bluuebunny/crossref_metadata_2025_split huggingface dataset:
The spectrum of functional responses during ABCDE stress echocardiography
Authors: Zagatina A , Ciampi Q , Cortigiani L , Borguezan-Daros C , De Castro E Silva Pretto J.L , Wierzbowska-Drabik K , Zanella H , Merlo P.M , Djordjevic-Dikic A , Boshchenko A , Arbucci R , Monte I , Lowenstein J , Rigo F , Picano E 
Published: November 2020

Abstract

Background
The new methodological standard in stress echo (SE) is the comprehensive approach with ABCDE protocol: step A for regional wall motion abnormalities (RWMA); step B for B-lines by lung ultrasound; step C for left ventricular contractile reserve (LVCR); step D for Doppler-based coronary flow velocity reserve (CFVR) in left anterior descending coronary artery; and step E for imaging-independent EKG-based heart rate reserve (HRR).

Purpose
To assess the feasibility of ABCDE-SE in a prospective, large scale, multicenter, international, effectiveness study.

Methods
From September 2016 to December 2019, we enrolled 4,585 all-comers patients (age 63±11 years, 2,566 males, 56%; ejection fraction 61±9%) with known or suspected chronic coronary artery disease referred to clinically-driven SE with exercise (n=1,774, 38.7%), dipyridamole (n=2,403, 52.4%), dobutamine (n=375, 8.2%) or adenosine (n=33, 0.7%). Recruitment involved 13-certified laboratories of 7 countries. All patients underwent ABCDE-SE. The same transducer was used for cardiac and lung scan. Criteria for abnormal response were: stress-induced changes in RWMA in 2 contiguous segments for step A; stress-rest increase in B-lines ≥2 for step B (4-site simplified scan, each site scored from 0= A-lines or black lung to 10= white lung for coalescing B-lines); LVCR ≤2.0 for exercise and dobutamine (≤1.1 for vasodilators) for step C; CFVR in LAD ≤2.0 for step D; HRR (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators) for step E.

Results
Success rate was 98%, 100%, 99%, 86% and 100% for A, B, C, D and E steps, respectively. The positivity rate was 19% for A, 27% for B, 35% for C, 27% for D and 37% for E. All 5 parameters were normal in 1,496 patients (32.6%), all 5 were abnormal in 183 patients (4.0%). Most patients had abnormal response of 1 (n=1,356, 29.6%), 2 (n=788, 17.2%), 3 (n=477, 9.7%) or 4 (n=315, 6.9%) criteria (see Figure).

Conclusions
ABCDE-SE is extremely feasible, user-friendly, with minimal increase in imaging and off-line analysis time. It allows a comprehensive and personalized functional stratification assessing different vulnerabilities: epicardial coronary artery stenosis (step A), pulmonary congestion (step B), global myocardial dysfunction (step C), coronary microcirculatory dysfunction (step D), and cardiac autonomic nervous system imbalance (step E). The SE response is not only black and white with step A but can be effectively titrated from benign green code (all steps negative) to more functionally malignant red code (at least 3 steps positive).
Figure 1

Funding Acknowledgement
Type of funding source: None
Parameters of left atrial during stress in patients with asymptomatic primary mitral regurgitation
Authors: Zvirblyte R , Tamulenaite E , Saniukaite A , Merkyte I , Mizariene V , Ereminiene E , Vaskelyte J.J 
Published: November 2020

Abstract

Introduction
Progressive volume overload caused by chronic mitral regurgitation (MR) leads to left atrium (LA) and left ventricle (LV) remodeling. Despite these structural changes, most of MR patients may remain asymptomatic for a long time. LA enlargement and reduced LA deformation parameters in asymptomatic MR patients predict a worse prognosis and may provide additional information to guide for earlier surgery.

Purpose
The aim of the study was to evaluate changes of LA size and deformation parameters in patients with asymptomatic primary MR during stress.

Methods
84 asymptomatic patients (age 59.87±13.47 years) with sinus rhythm and preserved left ventricle (LV) ejection fraction (EF) (&gt;50%) at rest were included in the study. Resting and stress (veloergometry as per protocol 25 + 25 W every 3 minutes) echocardiography and speckle tracking off-line analyses were performed to 52 (61.9%) patients with moderate MR (MR group) and 32 (38.1%) patients without significant heart valves disease (control group). Statistical analyses were performed using the SPSS 20.0 software. The value of p&lt;0.05 was considered as statistically significant.

Results
Volume index of LA was significantly higher in subjects with MR (picture 1). LA area was similar in MR and control groups at rest. However, during stress LA area became significantly larger in MR group (picture 1). LA myocardial deformation parameters were calculated during 3 phases of LA cycle: reservoir phase strain (LASr), conduit phase strain (LAScd), contraction phase strain (LASct). At rest, during peak stress and at recovery phase all of them were higher in controls but difference was not significant. During initial stress (25 W) LAScd was significantly higher in MR group (−16.86±−8.06% vs. −11.33 ±−6.26% p=0.034), while healthy subjects had a tendency to lower LASr (20.32±10.53% vs. 22.7±10.89%, p=0.535) (picture 1). Better LV EF at rest was related to smaller LA area (p=0.003, r – 0.390) and volume index (p=0.020, r – 0.308) during peak stress.

Conclusions
Stress provokes significant increase of LA size (volume and area) and LAScd in patients with primary mitral regurgitation. Other myocardial deformation parameters of LA were not significantly related to MR. LV EF at rest correlates with LA parameters during peak stress.
Changes of LA parameters during stress

Funding Acknowledgement
Type of funding source: None
The five-beat averaged method of assessing aortic stenosis in atrial fibrillation significantly underestimates stenosis severity compared to sinus rhythm
Authors: Tomlinson S , Mandala A , Hayman S , Scalia G 
Published: November 2020

Abstract

Background
Doppler echocardiographic assessment of aortic stenosis (AS) is dependent on trans-valvular flow rate (TVFR) and is most accurately performed in physiologically normal conditions (TVFR &gt;200ml/s). Atrial fibrillation (AF) complicates AS assessment with heart rate variability and reduced averaged indexed stroke volume (SVi) compared to sinus rhythm (SR). We hypothesize that the 5-beat averaging technique in AF leads to underestimation of severity of AS compared to SR, and that diagnostic accuracy may be improved by maximum SVi beat selection.

Methods
Patients with at least mild AS (mean aortic gradient (MG) &gt;15mmHg) with separate echocardiograms demonstrating SR and AF within a six-month period were identified. Patients with interval cardiac surgery, change in left ventricular ejection fraction (LVEF) of &gt;15%, aortic valve prostheses, infective endocarditis, paced rhythm, severe concomitant valvular dysfunction, LVEF &lt;35%, heart rate &gt;100 beats per minute (bpm) or TVFR &lt;200ml/s on their SR examination were excluded. In AF, individual beat SVi was calculated from individual beat aortic velocity time integral (VTI) and the reported aortic valve area (AVA) via the continuity equation.

Results
Seventeen patients were identified (mean time between echocardiograms 132 days, mean difference in LVEF 4%, mean difference in heart rate 11bpm). Using the 5-beat averaged model, compared to SR, the presence of AF significantly reduced SVi (−12.68ml/m2, p=0.00007) and TVFR (−69ml/s, p=0.00014). In AF, 9/17 cases demonstrated one or more beats with TVFR &lt;200ml/s, with 6/17 producing a 5-beat averaged TVFR &lt;200ml/s – consistent with a low flow state. Correspondingly, flow derived severity assessment parameters and calculated aortic valve area (AVA) in AF were reduced compared to SR (aortic peak velocity (Vmax) −0.42m/s, p=0.00005, MG −7.01mmHg, p=0.002, AVA −0.11cm2, p=0.025). As a proposed correction in AF, the single beat with the largest SVi was compared with SR. This measure improved concordance with flow conditions and severity assessment in SR (difference SVi −8.77ml/m2, p=0.004, TVFR −46ml/s, p=0.001, Vmax −0.21, p=0.003, MG −3.55mmHg, p=0.02) and equalized calculated AVA (−0.07cm2, p=0.09).

Conclusion
In individual patients with AS observed in SR and AF within a six-month period, AF was associated with significantly lower SVi and TVFR, with underestimation of AS severity assessment. AS assessment in AF using maximum observed stroke volume beat (as opposed to 5-beat average) improves concordance with SR assessment significantly.

Funding Acknowledgement
Type of funding source: None
A novel echocardiographic-derived classification after LAA closure can accurately predict incomplete ostial closure and significant peri-device leaks
Authors: Hamadanchi A , Ijuin S , Haertel F , Baez L , Franz M , Schulze C , Moebius-Winkler S 
Published: November 2020

Abstract

Background
The assessment of residual peri-device leaks (PDL) after percutaneous left atrial appendage closure (LAAC) remains crucial in the post-procedural management. Clinical significance of PDL is still poorly understood and echocardiographic recognition of PDL remains challenging. This study aimed to verify a novel proposed echocardiographic classification for prediction of clinically significant PDL following LAAC.

Methods
We retrospectively evaluated our echocardiographic data of 72 patients who underwent percutaneous LAAC at the University Hospital Jena between September 2015 - 2018. All echo images were transferred to a workstation for offline analysis by two independent investigators. Total number of studies was 127. We proposed a morphological classification of LAA devices (Fig. 1A-C) based on the amount of echodensity and luceny inside the devices into three types: type A: homogenous echodensity in 0, 45, 90 and 135°; indicating completely thrombosed device, type B with inhomogeneous echo-lucencies (&lt;50% of device) and type C: partially thrombosed device with echo-lucencies &gt;50% of total, which we labeled “ice-cream cone” sign. Each type was then matched to the degree of PDL and other clinical and paraclinical parameters.

Results
Tab.1 shows patient's characteristics. PDL was found in 21% of patients. Four patients showed regression of PDL after 160 days. Patients with type C had the most percentage of PDL in three types at 6 months follow-up (type A: 7%, type B: 33%, type C 100%, p&lt;0.001). Device size in patients with type C was largest in three types (type A: 25.9±3.6mm, type B: 25.8±3.4mm, type C 29.8±3.0mm, type A vs. B, p=0.018; type B vs. C, p=0.007). Mean compression rate after 45 days was 21±9.3% in type A vs. 14±7.4% in type C (p=0.022). Ice cream sign showed a sensitivity of 53.1%, specificity of 100% and positive predictive value of 100% for prediction of PDL.

Conclusion
Our data demonstrate that: 1) This novel classification irrespective of anticoagulation regimen, can accurately discriminate among various degrees of PDL, in such that type C or “ice cream sign” has a very high positive predictive value for PDL (100%). 2) Type A, the ideal type, is associated with smaller landing zones and a higher compression rate.

Funding Acknowledgement
Type of funding source: None
Fully automated contrast and non-contrast cardiac view detection in echocardiography a multi-centre, multi-vendor study
Authors: Gao S , Stojanovski D , Parker A , Marques P , Heitner S , Yadava M , Upton R , Woodward G , Lamata P , Beqiri A , Leeson P 
Published: November 2020

Abstract

Background
Correctly identifying views acquired in a 2D echocardiographic examination is paramount to post-processing and quantification steps often performed as part of most clinical workflows. In many exams, particularly in stress echocardiography, microbubble contrast is used which greatly affects the appearance of the cardiac views. Here we present a bespoke, fully automated convolutional neural network (CNN) which identifies apical 2, 3, and 4 chamber, and short axis (SAX) views acquired with and without contrast. The CNN was tested in a completely independent, external dataset with the data acquired in a different country than that used to train the neural network.

Methods
Training data comprised of 2D echocardiograms was taken from 1014 subjects from a prospective multisite, multi-vendor, UK trial with the number of frames in each view greater than 17,500. Prior to view classification model training, images were processed using standard techniques to ensure homogenous and normalised image inputs to the training pipeline. A bespoke CNN was built using the minimum number of convolutional layers required with batch normalisation, and including dropout for reducing overfitting. Before processing, the data was split into 90% for model training (211,958 frames), and 10% used as a validation dataset (23,946 frames). Image frames from different subjects were separated out entirely amongst the training and validation datasets. Further, a separate trial dataset of 240 studies acquired in the USA was used as an independent test dataset (39,401 frames).

Results
Figure 1 shows the confusion matrices for both validation data (left) and independent test data (right), with an overall accuracy of 96% and 95% for the validation and test datasets respectively. The accuracy for the non-contrast cardiac views of &gt;99% exceeds that seen in other works. The combined datasets included images acquired across ultrasound manufacturers and models from 12 clinical sites.

Conclusion
We have developed a CNN capable of automatically accurately identifying all relevant cardiac views used in “real world” echo exams, including views acquired with contrast. Use of the CNN in a routine clinical workflow could improve efficiency of quantification steps performed after image acquisition. This was tested on an independent dataset acquired in a different country to that used to train the model and was found to perform similarly thus indicating the generalisability of the model.
Figure 1. Confusion matrices

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Ultromics Ltd.
Exercise capacity is associated with rest and peak-exercise left ventricular global longitudinal strain in patients with hypertrophic cardiomyopathy
Authors: Fava A.M , Alashi A , Saijo Y , Sande Mathias I , Popovic Z , Thamilarasan M , Lever H , Desai M.Y 
Published: November 2020

Abstract

Background
Patients with hypertrophic cardiomyopathy (HCM) frequently have reduced exercise capacity, which can be associated with subclinical cardiac dysfunction. Left ventricle global myocardial strain (LV-GLS) is a sensitive index to detect subclinical myocardial dysfunction. However, the clinical utility of LV-GLS during exercise test remains uncertain.

Purpose
We assessed the association of functional capacity with LV-GLS at rest and at the peak of stress in HCM patients.

Methods
We examined 566 asymptomatic/minimally symptomatic HCM patients (54±14 years, 57% men, body mass index 30±6 kg/m2, 84% on beta-blockers) by echo at rest and following maximal exercise. We recorded clinical, echo variables (LV ejection fraction [LVEF], LV thickness, left ventricle mass index [LVMI], left ventricle outflow tract [LVOT] gradient, LV-GLS at rest and at peak stress), and exercise variables (percent of age-gender predicted metabolic equivalents [AGP-METs]).

Results
Echo parameters were as follows: LVEF at rest of 62±6%, wall thickness of 16.9±0.4 mm, LVMI of 117±47 g/m2, LVOT gradient at rest of 27±33 mmHg, LV-GLS at rest of −15.9±3.6%, LV-GLS at peak of stress of −17.4±4.3%, and change in LV strain from rest to stress of −1.9±2.3%. Only 41% of patients achieved &gt;85% of AGP-METs. Logistic regression demonstrating an association between AGP-METs less than 85% and various predictors are shown in Table 1.

Conclusion
Impaired deformation at peak of stress assessed by LV-GLS was associated with reduced exercise capacity measured as AGP-METs less than 85%. These findings suggest that early systolic cardiac deterioration should be considered as a cause of exercise impairment in patients with HCM.

Funding Acknowledgement
Type of funding source: None
Cardiac time intervals predict major adverse cardiovascular events in individuals with type 1 diabetes without known heart disease
Authors: Brainin P , Lassen M.C.H , Joergensen P.G , Biering-Soerensen T , Andersen H.U , Rossing P , Jensen M.T 
Published: November 2020

Abstract

Background
Cardiac time intervals, and in particular the myocardial performance index (MPI) which combines systolic and diastolic function, are associated with cardiovascular prognosis in various populations. We aimed to investigate if cardiac time intervals offer prognostic information on cardiovascular risk in individuals with type 1 diabetes (T1DM).

Methods
We prospectively included 1,088 individuals with T1DM without known heart disease (mean age 50±15 years; 53% male; duration of diabetes 26±15 years; 30% had albuminuria). All enrolled individuals underwent an echocardiographic examination with assessment of cardiac time intervals by color Tissue Doppler imaging M-mode. We evaluated the isovolumetric relaxation and contraction time (IVRT; IVCT) and ejection time (ET). The MPI was calculated as [(IVRT+IVCT)/ET]. In Cox proportional hazards models, we assessed major adverse cardiovascular events (MACE), a composite of incident heart failure or hospitalization for acute coronary syndrome or PCI/CABG. Multivariable models were adjusted for clinical information, pharmacotherapy and echocardiographic parameters.

Results
During the median follow-up time of 6 years [IQR 6, 7 years], 106 (10%) experienced MACE. In adjusted survival analyses the IVRT (HR: 1.13 per 10ms increase [1.01 to 1.26], P=0.026) and MPI (HR: 1.03 per 1 unit increase [1.01 to 1.04], P=0.005) were associated with MACE. Overall, the association between IVCT and outcome was borderline significant (HR: 1.15 per 10ms increase [0.97 to 1.36], P=0.10) while there was no association for ET (HR: 0.97 per 10ms increase [0.89 to 1.05], P=0.43). Sex modified the association for IVCT (P interaction&lt;0.05) such that IVCT (HR: 1.23 per 10ms increase [1.02 to 1.49], P=0.027) and MPI (HR 1.03 per 1 unit increase [1.01 to 1.05], P=0.005; Figure) were associated with MACE in women but not in men.

Conclusion
Cardiac time intervals are positively associated with MACE in T1D without known heart disease. Furthermore, the association is modified by sex in that the IVCT and MPI provide independent and prognostic information on the risk of future cardiovascular events particularly in female individuals while not significant in men. These findings suggest sex differences in myocardial impairment related to T1D.
Association between MACE and MPI in DM1

Funding Acknowledgement
Type of funding source: None
Prognostic utility of early systolic lengthening by speckle tracking echocardiography in patients with type 2 diabetes
Authors: Brainin P , Jensen M.T , Biering-Soerensen T , Moegelvang R , Fritz-Hansen T , Vilsboell T , Rossing P , Joergensen P.G 
Published: November 2020

Abstract

Background
Early systolic lengthening (ESL) has recently recognized as a predictor of cardiovascular events in patients with myocardial ischemia. Our aim was to evaluate the prognostic value of ESL in patients with type 2 diabetes.

Methods
In this prospective study we conducted speckle tracking examinations in 743 patients with type 2 diabetes (62% male; age 63±10 years; diabetes duration 11 [5, 17] years). Patients were free from interventricular conduction disturbances, atrial fibrillation, heart failure and ischemic heart disease at study inclusion. We assessed the ESL index, defined as: (−100 x [peak positive systolic strain / global longitudinal strain (GLS)]), and duration of ESL, defined as time from onset of QRS complex on the electrocardiogram to time of peak positive systolic strain. Measurements were averaged from 18 myocardial segments.

Results
During the median follow-up time of 4.8 years [IQR 4, 5.3 years], 93 (13%) patients experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction and cardiovascular death. Because GLS modified the association with MACE (P interaction &lt;0.05), the population was stratified by the median GLS value (low &gt;−15% and high ≤−15%). In patients with low GLS, the ESL index (HR 1.47 per 1% increase [1.12 to 1.93], P=0.005) and ESL duration (HR 1.73 per 1ms increase [1.10 to 2.72], P=0.017) were associated with MACE. Both associations remained significant in multivariable models adjusted for clinical, echocardiographic and speckle tracking measurements (Figure). No associations were found in patients with high GLS (Figure).

Conclusion
Assessment of ESL yields novel and independent prognostic information on major adverse cardiovascular events in patients with diabetes type 2 and reduced longitudinal strain.
Forest plot: ESL and risk of MACE by GLS

Funding Acknowledgement
Type of funding source: None
Echocardiographic predictors of atrial fibrillation in middle-aged patients without overt heart disease
Authors: Borizanova-Petkova A , Georgieva N , Kinova E , Goudev A , Koleva V 
Published: November 2020

Abstract

Background
Left atrial volume index (LAVi) has been established as a surrogate marker for chronically elevated left ventricular (LV) filling pressure. Moreover it is a powerful predictor of atrial fibrillation (AF) in different pathologies. However, there is limited data for additional and sensitive echocardiographic predictors of AF in patients without over heart disease.

Purpose
To investigate middle- aged AF patients without overt heart disease and to identify additional echocardiographic predictors of AF.

Methods
A total of 936 consecutive patients with AF, who had been admitted for sinus rhythm restoriation in our hospital for the period January 2016- December 2018, were screened for participation in the study. Only 70 patients met the inclusion criteria- stable sinus rhythm, age between 40–60 years, without over heart disease. They were separated in 2 groups: with new onset AF (n=33) and recurrent AF (n=37); 30 healthy subjects were enrolled in the control group. All patients underwent two dimensional echocardiographic assessment with volumetric and speckle tracking analyses.

Results
There were significant differences between all groups in: LAVi; LA total (LATEF), passive (LAPEF) and active (LAAEF) emptying fractions; LA reservoir (LASr), conduit (LAScd) and contractile (LASct) strain; LV global longitudinal strain (GLS), but not in other LV indices – table. Multiple regression analysis demonstrated that LAVi (B=0.012, p=0.05, 95% CI: 0.000–0.023), LASr (B=−0.055, p=0.0001, 95% CI: −0.071 to −0.039), LASct (B=0.041, p=0.001, 95% CI: 0.016–0.066) are independent predictors of AF.

Conclusion
In middle- aged patients without overt heart disease LASr and LASct have additive value beyond LAVi in prediction of AF.

Funding Acknowledgement
Type of funding source: None