bluuebunny/crossref_metadata_2025_split huggingface dataset:
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

Abstract

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 (&gt;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

Abstract
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

Abstract

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 &lt;0.001) (Figure). For classification of heart failure types based on LVEF (LVEF ≥50% or &lt;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

Abstract

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

Abstract

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 &lt; 0.001). Severe BVFR patients were more symptomatic and displayed an adverse remodeling and neurohumoral activation pattern (all P &lt; 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 &lt; 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 &lt; 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

Abstract

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 &gt; 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

Abstract

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 &gt;40mmHg and &gt;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 &lt;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 &lt; ± 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

Abstract

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 (&gt;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

Abstract

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 &lt; 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 &lt; 0.001) and in NF-HG (baseline, 55 ± 12 mmHg; 1-year, 11 ± 4 mmHg; p &lt; 0.001) together with an increase in AVA (PLF-LG: baseline, 0.73 ± 0.16 cm², 1-year: 1.82 ± 0.43 cm², p &lt; 0.001; NF-HG: baseline, 0.66 ± 0.18 cm², 1-year: 1.84 ± 0.38cm², p &lt; 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