bluuebunny/crossref_metadata_2025 huggingface dataset:
P339 Gradient adjusted cardiac power index does not improve prediction of survival post transcatheter aortic valve replacement compared to cardiac power index alone
Authors: Agasthi P , Mookadam F , Venepally N R , Wang P , Khetarpal B K , Sweeney J , Eleid M , Pollak P , Fortuin F D , Holmes D R , Arsanjani R
Published: January 2020

Funding Acknowledgements

None

Background

Cardiac Power Index (CPI) is an integrative hemodynamic measure of cardiac pumping capability and is the product of the simultaneously measured mean arterial pressure (MAP) and cardiac output (CO). In patients with aortic stenosis (AS), MAP is not reflective of mean systolic left ventricular (LV) pressure due to the transvalvular gradient. Non-invasive assessment of mean systolic LV pressure is challenging in severe aortic stenosis. CPI assessed using systemic MAP was previously shown to predict survival post transcatheter aortic valve replacement (TAVR).

Purpose

We evaluated the utility of a gradient adjusted CPI in predicting survival post TAVR compared to CPI alone

Methods

A retrospective study was performed including patients undergoing TAVR with 1 year follow-up. Baseline demographics, clinical, and echocardiographic data were abstracted from a cohort of 1,011 patients. CPI was calculated, (CO x MAP)/ (451 x BSA) Watts/m2. Gradient adjusted CPI was calculated using an augmented MAP i) adding aortic valve mean gradient(AVMG) to systolic blood pressure (CPI1); ii) adding aortic valve maximal instantaneous gradient to systolic blood pressure (CPI2) and iii) adding AVMG to MAP (CPI3). Patient survival score was calculated using a step up technique to identify the cut off value for CPI and gradient adjusted CPI to identify, where the maximum difference in mortality occurred. Multivariate cox-regression analysis was performed to adjust for baseline covariates. Receiver operator curves(ROC) for CPI and gradient adjusted CPI were calculated to predict survival post TAVR.

Results

The mortality rate at 1 yr was 16%. Mean age and AVMG of survivors was 81 +/- 9 yrs and 43 +/-14 mmHg vs 80 +/-9 yrs and 42 +/- 13 mmHg in the deceased group. Proportion of female patients was similar in both groups (p = 0.7). Patients in the deceased group at baseline had a higher prevalence of chronic lung disease, atrial fibrillation, heart failure within 2-weeks of procedure, higher STS-PROM score, lower serum albumin level, higher prevalence of moderate to severe tricuspid regurgitation, higher right ventricular systolic pressure and higher prevalence of dialysis. Both CPI and gradient adjusted CPI were independently associated with survival at 1 year. The area under ROC for CP, CP1, CP2 and CP3 were 0.67 (95% confidence interval [CI] 0.62 - 0.72), 0.65 (95% CI 0.60 – 0.70), 0.66 (95% CI 0.61 – 0.71) and 0.63 (95% CI 0.58 – 0.68) respectively.

Conclusion

Gradient adjusted CPI did not improve accuracy of predicting post TAVR survival at 1 year compared to CPI alone.

Abstract P339 Figure. Area under ROC
P342 Left atrial contraction longitudinal strain is a volume-independet parameter
Authors: Unlu S , Sezenoz B , Sahinarslan A , Arinsoy T , Cengel A
Published: January 2020

Background

The left atrium (LA) is the main contributor of left ventricular (LV) filling. LA volume and volume index are routinely evaluated during echocardiographic assessment as having prognostic value in a wide range of cardiovascular pathologies. Yet, LA volume is easily affected by volume status. Thus, a non-invasive novel parameter such as indices of LA longitudinal strain (LS) have been proposed as alternative measurements. LA strain was shown to be associated with LV filling pressures and it has been suggested to provide prognostic information in patients with heart failure, atrial fibrillation, ischemic and valvular heart diseases. Nevertheless the acute effect of hemodynamic changes on LA LS indices is not well-established due to lack of evidence in healthy subjects and patient populations. The aim of this study is to evaluate the LA mechanics and change in echocardiographic methods used for assessment of LA by examining the end stage kidney patients before and after the hemodialysis (HD).

Methods

Patients between 18 and 85 years of age, receiving HD for at least 6 months were included. The echocardiographic images were obtained before and after HD. 2D speckle tracking strain analysis was performed for LA in 45 patients. Reference points for analysis are set on the "P" waves. LA reservoir, conduit and contraction phase LS were calculated. The changes in echocardiographic methods before and after hemodialysis were examined. Correlation between volume depletion and change in echocardiographic parameters were calculated.

Results

45 patients (47.7 ± 14.7 years of age, 19 women) were included in study. The mean volume of ultrafiltration was 2755.12 ± 845.5 ml . The chamber sizes of LA are decreased after hemodialysis (LA diameter; 4.9 ± 0.8 cm vs. 4.4 ± 0.5 cm p < 0.001, LA area; 27.8 ± 4.0 cm2 vs. 19.6 ± 3.8 cm2 p < 0.001). LA reservoir phase LS measurements (% 44.6 ± 10.8 vs. % 38.15 ± 8.11 p < 0.001) showed significant changes after HD. In contrast LA contraction LS measurements (% -16.6 ± 7.0 vs. % -16.4 ± 7.1 p:0.893) did not differ after HD. The relative change in LA reservoir phase LS (r = 0.74, p:0.001) showed correlation with the ultrafiltrated volume.

Conclusion

LA contraction LS is a volume independent measurement obtained by 2D speckle tracking. Assessment of LA mechanics with echocardiography would be an easy and repeatable assessment which can guide to describe the cardiac pathophysiology and hemodynamics better. Moreover defining novel volume independent parameters for evaluation of LA would contribute to clinical perspectives of the patients.
P344 Echocardiography right atrial area and inferior vena cava diameter interest to predict right atrial pressure in pulmonary arterial hypertension
Authors: Fauvel C , Raitiere O , Burdeau J , Si Belkacem N , Bauer F
Published: January 2020

Background

Risk stratification in Pulmonary Arterial Hypertension (PAH) is based on multiparametric approach including invasive measurement of invasive right atrial pressure (RAP) by right heart catheterization (RHC). Therefore, following 2015 ESC/ERS pulmonary hypertension (PH) guidelines, RHC are frequently repeated every 4 to 6 months until RAP <8 mmHg.

Purpose

To explore the interest of right atrial area (RAA) and inferior vena cava (IVC) diameter measured by transthoracic echocardiography, as a surrogate for right atrial preload to detect RAP <8 mm Hg and avoid repeated RHC in PAH patients.

Methods

From a prospective single PAH referral center, we have included all patients with a diagnosis of PAH (confirmed by PH team). During the follow up, transthoracic echocardiography and a RHC was performed on the same day. RAA (cm2) was measured in the apical four-chamber view, at end-systole, just prior to tricuspid valve opening, excluding the area under tricuspid valve annulus. In the subcostal view, at 1.0 to 2.0 cm from the junction with the right atrium, IVC diameter (mm) was reported. Both RAA and IVC were compared to RAP.

Results

97 PAH patients were included (35 males, mean age 65 ± 16y, mean arterial pressure was 45 ± 16 mmHg, cardiac index 3.0 ± 1.0 l/min/m² and right atrial pressure was 7.6 ± 4.7 mm Hg). Both IVC diameter and RAA averaged 18.1 ± 6.3mm and 22.5 ± 8.2 mm by echocardiography, respectively. IVC diameter and RAA had a significant but weak correlation with right atrial pressure <8 mmHg measured by RHC (r = 0.42, p < 0.01 and r = 0.41, p < 0.01, respectively). Targeting a good specificity (Sp = 0.75), ROC curves analysis identified 10 mm for the IVC diameter and 20 cm² for RAA if IVC diameter was > 10 but < 20 mm to predict RAP <8 mmHg (area under the curve = 0.72). Thus, in our cohort, 40% could have been followed-up non-invasively by echocardiography with IVC diameter ≤10 mm or >10 but <20 mm with RAA ≤20 cm² with only 2% of misclassification. For the remaining 58% unclassified PAH patients out of these echocardiographic ranges, RHC would have been requested.

Conclusion

In a cohort of PAH patients, targeting a low risk clinical worsening or death (identified by RAP <8 mmHg in RHC), echocardiography, with the use of IVC diameter ≤10 mm or >10 but <20 mm with RAA ≤20 cm², right heart catheterisation may be avoided in 40% of cases with extremely low misclassification.
P362 Antimalarial-induced cardiomyopathy: retrospective case series
Authors: Pavsic N , Berlot B , Dolenc Strazar Z , Prokselj K
Published: January 2020

Background

Antimalarial drugs chloroquine and hydroxychloroquine represent an important therapeutic option in autoimmune diseases. Rare cases of potentially lethal antimalarial-induced cardiomyopathy (AMIC) have been described. Pattern of minimal changes with wall hypertrophy, followed by restrictive and end-stage dilative cardiomyopathy was proposed in AMIC.

Purpose

Our aim was to identify patients with definite AMIC and characterize their clinical and imaging findings.

Methods

Retrospective analysis of admissions to Cardiology department from January 2010 to January 2019 was done to identify patients with definite diagnosis of AMIC based on positive endomyocardial biopsy. Clinical, echocardiographic, and cardiac magnetic resonance (CMR) imaging findings were reviewed if available.

Results

Three patients with biopsy proven diagnosis of AMIC were identified. Two patients, 62 and 76-year-old females, presented with signs of congestive heart failure, while the third, a 41-year-old man presented with chest pain and cardiac conduction abnormalities necessitating pacemaker implantation. All were treated with chloroquine phosphate. Both females had a history of pacemaker due to atrioventricular block. All had positive troponin and coronary artery disease was excluded.

Echocardiography in the first case showed a severely dilated left ventricle (LV) with global hypokinesia and severe systolic dysfunction (LVEF 30%). CMR confirmed dilative cardiomyopathy, furthermore subepicardial late gadolinium enhancement (LGE) of the inferolateral LV wall and of the right ventricle free wall was present. In the second case a restrictive cardiomyopathy pattern was observed with mild biventricular systolic dysfunction and biatrial enlargement. CMR of this case was not available. Echocardiography in the third case showed a normal sized LV with mild diastolic and systolic dysfunction (LVEF 50%), along with septal hypokinesia. CMR showed patchy subepicardial and mid-wall LGE of the septum that was falsely attributed to myocarditis. Additionally, a chemical shift artefact suggestive of myocardial fatty infiltration (Image 1) was visible in the apical septum.

After discontinuation of chloroquine two patients improved, while the first patient deteriorated and eventually succumbed to refractory heart failure.

Conclusions

Our three cases confirm high diversity of cardiac imaging findings in AMIC. Even mild non-specific findings such as LV systolic dysfunction or wall motion abnormalities in patients on antimalarial drugs should therefore be thoroughly investigated. CMR with non-ischaemic LGE pattern may aid in diagnosis, however definite diagnosis is currently possible only with endomyocardial biopsy. Novel imaging techniques, such as T1 mapping, have a potential to increase the diagnostic yield given the known patohistological similarities between AMIC and Anderson-Fabry disease.

Abstract P362 Figure. Chemical shift artefact (arrow) in AMIC
P369 Patient specific virtual reality for education in congenital heart disease
Authors: Milano E G , Pajaziti E , Schievano S , Cook A , Capelli C
Published: January 2020

Funding Acknowledgements

La Fondation Dassault Systèmes, British Heart Foundation

Background

Virtual reality (VR) provides a unique possibility to interact with three-dimensional objects. Still in its infancy, the integration of VR with advanced cardiovascular imaging technology allows users to handle patient-specific cardiac models.

Purpose

The purpose of this study was to evaluate the potential role of VR in teaching cardiac morphology of congenital heart diseases to healthcare professionals.

Methods

From October 2018 to April 2019, a VR application was developed in-house and incorporated within the Cardiac Morphology courses run monthly at our centre. The VR software included patient-specific 3D models which were reconstructed from 3D imaging datasets (micro-CT, CT, CMR or 3D echo data). The most important cardiac structures were labelled to allow easier identification of anatomical features (Figure 1). Each participant had the possibility to evaluate 6 different patient specific models including: a foetal normal heart, a foetal Transposition of the Great Arteries, a foetal Atrioventricular septal defect, a four-month-old Tetralogy of Fallot, a four-month-old Double Outlet Right Ventricle with uncommitted ventricular septal defect and a one-year-old Patent Ductus Arteriosus. All the attendees could evaluate the models individually for 5 to 15 minutes. A short survey with six questions was administered at the end of the session. The survey included sections asking for professional background information, prior VR experience and feedback on the VR experience which was assessed with a 5 points Likert-type scale (from 1 to 5).

Results

The VR session was attended by 20 delegates with mixed professional backgrounds including cardiac surgeons, cardiologists, cardiac anaesthesiologists, paediatricians, pathologists and medical students. Only 2 out of 20 had tried a virtual reality application before, although neither of those prior VR experiences had a medical focus. The VR application was considered ‘’extremely helpful’’ (5/5) in understanding the anatomy by 44% of participants, and ‘’very helpful’’(4/5) by another 44%. The methods of interaction (e.g. grabbing objects, using a cutting tool) were considered "extremely intuitive’’ (5/5) by 72% of attendees, and "very intuitive"(4/5) by 27%. In 94% of the cases, the attendees responded to be "very willing"(4/5) or "extremely willing"(5/5) to implement a VR setup at their own institutions for the purpose of evaluating cardiac anatomies.

Conclusion

The use of the VR station in cardiac morphology courses was very well received by the attendees, as it is frequently considered easy to use and very helpful in aiding the understanding of congenital heart diseases. The survey highlighted a great potential for implementing this tool in educational programmes.

Abstract P369 Figure 1
426 Involvment of anterior lefleat and persistent MR at discharge are the 2 predictive risk factors for reintervention after mitral valve repair for significant and symptomatic MR
Authors: Fauvel C , Breil R , Doguet F , Raitiere O , Bauer F
Published: January 2020

Background

Mitral regurgitation (MR) is the second most common valve disease in Europe with mitral valve repair being the treatment of choice in symptomatic patients with degenerative MR grade 3+.

Purpose

the study goal is to evaluate the long-term survival, the rate and the predictive factors of reintervention following mitral valve repair.

Method

All patients admitted for mitral valve repair in the context of significant MR defined by symptoms and/or critical left ventricular enlargement were included in this retrospective registry from January 2001 to 31 December 2011. The only exclusion criteria was scheduled mitral valve repair converted into mitral valve replacement.

Results

426 consecutive patients had mitral valve repair. There were 137 women and 289 men with an average age of 62 ± 13 y. Twenty-two percent, 37%, 36% and 5 % patients were in NYHA functional class 1, 2, 3 and 4, respectively. All patients had MR grade 3+. Indication for mitral valve repair was endocarditis (n = 21), ring dilation (n = 21), ischemic functional MR (n = 26), rheumatic mitral valve (n = 8) and degenerative MR (n = 350). Operating room successful attained 95% % for mitral valve repair with only 5% in-hospital conversion to valve replacement. Of the 426 patients discharged after mitral valve repair, 39 patients died with a survival rate of 10.8 years (95% CI [10.4-11.3], 78.5% > 10 years) and 25 were re-operated. The two predictive factors for reintervention were anterior leaflet degeneration (OR = 3.4 IC95% [1.05-9.8]; p = 0.02) and persistence of mitral leak grade 2+ at discharge (OR = 6.7 IC95% [2-22]; p = 0.001).

Conclusion

Preoperative degenerative anterior leaflet and post-operative persistent grade 2+ mitral regurgitation are the 2 predictive risk factors for reintervention after mitral valve repair for significant MR.
431 Impact of endurance training versus non-endurance training on cardiac morphology and physical fitness in highly trained young athletes
Authors: Bjerring A W , Landgraff H E W , Leirstein S , Lihagen M , Skei M , Murbraech K , Brun H , Stokke T M , Haugaa K H , Hallen J , Edvardsen T , Sarvari S I
Published: January 2020

Funding Acknowledgements

South-Eastern Norway Regional Health Authority

OnBehalf

Center for Cardiological Innovation

Background

Endurance exercise is closely correlated with physical fitness and the development of the athlete’s heart. The impact of changes in exercise-patterns in young athletes is poorly described.

Aims

This study aims to explore the impact of endurance training versus non-endurance training on cardiac morphology and physical fitness in young endurance athletes.

Methods

Forty-eight cross-country skiers were examined at age 12 (12.1 ± 0.2 years) and then again at age 15 (15.3 ± 0.3 years). Echocardiography, including 3D echocardiography, and cardiopulmonary exercise testing was performed in all participants. Self-reported data on weekly hours of endurance and weekly hours of non-endurance training was collected.

Results

At follow-up, thirty-one (65%) of the endurance athletes were still active and 17 (35%) were not. There was a moderate, positive correlation between weekly hours of endurance-only training and changes in VO2 max from baseline to follow-up (R = 0.55, p < 0.001), but no correlation was found for weekly hours of all types of training (Figure). Weekly hours of endurance-only training also showed moderate, positive correlations with changes in chamber dimensions, including indexed 3D left ventricular (LV) end-diastolic volume (R = 0.45, p < 0.01), 3D LV end-systolic volume (R = 0.35, p < 0.05), right ventricular (RV) end-diastolic area (R = 0.39, p < 0.01) and RV end-systolic area (R = 0.44, p < 0.01). No correlation was found for weekly hours of all types of training.

Conclusion

Only endurance training is sufficient to induce cardiac remodeling, including dilatation of both ventricles, in highly trained adolescent athletes.

Abstract 431 Figure.
432 Traditional markers of myocardial dysfunction fail to detect marked reductions in physical capacity amoung chemotherapy patients
Authors: Howden E , Foulkes S , Wright L , Janssens K , Dillon H , Costello B , La Gerche A
Published: January 2020

Left ventricular ejection fraction (LVEF) is the current standard of care for evaluating chemotherapy-associated cardiotoxicity but changes in LVEF are poorly associated with outcomes and long-term heart failure risk. We sought to compare a more global measure of integrative cardiovascular function (VO2peak) that is strongly associated heart failure and early mortality risk with LVEF, global longitudinal strain (GLS) and cardiac biomarkers.

Methods

95 patients who were due to commence anti-cancer treatment (n = 58 anthracycline chemotherapy for breast cancer; n = 25 Bruton’s tyrosine kinase inhibitor and n = 12 allogeneic stem cell transplant for haematological cancers) completed a pre-treatment and follow-up assessment within 6 months of initiating treatment. Changes in echocardiographic measures of LV function (LVEF, GLS), cardiac biomarkers (troponin and BNP) and cardiopulmonary exercise test (CPET, VO2peak) were measured.

Results

Of 95 participants who underwent baseline testing, follow-up CPET and echocardiography data was available in 89 participants. LV function was normal prior to treatment (LVEF 61.5 ± 5.9%; GLS -19.4 ± 2.3) but VO2peak (23.4 ± 6.5ml/kg/min) was only 83 ± 21% (range 47-146%) of age-predicted. After treatment, we observed marked reductions in fitness (Δ-2.1 ± 3.7 ml/kg/min or -9 ± 15%, P < 0.001) which was associated with small non-clinically significant changes in LV function (LVEF Δ-2.4 ± 6.4% P = 0.001; GLS Δ-0.5 ± 1.9 P = 0.018). Troponin was increased significantly (4.0 ± 5.5 to 23.5 ± 22.5ng/ml, P < 0.001), with no change in BNP (37.5 ± 31.4 to 32.7 ± 22.0pg/ml, P = 0.87). Current diagnostic criteria for cardiac toxicity were not met in any patient despite some patients developing disabling reductions in functional capacity (VO2peak < 16ml/min/kg).

Conclusion

Despite normal resting LV function prior to commencing treatment VO2peak was below age predicted. Treatment further impaired exercise cardiovascular function with minimal impact on resting measures of LV function. The assessment of cardiovascular function using CPET prior to, and following chemotherapy may be a more sensitive means of identifying patients at increased risk of future heart failure.
508 Puerperal thrombosis on mitral valve prothesis
Authors: Moniz Mendonca F V , Sousa J A S , Monteiro J M , Mraquel M R , Neto M N , Caires G C , Freitas D F
Published: January 2020

Introduction

Replacement of a diseased heart valve with a prosthetic heart valve exchanges the native disease for prosthesis-related complications. Valve thrombosis can occur in mechanical prosthetic valves. The significant morbidity and mortality associated with this condition permits rapid diagnostic evaluation. A combination of transthoracic and transoesophageal echocardiography (TEE) is required to assess the haemodynamic effect of thrombosis, leaflet motion and thrombus size. Mechanical valves offer excellent haemodynamic performance and long-term durability, but the need for anticoagulation increases maternal and foetal mortality and morbidity, and the risk of major cardiac events during pregnancy.

Case report

A 23-year-old gravida 0 woman was admitted to the emergency obstetric care. At the age of 18 months, she underwent valve replacement surgery in the mitral position (St. Jude Medical Standard size 25mm), this requires use of warfarin after surgery. Although she was advised otherwise; the patient became pregnant. She had an increased risk of maternal cardiovascular complications [Modified World Health Organization classification (mWHO) III] and obstetrics complications. The warfarin treatment was discontinued, and it was started low molecular weight heparin (LMWH) 100IU, twice daily subcutaneously, on gestation 36 week. The last administration was 2 days before the admission (>48h before delivery). So, on gestation week 39, she was admitted to the department of Obstetrics. Then, as cardiotocography showed decreased foetal heart rate, an emergency caesarean section was performed. A healthy baby was delivered. After delivery, we perform an immediate two-dimensional transthoracic echocardiography (2D TTE), as there was a high-risk of valve thrombosis, and it showed an apparent normal prosthetic excursion but a high mean pressure gradient (25mmHg) – elevated transprosthetic gradient. It was not well visualized the occlude motion of the mechanical valve by 2D TTE, so we perform a TEE to answer the clinical question, if there was a dysfunction due to an acute process (i.e. thrombus). It revealed an obstruction – reduced mobility of one disc and elevated velocities by CW doppler (30mmHg), and a presence of thrombus (1.3X0.8mm). The anticoagulation with intravenous UFH was started immediately, but anticoagulation failed, and she underwent valve replacement surgery (St. Jude Medical standard size 27mm.

Conclusion

Our patient had a very-high risk of complications maternal cardiovascular complications - WHO risk classification III - because the risk of valve thrombosis is markedly increased during pregnancy. The risk is lower with adequate dosing of anticoagulant therapy, but our patient was not which increased the risk of thrombosis. Finally, it is important to notice that it is recommended to manage pregnancy in women with mechanical valves in a centre with a pregnancy heart team.

Abstract 508 Figure. Valve thrombosis
509 The importance of transesophageal echocardiography in the therapeutic approach of a patient with Hakim-Adams syndrome and right atrial mass
Authors: Miftode R S , Crisu D , Petris A O
Published: January 2020

Hakim-Adams Syndrome (HAS) or symptomatic normotensive hydrocephalus is a rare clinical entity (prevalence of 1:25 000 in the general population), characterized by the presence of triad: progressive dementia, ataxia (Parkinson-like) and urinary incontinence. The only efficient therapy for HAS is the implantation of ventriculo-atrial or ventriculo-peritoneal shunts, in order to drain the excess cerebrospinal fluid (CSF). However, long-term maintenance of these devices may predispose to severe complications (e.g. infection, thrombosis).

We report the case of a 38 years old patient who suffered a head trauma with subarachnoid hemorrhage and subsequent hydrocephalus, for which a shunt between left lateral cerebral ventricle and right atrium of the heart has been placed. The patient presented progressive resting dyspnea, chest pain and intermittent fever. The initial transthoracic echocardiography revealed a highly mobile mass in the right atrium, without being able to specify the exact place of insertion. In addition, severe pulmonary hypertension and major tricuspid regurgitation were observed. The computed tomography also revealed bilateral pulmonary embolism with areas of pulmonary infarction. The clinical features and echocardiography aspects suggested a possible infective endocarditis of tricuspid valve, therefore a transesophageal echocardiography was necessary. This exploration revealed the presence of a ∼ 40 mm pangliform mass originating from the inter-atrial septum, near the superior vena cava opening in the right atrium, without any link with the tricuspid valve. Basically it was a thrombus, an endoluminal molding of the shunt used to drain CSF. Given the coexistence of pulmonary embolism and the intra-cavitary mass with high emboligenic potential, the heart team in collaboration with neurosurgeons decided to administer heparin, with good clinical and biological evolution.

The association between Hakim-Adams syndrome and pulmonary embolism secondary to intra-shunt thrombosis is a very rare clinical entity. The case particularity is also determined by the initial suspicion of infective endocarditis, a diagnosis infirmed only through transesophageal echocardiography. This also guided the further therapeutic approach, considering that anticoagulants are a first-line choice in pulmonary embolism, but are not recommended in endocarditis.
540 Assessment of left ventricular ejection fraction from echocardiographic images using machine learning algorithm
Authors: Yamaguchi N , Kusunose K , Haga A , Morita S , Hirata Y , Torii Y , Nishio S , Ookushi Y , Takahashi T , Yamada N , Yamada H , Sata M
Published: January 2020

Background

Precise and reliable echocardiographic assessment of LVEF is needed for clinical decision-making. LVEF is currently determined through an observer dependent process that requires manual tracing. To remove this manual tracing step, which is both time-consuming and user dependent, automatic computer aided diagnosis systems may be useful in the clinical setting.

Purpose

The aim of this study was to evaluate whether a 3-dimensional convolutional neural networks (3DCNN) could estimate left ventricular ejection fraction (LVEF) and differentiate types of heart failure (preserved EF/reduced EF) using conventional 2-dimensional echocardiographic images.

Methods

We developed a deep learning model to automatically estimate LVEF from echocardiographic data. The 3DCNN model was trained on a dataset of 340 patients. The dataset creation consisted of three main steps: firstly, for each exam, cine-loops showing the parasternal and apical views were manually selected; then, 10 sequential frames were extracted from each 1 beat and; finally, each frame was pre-processed to fit the learning model. Each patient has 2 views, resulting in a total of 6,800 images. Reference LVEF measurement was calculated by two highly experienced readers in each case.

Results

A good correlation was found between estimated LVEF based on apical 2 and 4 chamber views and reference LVEF (r =0.88, p <0.001) (Figure). For classification of heart failure types based on LVEF (LVEF ≥50% or <50%), the area under the receiver-operating characteristic curve by the 3DCNN algorithm was over 0.95.

Conclusions

The 3DCNN can be applied to estimate and classify the LVEF in the clinical setting. Furthermore, this work will serve as a driver for future research using million image databases.

Abstract 540 Figure.
543 Automated detection of mitral annular plane systolic excursion in transoesophageal echocardiography based on deep learning
Authors: Nordal T , Berg E A R , Kiss G
Published: January 2020

Introduction

Major surgery and interventions may impact cardiac function. Perioperative monitoring is currently based on vital signs and clinical observations. However, this does not offer a complete monitoring of left ventricular function throughout the intervention. We hypothesize that functional monitoring of the heart can be performed automatically based on transoesphageal echocardiography (TOE) images. One parameter that has been shown to correlate well with ejection fraction is mitral annular plane systolic excursion (MAPSE). To aid functional monitoring of the left ventricle perioperatively, we propose a technique for detecting MAPSE in TOE images of the left ventricle.

Purpose

The purpose of this study is to automatically track the movement of the mitral annular plane in TOE sequences of the left ventricle and detect MAPSE via a deep learning approach.

Method

Recordings from 131 consecutive complete TOE exams from the Echocardiography Unit were anonymized and used for training. Recordings from 23 consecutive TOE exams, also anonymized, were used as test set. All recordings were manually annotated with the location of the landmarks indicated in both 4-chamber (4C) and 2-chamber (2C) views. All recordings were made using state-of-the-art clinical scanners. The captures include 3 to 5 heart cycles of standard 4C and 2C views.

An approach based on a fully convolutional neural network was implemented and trained in a supervised manner to predict the location of two landmarks on the mitral annular plane in B-mode TOE images from 4C and 2C views. The model was also trained to account for noise by recognizing when detecting the landmarks is not feasible due to poor image quality. We have implemented all necessary post processing calculations to automatically estimate MAPSE based only on raw TOE B-mode sequences.

Results

Preliminary results on the test data show that the landmark detector is able to track the vertical movement of landmarks on the mitral annular plane with a mean error of 0.88 mm and a standard deviation of 0.27 mm (Fig. 1: Upper left and lower left: tracked mitral attachment points on a sample case presented upper right. Lower right: all measured Y-axis excursion values versus the reference). The classifier for detecting ultrasound frames where landmark detection is not feasible has a sensitivity of 0.82 and a specificity of 0.91.

Conclusion

The landmark detector is showing promising results in tracking of the mitral annular plane excursion. This can provide a fast calculation of MAPSE and eliminate intraobserver variability. This may be included in a more extensive cardiac monitoring for any type of surgery without the need of manual input from echocardiographers. Further research is ongoing and a comparison with clinical MAPSE values is underway.

Abstract 543 Figure 1
552 Natural history of bivalvular functional regurgitation
Authors: Heitzinger G , Bartko P E , Arfsten H , Pavo N , Winter M P , Toma A , Strunk G , Hengstenberg C , Huelsmann M , Goliasch G
Published: January 2020

Introduction

Bivalvular functional regurgitation (BVFR) defined as concomitant mitral and tricuspid insufficiency has not been described or systematically assessed before. The present study therefore sought to define incidence, impact and natural history of BVFR in heart failure with reduced ejection fraction (HFrEF) to provide the foundation for risk assessment and directions for potential treatment strategies.

Methods

We enrolled 1021 consecutive patients with HFrEF under guideline-directed medical therapy and performed comprehensive echocardiographic and neurohumoral profiling. Mitral and tricuspid regurgitation was quantified by an integrated approach comprising valve morphology, width of the proximal regurgitant jet, proximal flow convergence, and pulmonary venous flow. All-cause mortality during a five-year follow up served as the primary endpoint.

Results

Thirty percent of patients suffered from moderate or severe BVFR. Long-term mortality increased with the presence and severity of FR with severe BVFR representing the highest risk-subset (P < 0.001). Severe BVFR patients were more symptomatic and displayed an adverse remodeling and neurohumoral activation pattern (all P < 0.05). Severe BVFR was associated with excess mortality (Figurel 1, Panel A) independently of clinical (adj.HR 1.52, 95%CI 1.39-1.84;P < 0.001) and echocardiographic (adj.HR 1.31, 95%CI 1.11-1.54;P = 0.001) confounders, guideline-directed medical therapy (adj. HR 1.55, 95%CI 1.35-1.79;P < 0.001) and neurohumoral activation (adj.HR 1.31, 95%CI 1.07-1.59;P = 0.009). Moderate BVFR (n = 99) comprised equal baseline characteristics and similar risk as isolated severe FR. (Figure 1, Panel B) (HR 0.95, 95%CI 0.69-1.30;P = 0.73).

Conclusion

This long-term outcome study shows the multi-faceted nature of FR and defines BVFR as an important clinical entity associated with impaired functional class, adverse cardiac remodeling and excess risk of mortality. Moderate BVFR conveys similar risk as isolated severe FR reflecting the deleterious impact of the global regurgitant load on the failing heart and the need of an integrated understanding for risk-assessment.

Abstract 552 Figure 1 (Panel A and B)
567 Interplay of infarct territory related myocardial mechanics and prognostic implications following acute myocardial infarction
Authors: Backhaus S J , Kowallick J T , Stiermaier T , Lange T , Koschalka A , Navarra J L , Lotz J , Kutty S , Bigalke B , Gutberlet M , Feistritzer H J , Hasenfus G , Thiele H , Eitel I , Schuster A
Published: January 2020

Background

Prognosis in acute myocardial infarction (AMI) depends on the amount of infarct related artery (IRA) subtended myocardium and associated damage but has not been described in great detail. Consequently, we sought to describe IRA associated pathophysiological consequences using cardiac magnetic resonance (CMR).

Methods

1235 AMI patients (n = 795 ST-elevation (STEMI) and 440 non-STEMI) underwent CMR following percutaneous coronary intervention. Blinded core-laboratory data were compared according to left anterior descending (LAD), left circumflex (LCx) and right coronary artery (RCA) regarding major adverse clinical events (MACE) within 12 months. Left ventricular (LV) global longitudinal/circumferential/radial (GLS/GCS/GRS) as well as left atrial (LA) total (εs), passive (εe) and active (εa) strains were determined using CMR-feature tracking. Tissue characterisation included infarct size (IS) and microvascular obstruction.

Results

LAD and LCx were associated with higher mortality compared to RCA lesions (4.6% and 4.4% vs 1.6%). LAD lesions showed largest IS (16.8%), largest ventricular (LV ejection fraction (EF) 47.4%, GLS -13.2%, GCS -20.8%) and atrial (εs 20.2%) impairment. There was less impairment in LCx (IS 11.8%, LVEF 50.8%, GLS -17.4%, GCS -25.0%, εs 20.7%) followed by RCA lesions (IS 11.3%, LVEF 50.8%, GLS -19.1%, GCS -26.6%, εs 21.7%). In AUC analyses εs (LAD, RCA) and GLS (LCx) best predicted MACE (AUC > 0.69). Multivariate analyses identified εs (p = 0.017) in LAD and GLS (p = 0.034) in LCx infarcts as independent predictors of MACE.

Conclusions

CMR allows IRA specific phenotyping and characterisation of morphologic and functional changes. These alterations carry infarct specific prognostic implications and may represent novel diagnostic and therapeutic targets following AMI.
571 Echo-Omics to estimate prognosis after an acute myocardial infarction: which one to pic?
Authors: De Campos D , Saleiro C , Teixeira R , Botelho A , Lopes J , Puga L , Ribeiro J M , Sousa J , Lourenco C , Reis L , Madeira M , Goncalves L
Published: January 2020

BACKGROUND

Simple and reproducible echocardiographic parameters are still the cornerstone of daily clinical practice. These data provides important information for the evaluation of patients with ST-segment elevation myocardial infarction (STEMI). The identification of prognostic echocardiographic parameters in STEMI would help in risk stratification.

PURPOSE

To evaluate the discriminatory capacity of echocardiographic parameters after a STEMI.

METHODS

Single centre retrospective observational study of 303 patients with STEMI who survived hospital stay and had a complete echocardiographic evaluation. The following ecocardiographic parameters were collected at discharge: left ventricular (LV) systolic and diastolic volumes; septal and posterior wall thickness; LV ejection fraction (LVEF); left atrial (LA) diameter; estimated systolic pulmonary artery pressure (SPAP). One year and long-term all cause mortality were analyzed.

RESULTS

For the patients enrolled (71% males, 64.6 ± 14.1 years old), peak troponin I was 99.1 ± 126.5 ng/mL; mean GRACE score was 153.6 ± 38.8 points and mean LVEF was 46.2 ± 11.2%. One year mortality was 8.3% and during a median 73 months follow-up, 25.1% patients were deceased. After adjustment for echocardiographic variables in a Cox regression model, SPAP (HR 1.07, 95%CI 1.02-1.12, P = 0.007) and septal thickness (HR 1.36, 95%CI 1.08-1.73, P = 0.01) were both independently associated with one year mortality. A Kaplan-Meier survival methodology using stratified SPAP and septal thickness showed a trend of different event rate (log rank P = 0.003 and P = 0.035, respectively), with a gradation of cumulative risk for all-cause mortality, with a sharp increase at >40mmHg and >11mm, respectively. Regarding longterm follow-up, only increased SPAP proved to be an independent predictor of mortality (HR 1.04, 95%CI 1.01-1.08, P = 0.016). The difference in favor of an SPAP <33mmHg (sensitivity 86.67% and specificity 54.1%) was seen early after the STEMI event and maintained at each interim analysis (log rank P = 0.002). Upon the visual analysis of the cubic spline curves, patients with SPAP < ± 30mmHg had a good long-term survival. No association of LV volumes or LVEF was noted for both one year and long-term mortality.

CONCLUSION

Classic echocardiographic parameters still have a role to estimate prognosis after STEMI. Estimated SPAP had the greatest discriminatory capabilities, surpassing left ventricular ejection fraction!

Abstract 571 FIGURE 1
618 Adaptive myocardial mechanics in aortic stenosis patients
Authors: Alfarih M , Alfuhied A , Kumar M P , Lloyd G , Hughes A D , Moon J C , Mohiddin S , Captur G , Nihoyannopoulos P
Published: January 2020

Introduction

Left ventricular (LV) hypertrophy in aortic stenosis (AS) becomes maladaptive over time, leading first to a reduction in global longitudinal strain (GLS) and in a later stage a reduction in ejection fraction (EF). The myocardial state of impaired GLS but preserved EF is a key remodeling turning point in AS, yet little is known about the coping mechanics of the LV at or around this sensitive juncture.

Aim

1) To study the relationship between LV mass index (LVMi) increase and measures of LV function, including strain in AS; 2) To investigate whether augmentation of global myocardial radial and circumferential strain (GRS, GCS) compensates for the GLS reduction in AS patients with preserved EF.

Methods

One-hundred and eleven patients with varying degrees of AS, and 20 age- and gender-matched healthy volunteers were prospectively enrolled. transthoracic echocardiography with offline strain analysis was performed using TomTec software. Intra- and inter-observer variability of linear LV internal dimensions/thickness, EF and strain indices was tested on 20 randomly selected patients.

Results

Clinical and demographic characteristics of cases and controls are shown in Figure 1. GLS was impaired in AS patients compared to controls. In AS with preserved EF (>50%), as LVMi increased, GLS progressively improved up to a point, beyond which any further increase in LVMi appeared counter-productive with impairment of GLS (Figure 1). EF preservation in these AS patients was mediated by a compensatory supernormal augmentation of GRS and a smaller augmentation of GCS (Figure 1). We observed a significant inverse correlation between GRS and GLS (r = 0.3, p = 0.002), and a similar trend between GCS and GLS (r = 0.275, p = 0.004). Intraclass correlation coefficient was high for all measurements (0.7-0.9).

Conclusion

In patients with AS and preserved EF, progressive myocardial hypertrophy improves GLS up to a point beyond which GLS drops and GRS increase to compensate. This plasticity of myocardial mechanics, in particular the supranormal augmentation of GRS is what enables the pathologically hypertrophied AS ventricle to delay the otherwise inexorable decline in its global systolic function.

Abstract 618 Figure 1
624 Is TAVI a useful procedure in paradoxical low flow-low gradient aortic stenosis? A long-term mortality study
Authors: Fusini L , Muratori M , Corrieri N , Capodaglio I , Tamborini G , Ghulam Ali S , Italiano G , Gripari P , Salvi L , Roberto M , Fabbiocchi F , Agrifoglio M , Bartorelli A L , Alamanni F , Pepi M
Published: January 2020

Background

Clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement are controversial. PLF-LG is a combination of a small aortic valve area (AVA < 1cm²), a preserved left ventricular (LV) ejection fraction (LVEF≥50%), and a ‘paradoxical’ low mean gradient due to the presence of low LV stroke volume (≤35 mL/m²). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Surgical aortic valve replacement has been associated with very positive outcomes in normal-flow high-gradient (NF-HG) AS, whereas poorer outcomes has been reported in patients with PLF-LG AS.

Purpose

The aim of this study is to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients.

Methods

A total of 624 patients (age 81 ± 7 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in 2 groups: group NF-HG included 554 patients (89%) and group PLF-LG including 70 patients (11%). At 1-year follow-up, death and clinical events were reported.

Results

TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30 ± 6 mmHg; 1-year, 12 ± 4 mmHg; p < 0.001) and in NF-HG (baseline, 55 ± 12 mmHg; 1-year, 11 ± 4 mmHg; p < 0.001) together with an increase in AVA (PLF-LG: baseline, 0.73 ± 0.16 cm², 1-year: 1.82 ± 0.43 cm², p < 0.001; NF-HG: baseline, 0.66 ± 0.18 cm², 1-year: 1.84 ± 0.38cm², p < 0.001). Perioperative mortality at 30-days was similar in group NF-HG (17/554, 3%) and in group PLF-LG (2/70, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p = 0.127).

Conclusions

Differently from surgical series, TAVI in PLF-LG AS is a useful procedure showing similar mortality and rehospitalization rates compared to NF-HG AS patients.

Abstract 624 Figure. Survival curve
P626 Peripartum cardiomyopathy with persistent ventricular dysfunction and intracavitary thrombosis despite treatment with dopamine receptors agonist. The role of the three-dimensional echocardiography
Authors: Vasquez-Ortiz Z Y , Gonzalez-Varela R , Navarrete Garcia J , Hernandez-Reyes P , Oseguera Moguel J
Published: January 2020

Introduction

Peripartum cardiomyopathy (MPP) is a type of cardiomyopathy characterized by heart failure secondary to left ventricular systolic dysfunction during the last month of pregnancy or in the first 5 months of puerperium without other apparent etiology, being a diagnosis of exclusion. The left ventricle is not always dilated, but the fraction of left ventricular ejection is always less than 45%. The natural history and prognosis of the disease is diverse. Ventricular dysfunction is usually transient and normalizes at 3-6 months in up to 60% of cases. Mortality is variable, with reports ranging from 0 to 28%, affecting more certain ethnic groups, in patients with persistent ventricular dysfunction, evidence of the efficacy of a specific treatment beyond optimal medical therapy for heart failure is limited.

Clinical case

We present the clinical case of a 22-year-old woman, who was referred to the our institute with an acute heart failure syndrome two months after the end of her first pregnancy. On admission to the hospital, dilated cardiomyopathy and intracavitary thrombi were documented by transthoracic echocardiography (TTE) with dilatation and eccentric left ventricular hypertrophy, generalized hypokinesia and mobile thrombi inside, the largest of 34x16mm with severe left ventricular dysfunction 3D LVEF of 28% and global longitudinal strain (GLS) of -5.8%, pulmonary hypertension and right ventricular dysfunction with severe functional tricuspid regurgitation. Other specific etiologies of dilated cardiomyopathy were investigated and discarded, finally establishing the diagnosis of peripartum cardiomyopathy. The support management was carried with inotropic, diuretic, supplemental oxygen and parenteral anticoagulation was initiated, with gradual improvement. Subsequently, optimal medical treatment was started for heart failure, cabergoline and vitamin K antagonist. He was released to his home on II NYHA. Two months later she presented with progressive dyspnea, increased abdominal perimeter. On March 14, 2018, a TTE was performed, with absence of improvement in conventional and advanced ventricular function parameters. Apical thrombi of smaller size compared with previous study, severe left ventricular dysfunction, which worsened with respect to the previous echocardiogram, with 3D LVEF of 25% and GLS 3.7%

Discussion

We present the case of a woman with MPP, in whom persistent left ventricular dysfunction after 6 months of diagnosis, although cabergoline scheme in addition to optimal medical management for heart failure, with no improvement. In patients who dont present an adequate response to the management, it is necessary to consider enlisting for heart transplantation.

Abstract P626 Figure. TTE, severe ventricular dysfunction