bluuebunny/crossref_metadata_2025_split huggingface dataset:
Significant disagreements between conventional functional metrics and 3D echocardiography-derived ejection fraction in the detection of right ventricular systolic dysfunction
Authors: Tolvaj M , Radu N , Cascella A , Muraru N , Lakatos B , Fabian A , Tokodi M , Tomaselli M , Gavazzoni M , Perelli F , Merkely B , Badano L P , Kovacs A , Surkova E 
Published: November 2023

Abstract

Background
The conventional echocardiographic parameters of the right ventricular (RV) systolic function (e.g., tricuspid annular plane systolic excursion - TAPSE, fractional area change – FAC, free wall longitudinal strain – FWLS) only partially portray the complex functional characteristics of the RV; therefore, they may fail to capture the full spectrum of RV dysfunction and associated adverse clinical outcomes. 3D echocardiography-derived RV ejection fraction (RVEF) is a well-validated and reproducible parameter that overcomes these limitations.

Purpose
We aimed to investigate the discordance between TAPSE, FAC, FWLS and RVEF in RV systolic function grading and associated outcomes.

Methods
Two retrospective databases from different centers including consecutive patients with various cardiac diseases who underwent clinically indicated 2D and 3D echocardiography (n=750) were analysed. Patients were followed up for the occurrence of all-cause mortality. RVEF was measured by a single, commercially available 3D software package. Guideline-recommended cut-off values were used to indicate RV systolic dysfunction (TAPSE&lt;17 mm, FAC&lt;35%, FWLS&gt;-20%). RVEF &lt;45% served as the "ground truth" of RV dysfunction.

Results
Among patients with normal RVEF (n=511), 109 (21%) had reduced TAPSE, 168 (33%) had reduced FAC, and 42 (8%) had reduced FWLS. Among patients with reduced RVEF (n=239), 109 (46%) had normal TAPSE, 61 (26%) had normal FAC, and 98 (41%) had normal FWLS. Correspondingly, sensitivity and specificity for discrimination of RV systolic dysfunction (RVEF&lt;45%) were 66% and 70% for TAPSE, 71% and 76% for FAC, and 89% and 69% for FWLS on ROC analysis, respectively (Figure 1). During the median follow-up time of 3.5 years, 112 patients (15%) died. Using univariable Cox regression, TAPSE (HR [95% CI]: 0.911 [0.881 - 0.942]), FAC (0.940 [0.924 - 0.957]), FWLS (1.101 [1.071 - 1.133], and RVEF (0.928 [0.913 - 0.944]) were all significant predictors of mortality (p&lt;0.001). Interestingly, combining the conventional functional measures based on how many of them indicate dysfunction shows that outcomes are the worst if at least two parameters are impaired and gradually better if only one or none of them (Kaplan-Meier curves, Figure 2, log-rank p&lt;0.001).

Conclusion
Guideline-recommended cut-off values of conventional echocardiographic parameters of RV systolic function are only modestly associated with RVEF-based assessment. Impaired values of FWLS show the closest association with the RVEF cut-off. Our results emphasize a multiparametric approach in the assessment of RV function, especially, if 3D echocardiography is not available.Figure 1.Figure 2.
Evaluation of the anatomic sinus after transcatheter aortic valve replacement
Authors: Moscarelli M , Prestera R , Fiore C , Pernice V , Milo S , Violante F , Cuffari F , Di Pasquale C , Ferlisi A , Speziale G , Angelini G D , Fattouch K 
Published: November 2023

Abstract

Background
Transcatheter aortic valve replacement (TAVR) determines the creation of outer area between the cage and the aortic wall named the ‘anatomic sinus’ (Figure 1 A-B). This newly formed space of the sinuses of Valsalva (SOV) might disrupt the physiological currents of Valsalva and contribute to the formation of subclinical leaflets thrombosis (SLT). The evaluation of the root geometry after TAVR is generally performed with multi detector computer tomography (MDCT), and the role of transthoracic echocardiography (TTE) needs further validation.

Purpose
The aim of this study was to test reproducibility of 2D TTE assessment of the anatomic sinus dimension with MDCT as reference. We also investigated predictors for SLT.

Methods
We enrolled 90 patients who underwent TAVR with self-expandable prosthesis. 2D TTE was performed using Philips EPIQ-7, and echocardiograms analysed offline with Philips QLAB cardiac analysis. Both SOV and prosthesis diameters were assessed in long and short-axis parasternal view (PLAX / PSAX) and the bidimensional area of the anatomic sinus was calculated (Figure 2 A-B). Inter-observer (observer 1 – 2) reproducibility was assessed by the means of interclass correlation coefficient (ICC). MDCT was performed in 50 individuals to evaluate concordance (Bland Altman test) with the 2D TTE anatomic sinus area and also to detect SLT (Figure 2 C-D). Multivariable model was built to assess predictors of SLT.

Results
Mean follow-up was 13.1 months. There was excellent and good correlation with regard to the diameter of the SOV and the prosthesis measured in PLAX view by observer 1 and 2: ICC: 0.93, 95% Confidence Interval (CI) (0.76–0.97), p&lt; 0.001; ICC: 0.87(0.63,0.96), p&lt;0.001, SOV and prosthesis respectively.
The correlation found with regard to the diameter of the SOV and the prosthesis measured in PSAX view was also excellent ICC: 0.90(0.68,0.97), p=0.001; and good ICC: 0.88(0.63,0.96), p &lt;0.001, SOV and prosthesis respectively. The anatomic sinus areas assessed by 2D TTE were similar compared to areas derived by MDCT (4.1 ± 1.09 cm2 vs. 4.02 ± 1.55 cm2, respectively, p=0.57). Bland–Altman analysis of anatomic sinus area measured on 2D TTE and MDCT respectively, indicated high level of agreement and no fixed or proportional bias. Native bicuspid valve, but not the anatomic sinus area, was the only independent predictors for SLT.

Conclusions
Following TAVR, the newly formed anatomic sinus could be assessed with good reproducibility with 2D TTE. We found a significant association between native bicuspid valve and SLT diagnosed with MDCT.Figure 1A-BFigure 2A-D
Cardiac magnetic resonance correlates of staging algorithm in patients with asymptomatic severe aortic stenosis
Authors: Conte C , Martino M , Ferrer-Sistach E , Teis A , Junca G , Weerts J , Kasa G , Vallejo N , Perez C , Lopez-Ayerbe J , Bayes Genis A , Delgado V 
Published: November 2023

Abstract

Background
The staging algorithm recently proposed to risk stratify patients with severe aortic stenosis (AS) has not been largely applied to patients who are asymptomatic. While the presence of severe tricuspid regurgitation, pulmonary hypertension and right ventricular dysfunction (stages 3-4) is expected to be low, the prevalence of left ventricular damage (LV), mitral regurgitation, left atrial (LA) dilation and atrial fibrillation (stages 1-2) can be higher in patients with asymptomatic severe AS. The cardiac magnetic resonance (CMR) correlates of the staging algorithm have not been described.

Purpose
To investigate the distribution of patients with asymptomatic severe AS in the staging algorithm and its differences with CMR findings. In addition, differences in CMR data between patients presenting with AS-related adverse events at 1-year follow-up and patients free of events were compared.

Methods
Patients with asymptomatic severe AS (aortic valve area, AVA&lt;1.0 cm2) and preserved LV ejection fraction (EF) (&gt;50%) that were referred to CMR were included. Biomarkers, echocardiographic and CMR data were assessed retrospectively. CMR-derived parameters included LV and right ventricular (RV) volumes and systolic function, LA volumes and tissue characterization were reported at baseline and compared with AS-related events (a composite of all-cause mortality, symptoms onset, or need for aortic valve replacement) during 1-year follow-up.

Results
Of 97 patients included (73±9 years old; 36% males), 3 (%) patients were classified in Stage 0, 34 (35%) in Stage 1, 59 (61%) in Stage 2, and 1 (1%) in Stage 3 or 4. Compared to stage 1, patients in stage 2 were older (P=0.006) and had a higher prevalence of overweight (P=0.037), hypertension (P=0.018), NT-proBNP (P=0.030) and hsTnT (p=0.011) levels. On CMR, they showed higher LV volumes and mass index, larger LA volumes and reduced LA ejection fraction, but no differences on myocardial tissue characteristics (Table 1).
Regarding prognosis, 45 (46.5%) patients presented AS-related events at 1-year follow-up. Those with events were mainly in stage 2 (36%) and presented higher NT-proBNP levels despite showing no differences in AVA. On CMR, those with events had lower LVEF, greater LV to RV end-diastolic volume ratio, greater left atrio-ventricular coupling index, reduced LA function and a higher extension of late gadolinium enhancement (Table 2).

Conclusions
In our cohort, most patients with severe asymptomatic AS were in stage 2. Stage 2 patients presented a higher degree of left-chambers remodelling on CMR compared to patients in stage 1. Patients in stage 2 or with lower LVEF, LV remodelling or reduced LAEF on CMR were those with an increased risk for events at follow-up.
Advanced 3D-TEE tools for mitral annular calcification characterisation. Correlation with CT scan
Authors: Mahia P , Provencio A , Ferrandez M , Ramos N , Marcos-Alberca P , Gomez De Diego J J , Cobos M A , Luaces M , Pozo E , Nombela L , Cobiella J , Perez-Villacastin J , De Agustin A 
Published: November 2023

Abstract

Background
Mitral annular calcification (MAC) is a degenerative process that leads to development of mitral regurgitation (MR). Its presence is associated with worse therapeutic results, due to technical challenges and risk of complications. The precise characterization has gained special importance in recent years. Due to the accuracy of the CT to detect calcium compared to transesophageal echocardiography (TEE), different prognostic scores based on this technique have been proposed.

Purpose
Our objective was to assess the usefulness of new tools based on 3D-TEE to determine the severity of MAC compared to CT in patients with MR.

Methods
Between 2019 -2022, patients with severe MR with different degrees of MAC were selected and evaluated by 3D-TEE and CT. Two independent expert observers blindly performed a quantitative standardized characterization of severity (1-10), applying the score proposed by Guerrero et al. based on four parameters: Calcium thickness, radial extension, involvement of trigones and leaflets both by CT (Figure 1, A) and advanced 3D-TEE tools (transillumination/True-Vue (Figure 1, B-C) and multiplanar/iSlice reconstruction (Figure 1, D). The agreement and correlation of both techniques were compared for each of the categories, as well as for the final classification of severity (Mild: 0-3, Moderate: 4-7, Severe 8-10).

Results
38 patients were included (Mean age: 80±5.7 years), 76% women. The MAC score measured by TEE was 6.1±0.4 vs. 8±0.4 by CT (p=0.03) with a very good agreement between both techniques estimated by the ICC (r=0.9) with an average difference of 1.2±1.4. Regarding the qualitative estimation, the concordance was good except for the estimation of the of the leaflet’s calcification (Table 1).

Conclusions
The use of advanced 3D-TEE imaging tools provides an excellent estimation and extension of the severity of MAC compared to CT, slightly overestimating the severity. These tools not only bring qualitative but also quantitative information and could be a first approximation before performing CT. This result highlights the usefulness and necessity of using multimodality imaging in the evaluation of degenerative mitral regurgitation.Figure 1Table 1
Correlation of transesophageal echocardiography acquired 3D-multiplane reconstruction-planimetry of aortic valve area (AVA) with AVA determined by standard and modified continuity equation
Authors: Blaser I , De Marchi S , Buffle E 
Published: November 2023

Abstract

Background
Currently the most accepted method for measuring aortic valve area is the continuity equation. Planimetry is an alternative method that allows the direct measurement of the Aortic valve area (AVA). There are, however, pitfalls in this method, such as artifacts caused by valve calcification and difficulty with the correct alignment of the cusps. Furthermore, these measurements may not correlate linearly, as effective AVA may vary due to contraction of flow and specific 3-dimensional conformation of the aortic valve. The advent of new technology with three-dimensional multiplane reconstruction echocardiography (3D-MPR) could overcome some of those limitations.

Methods
Measurements were taken from 119 patients who underwent elective transesophageal echocardiography (TEE), encompassing the whole spectrum of aortic opening. AVA was first calculated with the standard continuity equation (CE) in which left ventricular outflow tract (LVOT) area was calculated from its 2D diameter (AVA-CEstd). Secondly, a modified CE (AVA-CEmod) was used, measuring the LVOT area with 3D-MPR. Thirdly, the AVA was directly measured by 3D-MPR planimetry using the maximal opening at mid-systole (AVA-3D). In a subset of 30 Patients in which right and retrograde left heart catheterization was clinically indicated and performed, cardiac output was estimated by the Fick formula and AVA was calculated by the Gorlin formula (AVAGorling). We determined the correlation and level of agreement of AVA-3D with AVA-CEstd, AVA-CEmod and AVAGorling. Lastly, inter-observer reproducibility was evaluated for AVA-3D.

Results
The mean AVA-3D, AVA-CEmod and CEstd were as wollows: 1.87cm2, 1.81cm2 and 1.69cm2 respectively. There was a strong correlation between AVA-3D and AVA-CEmod (r = 0.963, p &lt; 0.001) with a mean difference of 0.056 cm2 ± 0.273. There was a strong correlation between AVA-3D and AVA-CEstd (r = 0.877, p &lt; 0.001) with a mean difference of 0.179 cm2 ± 0.477. There was a moderate correlation between AVAGorling , AVA-3D (r = 0.40, p &lt; 0.001), AVA-CEmod (r = 0.54, p &lt; 0.001) and AVA-CEstd (r = 0.49, p &lt; 0.001). Intra-observer (ICCs 0.991) and inter-observer (ICCs 0.983) agreement for AVA-3D measurements were excellent.

Conclusion
Comparison between AVA-3D, AVA-CEmod and CEstd showed a strong correlation and intra-observer and inter-observer variability for AVA-3D were excellent. The correlation of AVAGorling with the AVAs assessed by echocardiography was weaker. The mean differences and variability can be explained by the known hemodynamic and conceptual differences between the geometric AVA, effective AVA and AVA assessed by the Gorlin formula. We can therefore conclude that AVA-3D assessed by TEE is a useful tool in daily clinical practice as it overcomes some pitfalls of the planimetry method, although some of the limitations remain.
Prognostic impact of postprocedural pulmonary artery systolic pressure on late mortality after transcatheter aortic valve implantation
Authors: Karmpalioti M , Toutouzas K , Drakopoulou M , Oikonomou G , Simopoulou C , Apostolos A , Koliastasis L , Ktenopoulos N , Soulaidopoulos S , Latsios G , Synetos A , Tsioufis C 
Published: November 2023

Abstract

Background
Pulmonary hypertension is a common finding in patients with aortic stenosis. Although transcatheter aortic valve implantation (TAVI) is frequently associated with a reduction of pulmonary artery systolic pressure (PASP), data regarding the independent impact of postprocedural PASP (post PASP) on long-term clinical outcome are still contradictory.

Methods
Patients with severe and symptomatic aortic stenosis [effective orifice area (EOA)≤1cm2] referred for TAVI at our institution were consecutively enrolled. Prospectively collected demographic, laboratory and echocardiographic data were retrospectively analysed. Patients were stratified into three groups according to PASP at 30 days: group 1 (≤ 35mmHg), group 2 (36-49mmHg), group 3 (≥50mmHg). Primary clinical endpoint was all-cause mortality at 8 years, as defined by the criteria proposed by the Valve Academic Research Consortium3.

Results
A total of 166 consecutive patients were enrolled in the study: 76 (45.8%) patients in group 1, 71 (42.8%) in group 2 and 19 (11.4%) in group 3. The primary clinical end point occurred in 76.8% of all patients. The Kaplan–Meier curves for 8 year mortality showed that the high value of post PASP was associated with poor survival. Interestingly, patients in group 3 had the highest rate of all-cause mortality compared to patients in group 1 and 2 ( group 1 : 69%, group 2: 78.5%, group 3: 100%, p=0.016). Performing a multivariable analysis demonstrated that post PASP could independently predict cumulative 8 year mortality [OR 1.151, (95% CI 1.051 – 1.260, p=0.002)]. Using ROC analysis for 8 year survival, PASP had 75% sensitivity, and 64% specificity (p&lt;0.0001, AUC=0.730).

Conclusion
Patients with increased PASP at 30 days after TAVI are at higher risk of all cause mortality at 8 years. Moreover, post PASP is independent predictor of late mortality and should be performed to determine the best follow up strategy in TAVI patients.
Predicting aortic stenosis progression using a video-based deep learning model of aortic stenosis built for single-view two-dimensional echocardiography
Authors: Oikonomou E K , Holste G , Mcnamara R L , Velazquez E J , Nadkarni G N , Ouyang D , Krumholz H M , Wang Z , Khera R 
Published: November 2023

Abstract

Background
We have recently described a deep learning (DL) model that relies on 2-dimensional parasternal long axis (PLAX) videos from transthoracic echocardiography (TTE) without Doppler imaging to identify severe aortic stenosis (AS) at the point-of-care. However, the timely diagnosis of AS has traditionally required skilled examination with Doppler imaging at regular time intervals.

Purpose
To explore the role of a DL model previously trained to detect severe AS based on 2D-PLAX videos in predicting the rate of AS progression among patients with no, mild, or moderate AS.

Methods
In this retrospective cohort study, a random sample of 2354 individuals undergoing serial monitoring with at least two separate TTEs and available Doppler parameters of AS severity (peak aortic valve velocity, AV Vmax) between 2016 and 2021 in the Yale-New Haven Health system were included. Eligible participants had a left ventricular ejection fraction (LVEF) &gt;=50% and no evidence of severe AS at baseline. After automated selection of PLAX videos using an automated view classifier, the baseline deep learning-based AS probability index (DL-ASi) was calculated for each patient. The absolute change in the AV Vmax was divided by the time difference between each pair of consecutive TTE studies, and then averaged to derive the mean rate of AS progression. The association between the baseline DL-ASi and the mean rate of AS progression was assessed using ordinary least squares regression with adjustment for the patient’s sex, age, and baseline LVEF and AV Vmax. To visualize the interaction between the baseline DL-ASi and AV Vmax in predicting the rate of AS progression, an interaction term was included and a contour plot was plotted for both men and women.

Results
We included 8473 TTE studies from 2354 unique individuals (mean age 70±14 years, n=1138 [48.3%] women) performed over a median 2.5 (IQR 1.4-3.7) years (A). Higher DL-ASi at baseline was independently associated with a more rapid rate of AS progression (βadj 0.27 [95% CI 0.20-0.33, P&lt;0.001]). The rates of AV Vmax progression ranged from 0.06±0.01 m/sec/year in the &lt;0.2 DL-ASi group, to 0.29±0.04 m/sec/year in the ≥0.8 DL-ASi group (B). Contour plots illustrate how, for a given AV Vmax value, DL-ASi stratified the risk of AS progression in women and men (C).

Conclusion
In individuals with mild to moderate AS or no AS, a DL model trained to detect features of severe AS identifies individuals with a higher rate of AS severity progression, as assessed by the mean rate of AV Vmax change. This represents a promising approach for the longitudinal, point-of-care monitoring of patients with non-severe AS outside specialized centers.
New method for quantification of atrial septum defect shunting by echocardiography
Authors: Helle-Valle T , Murbraech K , Gude E , Andreassen A , Broch K , Sarvaro S , Beitnes J O , Skulstad H 
Published: November 2023

Abstract

Background
Atrial septum defect (ASD) is a common congenital heart disease. Echocardiography is the preferred method for detection and characterization of ASD. Accurate quantification of shunting is pivotal, but often requires right heart catheterization (RHC). In the present study, we introduce a new non-invasive method for accurate quantification of the ASD shunt by combined transesophageal- (TEE) and transthoracic (TTE) echocardiography. Shunt by RHC was used as a reference method.

Method
In 22 adults with secundum ASD, left ventricular (LV) stroke volume (SV) was measured by the pulsed Doppler method using 2D TTE. The shunt volume passing through the ASD was quantified as the ASD area measured by planimetry from 3D TEE, multiplied with the time velocity integral (TVI) of the PW Doppler obtained at the center of the ASD by TEE. Finally, the ratio of the pulmonary to systemic shunt (Qp:Qs) was calculated as (LVSV+ASDvolume)/LVSV. Shunt by RHC was assessed by the Fick’s principle.

Results
Mean shunt was 2.2±0.7 (±SD) by echocardiography and 2.1±0.7 by RHC, with a mean difference of -0.1±0.4 (Figure 1). The correlation between shunt measured by RHC and echocardiography was strong (r=0.86, p&lt;0.0001; Figure 2).

Conclusion
The present study demonstrates that ASD shunting can be quantified accurately by combining TTE and TEE, suggesting a new non-invasive approach in settings where RHC is not feasible or available.Figures