 0.27 (0.22-0.30) <0.001 Differences in left atrial function between TGA and control patients Abstract Figure. Fig. 1A and B