bluuebunny/crossref_metadata_2025 huggingface dataset:
Changes in coronary plaque component volumes comparing different virtual monoenergetic images using photon-counting computed tomography
Authors: Vattay B , Szilveszter B , Boussoussou M , Vecsey-Nagy M , Lin A , Konkoly G , Kubovje A , Schwarz F , Merkely B , Maurovich-Horvat P , Williams M C , Dey D , Kolossvary M
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BV was supported by the ÚNKP-22-3-II-SE New National Excellence Program of the Ministry for Culture and Innovation from the source of the National Research, Development and Innovation Fund.

Introduction

Photon-counting CT (PCCT) allows virtual monoenergetic images (VMIs) which may aid more precise assessment of coronary plaques. We aimed to analyze how plaque component volumes change on different VMIs.

Methods

Coronary CT angiography images were acquired using a dual-source PCCT and VMIs were reconstructed between 40–180 keV in 10 keV increments. Polychromatic images at 120 kVp (T3D) were also reconstructed and used as reference. Quantitative image quality analysis was performed on all reconstructed images. Quantitative plaque assessment was performed on T3D images and segmentation masks were copied to all VMI images. Calcified plaque (CP; >350 Hounsfield units, HU), non-calcified plaque (NCP; 30–350HU) and low-attenuation NCP (LAP; −100-30HU) volumes were calculated.

Results

We analyzed 51 plaques from 51 patients (67% male, mean age 65±12 years). Average attenuation and contrast-to-noise ratio (CNR) decreased significantly with increasing keV levels, with similar values observed between T3D and 70 keV images (299±209 vs 303±225 HU, p = 0.15 for mean HU; 15.5±3.7 vs. 15.8±3.5, p = 0.32 for CNR). Mean NCP volume was comparable between T3D and 100–180 keV reconstructions. There was a graded decrease in mean CP volume, with a significant difference between all VMI images and T3D (p<0.05). LAP volume increased with increasing VMI energy levels and all VMI images showed a significant difference compared to T3D, except for 50 keV (28.0±30.8 mm3 and 28.6±30.1 mm3, respectively, p = 0.63).

Conclusion

Fixed threshold settings result in significantly different plaque volumes when using VMIs as compared to T3D images. Normalization protocols are needed to have comparable results between future studies.
Echocardiography identifies geometric and functional cardiac alterations in patients with Familial Partial Lipodystrophy
Authors: Romano M , Sapalo A T , Guidorizzi N R , Moreira H T , Ines P A C , Kalil L C , Paula F J A , Foss M C
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Lipodystrophy (LPD) is a rare condition characterized by levels of loss of adipose tissue in a generalized or partial form. Cardiovascular disease is a significant cause of morbidity in this population,n but cardiomyopathy associated with LPD is still not well described. We sought to characterize cardiac morphology and left ventricle function in patients with partial LPD with no cardiac symptoms.

Methods

This is a cross-sectional case-control study. Adult patients with clinical diagnosis of familial partial LPD and Controls were invited to collect echocardiographic images prospectively. Transthoracic echocardiography was performed with conventional bidimensional and Doppler techniques and LV Speckle-tracking technique. Left atrium (LA) dimension and volumes, LV dimension, thickness, mass, and diastolic and systolic function were measured. Data between groups compared with appropriate tests according to variable distribution. Relation between echocardiographic variables and LPD diagnosis were tested with simple and multiple regression models, considering the effect of systolic arterial blood pressure (SBP) as an independent variable. The significance level was set as p <0.05.

Results

twenty-nine patients with LPD were compared to 17 control. LPD patients and control group did not differ in age (44.58±11.77 vs. 43.84±13.32, p = 0.94), gender, BMI (26.73±4.30 vs. 24.52±5.04 Kg/ml, p = 0.05) or BSA (1.70±0.23 vs. 1.67±0.16, p = 0.9). Patients with LPD had statistically higher SBP (122.7±14.85 vs. 110.9±11.08, p = 0.02). LPD had LA higher dimension (37.27±4.44 vs. 32.12±4.25 mm, p = 0.001) and volume (LAVi)(30.17±7.24 vs. 24.94±9.04 ml/m2, p = 0.02), LV mass_i (79.29±17.38 vs. 67.10±19.36, p = 0.02), and also reduced diastolic LV parameters as mitral tissue Doppler E' lateral (11.07±3.48 vs. 14.94±2.35 cm/s, p = 0.001) and E' septal ( 8.0±2.73 vs. 11.38±2.02 cm/s, p = 0.001, and also E/E' ratio (7.89±2.22 vs. 6.35±1.29, p = 0.02). Parameters of LV systolic function as LVEF (64.70±4.56 vs. 62.15±4.35 %, p = 0.08) or GLS were not statistically different between groups (−17.06±2.70vs. −18.02±1.98%, p = 0.25). There was a positive relation of LA dimension ( β 5.6, p<0.001), wall thickness (β 1.3, p 0.011), tissue Doppler E' lateral (β −3.5, p = 0.002) and E' septal (β −3.2, p<0.001) to LPD diagnosis, even after adjusted for SBP.

Conclusion

patients with familial partial LPD present early cardiomyopathy with LV hypertrophy, LA enlargement, and LV diastolic dysfunction before LV systolic dysfunction. Echocardiographic parameters are related to LPD diagnosis independent of SBP.
Association between diastolic dysfunction with coronary artery calcium score in stable coronary artery disease patients
Authors: Lubis H I L F A N , Ardini T E N G K U , Andra C U T , Lubis A N G G I A , Zebua J U A N G , Putri C U T , Rialdy I S F A N , Brahmana A N D R E W
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Objectives

Diastolic dysfunction is a common problem in patients with obesity, hypertension, diabetes, or coronary artery disease (CAD) including stable CAD. The coronary artery calcium score (CACS) is used to non-invasively evaluate cardiovascular risk in asymptomatic patients with a low to intermediate pre-test probability for CAD. The purpose of this study was to evaluate the association of diastolic dysfunction with an abnormal CAC score.

Materials and Methods

This study considered a cohort of patients > 18 years of age with normal ejection fraction who were admitted to the hospital with chest pain but low risk presentation for acute myocardial infarction. Patients then underwent cardiac CT for measurement of CAC score. Patients were excluded if they had prior history of CAD, ECG findings diagnostic of an acute coronary syndrome, an elevated troponin level, or hemodynamic instability.

Results

A total of 200 patients were included and 96 (48%) patients had echocardiographic evidence of diastolic dysfunction. Patients with diastolic dysfunction were more likely to have a higher mean calcium score (12,154.68 ± 17,588.30 vs 2,666.38 ± 9,725.82; p<0.001). Receiver operating characteristics (ROC) analysis showed the area under the curve was 86.3% and cut off was 129.5 with sensitivity 85% and specificity 74%.

Conclusions

Our study demonstrates that left ventricular diastolic dysfunction is associated with an abnormal CAC score. Patients without known CAD that present with chest pain with evidence of abnormal diastolic function on echocardiogram may warrant more thorough evaluation for coronary atherosclerotic disease with CAC score assessment.
Severe pulmonary regurgitation does not influence exercise capacity in patients with repaired Tetralogy of Fallot
Authors: Alborikan S A , Pandya B P , Vonklemperer K V , Bhattacharyya S B , Encarnacion D E , Althunyyan A T , Prista Monteiro R M , Lloyd G L
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Identifying exercise determinants in patients with repaired Tetralogy of Fallot (rTOF) is complex. We sought to investigate exercise performance and to identify the best exercise predictors.

Methods

We prospectively recruited 100 patients with rTOF, 60 patients with severe PR (SPR), and 40 patients with no PR (control). All patients underwent cardiopulmonary exercise testing with echocardiography. Right ventricle (RV) contractile reserve (CR) was defined by the change in peak systolic velocity (ΔRVS’), and change in fractional area change (ΔFAC). Left ventricle (LV) CR was defined by the change in systolic function (ΔLVS’), and change in global longitudinal strain (ΔLVGLS).

Results

There was no significant difference in the reduced exercise performance between the SPR and control groups by peak absolute oxygen consumption VO2(1695±627 vs 1744±521, ml/min, p>0.05). During exercise, lower RV CR was observed in the SPR group by ΔRVS’ (41±28 vs 48±20%, p<0.05); and ΔFAC (20±15 vs 23±16, %, p<0.05), while it was greater for LV CR by ΔLVS’ (67±34 vs 61±28%, p<0.05). Change in ΔLVGLS was the same (15±17 vs 16±15, %, p>0.05). There were no associations between exercise measures with the degree of PR and RV volume at rest and during exercise. Augmentation of LVGLS and FAC demonstrated independent associations with peak VO2(r=.55, r=.45, p<0.05).

Conclusions

There was an overall marked reduction in exercise capacity, but no difference between those with and without PR. The degree of exercise limitation is more dependent upon the ability of RV and LV to augment longitudinal function rather than severity of PR.
Effects of sacubitril/valsartan on atrial function and structure as treatment response indicators in patients with heart failure with reduced ejection fraction: an observational prospective study
Authors: Camilli M , Iannaccone G , Chiorazzo G , Felici T , Maggio L , Lombardo A , Crea F
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Sacubitril/valsartan (Sac/Val) has been shown to improve mortality and reduce hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF), also through reverse cardiac remodeling. However, temporal changes of functional and structural left atrial parameters, including speckle tracking (ST) analysis, have not been comprehensively characterized yet.

Purpose

This prospective study sought to: (1) evaluate the impact of Sac/Val on echo parameters, focusing on left atrial function and structure metrics, at two timepoints, 6 and 12 months, after treatment initiation; (2) assess the predictive role of these factors on Sac/Val response at 12 months, including LVEF and biomarker outcomes.

Methods

From January 2020 to September 2021, HFrEF patients from Policlinico Universitario Agostino Gemelli IRCSS outpatient HF service with indication to Sac/Val treatment were prospectively enrolled; subjects with history of atrial fibrillation and more than moderate mitral regurgitation were excluded. Echocardiographic evaluation was performed before Sac/Val, at 6 and 12 months after treatment initiation. Patients with improvement in left ventricular ejection fraction (LVEF) ≥ 35% and with N-terminal pro-b-type natriuretic peptide (NT pro-BNP) reduction below 1000 pg/mL were considered responders.

Results

Sixty-six patients (50 males, 16 females) with an age of 64 ± 12 years were finally enrolled, of which 41% were affected by chronic ischemic heart disease. At enrollment, 19 subjects were in New York Heart Association class III-IV, median NT-proBNP was 3063.00 pg/mL and mean LVEF was 30.3±7.7%. LA-EF was 27.8±12.8%, while Left Atrio-ventricular coupling index (LACi) was 0,30±0,12. At ST echocardiography, LV GLS was -8,2±3,0% and LA reservoir strain (LARS) 11,60%. All structural and functional LA parameters significantly improved at T1 and T2: at T2, LARS was 22,51%, LA-EF 37,4±15,8% and LACi 0,28±0,12 (respectively p <0,001, p = 0,05, p = 0,018 compared to baseline). No differences were detected according to dysfunction etiology. Improvements were larger among patients who achieved the pre-specified outcome. LA reservoir strain was the best predictor of positive changes in LVEF and NT-proBNP.

Conclusions

Precise characterization of LA structural and functional parameters, including ST analysis, may help identifying patients experiencing the highest benefit from Sac/Val, therefore guiding treatment in the HFrEF population.
Incremental prognostic value of fully-automatic machine-learning based global circumferential strain during a stress CMR exam
Authors: Pezel T , Garot P , Toupin S , Sanguineti F , Hovasse T , Unterseeh T , Chitiboi T , Jacob A J , Borgohain I , Sharma P , Champagne S , Garot J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular global circumferential strain using cardiovascular magnetic resonance (CMR) is an accurate indicator to predict cardiovascular events. Although several studies have shown the excellent prognostic value of stress CMR, the prognostic value of stress global circumferential strain (sGCS) remains unknown.

Aim

To investigate the prognostic value of sGCS for predicting cardiovascular events using a fully automatic machine learning algorithm without human correction in consecutive patients referred for stress CMR.

Methods

Between 2016 and 2018, all consecutive patients referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction (MI). A fully automatic machine learning algorithm was trained and validated on unseen CMR studies (MAGNETOM Aera and Skyra, Siemens Healthcare, Erlangen, Germany) to assess the sGCS from short-axis cine images at stress. The algorithm combines multiple deep learning networks for detection and segmentation with an active contours approach. Cox regressions were performed to determine the prognostic value of sGCS.

Results

Among 2,906 consecutive patients who underwent stress CMR, the automatic sGCS was successfully computed in 2,859 (98.4%) patients (68% male, mean age 64±12 years). A total of 256 (8.8%) MACEs were observed during a median (IQR) follow-up period of 4.5 (3.7–5.3) years. Using Kaplan-Meier analysis, sGCS and the presence of inducible ischemia were significantly associated with the occurrence of MACE (hazard ratio, HR: 1.12 [95% CI, 1.08–1.17]; and HR: 8.48 [95% CI, 6.05–11.91], both p<0.001; respectively). After adjustment for traditional risk factors, inducible ischemia and late gadolinium enhancement (LGE), sGCS was an independent predictor of a higher incidence of MACE (adjusted HR: 1.12 [95% CI, 1.05–1.20]). Finally, sGCS showed an incremental prognostic value to predict MACE compared to a multivariable model including traditional risk factors, the presence of inducible ischemia and LGE (C-statistic improvement: 0.05, p = 0.007; NRI= 0.169; IDI= 0.097; both p<0.001).

Conclusions

Automatic sGCS has an incremental prognostic value to predict MACE above traditional risk factors, and other stress CMR parameters.
Additional prognostic value of fully-automatic Global Longitudinal Strain using machine learning
Authors: Pezel T , Hovasse T , Toupin S , Sanguineti F , Garot P , Champagne S , Chitiboi T , Jacob A , Sharma P , Unterseeh T , Garot J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Several studies described the independent prognostic value of left ventricular global longitudinal strain (GLS) using cardiovascular magnetic resonance (CMR) to predict cardiovascular events. However, the potential interest of GLS using a fully automatic method assessed at rest during a stress CMR exam was not well established.

Aim

To assess the prognostic value of GLS to predict all-cause death using a fully automatic machine learning algorithm without human correction in consecutive patients referred for stress CMR.

Methods

Between 2016 and 2018, all consecutive patients referred for stress CMR were included and followed for the occurrence of all-cause death. A fully automatic machine learning algorithm was trained and validated unseen CMR studies (MAGNETOM Aera and Skyra, Siemens Healthcare, Erlangen, Germany) to assess the GLS from long-axis cine images acquired at rest. The algorithm combines multiple deep learning networks for detection and segmentation with an active contours approach. Cox regressions were performed to determine the prognostic value of GLS.

Results

Among 9,883 consecutive patients who underwent stress CMR between 2016 and 2018 retrospectively included, the automatic GLS was successfully computed in 9,638 (97.5%) patients (67% male, mean age 66±12 years). A total of 510 (5.3%) deaths were observed during a median (IQR) follow-up period of 4.5 (3.7–5.2) years. GLS, the presence of inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of death (hazard ratio, HR: 1.22 [95% CI, 1.17–1.26]; HR: 2.23 [95% CI, 1.61–3.10]; and HR: 2.04 [95% CI, 1.41–2.95], respectively, all p<0.001). After adjustment for traditional risk factors, inducible ischemia and LGE, GLS was an independent predictor of a higher incidence of death (adjusted HR: 1.14 [95% CI, 1.08–1.20]). Automatic GLS showed an incremental prognostic value to predict death compared to traditional risk factors, inducible ischemia and LGE (C-statistic improvement: 0.05; NRI=0.146; IDI=0.244; all p<0.001).

Conclusions

Automatic GLS measured at rest has an incremental prognostic value to predict all-cause death above traditional risk factors, and other stress CMR parameters.
Safety and incremental prognostic value of stress CMR in patients with known chronic kidney disease
Authors: Pezel T , Unterseeh T , Hovasse T , Sanguineti F , Garot P , Champagne S , Toupin S , Ah-Sing T , Faradji A , Nicol M , Hamzi L , Dillinger J G , Henry P , Bousson V , Garot J
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiovascular disease (CVD) is the main cause of mortality in patients with chronic kidney disease (CKD). Although several studies have demonstrated the consistently high prognostic value of stress cardiovascular magnetic resonance (CMR), its prognostic value in patients with CKD is not well established.

We aimed to assess the safety and the incremental prognostic value of vasodilator stress perfusion CMR in consecutive symptomatic patients with known CKD.

Methods

Between 2008 and 2021, we conducted a bi-center longitudinal study with all consecutive symptomatic patients with known CKD, defined by estimated glomerular filtration rate (eGFR) between 30 and 60 ml/min/1.73 m2, referred for vasodilator stress CMR. All patients with eGFR <30 ml/min/1.73 m² (n=62) were excluded due the risk of nephrogenic systemic fibrosis. All patients were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent nonfatal myocardial infarction (MI). Cox regressions were used to determine the prognostic value of stress CMR parameters.

Results

Of 825 patients with known CKD (71.4±8.8 years, 70% men), 769 (93%) completed the CMR protocol, and among those 702 (91%) completed the follow-up (median follow-up 6.4 (4.0–8.2) years). Stress CMR was well tolerated without occurrence of death or severe adverse event related to the injection of gadolinium or nephrogenic systemic fibrosis case. The presence of inducible ischemia was associated with the occurrence of MACE (hazard ratio [HR] 12.50; 95% confidence interval [CI]: 7.50–20.8; p<0.001). In multivariable analysis, ischemia and late gadolinium enhancement were independent predictors of MACE (HR 15.5; 95% CI: 7.72 to 30.9; and HR:4.67 [95%CI: 2.83–7.68]; respectively, both p<0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI=0.477; IDI=0.049).

Conclusions

In patients with known CKD, stress CMR is safe and its findings have an incremental prognostic value to predict MACE over traditional risk factors.
Transthoracic echocardiography parameters as predictors of 30-day readmission after admission for new-onset heart failure
Authors: Carrion I , Olmos C , Gutierrez E , Parraga R , Gil S , Mahia P , De Agustin A , Islas F
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

In an aging population. heart failure (HF) is one of the biggest challenges facing healthcare systems in the coming years. Hospital readmissions after discharge continue to be one of the main problems for both patients and health systems as they represent costs and work overload for staff. The aim of this study is to re-visit the prognostic value of transthoracic echo parameters (TTE) in readmissions after a new-onset HF episode.

Methods

Consecutive patients admitted with a first episode of HF were prospectively included into a registry. All patients underwent transthoracic echocardiography based on current guidelines for chamber quantification within 24hrs after admission. Conventional systolic and diastolic function parameters were obtained. In addition. longitudinal strain and ventricular-arterial coupling of both ventricles were evaluated.

Results

218 consecutive patients were included. Clinical and imaging characteristics are described in Table 1. 32 patients (14.7%) had readmission within 30-days. Mean age of the cohort was 73.4±13.4 years; mean LV ejection fraction (LVEF) was 42.3±14.2% and mean LV global longitudinal strain (LV-GLS) was −9.2±3.4%. Patients with 30-day readmissions had lower LVEF (37.8±3.1 vs 42.7±1.5%. p = 0.255) and significantly lower LV-GLS (−7.4±2.4 vs −9.5±3.4%. p = 0.042). Regarding diastolic function, patients with 30-day readmissions had a slightly higher E/e’ ratio (15.1±10.3 vs 14.3±7.2, p = 0.747) and a significantly larger left atrium volume index (57.2ml/m2 vs 45.5ml/m2). Right ventricular-arterial coupling (RVAc) was significantly lower in patients with readmissions (0.43±0.11 vs 0.69±0.9, p = 0.031). As for clinicals variables; only obesity was significantly associated with 30-day readmissions (Table 1). A model to predict 30-days readmissions that included LVEF, LV-GLS, LAVI and RVAc had an area under the ROC curve of 0.831. CI (0.72–0.95). Figure 1.

Conclusions

Several clinical scores have been proposed. however. cardiac function parameters are barely taken into account in most scores. Simple and feasible TTE parameters can accurately predict readmissions after a first episode of heart failure and might be included in clinical scores for better risk stratification of patients with new-onset HF.
Differential left atrial function in hypertensive and sarcomeric left ventricular hypertrophy
Authors: Ramos Jovani M , Loncaric F , Lopez A , Mimbrero M , Doltra A , Sanchis L , Bijnens B , Garcia-Alvarez A , Sitges M
Published: June 2023

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Emili Letang - Josep Font research contract fund.

Introduction

Left ventricular (LV) hypertrophy is a common finding in clinical practice that can be caused by multiple conditions. Left atrial (LA) dysfunction is common due to abnormalities in LV distensibility and impairment in LV filling. In patients with sarcomeric LV hypertrophy, primary cardiomyopathy disease might also involve the atria.

Purpose

To evaluate if there are differences in left atrial function between arterial hypertension (HT) and hypertrophic cardiomyopathy (HCM) patients.

Methods

37 patients with HCM (according to ESC guidelines criteria) and 36 patients with HT (under treatment with ≥1 hypertensive drug for ≥3 months) underwent an echocardiography to assess LA function with strain analysis and LV diastolic function. Continuous normally distributed variables were compared with T-student test, accepting as significant a p-value <0.05.

Results

HCM patients were slightly younger and showed thicker LV walls as compared to HT patients (48.7±17 vs. 55±5.9 y.o., and 17.7±5.8 vs. 12.4±2.2 mm, respectively, p<0.05 for both). LA volumes were larger in the HCM patients (82.4±37.4 vs. 62.8±20 ml, p<0.05). Also, HCM patients showed significantly lower LA contractile, conduit and reservoir strain as compared to HT patients (12.1±5.9% vs. 17.4±4.5%, 12.9±6.5% vs. 15.6±4, 25.2±10.4 vs. 33.1±6.8, all with p<0.05). Mitral annular velocities were lower (medial e` 7±2.7 vs. 8.2±1.86 and medial a` 8.4±3 vs. 10.2±2, both with p<0.05) and E/A ratio was slightly higher (1.32±0.65 vs. 1.02±0.26, p<0.05) in the HCM as compared to the HT group.

In the subgroup of patients with moderately severe LV hypertrophy (<15mm, n=39; HCM=12, HT=27), LA contractile strain was lower in HCM as compared to HT patients (12.5±6.1% vs. 16.7±4%, p<0.05) (Figure 1), despite being younger; no differences in mitral annular velocities, E/A ratio or in LA volume were noted between HCM and HT etiologies in this subgroup of patients.

Conclusions

Our study shows that LA strain is more impaired in HCM patients as compared to HT patients, especially the LA contractile strain, that remains lower even in those with moderately severe LV hypertrophy, despite having similar LV diastolic function and LA size. This finding could suggest the direct involvement of atrial cardiomyocites in sarcomeric disease and might help in the etiological differential diagnosis of moderately to severe LV hypertrophy. In the setting of a moderately severe hypertrophy of unknown origin, the presence of an abnormally reduced LA contractility strain could be suggestive of HCM.
Long-term prognostic value of stress echocardiography in patients with suspected coronary artery disease - Systematic review and meta-analysis
Authors: Ihekwaba U K , Johnson N , Choi J S , Savarese G , Orsini N , Khoo J , Squire I , Kardos A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Objective

To evaluate the association between results of stress echocardiography and outcomes for patients with suspected coronary artery disease.

Design

Systematic review and meta-analysis.

Data Sources

Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, and Clinicaltrials.

Eligibility criteria for selecting studies

Randomised controlled trials (RCT) evaluating long term outcome of SE in patients suspected of coronary artery disease.

Data Synthesis

A meta-analysis utilising the fixed effects model to evaluate evidence from recent RCT trials on SE or comparing SE to other non-invasive diagnostic modalities. The primary outcome was the composite of all-cause mortality, or cardiovascular death and non-fatal myocardial infarction. Positive SE result was defined as inducible ischaemia in at least 1 of the 16 left ventricular segments.

Results

Six trials fulfilled the search criteria. A total of 19477 subjects who underwent either pharmacological (Dobutamine or Dipyridamole) or treadmill SE were recruited in the meta-analysis with a median follow-up of 31 months (range 21–101). The mean age was 59 years, and 55% were male. Fifty six percent had hypertension, 48% dyslipidaemia, 33% history of smoking, 21% diabetes mellitus and 26% history of myocardial infarction. The overall annual event rate was 1.79% for the composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction and for death 1.82%. Positive SE result was associated with an increased risk of the composite outcome and death with an annual event rate of 1.98% vs 1.26%, Odds Ratio 1.99 (CI 1.75–2.26) and 3.59% vs. 0.93, Odds Ratio 2.06 (CI 1.80–2.35) for the composite outcome and death, respectively Figure A,B. Heterogeneity and inconsistency (Chi2 1.7 P= 0.89) were low. Imprecision was low in the composite outcomes, and the optimal information size was achieved across the studies.

Conclusions

In this meta -analysis positive SE results were associated with poorer long-term composite outcome of all-cause or cardiovascular mortality and non-fatal myocardial infarction as well as for death only.

Figure. Composite of all-cause mortality or cardiovascular death and non-fatal myocardial infarction. (Abstract picture 1)

All-cause or cardiovascular death. (Abstract picture 2)
Predictive value of diastolic function assessed by CMR feature tracking in patients with suspected myocarditis and preserved left ventricular ejection fraction
Authors: Schuetze J , Stark A W , Bernhard B , Safarkhanlo Y , Spano G , Boscolo M , Kwong R Y , Graeni C
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Reduced left ventricular systolic function is a well established predictor for outcome in Patients with myocarditis. However, the predictive role of diastolic function in patients with suspected myocarditis and preserved ejection fraction is unknown.

Purpose

Assess the predicative value of diastolic left ventricular function in patients with suspected myocarditis.

Methods

Late and early radial, circumferential and longitudinal diastolic strain rate was assessed as using CMR feature tracking in patients with clinically suspected myocarditis being referred for cardiac magnetic resonance imaging (CMR). The primary endpoint was defined as a composite of first major adverse cardiovascular events (MACE) including all-cause mortality, sustained ventricular tachycardia and hospitalization for heart failure.

Results

755 consecutive patients with suspected myocarditis and referred for CMR (277, 37% female; mean age 48 ± 16years) were included. Of those late gadolinium enhancement (LGE) was present in 417 (55.2%). 416 had a preserved ejection fraction >50% (55.1%).

Mace was documented in 123 patients (16.3%) during a median observational time of 3.77 years. After adjustment for LVEF, LGE extend, age, and gender early circumferential strain rate (HR=0.35 95% CI 0.16–0.77, p = 0.009), early longitudinal diastolic strain rate (HR=0.40 95% CI 0.17–0.96, p = 0.042) and late diastolic strain rate (HR=0.23 95% CI 0.07–0.74, p = 0.013) remained independent predictors of MACE.

Conclusion

CMR feature tracking diastolic strain rate is independently associated with outcome, beyond LVEF and LGE in patients with myocarditis, and might therefore contribute to improved risk stratification in this sclinical setting.
A novel approach in the assessment of paravalvular regurgitation after transcatheter aortic valve replacement using cardiac magnetic resonance imaging
Authors: Rooijakkers M J P , Van Wely M H , Habets J , El Messaoudi S , Van Royen N , Nijveldt R
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Paravalvular regurgitation (PVR) is a common complication after transcatheter aortic valve replacement (TAVR) that poses an increased risk of rehospitalization for heart failure and mortality. Two-dimensional (2D) cardiac magnetic resonance (CMR) quantitative flow assessment is the gold standard for evaluation of PVR after TAVR. Two novel techniques in flow assessment are 2D multi-velocity encoding (Venc) and four-dimensional (4D) flow. The 2D multi-venc sequence provides the advantage of integrating three different Venc values in a rapid, single breath-hold acquisition, specifically providing accurate measurements for both high and low velocities. 4D-flow allows a free-breathing acquisition with unlimited plane selection, and provides a comprehensive visualization of the blood flow. Although the use of these novel techniques is expanding, these have not yet been assessed for their correlation with standard 2D-flow.

Purpose

To compare the standard 2D-flow acquisition with both 2D multi-venc and 4D-flow acquisitions for the assessment of PVR using CMR-derived regurgitant fraction (CMR-RF).

Methods

In this substudy of the APPOSE trial (NCT04281771), 19 patients underwent CMR one month after TAVR using 2D multi-venc and 4D-flow, in addition to the standard 2D-flow acquisition. Medis Suite MR (Medis Medical Imaging, Leiden, the Netherlands) was used for analysis of the flow data. Scatterplots and Bland-Altman plots were used to assess correlation and visualize agreement between the techniques.

Results

Mean age was 79.8 ± 4.9 years, and 42.9% of the patients were men. Mean CMR-RF was 11.7 ± 10.0% using the standard 2D-flow sequence, 10.6 ± 7.0% using the 2D multi-venc sequence, and 9.6 ± 7.3% using the 4D-flow acquisition. Both the CMR-RF assessed with 2D multi-venc and 4D-flow showed a high correlation with the CMR-RF assessed with standard 2D-flow (r = 0.88, p < 0.001 and r = 0.74, p < 0.001, respectively). Bland-Altman plots revealed no significant bias between the mean values of CMR-RF (2D multi-venc: 1.31%; 4D-flow: 0.27%).

Conclusion

Both the 2D multi-venc and 4D-flow sequence produce accurate quantification of PVR after TAVR. Given the advantages of these approaches in terms of acquisition speed and plane selection, use of these techniques should be encouraged.
Tricuspid leaflet identification on 2D multiplane transoesophageal echocardiography: lessons from 3D
Authors: Vella A , Zannoni J , Donal E
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

—Tricuspid valve (TV) leaflet identification by two-dimensional (2D) transoesophageal echocardiography (TOE) is complex due to the high variability of the combinations of leaflets visualized in each view. While three-dimensional (3D) imaging can easily overcome this problem by acquiring the whole valve anatomy, the overall image quality is often suboptimal and the technique somewhat unsuitable for real-time monitoring during interventional procedures like TriClip implantation. Using information derived from both 2D and multiplanar reconstruction (MPR) of 3D datasets, we aimed at describing anatomical landmarks able to identify TV leaflets easily and effectively during multiplane 2D TOE.

Methods

—TOE data from 83 patients was retrospectively collected. Multiplane 2D images of the TV and matching 3D datasets recorded from the same probe position were compared to precisely identify the leaflets visualized on each 2D image. To increase the number of multiplane (orthogonal) 2D images available for analysis, a novel approach was used: the 3D data of each patient was appropriately sliced to simulate and accurately match what would be seen by "sweeping" the cursor across the TV during real-time multiplane imaging (Fig. 1). After data analysis, a comprehensive "two-step" reference table was generated. To evaluate the clinical utility of the findings, eleven (11) echocardiographers were shown a random set of 5 images, and asked to label the leaflets visualized, prior and after a brief explanation on how to use the proposed reference table.

Results

—After removal of redundant information, a total of 231 sets of leaflets combinations was obtained. The number of leaflets visualized (one or two) and the presence (or absence) of the interventricular septum allowed consistent identification of the TV leaflets depicted in the 2D home view, as confirmed by correlation with the matching 3D MPR dataset. A similar analysis was carried out on the orthogonal 2D images resulting from three different multiplane cursor positions (distal, mid, and proximal to the aortic valve/interventricular septum). By combining information from the two views, leaflet identification was accurate, intuitive and easy, as summarized in the reference table (Fig. 2). The accuracy in exact leaflet recognition was rather modest (mean score of 1 out of 5) among echocardiographers with different experience in TV TOE, but significantly increased (mean score of 3.2 out of 5) with the adoption of the proposed approach, accounting for a 44% improvement in accuracy (p <0.001).

Conclusion

— Simple anatomical landmarks allow precise TV leaflet identification during multiplane 2D TOE. A simplified two-step approach significantly improves accuracy in leaflet recognition among both beginners and advanced echocardiographers.
N-terminal natriuretic peptid does not relate to morfological and functional alterations in octagenarians without heart failure
Authors: Oliveira Da Silva C , Bastos L , Jonsson J , Hage C , Nagy A , Back M , Shahgaldi K , Manouras A
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Aims

To investigate whether mild elevation of N-terminal natriuretic peptide (NT-proBNP) in asymptomatic elderly individuals is associated with alterations in structural/ functional cardiac abnormalities and assess its prognostic significance.

Methods and results

201 individuals, 75 years of age, where randomly selected from a population-cohort study in Stockholm (STROKESTOP). Patients with permanent atrial fibrillation (AF), more than mild valvular disease or the heart failure (HF) diagnosis were excluded. NT-proBNP measurements, echocardiography, demographics and cardiovascular risk factors were accessed in all subjects. Thumb ECG was performed in all participants. Information regarding cardiovascular morbidity, HF and AF was obtained from the electronic medical record 5 years after inclusion [ median 5,01 years (interquartile range 4,8 – 5,5 years)]. The cohort was divided into three groups [group I: n=94, NT-proBNP 125–900 ng/L, no AF; group II: n= 77, NT-proBNP 125–900 ng/L, paroxysmal AF and group III: n=30; NT-proBNP < 125 ng/L, no AF. No association between NT-proBNP and echocardiographic or demographic variables was found in groups I and III. In group II, a weak correlation was found between NT-pro-BNP and body mass index (r=0.24, p = 0.038), left atrial volumes (r=0.28, p = 0.047) and E/é septal (r=0.30, p = 0.018). There was no association between individual risk factors and NT-proBNP levels in any group. Cox-regression analysis did not reveal any prognostic value of NT-proBNP for HF or AF development (p> 0.05).

Conclusion

Mild increase in NT-proBNP levels is not associated with morphologic, functional or prognostic information in octogenarians without HF diagnosis.
Trends in the clinical use of speckle tracking strain imaging: insights from a worldwide EACVI survey
Authors: Joshi S , Donal E , Cameli M , Edvardsen T , Cosyns B , Popescu B , Delgado V , Dweck M R , Sade L E
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Strain imaging has emerged as a sensitive measure of myocardial function and an early marker of myocardial involvement in different diseases.

Purpose and Methods

To evaluate the use of speckle tracking strain imaging in clinical practice, an open access online survey was conducted by the EACVI according to published criteria(1). The survey explored the feasibility, appropriate use and clinical implementation of echocardiographic strain imaging. Health care providers in cardiology from all levels of health care centres were encouraged to participate in this global survey.

Results

In all, 431 respondents from 77 countries participated. Most respondents worked within the cardiology and cardiothoracic departments (95%). Participants from tertiary centres (46%), and private clinics or public hospitals (54%) were also represented. Fifty eight percent of the participants were senior experienced echocardiographers, 40% were trained in strain imaging at an expert centre, 37% via research in strain imaging, 33% via the EACVI e-learning platform or hands-on courses and 29% via national teaching courses. Only 16% reported having no training. Despite almost universal access (98%) to speckle tracking strain quantification, only 39% performed and reported strain results frequently (more than half of their reports) and the majority (61%) reported it either infrequently (25–50% reports) or very rarely (<25% reports). The most common reason (65%) for not using the technology despite having access to it was related to post-processing difficulty. Strain quantification was used mainly to assess the left ventricle (LV)(99%), less frequently the right ventricle (RV)(57%), the left atrium (46%) and rarely the right atrium (8%). Eighty-six percent of users assessed LV global longitudinal strain (GLS) from the 3 apical views, with 88% preferring automated algorithms with manual correction to define the regions of interest.

The most common clinical conditions where LV strain assessment was considered useful clinically included chemotoxicity (88%) amyloidosis (87%), hypertrophic cardiomyopathy (73%), heart failure with preserved ejection fraction (68%), ischaemic heart disease (63%) and the early phase of dilated cardiomyopathy (59%, Figure 1). Just over half of the respondents quantified RV strain in pulmonary hypertension. Finally, the key areas of improvements identified by the respondents included higher reproducibility of the results (48%) and the ability to readily compare strain values across vendors (42%) (Figure 2).

Conclusion

Strain imaging is now widely available and many imagers have been trained in its use. Although strain imaging is used in line with the scientific evidence, it is still underutilised in clinical practice. Improved reproducibility and interchangeability of results across vendors may increase the uptake of this technique.
Coronary artery calcium identified on non-gated chest CT scans - A wasted opportunity to avoid the tragedy
Authors: Silva B V , Placido R , Rigueira J , Nobre Menezes M , Alves Da Silva P , Brito J , Abrantes A , Gregorio C , Oliveira C , Garcia B , Martins A M , G Almeida A , J Pinto F
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary artery calcium (CAC) is an independent predictor of cardiovascular events. While it is traditionally performed utilizing gating with specific acquisition parameters, CAC can be identified in non-gated standard chest computed tomography (CT). This study aimed to assess CAC on chest CTs, evaluating its correlation with coronary lesions on coronary angiography (CAG) and prognosis.

Methods

We retrospectively reviewed patients (pts) who underwent CAG due to acute coronary syndrome (ACS) who had undergone a prior non-gated non-contrast chest CT. CAC was qualitatively evaluated by visual assessment (mild/moderate/severe) and quantitatively assessed using Agatson score and stratified by terciles. Evaluation was performed by an investigator blinded to CAG report.

Results

We included 114 pts after reviewing 1000 CAGs: 67% male, mean age 68 years, 78% hypertension, 62% dyslipidemia, 38% chronic kidney disease, 38% diabetes. The mean time difference between CT and CAG was 23 months. CAG was performed due to unstable angina in 33% of pts, NSTEMI in 52% and STEMI in 16%. Significant lesions were found in 57% (69% performed PCI and 17% surgical revascularization).

CAC was visual classified as mild, moderate and severe in 31%, 33% and 16% of pts, respectively. Moderate or severe CAC was an independent predictor of significant lesions on CAG [OR 22, 95%CI 8–61, p<0.001] and all-cause mortality [OR 4, 95%CI 2–9, p = 0.001]. Pts with severe CAC had higher peak troponin than those with mild/moderate CAC (1780 vs 315 ng/L, p = 0.024).

Quantitative CAC score accurately predicted significant lesions (AUC 0.81, p<0.001; figure 1A), with higher scores in this subgroup (1308 vs 120, p<0.001) and strongly correlated with SYNTAX score (p<0.001).

Survival analysis stratified by severity of CAC assessment is shown in figure 1B and 1C.

The most severely calcified artery in the CT often matched the culprit vessel of future ACS, with 79%, 60% and 50% concordance for left anterior descending, circumflex, and right coronary artery, respectively.

While significant CAC was identified in 80% of CTs, formal reporting was as low as 25%, even with severe CAC, where only 2/18 reports mentioned it. Furthermore, only 62% pts were on statin therapy at the time of CAG.

Conclusion

CAC evaluation in chest CTs was feasible and strongly associated with the extent/severity of coronary artery disease on CAG, as well as mortality. Notwithstanding, CAC underreporting was frequent and statin therapy underused, suggesting a simple and common opportunity for preventive care.
Right ventricular global longitudinal strain and short-term prognosis in patients with first acute coronary syndrome
Authors: Anastasiou V A , Kamperidis V K , Daios S D , Moysidis D M V , Liatsos A C L , Peteinidou E P , Didagelos M D , Vassilikos V V , Ziakas A Z , Savopoulos C V
Published: June 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular (RV) dysfunction is recognized as an adverse prognostic feature in patients with Acute Coronary Syndromes (ACS). However, conventional echocardiographic indices for the evaluation of RV function have considerable limitations. Right Ventricular Global Longitudinal Strain (RV GLS) is a novel speckle-tracking echocardiographic index that assesses the overall intramyocardial function of the RV free wall and interventricular septum.

Purpose

The present study aimed to investigate the short-term prognostic value of RV GLS in patients with first ACS.

Methods

A total of 300 consecutive patients with first ACS (mean age 61.2±11.8 years, 74% males) were prospectively studied. A comprehensive transthoracic echocardiographic assessment was undertaken within 24 hours after revascularization and in-hospital mortality was assessed. Multiple multivariable Cox Regression analysis models were constructed to compare the predictive value of RV function indices for in-hospital mortality. Only significant variables (P<0.05) in the univariate analysis were included in the models. Due to the limited number of events, all multivariable models were constructed including a maximum of 3 variables. To further assess the prognostic value of RV GLS over a baseline model the change in χ2 was assessed using the likelihood ratio test. The absolute value of strain parameters was used for all analysis.

Results

Patients with anterior-STEMI had significantly more impaired RV GLS (anterior-STEMI 14.52±5.23 vs. inferior-STEMI 17.41±5.06 vs. lateral-STEMI 19.50±4.17 vs. Non-STEMI 20.61±3.69%, P<0.001). A total of 23 (7.7%) patients died in-hospital after revascularization. In univariate analysis RV GLS was significantly associated with in-hospital mortality (HR=0.717, 95% CI=0.642–0.801, P<0.001). After adjustment for Global Registry of Acute Coronary Event (GRACE) risk score and Left Ventricular Ejection Fraction (LVEF), RV function indices that retained independent association with in-hospital mortality were RV GLS, Fractional Area Change, and Tricuspid Annular Plane Systolic Excursion (Table). The model that included RV GLS demonstrated the highest overall χ2 value (Table). To prove the incremental value of RV GLS on in-hospital mortality prognosis, a baseline model including the GRACE risk score was created, and then LVEF was added. The further addition of RV GLS significantly increased the prognostic value the model (Figure).

Conclusions

RV GLS measured by transthoracic echocardiography within 24 hours after revascularization in patients with first ACS showed the strongest association with in-hospital mortality outperforming other RV function indices. RV GLS provides additine prognostic information over GRACE risk score and LVEF to predict in-hospital mortality.