Topic: Imaging

Abstract

Focused Transesophageal Echocardiography During Cardiac Arrest Resuscitation: JACC Review Topic of the Week.

Teran F, Prats MI, Nelson BP, Kessler R, ... Arntfield RT, Bahner D

Focused transthoracic echocardiography (TTE) during cardiac arrest resuscitation can enable the characterization of myocardial activity, identify potentially treatable pathologies, assist with rhythm interpretation, and provide prognostic information. However, an important limitation of TTE is the difficulty obtaining interpretable images due to external and patient-related limiting factors. Over the last decade, focused transesophageal echocardiography (TEE) has been proposed as a tool that is ideally suited to image patients in extremis-those in cardiac arrest and periarrest states. In addition to the same diagnostic and prognostic role provided by TTE images, TEE provides unique advantages including the potential to optimize the quality of chest compressions, shorten cardiopulmonary resuscitation interruptions, guide resuscitative procedures, and provides a continuous image of myocardial activity. This review discusses the rationale, supporting evidence, opportunities, and challenges, and proposes a research agenda for the use of focused TEE in cardiac arrest with the goal to improve resuscitation outcomes.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 10 Aug 2020; 76:745-754
Teran F, Prats MI, Nelson BP, Kessler R, ... Arntfield RT, Bahner D
J Am Coll Cardiol: 10 Aug 2020; 76:745-754 | PMID: 32762909
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Abstract

Machine Learning Assessment of Left Ventricular Diastolic Function Based on Electrocardiographic Features.

Kagiyama N, Piccirilli M, Yanamala N, Shrestha S, ... Narula J, Sengupta PP
Background
Left ventricular (LV) diastolic dysfunction is recognized as playing a major role in the pathophysiology of heart failure; however, clinical tools for identifying diastolic dysfunction before echocardiography remain imprecise.
Objectives
This study sought to develop machine-learning models that quantitatively estimate myocardial relaxation using clinical and electrocardiography (ECG) variables as a first step in the detection of LV diastolic dysfunction.
Methods
A multicenter prospective study was conducted at 4 institutions in North America enrolling a total of 1,202 subjects. Patients from 3 institutions (n = 814) formed an internal cohort and were randomly divided into training and internal test sets (80:20). Machine-learning models were developed using signal-processed ECG, traditional ECG, and clinical features and were tested using the test set. Data from the fourth institution was reserved as an external test set (n = 388) to evaluate the model generalizability.
Results
Despite diversity in subjects, the machine-learning model predicted the quantitative values of the LV relaxation velocities (e\') measured by echocardiography in both internal and external test sets (mean absolute error: 1.46 and 1.93 cm/s; adjusted R = 0.57 and 0.46, respectively). Analysis of the area under the receiver operating characteristic curve (AUC) revealed that the estimated e\' discriminated the guideline-recommended thresholds for abnormal myocardial relaxation and diastolic and systolic dysfunction (LV ejection fraction) the internal (area under the curve [AUC]: 0.83, 0.76, and 0.75) and external test sets (0.84, 0.80, and 0.81), respectively. Moreover, the estimated e\' allowed prediction of LV diastolic dysfunction based on multiple age- and sex-adjusted reference limits (AUC: 0.88 and 0.94 in the internal and external sets, respectively).
Conclusions
A quantitative prediction of myocardial relaxation can be performed using easily obtained clinical and ECG features. This cost-effective strategy may be a valuable first clinical step for assessing the presence of LV dysfunction and may potentially aid in the early diagnosis and management of heart failure patients.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 24 Aug 2020; 76:930-941
Kagiyama N, Piccirilli M, Yanamala N, Shrestha S, ... Narula J, Sengupta PP
J Am Coll Cardiol: 24 Aug 2020; 76:930-941 | PMID: 32819467
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Abstract

Epicardial Adipose Tissue Accumulation Confers Atrial Conduction Abnormality.

Nalliah CJ, Bell JR, Raaijmakers AJA, Waddell HM, ... Delbridge LMD, Kalman JM
Background
Clinical studies have reported that epicardial adipose tissue (EpAT) accumulation associates with the progression of atrial fibrillation (AF) pathology and adversely affects AF management. The role of local cardiac EpAT deposition in disease progression is unclear, and the electrophysiological, cellular, and molecular mechanisms involved remain poorly defined.
Objectives
The purpose of this study was to identify the underlying mechanisms by which EpAT influences the atrial substrate for AF.
Methods
Patients without AF undergoing coronary artery bypass surgery were recruited. Computed tomography and high-density epicardial electrophysiological mapping of the anterior right atrium were utilized to quantify EpAT volumes and to assess association with the electrophysiological substrate in situ. Excised right atrial appendages were analyzed histologically to characterize EpAT infiltration, fibrosis, and gap junction localization. Co-culture experiments were used to evaluate the paracrine effects of EpAT on cardiomyocyte electrophysiology. Proteomic analyses were applied to identify molecular mediators of cellular electrophysiological disturbance.
Results
Higher local EpAT volume clinically correlated with slowed conduction, greater electrogram fractionation, increased fibrosis, and lateralization of cardiomyocyte connexin-40. In addition, atrial conduction heterogeneity was increased with more extensive myocardial EpAT infiltration. Cardiomyocyte culture studies using multielectrode arrays showed that cardiac adipose tissue-secreted factors slowed conduction velocity and contained proteins with capacity to disrupt intermyocyte electromechanical integrity.
Conclusions
These findings indicate that atrial pathophysiology is critically dependent on local EpAT accumulation and infiltration. In addition to myocardial architecture disruption, this effect can be attributed to an EpAT-cardiomyocyte paracrine axis. The focal adhesion group proteins are identified as new disease candidates potentially contributing to arrhythmogenic atrial substrate.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 07 Sep 2020; 76:1197-1211
Nalliah CJ, Bell JR, Raaijmakers AJA, Waddell HM, ... Delbridge LMD, Kalman JM
J Am Coll Cardiol: 07 Sep 2020; 76:1197-1211 | PMID: 32883413
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Abstract

Natural History of Functional Tricuspid Regurgitation Quantified by Cardiovascular Magnetic Resonance.

Zhan Y, Debs D, Khan MA, Nguyen DT, ... Zoghbi WA, Shah DJ
Background
Quantitation of tricuspid regurgitant (TR) severity can be challenging with conventional echocardiographic imaging and may be better evaluated using cardiovascular magnetic resonance (CMR).
Objectives
In patients with functional TR, this study sought to examine the relationship between TR volume (TRVol) and TR fraction (TRF) with all-cause mortality.
Methods
We examined 547 patients with functional TR using CMR to quantify TRVol and TRF. The primary outcome was all-cause mortality. Thresholds for mild, moderate, and severe TR were derived based on natural history outcome data.
Results
During a median follow-up of 2.6 years (interquartile range: 1.7 to 3.3 years), there were 93 deaths, with an estimated 5-year survival of 79% (95% confidence interval [CI]: 73% to 83%). After adjustment of clinical and imaging variables, including RV function, both TRF (adjusted hazard ratio [AHR] per 10% increment: 1.26; 95% CI: 1.10 to 1.45; p = 0.001) and TRVol (AHR per 10-ml increment: 1.15; 95% CI: 1.04 to 1.26; p = 0.004) were associated with mortality. Patients in the highest-risk strata of TRVol ≥45 ml or TRF ≥50% had the worst prognosis (AHR: 2.26; 95% CI: 1.36 to 3.76; p = 0.002 for TRVol and AHR: 2.60; 95% CI: 1.45 to 4.66; p = 0.001 for TRF).
Conclusions
This is the first study to use CMR to assess independent prognostic implications of functional TR. Both TRF and TRVol were associated with increased mortality after adjustment for clinical and imaging covariates, including right ventricular ejection fraction. A TRVol of ≥45 ml or TRF of ≥50% identified patients in the highest-risk strata for mortality. These CMR thresholds should be used for patient selection in future trials to determine if tricuspid valve intervention improves outcomes in this high-risk group.

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 14 Sep 2020; 76:1291-1301
Zhan Y, Debs D, Khan MA, Nguyen DT, ... Zoghbi WA, Shah DJ
J Am Coll Cardiol: 14 Sep 2020; 76:1291-1301 | PMID: 32912443
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Abstract

Association Between Left Ventricular Noncompaction and Vigorous Physical Activity.

de la Chica JA, Gómez-Talavera S, García-Ruiz JM, García-Lunar I, ... Ibáñez B, Fuster V
Background
Left ventricular (LV) hypertrabeculation fulfilling noncompaction cardiomyopathy criteria has been detected in athletes. However, the association between LV noncompaction (LVNC) phenotype and vigorous physical activity (VPA) in the general population is disputed.
Objectives
The aim of this study was to assess the relationship between LVNC phenotype on cardiac magnetic resonance (CMR) imaging and accelerometer-measured physical activity (PA) in a cohort of middle-aged nonathlete participants in the PESA (Progression of Early Subclinical Atherosclerosis) study.
Methods
In PESA participants (n = 4,184 subjects free of cardiovascular disease), PA was measured by waist-secured accelerometers. CMR was performed in 705 subjects (mean age 48 ± 4 years, 16% women). VPA was recorded as total minutes per week. The study population was divided into 6 groups: no VPA and 5 sex-specific quintiles of VPA rate (Q1 to Q5). The Petersen criterion for LVNC was evaluated in all subjects undergoing CMR. For participants meeting this criterion (noncompacted-to-compacted ratio ≥2.3), 3 more restrictive LVNC criteria were also evaluated (Jacquier, Grothoff, and Stacey).
Results
LVNC phenotype prevalence according to the Petersen criterion was significantly higher among participants in the highest VPA quintile (Q5 = 30.5%) than in participants with no VPA (14.2%). The Jacquier and Grothoff criteria were also more frequently fulfilled in participants in the highest VPA quintile (Jacquier Q5 = 27.4% vs. no VPA = 12.8% and Grothoff Q5 = 15.8% vs. no VPA = 7.1%). The prevalence of the systolic Stacey LVNC criterion was low (3.6%) and did not differ significantly between no VPA and Q5.
Conclusions
In a community-based study, VPA was associated with a higher prevalence of CMR-detected LVNC phenotype according to diverse established criteria. The association between VPA and LVNC phenotype was independent of LV volumes. According to these data, vigorous recreational PA should be considered as a possible but not uncommon determinant of LV hypertrabeculation in asymptomatic subjects.

Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.

J Am Coll Cardiol: 12 Oct 2020; 76:1723-1733
de la Chica JA, Gómez-Talavera S, García-Ruiz JM, García-Lunar I, ... Ibáñez B, Fuster V
J Am Coll Cardiol: 12 Oct 2020; 76:1723-1733 | PMID: 33032733
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Abstract

Impact of Transcatheter Aortic Valve Durability on Life Expectancy in Low-Risk Patients With Severe Aortic Stenosis.

Tam DY, Wijeysundera HC, Naimark D, Gaudino M, ... Cohen DJ, Fremes SE
Background
Recent clinical trial results showed that transcatheter aortic valve replacement (TAVR) is noninferior and may be superior to surgical aortic valve replacement (SAVR) for mortality, stroke, and rehospitalization. However, the impact of transcatheter valve durability remains uncertain.
Methods
Discrete event simulation was used to model hypothetical scenarios of TAVR versus SAVR durability in which TAVR failure times were varied to determine the impact of TAVR valve durability on life expectancy in a cohort of low-risk patients similar to those in recent trials. Discrete event simulation modeling was used to estimate the tradeoff between a less invasive procedure with unknown valve durability (TAVR) and that of a more invasive procedure with known durability (SAVR). Standardized differences were calculated, and a difference >0.10 was considered clinically significant. In the base-case analysis, patients with structural valve deterioration requiring reoperation were assumed to undergo a valve-in-valve TAVR procedure. A sensitivity analysis was conducted to determine the impact of TAVR valve durability on life expectancy in younger age groups (40, 50, and 60 years).
Results
Our cohort consisted of patients with aortic stenosis at low surgical risk with a mean age of 73.4±5.9 years. In the base-case scenario, the standardized difference in life expectancy was <0.10 between TAVR and SAVR until transcatheter valve prosthesis failure time was 70% shorter than that of surgical prostheses. At a transcatheter valve failure time <30% compared with surgical valves, SAVR was the preferred option. In younger patients, life expectancy was reduced when TAVR durability was 30%, 40%, and 50% shorter than that of surgical valves in 40-, 50-, and 60-year-old patients, respectively.
Conclusions
According to our simulation models, the durability of TAVR valves must be 70% shorter than that of surgical valves to result in reduced life expectancy in patients with demographics similar to those of recent trials. However, in younger patients, this threshold for TAVR valve durability was substantially higher. These findings suggest that durability concerns should not influence the initial treatment decision concerning TAVR versus SAVR in older low-risk patients on the basis of current evidence supporting TAVR valve durability. However, in younger low-risk patients, valve durability must be weighed against other patient factors such as life expectancy.



Circulation: 27 Jul 2020; 142:354-364
Tam DY, Wijeysundera HC, Naimark D, Gaudino M, ... Cohen DJ, Fremes SE
Circulation: 27 Jul 2020; 142:354-364 | PMID: 32493077
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Abstract

Prevalence and Outcome of Potential Candidates for Left Atrial Appendage Closure After Stroke With Atrial Fibrillation: WATCH-AF Registry.

Ong E, Meseguer E, Guidoux C, Lavallée PC, ... Nighoghossian N, Amarenco P
Background and purpose
As a result of contraindications (eg, frailty, cognitive impairment, comorbidities) or patient refusal, many patients with stroke and atrial fibrillation cannot be discharged on oral anticoagulant. Among them, the proportion of potential candidates for left atrial appendage closure (LAAC) and their 12-month outcome is not well known.
Methods
The prospective WATCH-AF registry (Warfarin Aspirin Ten-A Inhibitors and Cerebral Infarction and Hemorrhage and Atrial Fibrillation) enrolled consecutive patients admitted within 72 hours of an acute stroke associated with atrial fibrillation in 2 stroke centers. Scales to evaluate stroke severity, disability, functional independence, risk of fall, cognition, ischemic and hemorrhagic risk-stratification, and comorbidities were systematically collected at admission, discharge, 3, 12 months poststroke. The 2 main end points were death or dependency (modified Rankin Scale score >3) and recurrent stroke (brain infarction and brain hemorrhage).
Results
Among 400 enrolled patients (370 with brain infarction, 30 with brain hemorrhage), 31 died before discharge and 57 (14.3%) were possible European Heart Rhythm Association/European Society of Cardiology and American Heart Association/American College of Cardiology/Heart Rhythm Society candidates for LAAC. At 12 months, the rate of death or dependency was 17.9%, and the rate of stroke recurrence was 9.8% in the 274/400 (68.5%) patients discharged on a long-term oral anticoagulant strategy, as compared with 17.5% and 24.7%, respectively, in 57 patients candidate for LAAC. As compared with patients on a long-term oral anticoagulant strategy, there was a 2-fold increase in the risk of stroke recurrence in the group with an indication for LAAC (adjusted hazard ratio, 2.58 [95% CI, 1.40-4.76]; P=0.002).
Conclusions
Fourteen percent of patients with stroke associated with atrial fibrillation were potential candidates for LAAC. The 12-month stroke risk of these candidates was 3-fold the risk of anticoagulated patients.



Stroke: 30 Jul 2020; 51:2355-2363
Ong E, Meseguer E, Guidoux C, Lavallée PC, ... Nighoghossian N, Amarenco P
Stroke: 30 Jul 2020; 51:2355-2363 | PMID: 32640939
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Abstract

Value of Vascular and Non-Vascular Pattern on Computed Tomography Perfusion in Patients With Acute Isolated Aphasia.

Rudilosso S, Rodríguez A, Amaro S, Obach V, ... Urra X, Chamorro Á
Background and purpose
Acute onset aphasia may be due to stroke but also to other causes, which are commonly referred to as stroke mimics. We hypothesized that, in patients with acute isolated aphasia, distinct brain perfusion patterns are related to the cause and the clinical outcome. Herein, we analyzed the prognostic yield and the diagnostic usefulness of computed tomography perfusion (CTP) in patients with acute isolated aphasia.
Methods
From a single-center registry, we selected a cohort of 154 patients presenting with acute isolated aphasia who had a whole-brain CTP study available. We collected the main clinical and radiological data. We categorized brain perfusion studies on CTP into vascular and nonvascular perfusion patterns and the cause of aphasia as ischemic stroke, transient ischemic attack, stroke mimic, and undetermined cause. The primary clinical outcome was the persistence of aphasia at discharge. We analyzed the sensitivity, specificity, positive and negative predictive values of perfusion patterns to predict complete clinical recovery and ischemic stroke on follow-up imaging.
Results
The cause of aphasia was an ischemic stroke in 58 patients (38%), transient ischemic attack in 3 (2%), stroke mimic in 68 (44%), and undetermined in 25 (16%). CTP showed vascular and nonvascular perfusion pattern in 62 (40%) and 92 (60%) patients, respectively. Overall, complete recovery occurred in 116 patients (75%). A nonvascular perfusion pattern predicted complete recovery (sensitivity 75.9%, specificity 89.5%, positive predictive value 95.7%, and negative predictive value 54.8%), and a vascular perfusion pattern was highly predictive of ischemic stroke (sensitivity 94.8%, specificity 92.7%, positive predictive value 88.7%, and negative predictive value 96.7%). The 3 patients with ischemic stroke without a vascular perfusion pattern fully recovered at discharge.
Conclusions
CTP has prognostic value in the workup of patients with acute isolated aphasia. A nonvascular pattern is associated with higher odds of full recovery and may prompt the search for alternative causes of the symptoms.



Stroke: 30 Jul 2020; 51:2480-2487
Rudilosso S, Rodríguez A, Amaro S, Obach V, ... Urra X, Chamorro Á
Stroke: 30 Jul 2020; 51:2480-2487 | PMID: 32684143
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Abstract

Left atrial cross-sectional area is a novel measure of atrial shape associated with cardioembolic strokes.

Tan TC, Nunes MCP, Handschumacher M, Pontes-Neto O, ... Ay H, Hung J
Objective
Cardioembolic (CE) stroke carries significant morbidity and mortality. Left atrial (LA) size has been associated with CE risk. We hypothesised that differential LA remodelling impacts on pathophysiological mechanism of major CE strokes.
Methods
A cohort of consecutive patients hospitalised with ischaemic stroke, classified into CE versus non-CE strokes using the Causative Classification System for Ischaemic Stroke were enrolled. LA shape and remodelling was characterised by assessing differences in maximal LA cross-sectional area (LA-CSA) in a cohort of 40 prospectively recruited patients with ischaemic stroke using three-dimensional (3D) echocardiography. Flow velocity profiles were measured in spherical versus ellipsoidal in vitro models to determine if LA shape influences flow dynamics. Two-dimensional (2D) LA-CSA was subsequently derived from standard echocardiographic views and compared with 3D LA-CSA.
Results
A total of 1023 patients with ischaemic stroke were included, 230 (22.5%) of them were classified as major CE. The mean age was 68±16 years, and 464 (45%) were women. The 2D calculated LA-CSA correlated strongly with the LA-CSA measured by 3D in both end-systole and end-diastole. In vitro flow models showed shape-related differences in mid-level flow velocity profiles. Increased LA-CSA was associated with major CE stroke (adjusted relative risk 1.10, 95% CI 1.04 to 1.16; p<0.001), independent of age, gender, atrial fibrillation, left ventricular ejection fraction and CHADS-VASc score. Specifically, the inclusion of LA-CSA in a model with traditional risk factors for CE stroke resulted in significant improvement in model performance with the net reclassification improvement of 0.346 (95% CI 0.189 to 0.501; p=0.00001) and the integrated discrimination improvement of 0.013 (95% CI 0.003 to 0.024; p=0.0119).
Conclusions
LA-CSA is a marker of adverse LA shape associated with CE stroke, reflecting importance of differential LA remodelling, not simply LA size, in the mechanism of CE risk.

© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.

Heart: 30 Jul 2020; 106:1176-1182
Tan TC, Nunes MCP, Handschumacher M, Pontes-Neto O, ... Ay H, Hung J
Heart: 30 Jul 2020; 106:1176-1182 | PMID: 31980438
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Abstract

Usefulness of Neuromuscular Co-morbidity, Left Bundle Branch Block, and Atrial Fibrillation to Predict the Long-Term Prognosis of Left Ventricular Hypertrabeculation/Noncompaction.

Stöllberger C, Hasun M, Winkler-Dworak M, Finsterer J

The prognosis of patients with left ventricular hypertrabeculation/noncompaction (LVHT) is assessed controversially. LVHT is associated with other cardiac abnormalities and with neuromuscular disorders (NMD). Aim of the study was to assess cardiac and neurological findings as predictors of mortality rate in adult LVHT-patients. Included were patients with LVHT diagnosed between 1995 and 2019 in 1 echocardiographic laboratory. Patients underwent a baseline cardiologic examination and were invited for a neurological investigation. In January 2020, their survival status was assessed. End points were death or heart transplantation. LVHT was diagnosed by echocardiography in 310 patients (93 female, aged 53 ± 18 years) with a prevalence of 0.4%/year. A neurologic investigation was performed in 205 patients (67%). A specific NMD was found in 33 (16%), NMD of unknown etiology in 123 (60%) and the neurological investigation was normal in 49 (24%) patients. During follow-up of 84 ± 71 months, 59 patients received electronic devices, 105 patients died, and 6 underwent heart transplantation. The mortality was 4.7%/year, the rate of heart transplantation/death 5%/year. By multivariate analysis, the following parameters were identified to elevate the risk of mortality/heart transplantation: increased age (p = 0.005), inpatient (p = 0.001), presence of a specific NMD (p = 0.0312) or NMD of unknown etiology (p = 0.0365), atrial fibrillation (p = 0.0000), ventricular premature complexes (p = 0.0053), exertional dyspnea (p = 0.0023), left bundle branch block (p = 0.0201), and LVHT of the posterior wall (p = 0.0158). In conclusion, LVHT patients should be systematically investigated neurologically since neurological co-morbidity has a prognostic impact.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:168-173
Stöllberger C, Hasun M, Winkler-Dworak M, Finsterer J
Am J Cardiol: 31 Jul 2020; 128:168-173 | PMID: 32650915
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Abstract

Characteristics and Implications of Left Atrial Calcium on Cardiac Computed Tomography in Patients With Earlier Mitral Valve Operation.

Choi JY, Suh YJ, Kim YJ, Lee SH, ... Ha JW, Shim CY

Left atrial calcium (LAC) is often observed in patients who have undergone mitral valve (MV) surgery, but little is known about its characteristics and clinical implications. Therefore, we sought to investigate the structural and hemodynamic significance of LAC and its association with clinical outcomes. We investigated 327 patients with repaired or prosthetic MV who underwent cardiac CT from 2010 to 2017. The degree of LAC was analyzed and classified into three groups: group 1 (no LAC), group 2 (mild-to-moderate LAC), and group 3 (severe LAC). Clinical and echocardiographic characteristics and clinical outcomes were compared in three groups. LAC was seen in 79 (24.2%) patients. Groups 2 and 3 showed more prevalent atrial fibrillation, a rheumatic etiology, a higher number of previous surgeries, a larger LA volume index, and higher pulmonary artery systolic pressure than group 1. Paravalvular leakage of the MV increased progressively according to severity of LAC (15.4% in group 1, 39.3% in group 2, and 66.7% in group 3, p <0.001). Event-free survival rate for major adverse cardiovascular adverse events (log rank p = 0.033) and all-cause mortality (log rank p <0.001) were significantly different according to LAC group. In Cox regression analyses, presence of severe LAC was an independent predictor of all-cause mortality (hazard ratio: 4.44, 95% confidence interval: 1.71 to 11.58, p = 0.002). LAC on cardiac CT is not uncommon and reflects more advanced LA remodeling and a stiff LA. The presence and severity of LAC are associated with a worse clinical outcome after MV surgery.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:60-66
Choi JY, Suh YJ, Kim YJ, Lee SH, ... Ha JW, Shim CY
Am J Cardiol: 31 Jul 2020; 128:60-66 | PMID: 32650925
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Abstract

Progression of Normal Flow Low Gradient \"Severe\" Aortic Stenosis With Preserved Left Ventricular Ejection Fraction.

Chadha G, Bohbot Y, Lachambre P, Rusinaru D, ... Vanoverschelde JL, Tribouilloy C

Normal-flow low-gradient severe aortic stenosis (NF-LG-SAS), defined by an aortic valve area (AVA) <1 cm², mean pressure gradient (MPG) <40 mm Hg and indexed stroke volume ≥35 ml/m², is the most prevalent form of low-gradient aortic stenosis (AS) with preserved ejection fraction (PEF). However, the true severity of AS in these patients is controversial. The aim of this Doppler echocardiographic study was to investigate changes over time in the hemodynamic severity of patients with NF-LG-SAS with PEF. We retrospectively identified 96 patients who had 2 Doppler echocardiographic examinations without an intervening event. After a median follow-up of 25 (interquartile range 15 to 52) months, progression was observed, with increased transaortic MPG (from 28 [25 to 33] to 39 [34 to 50] mm Hg; p<0.001), peak aortic jet velocity (from 3.46 [3.20 to 3.64] to 4.01 [3.70 to 4.39] m/s; p<0.001), and decreased AVA (from 0.87 [0.82 to 0.94] to 0.72 [0.62 to 0.81] cm²; p<0.001). Median annual rates of progression were 4.3 (1.7 to 8.1) mm Hg/year, 0.25 (0.08 to 0.44) m/s/year, and -0.05 (-0.10 to -0.02) cm²/year, respectively. There was no significant change in left ventricular ejection fraction over time (p = 0.74). At follow-up, 46 patients (48%) acquired the features of classical high-gradient severe AS (MPG ≥40 mm Hg). This study shows that most patients with NF-LG-SAS with PEF exhibit significant hemodynamic progression of AS severity without EF impairment. These findings suggest that NF-LG-SAS with PEF is an \"intermediate\" stage between moderate AS and classical high-gradient severe AS requiring close monitoring.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Jul 2020; 128:151-158
Chadha G, Bohbot Y, Lachambre P, Rusinaru D, ... Vanoverschelde JL, Tribouilloy C
Am J Cardiol: 31 Jul 2020; 128:151-158 | PMID: 32650909
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Abstract

Impact of different dipping patterns on left atrial function in hypertension.

Tadic M, Cuspidi C, Pencic B, Mancia G, ... Quarti-Trevano F, Celic V
Objective
We aimed to investigate left atrial phasic function in the recently diagnosed hypertensive patients and determine association between circadian blood pressure (BP) patterns and left atrial function.
Methods
The present study involved 256 untreated hypertensive patients who underwent 24-h ambulatory BP monitoring and comprehensive echocardiographic examination. All patients were divided into four groups according to the percentage of nocturnal BP drop (dippers, extreme dippers, nondippers and reverse dippers).
Results
There was no significant difference in daytime BPs between the observed groups, whereas night-time BPs significantly and gradually increased from extreme dippers and dippers, across nondippers, to reverse dippers. Total, passive and active left atrial emptying fractions that correspond with left atrial reservoir, conduit and contractile function were lower in nondippers and reverse dippers than in dippers and extreme dippers. Reservoir and contractile left atrial strains were lower in reverse dippers than in dippers and extreme dippers, whereas conduit left atrial strain was lower in reverse dippers in comparison with extreme dippers. Nondipping and reverse dipping BP patterns were, independently of age, sex, nocturnal BPs, left ventricular mass index, E/e\', associated with reduced reservoir function. Nevertheless, only reverse dipping profile was independently of other circadian BP profiles, nocturnal BP, demographic and echocardiographic parameters related with reduced conduit and contractile functions.
Conclusion
Nondipping and reverse dipping BP patterns were related with impaired left atrial phasic function. However, reverse pattern was the only circadian profile that was independently of other clinical parameters, including night-time BP, associated with decreased reservoir, conduit and contractile function.



J Hypertens: 30 Oct 2020; 38:2245-2251
Tadic M, Cuspidi C, Pencic B, Mancia G, ... Quarti-Trevano F, Celic V
J Hypertens: 30 Oct 2020; 38:2245-2251 | PMID: 32649632
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Abstract

Additive effect of hypertension on left ventricular structure and function in patients with asymptomatic type 2 diabetes mellitus.

Jiang L, Ren Y, Yu H, Guo YK, ... Han PL, Yang ZG
Objective
We aimed to comprehensively determine the effects of hypertension on left ventricular (LV) structure, microcirculation, tissue characteristics, and deformation in type 2 diabetes mellitus (T2DM) using multiparametric cardiac magnetic resonance (CMR) imaging.
Methods
We prospectively enrolled 138 asymptomatic patients with T2DM (80 normotensive and 58 hypertensive individuals) and 42 normal glucose-tolerant and normotensive controls and performed multiparametric CMR examination to assess cardiac geometry, microvascular perfusion, extracellular volume (ECV), and strain. Univariable and multivariable linear analysis was performed to analyze the effect of hypertension on LV deformation in patients with T2DM.
Results
Compared with controls, patients with T2DM exhibited decreased strain, decreased microvascular perfusion, increased LV remodeling index, and increased ECV. Hypertension lead to greater deterioration of LV strain (peak strain-radial, P = 0.002; peak strain-longitudinal, P = 0.006) and LV remodeling index (P = 0.005) in patients with T2DM after adjustment for covariates; however, it did not affect microvascular perfusion (perfusion index, P = 0.469) and ECV (P = 0.375). In multivariable analysis, hypertension and diabetes were independent predictors of reduced LV strain, whereas hypertension is associated with greater impairment of diastolic function (P = 0.009) but not systolic function (P = 0.125) in the context of diabetes, independent of clinical factors and myocardial disorder.
Conclusion
Hypertension in the context of diabetes is significantly associated with LV diastolic function and concentric remodeling; however, it has little effect on systolic function, myocardial microcirculation, or fibrosis independent of covariates, which provide clinical evidence for understanding the pathogenesis of comorbidities and explaining the development of distinct heart failure phenotypes.



J Hypertens: 05 Oct 2020; epub ahead of print
Jiang L, Ren Y, Yu H, Guo YK, ... Han PL, Yang ZG
J Hypertens: 05 Oct 2020; epub ahead of print | PMID: 33031176
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Abstract

Worth Remembering: Cardiac Memory Presenting as Deep Anterior T-wave Inversions Explained by Intermittent Left Bundle Branch Block.

Pierce JB, Rosenthal J, Stone NJ

Cardiac memory is a common cause of deep T-wave inversions (TWI) in the anterior precordial leads and can be difficult to distinguish from alternative causes of TWI such as myocardial ischemia. Cardiac memory is generally a benign condition except in the setting of prolonged QT when it can contribute to the precipitation of torsades de pointes. Herein, we describe the presentation and clinical course of a case of cardiac memory due to intermittent left bundle branch block (LBBB) that presented asymptomatically to our outpatient cardiology clinic with deep anterior TWI. We discuss common causes of and mechanisms underlying cardiac memory and how to distinguish it from alternative causes of TWI based on 12-lead electrocardiogram. In conclusion, intermittent LBBB is an under-recognized cause of cardiac memory that can present as deep anterior TWI mimicking cardiac ischemia, and awareness of this clinical entity may help prevent unnecessary invasive and expensive testing on otherwise healthy patients.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 27 Aug 2020; epub ahead of print
Pierce JB, Rosenthal J, Stone NJ
Am J Cardiol: 27 Aug 2020; epub ahead of print | PMID: 32866450
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Abstract

Cryoballoon Ablation and Bipolar Voltage Mapping in Patients with Left Atrial Appendage Occlusion Devices.

Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG

Left atrial appendage occlusion (LAAO) is utilized as a 2 line therapy to long term oral anticoagulation in appropriately selected patients with atrial fibrillation (AF). We examined the feasibility of cryoballoon (CB) pulmonary vein isolation (PVI) subsequent to Watchman device implantation. The study prospectively identified patients with Watchman devices (>90 days old) who underwent CB-PVI ablation between 2018 and 2019. Twelve consecutive patients (male 50%; mean age 71 ± 9 years; CHADS-VASc score 3.4 ± 1.1) underwent CB-PVI procedures after Watchman device implantation (mean 182 ± 82 days). Acute PVI was achieved in 100% of patients. All patients had evidence of complete (n=9) or partial (n=3) endothelialization of the surface of the Watchman device with conductive tissue properties demonstrated during electrophysiologic testing. There were no major procedure-related complications including death, stroke, pericardial effusion, device dislodgment, device thrombus, or new or increasing peri-device leak. Mean peri-device leak size (45-day post-implant: 0.06 ± 0.09 mm vs. Post-PVI: 0.04 ± 0.06 mm; p=0.61) remained unchanged. Two patients had recurrence of AF after the 90-day blanking period (13.2 ± 6.6 months). One patient underwent a redo ablation procedure for recurrent AF. This pilot study suggests the potential feasibility of CB-PVI ablation in patients with chronic Watchman LAAO devices. Larger prospective studies are needed to confirm the clinical efficacy and safety of this approach.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 27 Aug 2020; epub ahead of print
Huang HD, Krishnan K, Sharma PS, Kavinsky CJ, ... Larsen TR, Trohman RG
Am J Cardiol: 27 Aug 2020; epub ahead of print | PMID: 32866447
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Abstract

Improvement of the Prognosis Assessment of Severe Tricuspid Regurgitation by the Use of a Five-Grade Classification of Severity.

Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C

It is well known that some patients present with \"more than severe\" tricuspid regurgitation (TR). We aimed to assess the prognosis of these very severe TR patients. We defined very severe TR using 3 simple echocardiographic parameters: a coaptation gap≥10mm, a laminar TR flow and a systolic reversal of the hepatic vein flow. We included 259 consecutive patients (76 ± 13 years; 46% men) with moderate-to-severe TR (n = 114) and severe TR (n = 145). The primary end point was the combination of hospitalisation for right heart failure (RHF) and cardiovascular mortality. Median follow-up was 24(7 to 47) months. In patients with severe TR, 52 (36%) met the definition of very severe TR. These patients were younger, had more history of RHF and were more frequently treated with loop diuretics than those with moderate-to-severe TR (all p < 0.001). Four-year event-free survival rates were 68 ± 5%, for moderate-to-severe TR, 48 ± 6% for severe TR and only 35 ± 7% for very-severe TR (p < 0.001). On multivariable analysis, after adjustment for outcome predictors including age, comorbidity, RHF, TR etiology, left and right ventricular dysfunction, and tricuspid valve surgery, patients with very severe TR had a worsened prognosis than those with moderate-to-severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.43 [1.18 to 5.53]; p = 0.002) and than those with severe TR (Adjusted Hazard Ratio [95% Confidence Interval] = 2.23 [1.06 to 5.56]; p = 0.015). In conclusion, very severe TR is frequent in patients with severe TR, corresponds to a more advanced stage of the disease and is associated with poor outcomes. Therefore, the use of a 5-grade classification of TR severity is justified in routine clinical practice. (ID-RCB: 2017-A03233-50).

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:119-125
Peugnet F, Bohbot Y, Chadha G, Delpierre Q, ... Beyls C, Tribouilloy C
Am J Cardiol: 30 Sep 2020; 132:119-125 | PMID: 32741538
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Abstract

Ventricular Septal Myectomy for the Treatment of Left Ventricular Outflow Tract Obstruction Due to Fabry Disease.

Raju B, Roberts CS, Sathyamoorthy M, Schiffman R, Swift C, McCullough PA

Fabry cardiomyopathy can cause symptomatic left ventricular outflow tract obstruction. We review a case of Fabry cardiomyopathy mimicking hypertrophic cardiomyopathy on echocardiography with severe left ventricular outflow tract obstruction treated with ventricular septal myectomy.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 30 Sep 2020; 132:160-164
Raju B, Roberts CS, Sathyamoorthy M, Schiffman R, Swift C, McCullough PA
Am J Cardiol: 30 Sep 2020; 132:160-164 | PMID: 32773220
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Abstract

Predicting the Development of Reduced Left Ventricular Ejection Fraction in Patients with Left Bundle Branch Block.

Atwater BD, Emerek K, Samad Z, Sze E, ... Søgaard P, Friedman DJ

Left bundle branch block (LBBB) increases the likelihood of developing reduced left ventricular (LV) ejection fraction (EF) but predicting which patients with LBBB and normal LVEF will develop decreased LVEF remains challenging. Fifty patients with LBBB and normal LVEF were retrospectively identified. Clinical, electrocardiographic (ECG), and echocardiographic variables were compared between patients who developed a decreased LVEF and those who did not. A total of 16/50 patients developed reduced LVEF after 4.3 (SD=2.8) years of follow-up. Baseline patient and ECG variables were similar between patients who did and did not develop decreased LVEF. Baseline LVEF was lower in patients who developed decreased LVEF than in those who did not [51.9% (SD=2.2%) vs. 54.9% (SD=4.4%), P<0.01.] Diastolic filling time (DFT) accounted for a significantly smaller percentage of the cardiac cycle in patients who developed decreased LVEF than in those who did not [35.9%, (SD=6.9%) vs. 44.4% (SD=4.5%) P<0.01]. In univariable logistic regression, DFT had a C-statistic of 0.86 (P<0.0001) for prediction of development of decreased LVEF. In conclusion, patients in whom DFT accounted for <38% of the cardiac cycle had a relative risk of developing decreased LVEF of 7.0 (95% CI 3.0-16.0) compared to patients with DFT accounting for ≥38% of the cardiac cycle.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 26 Sep 2020; epub ahead of print
Atwater BD, Emerek K, Samad Z, Sze E, ... Søgaard P, Friedman DJ
Am J Cardiol: 26 Sep 2020; epub ahead of print | PMID: 32998010
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Abstract

Effect of Progression of Valvular Calcification on Left Ventricular Structure and Frequency of Incident Heart Failure (from the Multiethnic Study of Atherosclerosis).

Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED

Heart failure (HF) is a leading cause of morbidity. Strategies for preventing HF are paramount. Prevalent extracoronary calcification is associated with HF risk but less is known about progression of mitral annular (MAC) and aortic valve calcification (AVC) and HF risk. Progression of valvular calcification (VC) [interval change of >0 units/yr] was assessed by 2 cardiac computed tomography scans over a median of 2.4 years. We used Cox regression to determine the risk of adjudicated HF and linear mixed effects models to determine 10-year change in left ventricular (LV) parameters measured by cardiac magnetic resonance imaging associated with VC progression. We studied 5,591 MESA participants free of baseline cardiovascular disease. Mean ± SD age was 62 ± 10 years; 53% women; 83% had no VC progression, 15% progressed at 1 site (AVC or MAC) and 3% at both sites. There were 251 incident HF over 15 years. After adjusting for cardiovascular risk factors, the hazard ratios (95% confidence interval) of HF associated with VC progression at 1 and 2 sites were 1.62 (1.21 to 2.17) and 1.88 (1.14 to 3.09), respectively, compared with no progression (p-for-trend <0.001). Hazard ratios were higher for HFpEF (2.52 [1.63 to 3.90] and 2.49 [1.19 to 5.25]) but nonsignificant for HFrEF. Both AVC (1.61 [1.19 to 2.19]) and MAC (1.50 [1.09 to 2.07]) progression were associated with HF. VC was associated with worsening of some LV parameters over 10 years. In conclusion, VC progression was associated with increased risk of HF and change in LV function. Interventions targeted at reducing VC progression may also impact HF risk, particularly HFpEF.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:99-107
Fashanu OE, Upadhrasta S, Zhao D, Budoff MJ, ... Lima JAC, Michos ED
Am J Cardiol: 31 Oct 2020; 134:99-107 | PMID: 32917344
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Abstract

Cardiac Imaging to assess Left Ventricular Systolic Function in Atrial Fibrillation.

Bunting KV, O\'Connor K, Steeds RP, Kotecha D

The validity and reproducibility of systolic function assessment in patients with atrial fibrillation (AF) using cardiac magnetic resonance (CMR), echocardiography, nuclear imaging and computed tomography (CT) is unknown. A prospectively-registered systematic review was performed, including 24 published studies with patients in AF at the time of imaging and reporting validity or reproducibility data on left ventricular systolic parameters (PROSPERO: CRD42018091674). Data extraction and risk of bias were performed by 2 investigators independently and synthesized qualitatively. In 3 CMR studies (40 AF patients), LVEF and stroke volume measurements correlated highly with catheter angiography (r≥0.85), and intra/inter-observer variability were low. From 3 nuclear studies (171 AF patients), there were no external validation assessments but intra/inter-observer and inter-session variability were low. In 18 echocardiography studies (2566 AF patients), 2 studies showed high external validity of global longitudinal strain (GLS) and tissue Doppler s\' with angiography-derived dP/dt (r≥0.88). GLS and myocardial performance index were both associated with adverse cardiovascular events. Reproducibility of echocardiography was better when selecting an index beat (where two preceding RR intervals are similar) compared to averaging of consecutive beats. There were no studies relating to CT. Most studies were small and biased by selection of patients with good quality images, limiting clinical extrapolation of results. The validity of systolic function measurements in patients with AF remains unclear due to the paucity of good-quality data.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 12 Oct 2020; epub ahead of print
Bunting KV, O'Connor K, Steeds RP, Kotecha D
Am J Cardiol: 12 Oct 2020; epub ahead of print | PMID: 33065079
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Abstract

Utility of Cardiac Magnetic Resonance Imaging Versus Cardiac Positron Emission Tomography for Risk Stratification for Ventricular Arrhythmias in Patients With Cardiac Sarcoidosis.

Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J

Abnormalities on cardiac magnetic resonance imaging (CMR) and positron emission tomography (PET) predict ventricular arrhythmias (VA) in patients with cardiac sarcoidosis (CS). Little is known whether concurrent abnormalities on CMR and PET increases the risk of developing VA. Our aim was to compare the additive utility of CMR and PET in predicting VA in patients with CS. We included all patients treated at our institution from 2000 to 2018 who (1) had probable or definite CS and (2) had undergone both CMR and PET. The primary endpoint was VA at follow up, which was defined as sustained ventricular tachycardia, sudden cardiac death, or any appropriate device tachytherapy. Fifty patients were included, 88% of whom had a left ventricular ejection fraction >35%. During a mean follow-up 4.1 years, 7/50 (14%) patients had VA. The negative predictive value of LGE for VA was 100% and the negative predictive value of FDG for VA was 79%. Among groups, VA occurred in 4/21 (19%) subjects in the LGE+/FDG+ group, 3/14 (21%) in the LGE+/FDG- group, and 0/15 (0%) in the FDG+/LGE- group. There were no LGE-/FDG- patients. In conclusion, CMR may be the preferred initial clinical risk stratification tool in patients with CS. FDG uptake without LGE on initial imaging may not add additional prognostic information regarding VA risk.

Copyright © 2020. Published by Elsevier Inc.

Am J Cardiol: 31 Oct 2020; 134:123-129
Gowani Z, Habibi M, Okada DR, Smith J, ... Tandri H, Chrispin J
Am J Cardiol: 31 Oct 2020; 134:123-129 | PMID: 32950203
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Abstract

Comparison of the Usefulness of Strain Imaging by Echocardiography Versus Computed Tomography to Detect Right Ventricular Systolic Dysfunction in Patients With Significant Secondary Tricuspid Regurgitation.

Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ

Assessment of right ventricular (RV) systolic function in patients with significant secondary tricuspid regurgitation (STR) remains challenging. In patients with severe aortic stenosis treated with transcatheter aortic valve implantation (TAVI), STR and RV enlargement have been associated with poor outcomes. In these patients, speckle tracking echocardiography (STE) may detect RV systolic dysfunction better than 3-dimensional (3D) RV ejection fraction (EF). The purpose of this study was to investigate the prevalence of RV dysfunction when assessed with STE in patients with significant STR (≥3+) compared with patients without significant STR (<3+) matched for 3D RV dimensions and RVEF on dynamic computed tomography (CT). Patients with dynamic CT data before TAVI were evaluated retrospectively. To assess the performance of RV-free wall strain (RVFWS) for identifying patients with impaired RV systolic function, patients were subsequently matched 1:1 based on age, gender, indexed RV end-diastolic volume (RVEDVi), indexed RV end-systolic volume (RVESVi), RVEF, and left ventricular ejection fraction (LVEF). In a total 267 patients (80 ± 8 years, 48% male), significant STR (≥3+) was observed in 67 patients. Patients with STR≥3+ had larger RVEDVi, larger RVESVi, lower LVEF, and more impaired RVFWS compared with patients with STR<3+ (n = 200). After propensity score matching, patients with STR≥3+ (n = 53) had significantly more impaired RVFWS compared with patients with STR<3+ (n = 53): -18.2 ± 5.0% versus -21.1 ± 3.7%, p = 0.001. In conclusion, patients with significant STR have more pronounced RV systolic dysfunction as assessed with STE than the patients without significant STR despite having similar 3D RV dimensions and RVEF on dynamic CT.

Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.

Am J Cardiol: 31 Oct 2020; 134:116-122
Hirasawa K, van Rosendael PJ, Dietz MF, Ajmone Marsan N, Delgado V, Bax JJ
Am J Cardiol: 31 Oct 2020; 134:116-122 | PMID: 32891401
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Abstract

Menopausal age and left ventricular remodeling by cardiac magnetic resonance imaging among 14,550 women.

Honigberg MC, Pirruccello JP, Aragam K, Sarma AA, ... Wood MJ, Natarajan P

The present study included 14,550 postmenopausal female participants in the UK Biobank who completed cardiac magnetic resonance imaging. Earlier age at menopause was significantly and independently associated with smaller left ventricular end-diastolic volume and smaller stroke volume, a pattern suggesting acceleration of previously described age-related left ventricular remodeling. These findings may have implications for understanding mechanisms of heart failure, specifically heart failure with preserved ejection fraction, among women with early menopause.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am Heart J: 19 Aug 2020; 229:138-143
Honigberg MC, Pirruccello JP, Aragam K, Sarma AA, ... Wood MJ, Natarajan P
Am Heart J: 19 Aug 2020; 229:138-143 | PMID: 32827459
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Characteristics and Prognostic Associations of Echocardiographic Pulmonary Hypertension With Normal Left Ventricular Systolic Function in Patients ≥90 Years of Age.

Shimada S, Uno G, Omori T, Rader F, Siegel RJ, Shiota T

The high prevalence of pulmonary hypertension (PH) in elderly patients is well known. However, much remains unknown about those population. We sought to find the clinical characteristics of echocardiographic PH and the prognostic factors in patients ≥90 years of age. We retrospectively reviewed 310 patients ≥90 years of age (median age 92 years, 64% women) diagnosed as echocardiographic PH (peak systolic pulmonary arterial pressure ≥40 mm Hg) with normal left ventricular systolic function. We defined left heart disease (LHD) as significant left-sided valve diseases, left ventricular hypertrophy and left ventricular diastolic dysfunction by using echocardiography. The endpoint was all-cause death at 2,000 days after diagnosis. LHD was found in 92% of patients. During the median follow-up of 367 days (interquartile range, 39-1,028 days), 151 all-cause deaths (49%) occurred. Multivariable Cox regression analysis demonstrated that right ventricular fraction area change <35% (adjusted hazard ratio [HR]: 2.31; p <0.001), pericardial effusion (adjusted HR: 2.28; p <0.001), serum albumin <3.5 g/dL (adjusted HR: 1.76; p = 0.001), chronic obstructive pulmonary disease (adjusted HR: 1.93; p = 0.001) and New York Heart Association (NYHA) class ≥II (adjusted HR: 1.73; p = 0.004) were associated with mortality after adjusted for age. In conclusion, LHD was significantly associated with echocardiographic PH in most patients ≥90 years of age. Also, the co-morbid factors at diagnosis (right ventricular systolic dysfunction, pericardial effusion, hypoalbuminemia, chronic obstructive pulmonary disease, and NYHA class ≥II) were independently associated with mortality.

Copyright © 2020 Elsevier Inc. All rights reserved.

Am J Cardiol: 14 Aug 2020; 129:95-101
Shimada S, Uno G, Omori T, Rader F, Siegel RJ, Shiota T
Am J Cardiol: 14 Aug 2020; 129:95-101 | PMID: 32624190
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Abstract

Left Ventricular Diastolic Function in Healthy Adult Individuals: Results of the World Alliance Societies of Echocardiography Normal Values Study.

Miyoshi T, Addetia K, Citro R, Daimon M, ... Asch FM,
Background
The World Alliance Societies of Echocardiography (WASE) study was conducted to describe echocardiographic normal values in adults and to compare races and nationalities using a uniform acquisition and measurement protocol. This report focuses on left ventricular (LV) diastolic function.
Methods
WASE is an international, cross-sectional study. Participants were enrolled with equal distribution according to age and gender. Echocardiograms were analyzed in a core laboratory based on the latest American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. Left ventricular diastolic function was assessed by E, E/A, e\' velocities, E/e\', left atrial volume index (LAVI), and tricuspid regurgitation velocity. Determination of LV diastolic function was made using the algorithm proposed by the guidelines.
Results
A total of 2,008 subjects from 15 countries were enrolled. The majority were of white or Asian race (42.8%, 41.8%, respectively). E and E/e\' were higher in female patients, while LAVI was similar in both genders. Consistent increase in E/e\' and decrease in E/A, E, and e\' were found as age increased. The upper limit of normal for LAVI was higher in WASE compared with the guidelines. The lower limits of normal for e\' were smaller in elder groups than those in the guidelines, while the upper limits of normal for E/e\' were below the guideline values. These findings suggest that the cutoff value for LAVI should be shifted upward and age-specific cutoff values for e\' should be considered. In WASE, <93.6% of patients were classified as normal LV diastolic function using the guidelines\' algorithm, and the proportion increased to 97.4% when applying the revised cutoff values for LAVI obtained in our study.
Conclusions
Guideline-recommended normal values for e\' velocities and LAVI should be reconsidered. The algorithm for the determination of LV diastolic function proposed by the guidelines is useful, but adjustments to LAVI could further improve it.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print
Miyoshi T, Addetia K, Citro R, Daimon M, ... Asch FM,
J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print | PMID: 32741597
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Abstract

Reproducibility of Clinical Late Gadolinium Enhancement Magnetic Resonance Imaging in Detecting Left Atrial Scar after Atrial Fibrillation Ablation.

Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
Background
Late gadolinium enhancement (LGE) cardiac MRI can be used to detect post-ablation atrial scar (PAAS) but its reproducibility and reliability in clinical scans across different magnetic flux densities and scar detection methods is unknown.
Methods
Patients (n=45) having undergone two consecutive MRIs (three months apart) on 3T and 1.5T scanners were studied. We compared PAAS detection reproducibility using four methods of thresholding: simple thresholding, Otsu thresholding, 3.3 standard deviations (SD) above blood pool (BP) mean intensity, and image intensity ratio (IIR). We performed a texture study by dividing the left atrial wall intensity histogram into deciles and evaluated the correlation of the same decile of the two scans as well as to a randomized distribution of intensities, quantified using Dice Similarity Coefficient (DSC).
Results
The choice of scanner did not significantly affect the reproducibility. The scar detection performed by Otsu thresholding (DSC of 71.26±8.34) resulted in better correlation of the two scans compared to the methods of 3.3 SD above BP mean intensity (DSC of 57.78±21.2, p<0.001) and IIR above 1.61 (DSC of 45.76±29.55, p<001). Texture analysis showed that correlation only for voxels with intensities in deciles above the 70 percentile of wall intensity histogram was better than random distribution (p<0.001).
Conclusions
Our results demonstrate that clinical LGE-MRI can be reliably used for visualizing PAAS across different magnetic flux densities if the threshold is greater than 70 percentile of the wall intensity distribution. Also, atrial wall based thresholding is better than BP based thresholding for reproducible PAAS detection. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print
Kamali R, Schroeder J, DiBella E, Steinberg B, ... Macleod RS, Ranjan R
J Cardiovasc Electrophysiol: 14 Sep 2020; epub ahead of print | PMID: 32931635
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The Obesity Paradox in Patients with Significant Tricuspid Regurgitation: Effects of Obesity on Right Ventricular Remodeling and Long-Term Prognosis.

Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V
Background
Obesity may cause right ventricular (RV) remodeling due to volume overload. However, obesity is also associated with better prognosis compared with normal weight in patients with various cardiac diseases. The aim of this study was to assess the impact of obesity on RV remodeling and long-term prognosis in patients with significant (moderate and severe) tricuspid regurgitation (TR).
Methods
A total of 951 patients with significant TR (median age, 70 years; interquartile range, 61-77 years; 50% men) were divided into three groups according to body mass index (BMI): normal weight (BMI 18.5-24.9 kg/m), overweight (BMI 25-29.9 kg/m), and obese (BMI ≥ 30 kg/m). Patients with congenital heart disease, peripheral edema, active endocarditis, and BMI < 18.5 kg/m were excluded. RV size and function for each group were measured using transthoracic echocardiography and compared with reference values of healthy study populations. The primary end point was all-cause mortality. Event rates were compared across the three BMI categories.
Results
Four hundred seventy-six patients (50%) with significant TR had normal weight, 356 (37%) were overweight, and 119 (13%) were obese. RV end-diastolic and end-systolic areas were larger in overweight and obese patients compared with normal-weight patients. However, no differences in RV systolic function were observed. During a median follow-up period of 5 years, 358 patients (38%) died. Five-year survival rates were significantly better in overweight and obese patients compared with patients with normal weight (65% and 67% vs 58%, respectively, P < .001 and P = .005). In multivariate analysis, overweight and obesity were independently associated with lower rates of all-cause mortality compared with normal weight (hazard ratios, 0.628 [95% CI, 0.493-0.800] and 0.573 [95% CI, 0.387-0.848], respectively).
Conclusions
In patients with significant TR, overweight and obese patients demonstrated more RV remodeling compared with patients with normal weight. Nevertheless, a higher BMI was independently associated with better long-term survival, confirming the obesity paradox in this context.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 09 Sep 2020; epub ahead of print
Dietz MF, Prihadi EA, van der Bijl P, Ajmone Marsan N, Bax JJ, Delgado V
J Am Soc Echocardiogr: 09 Sep 2020; epub ahead of print | PMID: 32921538
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Abstract

Prognostic Importance of Left Ventricular Global Longitudinal Strain in Patients with Severe Aortic Stenosis and Preserved Ejection Fraction.

Thellier N, Altes A, Appert L, Binda C, ... Tribouilloy C, Maréchaux S
Background
Impaired left ventricular (LV) speckle-tracking-derived global longitudinal strain (GLS) magnitude (GLS worse than 14.7%) has been associated with poor outcome in patients with severe aortic stenosis (AS) and preserved LV ejection fraction (EF).
Objectives
To test the hypothesis that GLS magnitude ≤ 15% obtained with vendor-independent speckle-tracking strain software may be able to identify patients with severe AS who are at higher risk of death, despite preserved LVEF and no or mild symptoms.
Methods
GLS was retrospectively obtained in 332 patients with severe AS (aortic valve area indexed [AVAi] < 0.6 cm/m), no or mild symptoms, and LVEF ≥ 50%. Absolute values of GLS were collected. Survival analyses were carried out to study the impact of GLS magnitude on all-cause mortality.
Results
During a median follow-up period of 42 (37-46) months, 105 patients died. On multivariate analysis, and after adjustment of known clinical and/or echocardiographic predictors of outcome and aortic valve replacement as a time-dependent covariate, GLS magnitude ≤ 15% was independently associated with mortality during follow-up (all P < .01). Adding GLS magnitude ≤ 15% (adjusted hazard ratio = 1.99 [1.17-3.38], P = .011) to a multivariate model including clinical and echocardiographic variables of prognostic importance (aortic valve replacement, aortic valve area, LV stroke volume index < 30 mL/m, and LVEF<60%) improved the predictive performance with improved global model fit, reclassification, and better discrimination. After propensity score matching (n = 196), increased risk of mortality persisted among patients with GLS magnitude ≤ 15% compared with those with GLS > 15% (hazard ratio = 2.10; 95% confidence interval, 1.20-3.68; P = .009).
Conclusions
In this series of patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, GLS obtained with vendor-independent speckle-tracking strain software was an effective tool to identify patients with a poor outcome. Detection of myocardial dysfunction by identifying GLS magnitude < 15% in patients with severe AS, no or mild symptoms, and LVEF ≥ 50%, can aid in risk assessment.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Thellier N, Altes A, Appert L, Binda C, ... Tribouilloy C, Maréchaux S
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919856
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Abstract

Identification of Subclinical Myocardial Dysfunction and Association with Survival after Transcatheter Mitral Valve Repair.

Fukui M, Niikura H, Sorajja P, Hashimoto G, ... Gössl M, Cavalcante JL
Background
Transcatheter mitral valve repair (TMVr) using edge-to-edge mitral valve clip is effective for patients with mitral regurgitation (MR) and high or prohibitive surgical risk. Global longitudinal strain (GLS) allows evaluation of subclinical myocardial dysfunction, but its incremental clinical utility into risk stratification, beyond traditional clinical parameters, is unknown in patients treated with TMVr. We sought to evaluate the association of baseline GLS with 1-year all-cause mortality in patients treated with TMVr using edge-to-edge mitral valve clip.
Methods
We analyzed 155 patients who underwent transcatheter edge-to-edge mitral valve clip implantation (mean age, 83 ± 7 years; 48% were women; mean left ventricular ejection fraction, 56% ± 10%, Society of Thoracic Surgeons Predicted Risk of Mortality score for repair, 6.62% ± 5.22%). Baseline left ventricular GLS was obtained by two-dimensional speckle-tracking echocardiography, averaging 18 segments from three apical views. Receiver operating characteristic analyses were used to assess the GLS cut point associated with all-cause mortality. Multivariable models with Cox regression tested its relationship after adjustment for baseline comorbidities.
Results
During a median follow-up of 316 days, all-cause deaths occurred in 30 patients at a median of 156 days after TMVr. The area under the curve of preoperative GLS associated with the outcome was 0.60, with a cutoff point of -14.5%. Baseline GLS > -14.5% was associated with 1-year mortality (hazard ratio = 2.50; 95% CI, 1.20-5.21; P = .02) before and after adjustment for baseline characteristics. After accounting for baseline characteristics, patients with GLS > -14.5% had worse 1-year mortality than those with GLS ≤ -14.5% (χP < .001). In nested Cox proportional hazards models, the addition of baseline GLS to Society of Thoracic Surgeons Predicted Risk of Mortality score, left ventricular ejection fraction, and the etiology of MR significantly increased the model χ value (χ = 12.32).
Conclusions
Baseline GLS is independently associated with 1-year all-cause mortality in patients who undergo TMVr, and its assessment improves risk stratification in these patients.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print
Fukui M, Niikura H, Sorajja P, Hashimoto G, ... Gössl M, Cavalcante JL
J Am Soc Echocardiogr: 08 Sep 2020; epub ahead of print | PMID: 32919854
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Impact:
Abstract

Amplatzer left atrial appendage closure: Single versus combined procedures.

Kleinecke C, Buffle E, Link J, Häner J, ... Meier B, Gloekler S
Objectives
This study compares procedural and late clinical outcomes of left atrial appendage closure (LAAC) with Amplatzer devices as a single versus a combined procedure with other structural or coronary interventions.
Background
Multiple cardiac conditions are frequent among elderly patients and invite simultaneous treatment to ensure a favorable patient outcomes.
Methods
559 consecutive patients (73.3 ± 11.1 years) underwent LAAC with Amplatzer devices at two centres (Bern and Zurich university hospitals, Switzerland) either as a single procedure or combined with other interventions. The primary safety endpoint was a composite of major peri-procedural complications and major bleeding at follow-up, the primary efficacy endpoint included stroke, systemic embolism, and cardiovascular/unexplained death. All event rates are reported per 100 patient-years.
Results
In 263 single and 296 combined procedures with percutaneous coronary interventions (47.6%), closure of an atrial septal defect (8.4%) or a patent foramen ovale (36.5%), transcatheter aortic valve implantation (10.1%), mitral clipping (4.1%), atrial fibrillation ablation (8.8%), or another procedure (3.0%) were analyzed. Device success (96.6% [single] vs. 99.0% [combined], p = .08) did not differ between the groups. After a mean follow-up of 2.6 ± 1.5 vs. 2.5 ± 1.5 years and a total of 1,422 patient-years, the primary efficacy (40/677, 5.9% [single] vs. 37/745, 5.0% [combined]; HR, 1.2, 95% CI, 0.8-1.9, p = .44), as well as the primary safety endpoint (25/677, 3.7% vs 28/745, 3.8%; HR, 1.0, 95% CI, 0.6-1.8, p = .89) were comparable.
Conclusions
LAAC with Amplatzer devices combined with structural, coronary, and electrophysiological procedures offers procedural feasibility and safety, as well as long-term efficacy.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 14 Sep 2020; epub ahead of print
Kleinecke C, Buffle E, Link J, Häner J, ... Meier B, Gloekler S
Catheter Cardiovasc Interv: 14 Sep 2020; epub ahead of print | PMID: 32930492
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Impact:
Abstract

Cardiovascular Magnetic Resonance may avoid unnecessary coronary angiography in patients with unexplained left ventricular systolic dysfunction: a retrospective diagnostic pilot study.

Desroche LM, Milleron O, Safar B, Ou P, ... Ronchard T, Jondeau G
Backgrounds
Coronary angiography(CA) is usually performed in patients with reduced left ventricular ejection fraction(LVEF) to SEARCH: ischemic cardiomyopathy. Our aim was to examine the agreement between CA and cardiovascular magnetic resonance(CMR) among a cohort of patients with unexplained reduced LVEF, and estimate what would have been the consequences of using CMR as the first-line exam.
Methods
Three hundred and five patients with unexplained reduced LVEF≤ 45% who underwent both CA and CMR were retrospectively registered. Patients were classified as CMR or CMR according to presence or absence of myocardial ischemic scar, and classified CA or CA according to presence or absence of significant coronary artery disease(CAD).
Results
CMR+(n=89) included all 54CA+ patients, except 2 with distal CAD in whom no revascularization was proposed. Among the 247CA patients, 15% were CMR. CMR had 96% sensitivity, 85% specificity, 99% negative predictive value, and 58% positive predictive value for detecting CA+ patients. Revascularization was performed in 6.5% of the patients (all CMR). Performing CA only for CMR patients would have decreased the number of CAs by 71%.
Conclusions
In reduced LVEF, performing CA only in CMR patients may significantly reduce the number of unnecessary CAs performed, without missing any patients requiring revascularization.

Copyright © 2020. Published by Elsevier Inc.

J Card Fail: 13 Sep 2020; epub ahead of print
Desroche LM, Milleron O, Safar B, Ou P, ... Ronchard T, Jondeau G
J Card Fail: 13 Sep 2020; epub ahead of print | PMID: 32942010
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Impact:
Abstract

Prominent Longitudinal Strain Reduction of Basal Left Ventricular Segments in Patients with COVID-19.

Goerlich E, Gilotra NA, Minhas AS, Bavaro N, Hays AG, Cingolani OH
Background
COVID-19 has been associated with overt and subclinical myocardial dysfunction. We observed a recurring pattern of reduced basal left ventricular (LV) longitudinal strain (LS) on speckle-tracking echocardiography (STE) in hospitalized COVID-19 patients and subsequently aimed to identify characteristics of affected patients. We hypothesized that COVID-19 patients with reduced basal LV strain would demonstrate elevated cardiac biomarkers.
Methods
81 consecutive COVID-19 patients underwent STE. Those with poor quality STE (n=2) or known LV ejection fraction<50% (n=4) were excluded. Patients with absolute value basal LS<13.9% (2SD below normal) were designated as cases (n=39); those with basal LS≥13.9% as controls (n=36). Demographics and clinical variables were compared.
Results
Of 75 included patients (mean age 62±14 years, 41% women), 52% had reduced basal strain. Cases had higher BMI (median[IQR]) (34.1[26.5-37.9]kg/m vs. 26.9[24.8-30.0]kg/m, p=0.009), and greater proportions of Black (74% vs. 36%, p=0.0009), hypertensive (79% vs. 56%, p=0.026) and diabetic patients (44% vs. 19%, p=0.025) compared to controls. Troponin and NT-proBNP levels trended higher in cases but were not significantly different.
Conclusions and relevance
Reduced basal LV strain is common in COVID-19 patients. Patients with hypertension, diabetes, obesity, and Black race were more likely to have reduced basal strain. Further investigation into the significance of this strain pattern is warranted.

Copyright © 2020. Published by Elsevier Inc.

J Card Fail: 25 Sep 2020; epub ahead of print
Goerlich E, Gilotra NA, Minhas AS, Bavaro N, Hays AG, Cingolani OH
J Card Fail: 25 Sep 2020; epub ahead of print | PMID: 32991982
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Impact:
Abstract

Left Atrial Strain in Evaluation of Heart Failure with Preserved Ejection Fraction.

Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
Background
Patients with heart failure with preserved ejection fraction (HFpEF) may have elevated left ventricular filling pressure with exercise (LVFP-ex), despite normal LVFP at rest. The aim of this study was to assess the diagnostic value of resting left atrial strain (LAS) in detecting elevated LVFP-ex in patients with dyspnea evaluated on exercise stress echocardiography.
Methods
Two-dimensional speckle-tracking analysis for LAS was performed in 669 consecutive patients (mean age, 64 ± 14 years; 53% men) who underwent treadmill echocardiographic evaluation and had left ventricular ejection fractions ≥ 50%. Assessment of LVFP at rest LVFP-ex was based on the 2016 American Society of Echocardiography guidelines for diastolic function assessment. An E/e\' ratio ≥ 15 after exercise is considered to indicate elevated LVFP-ex. A continuous diagnostic score of HFpEF was calculated on the basis of the European Society of Cardiology HFA-PEFF diagnostic algorithm.
Results
LAS was lowest in patients with elevated LVFP at rest (n = 81) and lower in those with normal resting filling pressure who developed elevated LVFP-ex (n = 108) compared with those who maintained normal LVFP-ex (29.0 ± 5.2% vs 33.1 ± 5.0% vs 39.3 ± 4.8%, P < .001). Lower LAS was associated with worse exercise capacity as assessed by metabolic equivalents, exercise time, and functional aerobic capacity (multivariate-adjusted P values all < .05). In patients with normal or indeterminate LVFP at rest (n = 587), LAS and preexercise HFA-PEFF score demonstrated areas under the curve of 0.82 and 0.7, respectively, for elevated LVFP-ex. There were 28% higher odds of developing elevated LVFP-ex per 1% decrease in LAS (odds ratio, 0.78; 95% CI, 0.74-0.82). Among patients with intermediate scores (n = 461), 123 developed elevations in LVFP-ex and were classified as having HFpEF per the diagnostic algorithm. The addition of LAS improved the diagnostic value of HFA-PEFF score for HFpEF (area under the curve increased from 0.71 to 0.80, P = .01).
Conclusions
LAS has potential to identify patients with intermediate scores for HFpEF who may develop elevated LVFP-ex only and is therefore a promising alternative to aid in diagnosis when exercise testing is not feasible.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Ye Z, Miranda WR, Yeung DF, Kane GC, Oh JK
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981787
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Impact:
Abstract

Accuracy of contrast-enhanced computed tomography for thrombus detection prior to atrial fibrillation ablation and role of novel Left Atrial Appendage Enhancement Index in appendage flow assessment.

Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Aims
To evaluate diagnostic accuracy of different protocols of contrast enhanced computed tomography venogram (CTV) for LAA thrombus detection in patients undergoing AF ablation and study the correlation of the novel LAA enhancement index (LAA-EI) to LAA flow velocity obtained using transesophageal echocardiography (TEE).
Methods
Study comprised of patients undergoing CTV and TEE on the same day from October 2016 to December 2017. Three CTV scanning protocols (described in results), were evaluated wherein ECG gating was used only for those with sinus rhythm on day of CTV. LAA-EI was calculated as Hounsfield Unit (HU) in the LAA divided by the HU unit in the center of the LA. The diagnostic accuracy for CTV was calculated in comparison to TEE. The LAA-EI was compared to LAA emptying velocities as obtained from TEE.
Results
590 patients with 45.6% non-ECG-gated without delayed imaging, 26.9% non-ECG-gated with delayed imaging and 27.5% ECG-gated with delayed imaging, were included in the study. All three protocols had 100% negative predictive value with improvement in specificity from 61.8% to 98.1% upon adding delayed imaging. The LAA-EI correlated significantly with reduced LAA flow velocities (r = 0.45, p < .0001). The mean LAA emptying velocity in patients with LAA-EI of ≤ 0.6 was significantly lower than in those with LAA-EI of >0.6 (36.2 cm/s [95% CI: 32.6-39.7] vs, (58 cm/s [95% CI 55.3-60.8]), respectively (p < .0001).
Conclusion
CTV with delayed imaging (with or without ECG gating) is highly specific in ruling out LAA thrombus. The novel LAA-EI can detect low LAA flow velocities.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 31 Oct 2020; 318:147-152
Guha A, Dunleavy MP, Hayes S, Afzal MR, ... Raman SV, Harfi TT
Int J Cardiol: 31 Oct 2020; 318:147-152 | PMID: 32629004
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Impact:
Abstract

Evaluation of the right heart using cardiovascular magnetic resonance imaging in patients with cardiac devices.

Löbe S, Paetsch I, Hilbert S, Spampinato R, ... Hindricks G, Jahnke C
Background
Patients with cardiac implantable electronic devices (CIED) necessitate comprehensive cardiovascular magnetic resonance (CMR) examinations. The aim of this study was to provide data on CMR image quality and feasibility of functional assessment of the right heart in patients with CIED depending on the device type and imaging sequence used.
Methods
120 CIED carriers (Insertable cardiac monitoring system, n = 13; implantable loop-recorder, n = 22; pacemaker, n = 30; implantable cardioverter-defibrillator (ICD), n = 43; and cardiac resynchronization therapy defibrillator (CRT-D), n = 12) underwent clinically indicated CMR imaging using a 1.5 T. CMR protocols consisted of cine imaging and myocardial tissue characterization including T1-and T2-weighted blackblood imaging and late gadolinium enhancement (LGE) imaging. Image quality was evaluated with regard to device-related imaging artifacts per right-ventricular (RV) segment.
Results
RV segmental evaluability was influenced by the device type and CMR imaging sequence: Cine steady-state-free-precision (SSFP) imaging was found to be non-diagnostic in patients with ICD/CRT-D and implantable loop recorders; a significant improvement of image quality was achieved when using cine turbo-field-echo (TFE) sequences with a further improvement on post-contrast TFE imaging. LGE scans were artifact-free in at least 91% of RV segments with best results in patients with a pacemaker or an insertable cardiac monitoring system.
Conclusions
In patients with CIED, artifact-free CMR imaging of the right ventricle was performed in the majority of patients and resulted in highly reproducible evaluability of RV functional parameters. This finding is of particular importance for the diagnosis and follow-up of right-ventricular diseases.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Sep 2020; 316:266-271
Löbe S, Paetsch I, Hilbert S, Spampinato R, ... Hindricks G, Jahnke C
Int J Cardiol: 30 Sep 2020; 316:266-271 | PMID: 32389768
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Impact:
Abstract

Enhanced Echo Intensity of Skeletal Muscle Is Associated With Exercise Intolerance in Patients With Heart Failure.

Nakano I, Hori H, Fukushima A, Yokota T, ... Abe T, Anzai T
Background
Skeletal muscle is quantitatively and qualitatively impaired in patients with heart failure (HF), which is closely linked to lowered exercise capacity. Ultrasonography (US) for skeletal muscle has emerged as a useful, noninvasive tool to evaluate muscle quality and quantity. Here we investigated whether muscle quality based on US-derived echo intensity (EI) is associated with exercise capacity in patients with HF.
Methods and results
Fifty-eight patients with HF (61 ± 12 years) and 28 control subjects (58 ± 14 years) were studied. The quadriceps femoris echo intensity (QEI) was significantly higher and the quadriceps femoris muscle thickness (QMT) was significantly lower in the patients with HF than the controls (88.3 ± 13.4 vs 81.1 ± 7.5, P= .010; 5.21 ± 1.10 vs 6.54 ±1.34 cm, P< .001, respectively). By univariate analysis, QEI was significantly correlated with age, peak oxygen uptake (VO), and New York Heart Association class in the HF group. A multivariable analysis revealed that the QEI was independently associated with peak VO after adjustment for age, gender, body mass index, and QMT: β-coefficient = -11.80, 95%CI (-20.73, -2.86), P= .011.
Conclusion
Enhanced EI in skeletal muscle was independently associated with lowered exercise capacity in HF. The measurement of EI is low-cost, easily accessible, and suitable for assessment of HF-related alterations in skeletal muscle quality.

Copyright © 2019 Elsevier Inc. All rights reserved.

J Card Fail: 30 Jul 2020; 26:685-693
Nakano I, Hori H, Fukushima A, Yokota T, ... Abe T, Anzai T
J Card Fail: 30 Jul 2020; 26:685-693 | PMID: 31533068
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Impact:
Abstract

Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool.

Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
Background
Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering.
Methods
We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation.
Results
TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05).
Conclusions
The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print
Karagodin I, Addetia K, Singh A, Dow A, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 20 Sep 2020; epub ahead of print | PMID: 32972777
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Impact:
Abstract

Diagnostic Performance of Transesophageal Echocardiography and Cardiac Computed Tomography in Infective Endocarditis.

Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
Background
Multimodality imaging is essential for infective endocarditis (IE) diagnosis. The aim of this work was to evaluate the agreement between transesophageal echocardiography (TEE) and cardiac computed tomography (CT) findings in patients with surgically confirmed IE.
Methods
Sixty-eight patients (mean age 63 ± 2 years) with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, on both native and prosthetic valves, underwent TEE and cardiac CT before surgery. The presence of valvular (vegetations, erosion) and paravalvular (abscess, pseudoaneurysm) IE-related lesions were compared between both modalities. Perioperative inspection was used as reference.
Results
TEE performed better than CT in detecting valvular IE-related lesions (TEE area under the curve [AUC] = 0.881 vs AUC = 0.720, P = .02) and was similar to CT with respect to paravalvular IE-related lesions (AUC = 0.830 vs AUC = 0.816, P = .835). The ability of TEE to detect vegetation was significantly better than that of CT (AUC = 0.863 vs AUC = 0.693, P = .02). The maximum size of vegetations was moderately correlated between modalities (Spearman\'s rho = 0.575, P < .001). Computed tomography exhibited higher sensitivity than TEE for pseudoaneurysm detection (100% vs 66.7%, respectively) but was similar with respect to diagnostic accuracy (AUC = 0.833 vs AUC = 0.984, P = .156).
Conclusions
In patients with a definite diagnosis of left-side IE according to the modified European Society of Cardiology Duke criteria, TEE performed better than CT for the detection of valvular IE-related lesions and similar to CT for the detection of paravalvular IE-related lesions.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print
Sifaoui I, Oliver L, Tacher V, Fiore A, ... Ternacle J, Deux JF
J Am Soc Echocardiogr: 23 Sep 2020; epub ahead of print | PMID: 32981789
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Impact:
Abstract

Safety and cost-effectiveness of same-day complex left atrial ablation.

He H, Datla S, Weight N, Raza S, ... Hayat S, Osman F
Background
Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.
Method
Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.
Results
A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.
Conclusions
Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 27 Sep 2020; epub ahead of print
He H, Datla S, Weight N, Raza S, ... Hayat S, Osman F
Int J Cardiol: 27 Sep 2020; epub ahead of print | PMID: 33002522
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Impact:
Abstract

Prognostic value of multiple cardiac magnetic resonance imaging parameters in patients with idiopathic dilated cardiomyopathy.

Fu H, Wen L, Xu H, Liu H, ... Yang Z, Guo Y
Purpose
Our study aimed to comprehensively explore efficient prognostic indicators in idiopathic dilated cardiomyopathy (IDCM) patients with reduced left ventricular ejection fraction (LVEF<40%).
Background
Prognostic value of cardiac magnetic resonance(CMR) parameters for IDCM have been inconsistent.
Methods
126 IDCM patients with reduced LVEF (<40%) were retrospectively enrolled. Cardiac function parameters, myocardial strain indices and myocardial fibrosis were evaluated. Laboratory data also were analyzed. The endpoint was a combination of major adverse cardiac events (MACEs), including cardiac death, heart transplantation, and rehospitalization. Prognostic value was evaluated by the Kaplan-Meier method and Cox regression.
Results
During a median follow-up of 31 months, 44 patients experienced MACEs, including 9 deaths, 1 heart transplantation, and 34 rehospitalizations due to heart failure. Univariate and multivariate Cox analyses showed that cardiac function and myocardial strain indexes were not associated with the prognosis of IDCM (all p > 0.05). NT-proBNP (HR 1.5, 95%CI: 1.053 to 2.137), Late‑gadolinium enhancement(LGE) mass (HR 1.022, 95%CI: 1.005 to 1.038), and LGE mass/left ventricle mass were significant predictors (HR 1.027, 95%CI: 1.007 to 1.046) for MACEs, all p < 0.05. Besides, poorest prognosis was observed in IDCM patients with positive LGE combined with NT-proBNP (log-rank = 27.261, p ≤ 0.001).
Conclusion
NT-proBNP and extent of LGE were reliable predictors in IDCM patients with reduced LVEF. Additionally, presence of LGE combined with NT-proBNP showed the strongest prognostic value in IDCM with reduced LVEF. Myocardial strain parameters seemed to have no prognostic value in IDCM patients with reduced LVEF.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 06 Oct 2020; epub ahead of print
Fu H, Wen L, Xu H, Liu H, ... Yang Z, Guo Y
Int J Cardiol: 06 Oct 2020; epub ahead of print | PMID: 33038407
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Impact:
Abstract

State-of-the-art preclinical testing of the OMEGA left atrial appendage occluder.

De Backer O, Hafiz H, Fabre A, Lertsapcharoen P, ... Foley D, Sondergaard L
Objectives
This study aimed to present a new approach of thorough preclinical testing of a novel left atrial appendage (LAA) occluder device.
Background
The development of a safe and effective LAA occluder has been shown to be challenging.
Methods
The novel OMEGATM LAA occluder (Eclipse Medical, Ireland) was tested in a porcine model and three-dimensional (3D) human LAA models - this as a prelude to its first-in-human use.
Results
In a first series of in-vivo experiments, the OMEGATM LAA occluder was shown to have a satisfactory device biocompatibility in a porcine model. The design of the OMEGATM device was further refined and optimized following three more series of in-vivo experiments. The second generation OMEGATM device was designed with thinner wires, leading to a profile reduction. Based on in-vitro testing of different OMEGATM device sizes implanted at different depths in human three-dimensional (3D) LAA models, it could be determined that (1) the landing zone should be measured at a median depth of 12 mm from the LAA ostium; (2) the distal self-retaining inverted cup should have 10%-25% compression to minimize device embolization risk; and (3) the disc should be slightly inverted, i.e. pulled into the LAA, to promote complete LAA occlusion. The combined in-vivo and in-vitro testing resulted in an optimized pre-procedural planning of the first-in-human case treated with the OMEGATM device.
Conclusions
This series of carefully planned in-vivo and in-vitro experiments allowed demonstration of the safety and efficacy of the OMEGATM LAA occluder. This approach of thorough preclinical testing of medical devices may reduce the risk of complications in first-in-human cases and may become the standard approach for device development and preclinical testing in the future.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 08 Oct 2020; epub ahead of print
De Backer O, Hafiz H, Fabre A, Lertsapcharoen P, ... Foley D, Sondergaard L
Catheter Cardiovasc Interv: 08 Oct 2020; epub ahead of print | PMID: 33034944
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Impact:
Abstract

The Prognostic Value of Exercise Echocardiography after Percutaneous Coronary Intervention.

Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
Background
Exercise echocardiography (EE) is a valuable noninvasive method for diagnostic and prognostic assessment of ischemic cardiac disease. The prognostic value of normal findings on EE is well known overall, but its role in patients who undergo percutaneous coronary intervention remains poorly validated. The aim of this study was to ascertain the prognostic value of treadmill EE and to determine predictors of cardiac events in this population, with an emphasis on nonpositive (negative or inconclusive) findings.
Methods
A retrospective single-center study was performed. It included 516 patients (83% man; mean age, 62 ± 9 years) previously subjected to percutaneous coronary intervention who underwent treadmill EE between 2008 and 2017. Demographic, clinical, echocardiographic, and angiographic data were collected. The occurrence of cardiac events (cardiac death, acute coronary syndrome, or coronary revascularization) during follow-up was investigated. A multivariate Cox regression analysis was used to evaluate predictors of cardiac events. The Kaplan-Meier method was used to evaluate event-free survival rates.
Results
The results of EE were negative for myocardial ischemia in 245 patients (47.5%), inconclusive in 144 (27.9%), and positive in 127 (24.6%). During a mean follow-up period of 40 ± 34 months, cardiac events occurred in 152 patients (29.5%). The positive and negative predictive values of EE were 81.6% and 85.3%, respectively. The sensitivity of the exercise test was 73.9%, with specificity of 90.1%. Predictors of cardiac events were typical angina (hazard ratio [HR], 1.95; 95% CI, 1.16-3.27; P = .011), a positive ischemic response detected by electrocardiographic monitoring during EE (HR, 2.01; 95% CI, 1.21-3.34; P = .007), and the test result (inconclusive result: HR, 1.06; 95% CI, 0.51-2.19; P = .878; positive result: HR, 4.35; 95% CI, 2.42-7.80; P < .001). Patients with inconclusive (log-rank P = .038) and positive (log-rank P < .001) results had significantly more cardiac events during follow-up than those with negative findings on EE. Focusing on those patients with nonpositive results, cardiac event-free survival rates at 1, 3, and 5 years were 96.6 ± 0.9%, 88.3 ± 1.9%, and 79.5 ± 2.6%, respectively. In this subpopulation, an inconclusive test result (HR, 1.67; 95% CI, 1.03-2.70; P = .039), more extensive coronary artery disease (two vessels: HR, 1.37; 95% CI, 0.75-2.30; P = .304; three vessels: HR, 2.59; 95% CI, 1.38-4.87; P = .003), and arterial hypertension (HR, 2.07; 95% CI, 1.10-3.91; P = .025) were significantly associated with the occurrence of cardiac events.
Conclusion
Patients with known coronary disease with negative results on EE are at low risk for hard events. Patients with inconclusive results are at higher risk for cardiac events than those with negative results. The detection of patients with low-risk results on EE should decrease the number of unnecessary repeat invasive coronary angiographic examinations.

Copyright © 2020. Published by Elsevier Inc.

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Marques A, Cruz I, João I, Almeida AR, ... Lopes LR, Pereira H
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036819
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Impact:
Abstract

Prevalence of left ventricular hypertrabeculation/noncompaction among patients with congenital dyserythropoietic anemia Type 1 (CDA1).

Abramovich-Yoffe H, Shalev A, Barrett O, Shalev H, Levitas A
Background
Congenital dyserythropoietic anemia type 1 (CDA1) is a rare autosomal recessive disease characterized by macrocytic anemia, ineffective erythropoiesis, and secondary hemochromatosis. Left-ventricular noncompaction (LVNC) is a cardiomyopathy that is commonly attributed to intrauterine arrest of normal compaction during the endomyocardial morphogenesis. LV hypertrabeculation/noncompaction (LVHT/NC) morphology, however, might exist in various hemoglobinopathies. Our primary objective was to determine whether the pattern of LVHT/NC is more prevalent among patients with CDA1, in comparison to subjects without CDA1, and to find potential risk factors for LVHT/NC among these patients. Our secondary objective was to evaluate the clinical implication of LVHT/NC.
Methods
We retrospectively assessed 32 CDA1 patients (median age 17.5, range 6-61) that underwent routine assessment of iron overload by cardiac magnetic resonance. Number and distribution of noncompacted LV segments were assessed in CDA1 patients and compared to 64 age- and gender-matched patients without CDA1. The ratio of noncompacted to compacted myocardium (NC/C ratio) in end-diastole was calculated for each of the three long-axis views. NC/C ratio > 2.3 was considered diagnostic for LVHT/NC.
Results
In multivariate analysis, the presence of CDA1 was independently associated with NC/C ratio > 2.3, a feature of LVHT/NC (adjusted OR = 11.46, 95%CI = 2.6-50.68, p = .001). CDA1 was strongly associated with increased number of myocardial segments exhibiting LVHT/NC pattern. Cardiac volumes and ejection fraction were preserved without clinical adverse events in long term follow-up.
Conclusions
CDA1 patients have a higher prevalence of LVHT/NC than normal individuals, independent of myocardial iron overload and without effect on ejection fraction or clinical outcome.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Oct 2020; 317:96-102
Abramovich-Yoffe H, Shalev A, Barrett O, Shalev H, Levitas A
Int J Cardiol: 14 Oct 2020; 317:96-102 | PMID: 32512057
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Abstract

Are left atrial diverticula and left-sided septal pouches relevant additional findings in cardiac CT? Correlation between left atrial outpouching structures and ischemic brain alterations.

Celik E, Pennig L, Laukamp KR, Hammes J, ... Caldeira L, Hickethier T
Purpose
To evaluate the correlation between left atrial diverticula (LAD) and left-sided septal pouches (LSSP) with ischemic brain alterations in MRI.
Methods
A retrospective analysis of 174 patients who received both, a dedicated cardiac CT angiography (CCTA) and a brain MRI examination was performed. Two radiologists independently reviewed all examinations for the presence of LAD and LSSP as well as ischemic alterations of the brain. Subsequently, the correlation between these cardiac and cerebral findings as well as to other potentially related risk factors was assessed.
Results
71 LAD (total prevalence 41%) and 65 LSSP (total prevalence 37%) were identified in 174 patients. Combined prevalence was 10%. Ischemic brain alterations were found in patients with a LAD in 42.3% (30/71) and with a LSSP in 64.6% (42/65). Patients without any anatomical variant in the left atrium showed ischemic brain alterations in 39.4% (26/66). The presence of a LSSP was associated with an increased risk for ischemic brain alterations in multivariate logistic regression analysis after adjusting for other risk factors (OR = 3.57, 95% CI = 0.51-2.09, p <  .01).
Conclusion
In our study cohort LAD and LSSP are highly prevalent anatomical structures within the left atrium. Patients with LSSP showed an approximated 3.5-fold higher probability for ischemic brain alterations. Therefore, LSSP should be considered as a potential risk factor for cardioembolic strokes and its presence should be stated in cardiac CT reports.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Oct 2020; 317:216-220
Celik E, Pennig L, Laukamp KR, Hammes J, ... Caldeira L, Hickethier T
Int J Cardiol: 14 Oct 2020; 317:216-220 | PMID: 32461119
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Abstract

Outcomes and predictors of cardiac events in medically treated patients with atrial functional mitral regurgitation.

Kim K, Kitai T, Kaji S, Pak M, ... Kinoshita M, Furukawa Y
Background
Little is known about the outcomes and predictors of adverse cardiac events in medically treated patients with atrial functional mitral regurgitation (FMR).
Methods
We screened 1405 consecutive patients with grade ≥ 3+ mitral regurgitation (MR) detected by echocardiography. After excluding patients with previous or early (within 3 months from diagnosis) mitral valve surgery, congenital heart disease, hypertrophic cardiomyopathy, severe aortic valve disease, or unknown etiology, the study population consisted of 319 patients with primary MR, 395 patients with FMR with left ventricular (LV) dysfunction, and 184 patients with atrial FMR. Atrial FMR was defined as FMR in patients without LV wall motion abnormality or dilatation.
Results
The cumulative incidence of the composite of cardiac death and heart failure hospitalization at 3 years was 10.5% in primary MR, 37.5% in FMR with LV dysfunction, and 14.0% in atrial FMR (p < .001). In atrial FMR patients, LV end-diastolic volume index (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.02-1.10), severe MR (grade 4+) (HR 2.73, 95% CI 1.21-6.12), being symptomatic (NYHA ≥ 2) (HR 2.82, 95% CI 1.15-6.92), and having ≥1 comorbidities (HR 3.96, 95% CI 1.74-9.00) were independently associated with an increased risk for adverse cardiac events by a multivariable Cox regression analysis.
Conclusions
Outcomes of medically treated patients with atrial FMR were better than those of FMR with LV dysfunction, but worse than those of primary MR. In atrial FMR patients, LV dilatation, severe MR, being symptomatic, and the presence of comorbidities were independently associated with an increased risk for adverse cardiac events.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Sep 2020; 316:195-202
Kim K, Kitai T, Kaji S, Pak M, ... Kinoshita M, Furukawa Y
Int J Cardiol: 30 Sep 2020; 316:195-202 | PMID: 32610155
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Abstract

Automated extraction of left atrial volumes from two-dimensional computer tomography images using a deep learning technique.

Chen HH, Liu CM, Chang SL, Chang PY, ... Chen SA, Lu HH
Background
Precise segmentation of the left atrium (LA) in computed tomography (CT) images constitutes a crucial preparatory step for catheter ablation in atrial fibrillation (AF). We aim to apply deep convolutional neural networks (DCNNs) to automate the LA detection/segmentation procedure and create three-dimensional (3D) geometries.
Methods
Five hundred eighteen patients who underwent procedures for circumferential isolation of four pulmonary veins were enrolled. Cardiac CT images (from 97 patients) were used to construct the LA detection and segmentation models. These images were reviewed by the cardiologists such that images containing the LA were identified/segmented as the ground truth for model training. Two DCNNs which incorporated transfer learning with the architectures of ResNet50/U-Net were trained for image-based LA classification/segmentation. The LA geometry created by the deep learning model was correlated to the outcomes of AF ablation.
Results
The LA detection model achieved an overall 99.0% prediction accuracy, as well as a sensitivity of 99.3% and a specificity of 98.7%. Moreover, the LA segmentation model achieved an intersection over union of 91.42%. The estimated mean LA volume of all the 518 patients studied herein with the deep learning model was 123.3 ± 40.4 ml. The greatest area under the curve with a LA volume of 139 ml yielded a positive predictive value of 85.5% without detectable AF episodes over a period of one year following ablation.
Conclusions
The deep learning provides an efficient and accurate way for automatic contouring and LA volume calculation based on the construction of the 3D LA geometry.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 30 Sep 2020; 316:272-278
Chen HH, Liu CM, Chang SL, Chang PY, ... Chen SA, Lu HH
Int J Cardiol: 30 Sep 2020; 316:272-278 | PMID: 32507394
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Abstract

Usefulness of Noninvasive Myocardial Work to Predict Left Ventricular Recovery and Acute Complications after Acute Anterior Myocardial Infarction Treated by Percutaneous Coronary Intervention.

Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
Background
Predicting left ventricular recovery (LVR) after acute ST-elevation myocardial infarction (STEMI) is challenging and of prognostic importance. Our objective was to evaluate the usefulness of noninvasive myocardial work (MW), a new index of global and regional myocardial performance, to predict LVR and in-hospital complications after STEMI.
Methods
Ninety-three patients with anterior STEMI (mean age, 59 ± 12 years) treated by percutaneous coronary intervention (PCI) were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24-48 hours after PCI and a median of 92 days at follow-up. Myocardial work is derived from the strain-pressure relation, integrating in its calculation the noninvasive arterial pressure. Segmental LVR was defined as a normalization of wall motion abnormalities of the affected segments and global recovery as an absolute improvement of left ventricular ejection fraction (LVEF) > 5% in patients with baseline LVEF ≤ 50%. In-hospital complications were defined as a composite of death, reinfarction, heart failure, and LV apical thrombus.
Results
Segmental MW was impaired in infarct segments, more severely in nonrecovering versus recovering segments (P < .01). Furthermore, global constructive MW was significantly correlated with follow-up LVEF (r = 0.58) and global longitudinal strain (r = -0.67; all P < .01). Constructive MW was the best index to predict segmental (P < .01 vs MW index, MW efficiency, and wasted work) and global recovery (P < .05 vs global longitudinal strain) with an independent association (odds ratio = 1.17, 95% CI, 1.13-1.20, and odds ratio = 1.43, 95% CI, 1.18-1.68, respectively; all P < .001). Moreover, global constructive MW was more severely impaired in patients with in-hospital complications (n = 16; P < .01).
Conclusions
In patients with anterior STEMI treated by PCI, constructive MW is an independent predictor of segmental and global LVR and is significantly impaired in patients with in-hospital complications.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190
Meimoun P, Abdani S, Stracchi V, Elmkies F, ... Zemir H, Clerc J
J Am Soc Echocardiogr: 29 Sep 2020; 33:1180-1190 | PMID: 33010853
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Abstract

Color Doppler Splay: A Clue to the Presence of Significant Mitral Regurgitation.

Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
Background
The authors describe a previously unreported Doppler signal associated with mitral regurgitation (MR) as imaged using transthoracic echocardiography. Horizontal \"splay\" of the color Doppler signal along the atrial surface of the valve may indicate significant regurgitation when the MR jet otherwise appears benign.
Methods
Splay was defined as a nonphysiologic arc of color centered at the point at which the MR jet emerges into the left atrium. The authors present a series of 10 cases of clinically significant MR (moderately severe or severe as defined by transesophageal echocardiography) that were misclassified on transthoracic echocardiography as less than moderate. The splay signal was present on at least one standard transthoracic view in each case. To better characterize the splay signal, two groups were created from existing clinically driven transthoracic echocardiograms: 100 consecutive patients with severe MR and 100 with mild MR.
Results
Splay was present in the majority of severe MR cases (81%) regardless of vendor machine, ejection fraction, or MR etiology. Splay was particularly prevalent among patients with wall-hugging jets (28 of 30 [93%]). In patients with mild MR, splay was present less often (16%), on fewer frames per clip, and had smaller dimensions compared with severe MR. Color scale did not differ between subjects with and those without splay, but color gain was higher when splay was present (P = .04). Machine settings were further explored in a single subject with prominent splay: increasing transducer frequency reduced splay, while increasing color gain increased it.
Conclusions
The authors describe a new transthoracic echocardiographic sign of MR. Horizontal splay may be a clue to the presence of severe MR when the main body of the jet is out of the imaging plane. Splay is likely generated as a side-lobe artifact due to a high-flux regurgitant jet.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1
Wiener PC, Friend EJ, Bhargav R, Radhakrishnan K, Kadem L, Pressman GS
J Am Soc Echocardiogr: 29 Sep 2020; 33:1212-1219.e1 | PMID: 32712051
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Abstract

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy.

Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
Objective
Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not.
Methods
Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n = 40) or placebo (n = 20) for 3 months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41 ± 12 years, and their ejection fraction was 32% ± 7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormone levels were measured at baseline and 3 months after treatment.
Results
All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P < .001) and echocardiographic parameters including end-diastolic diameter (P < .001), end-systolic diameter (P < .001), mitral regurgitation severity reduction (P < .001), and increased ejection fraction (P < .001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P < .005) when compared with placebo group.
Conclusions
Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244
Badran HM, Faheem N, Zidan A, Yacoub MH, Soltan G
J Am Soc Echocardiogr: 29 Sep 2020; 33:1234-1244 | PMID: 32792320
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Abstract

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study.

Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
Background
Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening.
Methods
Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging.
Results
Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r = 0.88 and r = 0.92, respectively, P < .0001). Correlations were significant but lower for MA diameters (r = 0.68-0.72, P < .0001) and mitroaortic angle (r = 0.53, P = .0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15 cm for MA area (area under the curve [AUC] = 0.88-0.91, P < .0001), 128 to 139 mm for MA perimeter (AUC = 0.85-0.91, P < .0001), 35 to 39 mm for anteroposterior diameter (AUC = 0.79-0.84, P < .0001), and 37 to 42 mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, P < .0001).
Conclusions
Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2
Coisne A, Pontana F, Aghezzaf S, Mouton S, ... Modine T, Montaigne D
J Am Soc Echocardiogr: 29 Sep 2020; 33:1245-1252.e2 | PMID: 32718722
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Abstract

Effectiveness of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with late gadolinium enhancement on cardiac magnetic resonance.

Polaková E, Liebregts M, Marková N, Adla T, ... Bonaventura J, Veselka J
Background
According to European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) may be less effective in patients with extensive septal scarring on cardiac magnetic resonance (CMR). This study aimed to analyze the impact of late gadolinium enhancement (LGE) on CMR on the effectiveness of ASA.
Method
We conducted an observational retrospective study involving adult patients with symptomatic drug-refractory HOCM who underwent CMR before ASA at two European centres from May 2010 through June 2019. Patients were compared in binary format based on LGE presence. Moreover, a subanalysis focused on patients with septal fibrosis was performed. The effectiveness of ASA was evaluated by echocardiographic, ECG and clinical findings.
Results
Of the 113 study patients, 54 (48%) had LGE on CMR. The LGE quantification performed in 29 patients revealed septal fibrosis in 17. The mean follow-up was 4.4 ± 2.6 years. Baseline parameters were similar between groups except for basal septal thickness that was greater in LGE+ group (21.1 ± 3.9 mm for LGE+ vs. 19.2 ± 3.2 mm for LGE-: p = .005). ASA improved symptoms in all groups and reduced left ventricular outflow tract obstruction (LVOTO) (delta gradient reduction: LGE+: 62 ± 37.3%; septal LGE+: 75.6 ± 20.8%; LGE-: 72.5 ± 21.0%). However, 13% of the LGE+ and 2% of the LGE- group had residual LVOTO above 30 mmHg (p = .027).
Conclusion
ASA was effective in all patients with HOCM, whether they had LGE on CMR or not and whether they had septal fibrosis or not.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Nov 2020; 319:101-105
Polaková E, Liebregts M, Marková N, Adla T, ... Bonaventura J, Veselka J
Int J Cardiol: 14 Nov 2020; 319:101-105 | PMID: 32682963
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Abstract

Noninvasive Myocardial Work Indices 3 Months after ST-Segment Elevation Myocardial Infarction: Prevalence and Characteristics of Patients with Postinfarction Cardiac Remodeling.

Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
Background
Assessment of left ventricular (LV) remodeling after ST-segment elevation myocardial infarction (STEMI) is pivotal for patient management. Noninvasive myocardial work indices obtained from echocardiography-derived strain-pressure loops provide a new tool that permits characterization of LV mechanics. We aimed at characterizing myocardial work indices in patients with LV remodeling after STEMI versus patients without remodeling.
Methods
Six-hundred STEMI patients were retrospectively analyzed (456 men, mean age: 61 ± 11 years) and divided according to the presence of LV remodeling 3 months after the index admission (≥20% increase in LV end-diastolic volume). Noninvasive myocardial work indices were measured at 3 months after STEMI.
Results
LV remodeling was observed in 150 patients (25%) who showed more impaired global myocardial work indices compared with their counterparts: work index (1,708 ± 522 mm Hg% vs 1,979 ± 450 mm Hg%; P < .001), constructive work (1,941 ± 598 mm Hg% vs 2,272 ± 519 mm Hg%; P < .001), and work efficiency (92% [range 88%-96%] vs 95% [range 93%-96%]; P < .001). In addition, patients with LV remodeling had significantly increased wasted work (116 mm Hg% [range 73-184 mm Hg%] vs 91 mm Hg% [range 61-132 mm Hg%]; P < .001). The frequency of impaired global work index, constructive and work efficiency, and increased wasted work was significantly higher among patients with LV remodeling compared with their counterparts: 21.3%, 34.7%, 34.7%, and 14.0%, respectively, versus 5.3%, 9.6%, 8.9%, and 4.9%, respectively (P < .001).
Conclusions
At 3-month follow-up after STEMI, patients with LV remodeling revealed more impaired myocardial work indices compared with patients without LV remodeling. The prevalence of impaired myocardial work indices was higher among patients with LV remodeling compared with patients without.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179
Lustosa RP, van der Bijl P, El Mahdiui M, Montero-Cabezas JM, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 29 Sep 2020; 33:1172-1179 | PMID: 32651125
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Abstract

Cardiac Reserve and Exercise Capacity: Insights from Combined Cardiopulmonary and Exercise Echocardiography Stress Testing.

Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
Background
Cardiopulmonary exercise testing (CPET) represents the gold standard to estimate peak oxygen consumption (VO) noninvasively. To improve the analysis of the mechanisms behind effort intolerance, we examined whether exercise stress echocardiography measurements relate to directly measured peak VO during exercise in a large cohort of patients within the heart failure (HF) spectrum.
Methods
We performed a symptom-limited graded ramp bicycle CPET exercise stress echocardiography in 30 healthy controls and 357 patients: 113 at risk of developing HF (American College of Cardiology/American Heart Association stage A-B) and 244 in HF stage C with preserved (HFpEF, n = 101) or reduced ejection fraction (HFrEF, n = 143).
Results
Peak VO significantly decreased from controls (23, 21.7-29.7 mL/kg/minute; median, interquartile range) to stage A-B (18, 15.4-20.7 mL/kg/minute) and stage C (HFpEF: 13.6, 11.8-16.8 mL/kg/minute; HFrEF: 14.2, 10.7-17.5 mL/kg/minute). A regression model to predict peak VO revealed that peak left ventricular (LV) systolic annulus tissue velocity (S\'), peak tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (right ventricle-pulmonary artery coupling), and low-load left atrial (LA) reservoir strain/E/e\' (LA compliance) were independent predictors, in addition to peak heart rate, stroke volume, and workload (adjusted R = 0.76, P < .0001). The model was successfully tested in subjects with atrial fibrillation (n = 49) and with (n = 224) and without (n = 163) beta-blockers (all P < .01). Peak S\' showed the highest accuracy in predicting peak VO < 10 mL/kg/minute (cut point ≤ 7.5 cm/sec, area under the curve = 0.92, P < .0001) and peak VO > 20 mL/kg/minute (cut point > 12.5 cm/sec, area under the curve = 0.84, P < .0001) in comparison with the other cardiac variables of the model (P < .05).
Conclusions
Peak VO is directly related to measures of LV systolic function, LA compliance, and right ventricle-pulmonary artery coupling, in addition to heart rate and stroke volume and independently of workload, age, and sex. The evaluation of cardiac mechanics may provide more insights into the causes of effort intolerance in subjects from HF stages A-C.

Copyright © 2020 American Society of Echocardiography. All rights reserved.

J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print
Pugliese NR, De Biase N, Conte L, Gargani L, ... Borlaug BA, Masi S
J Am Soc Echocardiogr: 05 Oct 2020; epub ahead of print | PMID: 33036818
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Abstract

Association of Septal Late Gadolinium Enhancement on Cardiac Magnetic Resonance with Ventricular Tachycardia Ablation Targets in Nonischemic Cardiomyopathy.

Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
Background
Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.
Methods
LGE-CMR was performed prior to EAM mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal intensity z-scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.
Results
Bipolar and unipolar (EGM) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p<0.05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be >-0.15 for border zone and >0.03 for dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in range of -0.97~2.06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5±31.2 mm, mitral valve: 21.2±8.7 mm) in non-sarcoidosis cases.
Conclusions
Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal intensity thresholds. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print
Kuo L, Liang JJ, Han Y, Frankel DS, ... Desjardins B, Nazarian S
J Cardiovasc Electrophysiol: 17 Oct 2020; epub ahead of print | PMID: 33070414
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Abstract

Measuring atrial stasis during sinus rhythm in patients with paroxysmal atrial fibrillation using 4 Dimensional flow imaging: 4D flow imaging of atrial stasis.

Costello BT, Voskoboinik A, Qadri AM, Rudman M, ... Kistler PM, Taylor AJ
Background
Paroxysmal atrial fibrillation (PAF) is associated with cardioembolic risk, however events may occur during sinus rhythm (SR). 4D-flow cardiac magnetic resonance (CMR) imaging allows visualisation of left atrial blood flow, to determine the residence time distribution (RTD), an assessment of atrial transit time.
Objective
To determine if atrial transit time is prolonged in PAF patients during SR, consistent with underlying atrial stasis.
Method
91 participants with PAF and 18 healthy volunteers underwent 4D flow analysis in SR. Velocity fields were produced RTDs, calculated by seeding virtual \'particles\' at the right upper pulmonary vein and counting them exiting the mitral valve. An exponential decay curve quantified residence time of particles in the left atrium, and atrial stasis was expressed as the derived constant (RTD) based on heartbeats. The RTD was evaluated within the PAF group, and compared to healthy volunteers.
Results
Patients with PAF (n = 91) had higher RTD compared with gender-matched controls (n = 18) consistent with greater atrial stasis (1.68 ± 0.46 beats vs 1.51 ± 0.20 beats; p = .005). PAF patients with greater thromboembolic risk had greater atrial stasis (median RTD of 1.72 beats in CHA₂DS₂-VASc≥2 vs 1.52 beats in CHA₂DS₂-VASc<2; p = .03), only female gender and left ventricular ejection fraction contributed significantly to the atrial RTD (p = .006 and p = .023 respectively).
Conclusions
Atrial stasis quantified by 4D flow is greater in PAF, correlating with higher CHA₂DS₂-VASc scores. Female gender and systolic dysfunction are associated with atrial stasis. RTD offers an insight into atrial flow that may be developed to provide a personalised assessment of thromboembolic risk.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Sep 2020; 315:45-50
Costello BT, Voskoboinik A, Qadri AM, Rudman M, ... Kistler PM, Taylor AJ
Int J Cardiol: 14 Sep 2020; 315:45-50 | PMID: 32439367
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Impact:
Abstract

Tissue Doppler-Derived Left Ventricular Systolic Velocity Is Associated with Lethal Arrhythmias in Cardiac Device Recipients Irrespective of Left Ventricular Ejection Fraction.

Barakat MF, Chehab O, Kaura A, Sunderland N, ... Scott PA, Okonko DO
Background
Life-threatening arrhythmias (LTAs) can trigger sudden cardiac death or provoke implantable cardioverter-defibrillator (ICD) discharges that escalate morbidity and mortality. Longitudinal myofibrils predominate in the subendocardium, which is uniquely sensitive to arrhythmogenic triggers. In this study, we test the hypothesis that mitral annular systolic velocity (S\'), a simple routinely obtained tissue Doppler index of LV long-axis systolic function, might predict lethal arrhythmias irrespective of left ventricular ejection fraction (LVEF).
Methods
This is a retrospective analysis of data from 302 patients (mean age, 68 years; LVEF, 32%; 77% male; 52% ischemic; 35% primary prevention; and 53% cardiac resynchronization therapy defibrillator [CRT-D]) who were followed up (median, 15 months) at two centers after receipt of an ICD or CRT-D for diverse indications. S\', averaged from tissue Doppler-derived medial and lateral mitral annular velocities, was correlated with the primary outcome of time to sustained ventricular tachycardia (VT) or fibrillation (VF) needing device therapy.
Results
The median S\' was 5.1 (interquartile range, 4.0-6.2) cm/sec and lower in CRT-D than ICD subjects (4.5 [3.8-5.6] cm/sec vs 5.5 [4.8-6.8] cm/sec, P < .001). Fifty-six (19%) subjects had LTA. Each 1 cm/sec higher S\' correlated to a 30% decreased risk of LTA (hazard ratio = 0.70; 95% CI, 0.57-0.87; P = .001) independently of age, sex, β-blocker use, center, ICD use, and LVEF. Adding S\' to the baseline Cox model improved net reclassification (P = .02). An S\' > 5.6 cm/sec was the best cutoff and linked to a 58% lower LTA risk than an S\' ≤ 5.6 cm/sec (95% CI, 0.23-0.85; P = .02).
Conclusions
A higher S\' is associated with a reduced probability of LTA in cardiac device recipients irrespective of LVEF and may have the potential to be used clinically to titrate medical, device, and ablative therapies to mitigate future arrhythmic risk.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 09 Oct 2020; epub ahead of print
Barakat MF, Chehab O, Kaura A, Sunderland N, ... Scott PA, Okonko DO
J Am Soc Echocardiogr: 09 Oct 2020; epub ahead of print | PMID: 33051107
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Abstract

Effect of Regional Upper Septal Hypertrophy on Echocardiographic Assessment of Left Ventricular Mass and Remodeling in Aortic Stenosis.

Guzzetti E, Tastet L, Annabi MS, Capoulade R, ... Clavel MA, Pibarot P
Background
Transthoracic echocardiography (TTE) is the reference method for evaluation of aortic stenosis (AS), and it is extensively used to quantitate left ventricular (LV) mass and volumes. Regional upper septal hypertrophy (USH) or septal bulge is a frequent finding in patients with AS and may lead to overestimation of LV mass when using linear measurements. The objective of this study was to compare estimates of LV mass obtained by two-dimensional transthoracic echocardiographic LV dimensions measured at different levels of the LV cavity with those obtained by cardiovascular magnetic resonance (CMR).
Methods
One hundred six patients (mean age, 63 ± 15 years; 68% men) with AS were included in this subanalysis of the PROGRESSA study. Two-dimensional transthoracic echocardiographic measurements of LV dimensions were obtained at the basal level (BL; as recommended in guidelines), immediately below the septal bulge (BSB), and at a midventricular level (ML). Regional USH was defined as a basal interventricular septal thickness ≥ 13 mm and >1.3 times the thickness of the septal wall at the ML. Agreement between transthoracic echocardiographic and CMR measures was evaluated using Bland-Altman analysis.
Results
The distribution of AS severity was mild in 23%, moderate in 57%, and severe in 20% of patients. Regional USH was present in 28 patients (26%). In the whole cohort, two-dimensional TTE overestimated LV mass (bias: BL, +60 ± 31 g; BSB, +59 ± 32 g; ML, +54 ± 32 g; P = .02). The biplane Simpson method slightly but significantly underestimated LV end-diastolic volume (bias -10 ± 20 mL, P < .001) compared with CMR. Overestimation of LV mass was more marked in patients with USH when measuring at the BL and was significantly lower when measuring LV dimensions at the ML (P < .025 vs BL and BSB).
Conclusions
Two-dimensional TTE systematically overestimated LV mass and underestimated LV volumes compared with CMR. However, the bias between TTE and CMR was less important when measuring at the ML. Measurements at the BL as suggested in guidelines should be avoided, and measurements at the ML should be preferred in patients with AS, especially in those with USH.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 13 Oct 2020; epub ahead of print
Guzzetti E, Tastet L, Annabi MS, Capoulade R, ... Clavel MA, Pibarot P
J Am Soc Echocardiogr: 13 Oct 2020; epub ahead of print | PMID: 33067075
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Abstract

Impact of Arterial Blood Pressure on Ultrasound Hemodynamic Assessment of Aortic Valve Stenosis Severity.

Hayek A, Derimay F, Green L, Rosset M, ... Rioufol G, Finet G
Background
Aortic stenosis (AS) severity assessment is based on several indices. Aortic valve area (AVA) is subject to inaccuracies inherent to the measurement method, while velocities and gradients depend on hemodynamic status. There is controversy as to whether blood pressure directly affects common indices of AS severity.
Objectives
The study objective was to assess the effect of systolic blood pressure (SBP) variation on AS indices, in a clinical setting.
Methods
A prospective, single-center study included 100 patients with at least moderately severe AS with preserved left ventricle ejection fraction. Patients underwent ultrasound examination during which AS severity indices were collected, with three hemodynamic conditions: (1) low SBP: <120 mm Hg; (2) intermediate SBP: between 120 and 150 mm Hg; (3) high SBP: ≥150 mm Hg. For each patient, SBP profiles were obtained by injection of isosorbide dinitrate or phenylephrine.
Results
At baseline state, 59% presented a mean gradient (G) ≥ 40 mm Hg, 44% a peak aortic jet velocity (V) ≥4 m/sec, 66% a dimensionless index (DI) ≤0.25, and 87% an indexed AVA (AVAi) ≤ 0.6 cm/m. Compared with intermediate and low SBP, high SBP induced a significant decrease in G (39 ± 12 vs 43 ± 12 and 47 ± 12 mm Hg, respectively; P < .05) and in V (3.8 ± 0.6 vs 4.0 ± 0.6 and 4.2 ± 0.6 mm Hg; P < .05). Compared with the baseline measures, in 16% of patients with an initial G< 40 mm Hg, gradient rose above 40 mm Hg after optimization of the afterload (low SBP; P < .05). Conversely, DI and AVAi did not vary with changes in hemodynamic conditions. Flow rate, not stroke volume was found to impact G and V but not AVA and DI (P < .05).
Conclusions
Hemodynamic conditions may affect the AS ultrasound assessment. High SBP, or afterload, leads to an underestimation of AS severity when based on gradients and velocities. Systolic blood pressure monitoring and control are crucial during AS ultrasound assessment.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 28 Aug 2020; epub ahead of print
Hayek A, Derimay F, Green L, Rosset M, ... Rioufol G, Finet G
J Am Soc Echocardiogr: 28 Aug 2020; epub ahead of print | PMID: 32868157
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Abstract

Transcatheter Aortic Valve Replacement and Left Ventricular Geometry: Survival and Gender Differences.

Truong VT, Mazur W, Broderick J, Egnaczyk GF, ... Bartone C, Chung ES
Background
The aim of this study was to examine the relationship between baseline left ventricular (LV) geometry and outcomes after transcatheter aortic valve replacement (TAVR).
Methods
Patients undergoing TAVR (n = 206) had baseline LV geometry classified as (1) concentric hypertrophy, (2) eccentric hypertrophy, (3) concentric remodeling, or (4) normal. Descriptive statistics, Kaplan-Meier time-to-event analysis, and Cox regression were performed.
Results
Distribution of baseline LV geometry differed between male and female patients (χ = 16.83, P = .001) but not at 1 month (χ = 2.56, P = .47) or 1 year (χ = 5.68, P = .13). After TAVR, a majority of patients with concentric hypertrophy evolved to concentric remodeling. Survival differed across LV geometry groups at 1 year (χ[3] = 8.108, P = .044, log-rank test) and at 6.5 years (χ[3] = 9.023, P = .029, log-rank test). Compared with patients with concentric hypertrophy, patients with normal geometry (hazard ratio, 2.25; 95% CI, 1.12-4.54; P = .023) and concentric remodeling (hazard ratio, 1.89; 95% CI, 1.12-3.17; P = .016) had higher rates of all-cause mortality.
Conclusions
Baseline concentric hypertrophy confers a survival advantage after TAVR. Although baseline patterns of LV geometry appear gender specific (with women demonstrating more concentric hypertrophy), this difference resolves after TAVR.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Truong VT, Mazur W, Broderick J, Egnaczyk GF, ... Bartone C, Chung ES
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828622
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Abstract

Speckle-Tracking Echocardiography for the Assessment of Atrial Function during Fetal Life.

Rato J, Vigneswaran TV, Simpson JM
Introduction
Speckle-tracking echocardiography has become a major tool in the evaluation of heart function. Atrial strain has emerged as an important component in the assessment of cardiac function, but there is a paucity of prenatal data. The aim of this study was to describe our initial experience of measurement of atrial strain in fetuses, with respect to both feasibility and the strain patterns observed.
Methods
Four-chamber Digital Imaging and Communications in Medicine loops were acquired prospectively for deformation imaging. Fifty-three normal fetuses with no morphologic or functional abnormalities were selected for analysis. The three strain components of atrial cycle for both left atrium (LA) and right atrium (RA) were acquired-reservoir (LAres or RAres), conduit, and contraction (LAct or RAct)-and are expressed as a percentage. Ratios of these components were calculated. Simple linear regression was used to analyze how the dependent variables changed according to gestational age and frame rate.
Results
The median gestational age was 30 weeks (range, 23-35), and the frame rate was 74 frames per second (fps; range, 35-121). Left atrial strain was feasible in 48/53 (91%), and right atrial strain in 46/53 (87%) of cases. The onset of LA contraction could be identified on the strain curves in 32 of 48 (67%) cases, and of the RA in 17 of 46 (37%) cases. The values of RAres and RAct were higher compared with those of LAres and LAct (33.9% vs 30.3%, P = .014; and 21.5% vs 16.8%, P = .005), and the contraction:reservoir ratio was also higher for RA (0.63 vs 0.55 for LA, P = .003). Higher values for LAres, LAct, RAres, and RAct were associated with higher frame rate (P = .007, .020, .049, and .012, respectively). The onset of LA contraction was better identified with a higher frame rate (mean 77 vs 59 fps when not seen, P = .007). A higher LA contraction:reservoir ratio was associated with a lower gestational age (P = .042).
Conclusion
Measurement of atrial strain is feasible in the fetal heart. The values are influenced by gestational age and frame rate, so it is necessary to account for these variables. Comparison of left versus right atrial strain values contrasts with those observed postnatally. Atrial function merits further study during fetal life, to aid understanding of maturational changes and disease states.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print
Rato J, Vigneswaran TV, Simpson JM
J Am Soc Echocardiogr: 18 Aug 2020; epub ahead of print | PMID: 32828625
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Abstract

Evaluation of Left Atrial Size and Function: Relevance for Clinical Practice.

Thomas L, Muraru D, Popescu BA, Sitges M, ... Donal E, Badano LP

Left atrial (LA) structural and functional evaluation have recently emerged as powerful biomarkers for adverse events in a variety of cardiovascular conditions. Moreover, noninvasive evaluation of LA pressure has gained importance in the characterization of the hemodynamic profile of patients. This review describes the methodology, benefits and pitfalls of measuring LA size and function by echocardiography and provides a brief overview of the prognostic utility of newer echocardiographic metrics of LA geometry and function (i.e., three-dimensional volumes, longitudinal strain, and phasic function parameters).

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; 33:934-952
Thomas L, Muraru D, Popescu BA, Sitges M, ... Donal E, Badano LP
J Am Soc Echocardiogr: 30 Jul 2020; 33:934-952 | PMID: 32762920
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Abstract

Left Atrial Structure and Function Predictors of New-Onset Atrial Fibrillation in Patients with Chagas Disease.

Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, ... Mediano MFF, Veloso HH
Background
Atrial fibrillation (AF) carries ominous consequences in patients with Chagas disease. The aim of this study was to determine whether left atrial (LA) volume and function assessed using three-dimensional echocardiographic (3DE) imaging and two-dimensional speckle-tracking echocardiographic deformation analysis of strain (ε) could predict new-onset AF in patients with Chagas disease.
Methods
A total of 392 adult patients with chronic Chagas disease (59% women; mean age, 53 ± 11 years) who underwent echocardiography were consecutively enrolled in this prospective longitudinal study. Echocardiographic evaluation included two-dimensional (2D) Doppler echocardiography, with evaluation of left ventricular systolic and diastolic function, LA size, and LA and left ventricular function on 3DE and ε analyses. Multivariate Cox proportional-hazards regression analysis models adjusting for age, sex, hypertension, presence of a pacemaker, and 2D Doppler echocardiographic parameters were used to test if the variables of interest had independent prognostic value for AF prediction.
Results
Patients with Chagas disease were followed for 5.6 ± 2.7 years. Among these, 139 (35.5%) had the indeterminate form, 224 (57.1%) had the cardiac form, five (1.3%) had the digestive form, and 24 (6.1%) had the cardiodigestive form. The study end point of AF occurred in 45 patients. Total LA emptying fraction (hazard ratio, 0.93; 95% CI, 0.89-0.98; P = .002), passive LA emptying fraction (HR, 0.95; 95% CI, 0.91-0.99; P = .02), and peak negative global LA ε (HR, 1.22; 95% CI, 1.05-1.41; P = .01) were predictors of new-onset AF independent of clinical and 2D Doppler echocardiographic parameters.
Conclusions
LA function assessed on 3DE and ε analyses predicts new-onset AF in patients with Chagas disease independent of clinical and 2D Doppler echocardiographic indexes.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print
Saraiva RM, Pacheco NP, Pereira TOJS, Costa AR, ... Mediano MFF, Veloso HH
J Am Soc Echocardiogr: 30 Jul 2020; epub ahead of print | PMID: 32747223
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Abstract

Left Ventricular Systolic Function in Patients with Systemic Lupus Erythematosus and Its Association with Cardiovascular Events.

Gegenava T, Gegenava M, Steup-Beekman GM, Huizinga TWJ, ... Delgado V, Marsan NA
Background
Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder with potential cardiovascular involvement. The aim of this study was to assess left ventricular (LV) systolic function in a large cohort of patients with SLE using standard echocardiographic measurements and global longitudinal strain (GLS) by two-dimensional speckle-tracking analysis. Furthermore, the association between echocardiographic parameters and the occurrence of cardiovascular events was assessed.
Methods
A total of 102 patients with SLE (88% women; mean age, 43 ± 14 years) undergoing a dedicated multidisciplinary assessment were analyzed, including echocardiography, at the time of their first visit. A control group consisted of 50 age- and sex-matched healthy subjects.
Results
Compared with control subjects, patients with SLE showed impaired LV systolic function on the basis of LV ejection fraction (51 ± 6% vs 62 ± 6%, P < .001) and by LV GLS (-15 ± 3% vs -19 ± 2%, P < .001). During a median follow-up period of 2 years (interquartile range, 1-6 years), 38 patients (37%) developed cardiovascular events. Kaplan-Meier survival curves showed that patients with SLE with more impaired LV GLS (on the basis of the median value of -15%) experienced higher cumulative rates of cardiovascular events compared with those with less impaired LV GLS (χ = 8.292, log-rank P = .004). On multivariate Cox regression analysis, LV GLS demonstrated an independent association with cardiovascular events (hazard ratio, 2.171; 95% CI, 1.015-4.642; P = .046), whereas LV ejection fraction was not significantly associated with the outcome.
Conclusions
In patients with SLE, LV systolic function as measured by LV GLS is significantly impaired and associated with cardiovascular events, potentially representing a new tool to improve risk stratification in these patients.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2020; 33:1116-1122
Gegenava T, Gegenava M, Steup-Beekman GM, Huizinga TWJ, ... Delgado V, Marsan NA
J Am Soc Echocardiogr: 30 Aug 2020; 33:1116-1122 | PMID: 32622589
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Abstract

Poor Survival with Impaired Valvular Hemodynamics After Aortic Valve Replacement: The National Echo Database Australia Study.

Playford D, Stewart S, Celermajer D, Prior D, ... Strange G,
Background
There are limited data to describe the relationship between the transvalvular gradient and mortality among patients who undergo aortic valve replacement.
Methods
Using the National Echo Database Australia, valvular hemodynamics were characterized in 3,943 men (mean age, 62 ± 18 years) and 2,107 women (mean age, 62 ± 19 years) who underwent aortic valve replacement (median follow-up duration, 770 days; interquartile range, 381-1,584 days). The degree of impaired valvular hemodynamics (IVH) was categorized as mild (mean gradient 10.0-19.9 mm Hg, peak velocity 2.0-2.9 m/sec), moderate (mean gradient 20.0-39.9 mm Hg, peak velocity 3.0-3.9 m/sec), or severe (mean gradient ≥ 40.0 mm Hg, peak velocity ≥ 4 m/sec or effective orifice area < 0.8 cm).
Results
Overall, 2,175 (36.0%), 2,598 (42.9%), 698 (11.5%), and 579 (9.6%) patients had no, mild, moderate, and severe IVH, respectively. Those with residual moderate or severe IVH had 5-year mortality of 45.5% and 57.3%, respectively, and higher adjusted long-term all-cause mortality (adjusted hazard ratios, 1.44 and 2.02; P < .001) compared with \"no IVH.\" Patients with mild IVH had similar mortality rates to those without IVH. A mortality threshold was evident above a mean transvalvular gradient >22.5 mm Hg after adjusting for age, sex, stroke volume index, aortic regurgitation, and effective orifice area.
Conclusions
After aortic valve replacement, most patients displayed an acceptable aortic valve hemodynamic profile. Moderate to severe IVH, however, was associated with poor long-term survival, with a threshold for increased mortality similar to that of native valvular aortic stenosis evident.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2020; 33:1077-1086.e1
Playford D, Stewart S, Celermajer D, Prior D, ... Strange G,
J Am Soc Echocardiogr: 30 Aug 2020; 33:1077-1086.e1 | PMID: 32593505
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Abstract

Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance.

Guzzetti E, Capoulade R, Tastet L, Garcia J, ... Clavel MA, Pibarot P
Background
In aortic stenosis, accurate measurement of left ventricular stroke volume (SV) is essential for the calculation of aortic valve area (AVA) and the assessment of flow status. Current American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines suggest that measurements of left ventricular outflow tract diameter (LVOTd) at different levels (at the annulus vs 5 or 10 mm below) yield similar measures of SV and AVA. The aim of this study was to assess the effect of the location of LVOTd measurement on the accuracy of SV and AVA measured on transthoracic echocardiography (TTE) compared with cardiovascular magnetic resonance (CMR).
Methods
One hundred six patients with aortic stenosis underwent both TTE and CMR. SV was estimated on TTE using the continuity equation with LVOTd measurements at four locations: at the annulus and 2, 5, and 10 mm below annulus. SV was also determined on CMR using phase contrast acquired in the aorta (SV), and a hybrid AVA was calculated by dividing SV by the transthoracic echocardiographic Doppler aortic velocity-time integral. Comparison between methods was made using Bland-Altman analysis.
Results
Compared with the referent method of phase-contrast CMR for the estimation of SV and AVA (SV 83 ± 16 mL, AVA 1.27 ± 0.35 cm), the best agreement was obtained by measuring LVOTd at the annulus or 2 mm below (P = NS), whereas measuring 5 and 10 mm below the annulus resulted in significant underestimation of SV and AVA by up to 15.9 ± 17.3 mL and 0.24 ± 0.28 cm, respectively (P < .01 for all). Accuracy for classification of low flow was best at the annulus (86%) and 2 mm below (82%), whereas measuring 5 and 10 mm below the annulus significantly underperformed (69% and 61%, respectively, P < .001).
Conclusions
Measuring LVOTd at the annulus or very close to it provides the most accurate measures of SV and AVA, whereas measuring LVOTd 5 or 10 mm below significantly underestimates these parameters and leads to significant overestimation of the severity of aortic stenosis and prevalence of low-flow status.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; 33:953-963.e5
Guzzetti E, Capoulade R, Tastet L, Garcia J, ... Clavel MA, Pibarot P
J Am Soc Echocardiogr: 30 Jul 2020; 33:953-963.e5 | PMID: 32580897
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Abstract

Contrast-Enhanced Echocardiographic Measurement of Left Ventricular Wall Thickness in Hypertrophic Cardiomyopathy: Comparison with Standard Echocardiography and Cardiac Magnetic Resonance.

Urbano-Moral JA, Gonzalez-Gonzalez AM, Maldonado G, Gutierrez-Garcia-Moreno L, ... Rodriguez-Palomares JF, Evangelista-Masip A
Background
Left ventricular wall thickness (LVWT) measurement is key in the diagnostic and prognostic assessment of hypertrophic cardiomyopathy (HCM). Recent investigations have highlighted discrepancies in LVWT by cardiac magnetic resonance (CMR) and standard echocardiography (S-Echo) in this condition. The aim of this study was to elucidate the role of contrast-enhanced echocardiography (C-Echo) to optimize LVWT measurement in patients with HCM.
Methods
Fifty patients with HCM were prospectively enrolled, undergoing S-Echo, C-Echo, and CMR. Blinded LVWT measurements were performed according to a 16-segment left ventricular model using all three imaging techniques. Agreement between both echocardiographic modalities and CMR (as the reference technique) at the segmental level was tested using Bland-Altman analyses. Reproducibility on segmental measurements by S-Echo and C-Echo was also investigated.
Results
Patients\' mean age was 47 ± 21 years, and 35 (70%) were men. Maximal mean LVWT by S-Echo (20.1 ± 3.8 mm) was greater than the values derived using C-Echo (17.6 ± 4.0 mm, P < .01) and CMR (17.7 ± 4.5 mm, P < .01), with no statistically significant difference between the latter two. Segmental Bland-Altman models demonstrated globally smaller bias and narrower 95% limits of agreement for C-Echo compared with S-Echo. Across all left ventricular segments, LVWT by C-Echo was 2.4 mm lower (range, 1.0-2.5 mm) than that derived by S-Echo, which accounted for a 25% intertechnique difference. Regarding maximal LVWT, the mean absolute difference between C-Echo and S-Echo was 3.0 ± 1.9 mm (range, 0.0-7.9 mm), which represented a 15% intertechnique change. Data analyses demonstrated globally less intra- and interobserver variability in segmental LVWT derived from C-Echo compared with S-Echo.
Conclusions
C-Echo rendered LVWT measurements closer to those derived by the reference technique (CMR) and improved reproducibility compared with S-Echo. C-Echo represents a suitable tool for LVWT measurement in patients with HCM as an alternative to CMR whenever this is not available or possible.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2020; 33:1106-1115
Urbano-Moral JA, Gonzalez-Gonzalez AM, Maldonado G, Gutierrez-Garcia-Moreno L, ... Rodriguez-Palomares JF, Evangelista-Masip A
J Am Soc Echocardiogr: 30 Aug 2020; 33:1106-1115 | PMID: 32564979
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Abstract

Correlates and Long-Term Implications of Left Ventricular Mechanical Dispersion by Two-Dimensional Speckle-Tracking Echocardiography in Patients with ST-Segment Elevation Myocardial Infarction.

Abou R, Goedemans L, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
Background
Left ventricular (LV) mechanical dispersion (LVMD), measured with speckle-tracking echocardiography (STE) after ST-segment elevation myocardial infarction (STEMI), has been proposed as a measurement of regional heterogeneity of myocardial contraction and may reflect changes in the myocardial structure (e.g., fibrosis or edema). Further insight into this parameter may aid in the risk stratification of STEMI patients.
Methods
A total of 1,000 STEMI patients (77% male, 60 ± 12 years) treated with primary percutaneous coronary intervention were retrospectively analyzed. The LVMD was assessed with two-dimensional STE within 48 hours following the index infarction. Patients were followed for the occurrence of all-cause mortality.
Results
After a median follow-up of 117 months, 229 (23%) patients died. Nonsurvivors showed worse LV ejection fraction (43% ± 10% vs 48% ± 9%; P < .001) and global longitudinal strain (-12.0% ± 3.5% vs -14.2% ± 3.5%; P = .001) and prolonged LVMD (63 [interquartile range, 50-85] msec vs 52 [interquartile range, 42-63] msec; P < .001) compared with survivors. Increasing age, systolic blood pressure, and heart rate at discharge as well as diabetes mellitus, anterior STEMI, TIMI flow < 2, less usage of angiotensin converter enzyme inhibitors or angiotensin receptor blockers, and impaired LV global longitudinal strain were independently associated with more prolonged LVMD. On multivariable analysis, prolonged LVMD was independently associated with increased risk of all-cause mortality (hazard ratio = 1.012; 95% CI, 1.005-1.018; P = .001) and had incremental value for all-cause mortality over clinical and echocardiographic parameters.
Conclusions
In contemporary STEMI patients, prolonged LVMD was associated with various clinical and echocardiographic parameters. Prolonged LVMD was associated with worse long-term outcome.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; 33:964-972
Abou R, Goedemans L, van der Bijl P, Fortuni F, ... Bax JJ, Delgado V
J Am Soc Echocardiogr: 30 Jul 2020; 33:964-972 | PMID: 32381361
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Abstract

Right Atrial Conduit Phase Emptying Predicts Risk of Adverse Events in Pediatric Pulmonary Arterial Hypertension.

Frank BS, Schafer M, Thomas TM, Haxel C, Ivy DD, Jone PN
Background
Idiopathic pulmonary arterial hypertension (PAH) is a severe disease associated with a 20% 5-year mortality, often due to right heart failure. Recent studies suggest that compensatory changes in right atrial (RA) function may precede other clinical and echocardiographic evidence of right ventricular dysfunction. No prior prospective study has evaluated the role of RA emptying pattern as a prognostic marker of adverse clinical events in pediatric PAH.
Objective
To demonstrate whether RA fractional emptying indices will prospectively predict risk of adverse clinical outcomes in pediatric PAH patients.
Methods
Single-center, prospective cohort analysis of 41 patients with idiopathic or heritable PAH and 1:1 age and sex-matched controls with normal echo and electrocardiogram. Right atrial area (RAA) was measured just prior to tricuspid valve opening (RAAmax), at electrical p wave (RAAp), and just after tricuspid valve closing (RAAmin). Right atrial conduit fraction percent (RA cF%) was defined as the percentage of total RAA change happening prior to the electrical p wave = (RAAmax - RAAp)/(RAAmax - RAAmin) ∗ 100. Clinical worsening was analyzed with a predefined composite adverse event outcome.
Results
RA measurements were technically feasible in all study participants. The PAH patients (median age 11.9 years) had decreased RA cF% compared with controls (P < .0001), and PAH subjects with lower RA cF% demonstrated higher right ventricular systolic (R = -0.49, P = .019) and end-diastolic (R = -0.52, P = .012) pressure than those with higher RA cF%. Sixteen subjects had a clinical event. Right atrial cF% (hazard ratio = 0.09; P < .001) was highly prognostic for risk of adverse clinical event with area under the curve = 0.90 on receiver operating characteristic curve analysis (median 3.2-year follow-up).
Conclusions
Right atrial conduit phase emptying is significantly altered in pediatric PAH. Within the PAH population, decreased RA cF% was prognostic for risk of clinical worsening. The combination of accuracy and ease of measurement could make RA cF% a clinically useful, noninvasive biomarker of early right heart failure and risk of disease progression in pediatric PAH.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; 33:1006-1013
Frank BS, Schafer M, Thomas TM, Haxel C, Ivy DD, Jone PN
J Am Soc Echocardiogr: 30 Jul 2020; 33:1006-1013 | PMID: 32336608
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Abstract

Longitudinal Variation in Presence and Severity of Cardiac Valve Regurgitation in Healthy Children.

Colan SD, Sleeper LA
Background
The goal of this study was to document the frequency and longitudinal variation in the presence and severity of echocardiographically documented valvular regurgitation (VR) in healthy children free of evidence of heart disease. We hypothesized that significant variation is common, and our specific aim was to determine change in prevalence and severity of VR in children free of heart disease.
Methods
The presence of VR was documented on each of the four valves, and the severity of regurgitation was assessed as the body surface area (BSA)-adjusted width of the vena contracta on each of two sequential echocardiograms in healthy children free of clinical and echocardiographic evidence of heart disease.
Results
We included 200 children ages 10.0 ± 4.5 years, BSA = 1.2 ± 0.43 m, at the first exam and 12.8 ± 4.9 years, BSA = 1.42 ± 0.44 m, at the second exam. Frequency of VR was similar on the two exams (tricuspid = 61.5% vs 57.0%, pulmonary = 55.5 vs 57.5%, mitral = 14.5% vs 16.0%, aortic = 3.0 vs 3.5%). The frequency of new appearance was similar to the frequency of resolution of VR for all four valves. For instances where the severity of VR was classified as trace versus mild, the frequency of change from mild to trace between the two exams was similar to the frequency of change from trace to mild.
Conclusions
In healthy children with no evidence of heart disease, there is substantial temporal variation in the presence and severity of tricuspid and pulmonary VR. The prevalence of mitral and aortic VR is lower in healthy children, but temporal variation is also noted for these valves. The finding of new-onset echocardiographic trace or mild VR cannot be assumed to represent incident valve pathology.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print
Colan SD, Sleeper LA
J Am Soc Echocardiogr: 29 Jul 2020; epub ahead of print | PMID: 32741595
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Abstract

Prognostic Value of Right Ventricular Two-Dimensional and Three-Dimensional Speckle-Tracking Strain in Pulmonary Arterial Hypertension: Superiority of Longitudinal Strain over Circumferential and Radial Strain.

Li Y, Wang T, Haines P, Li M, ... Lv Q, Xie M
Background
Right ventricular (RV) dysfunction is a predictor of adverse outcomes in patients with pulmonary arterial hypertension (PAH). Three-dimensional (3D) speckle-tracking echocardiography (STE) has been increasingly used to quantify RV function. However, the strain parameters evaluated by two-dimensional (2D) STE and 3D STE, which provide the most valuable clinical information, remain unknown. The purpose of our study was to investigate whether RV longitudinal strain (LS) provided a superior estimation of RV systolic performance and prognostic information compared with other strain vectors.
Methods
We prospectively studied 54 treatment-naïve patients with PAH and 35 normal controls. Pulmonary artery systolic pressure classified patients with PAH into three subgroups. Patients with PAH underwent echocardiography, cardiac magnetic resonance (CMR) imaging, 6-minute walking tests, and right-sided cardiac catheterization before and six months after vasodilator therapy. The 2D LS, 3D LS, circumferential strain (CS), and radial strain (RS) of RV free wall were calculated by 2D and 3D STE. RV ejection fraction (RVEF) was obtained from CMR. The patients were followed for a predefined endpoint of PAH-related hospitalization and death.
Results
Our findings revealed that 2D and 3D LS showed significant reduction in mild PAH patients, whereas CS and RS were decreased in moderate and severe PAH patients. Right ventricular 3D LS had a similar correlation with CMR RVEF and hemodynamic parameters as 2D LS and the other strain vectors. The 2D and 3D LS improved 6 months after vasodilator therapy (P < .001 for both). After a median follow-up of 28 months, 20 patients had endpoint events. Receiver operating characteristic curve analysis demonstrated that RV 3D LS displayed a similar diagnostic performance for detecting adverse cardiac events as 2D LS (area under the curve: 0.84 vs 0.76, P = .11). Separate multivariable Cox analysis showed that RV 2D LS (hazard ratio [HR] = 1.19; 95% CI, 1.03~1.45; P = .01) and 3D LS (HR = 1.28; 95% CI, 1.08~1.52; P = .005) were significant predictors of adverse outcomes.
Conclusions
Patients with PAH show reduced RV strain. Two-dimensional and 3D LS can track clinical improvement following vasodilator therapy and provide valuable prognostic information.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Jul 2020; 33:985-994.e1
Li Y, Wang T, Haines P, Li M, ... Lv Q, Xie M
J Am Soc Echocardiogr: 30 Jul 2020; 33:985-994.e1 | PMID: 32532643
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Abstract

Myocardial Scar by Pulse-Cancellation Echocardiography Is Independently Associated with Appropriate Defibrillator Intervention for Primary Prevention after Myocardial Infarction.

Gaibazzi N, Suma S, Lorenzoni V, Sartorio D, ... Siniscalchi C, Garibaldi S
Background
Myocardial scar burden impacts prognosis in patients with coronary artery disease who have experienced a myocardial infarction (MI). This has been demonstrated by late gadolinium enhancement cardiac magnetic resonance. Clinical experience with echocardiography suggests that the reflected ultrasound signal is enhanced in infarcted myocardial segments. Scar imaging with an ultrasound multipulse scheme (eScar) has been preliminarily validated in prior studies.
Objective
To assess whether scar burden, as detected by eScar, is associated with implantable cardioverter-defibrillator (ICD) shocks in post-MI patients.
Methods
We retrospectively selected 50 post-MI patients with an ejection fraction <35% who received an ICD for primary prevention and subsequently had at least one appropriate shock (cases). These were compared with 50 post-MI patients, matched for clinical variables and ejection fraction, who never experienced an appropriate defibrillator shock (controls). Subjects were assessed with the eScar technique at the time of implantation or during follow-up.
Results
An eScar was present in ≥1 segment in 40 of 50 (80%) cases vs 26 of 50 (52%) controls and was associated with appropriate ICD shocks (P = .004). Receiver operating characteristic curve analysis, using a threshold of ≥3 segments by eScar, showed an area under the curve (AUC) of 0.715. On models including clinical and echocardiographic variables, eScar remained significantly associated with ICD shocks (P = .050 or P = .033 depending on the model). Adding eScar to a multivariate logistic regression model including indexed left ventricular end-systolic volume led to an increase in AUC from 0.734 to 0.782 (P = .049), while substituting indexed left ventricular end-diastolic volume for indexed left ventricular end-systolic volume resulted in a nonsignificant increase in AUC from 0.747 to 0.785 (P = .098).
Conclusions
Presence and extent of eScar were independently associated with appropriate ICD shocks in this study of patients with prior MI and reduced ejection fraction. However, the addition of eScar assessment to the clinical multivariable model that included also indexed left ventricular end-diastolic volume did not provide significant incremental value.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2020; 33:1123-1131
Gaibazzi N, Suma S, Lorenzoni V, Sartorio D, ... Siniscalchi C, Garibaldi S
J Am Soc Echocardiogr: 30 Aug 2020; 33:1123-1131 | PMID: 32622588
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Abstract

Refining Severe Tricuspid Regurgitation Definition by Echocardiography with a New Outcomes-Based \"Massive\" Grade.

Kebed KY, Addetia K, Henry M, Yamat M, ... Mor-Avi V, Lang RM
Background
Current echocardiographic guidelines recommend that tricuspid regurgitation (TR) severity be graded in three categories, following assessment of specific parameters. Findings from recent trials have shown that the severity of TR frequently far exceeds the current definition of severe. We postulated that a grading approach that emphasizes outcomes could be useful to identify patients with severe TR at increased risk of mortality.
Methods
We identified 284 patients with echocardiograms demonstrating severe functional TR, defined as vena contracta (VC) ≥ 0.7 cm. Demographics and mortality data were obtained from the medical records. Patients were divided into study (n = 122 patients with three-dimensional images) and validation (n = 162) cohorts. The VC was measured in both the right ventricular (RV) inflow and apical four-chamber views and averaged. For the study cohort, tricuspid annular, RV end-diastolic (basal, mid, long axis) dimensions, tricuspid leaflet tenting height and area, RV free-wall longitudinal strain, and RV volumes were measured from two- and three-dimensional data sets. A K-partition algorithm was used in the study cohort to derive a mortality-related cutoff VC value, above which TR was termed \"massive.\" The ability of this VC cutoff to identify patients at greater mortality risk was then tested in the validation cohort using Kaplan-Meier survival analysis.
Results
In the study cohort, VC > 0.92 cm (massive TR) was optimally associated with worse survival. Tricuspid annular and RV size were larger in the massive group (P < .05), while there were no significant differences in demographics between the TR groups. Importantly, in the independent validation cohort, the above VC cutoff also correlated with increased mortality in the massive group (log-rank P < .05).
Conclusions
Among patients traditionally defined as having severe TR, a subset exists with massive TR, resulting in greater adverse RV remodeling and increased mortality. These patients may derive the greatest benefit from emerging percutaneous therapies.

Copyright © 2020 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

J Am Soc Echocardiogr: 30 Aug 2020; 33:1087-1094
Kebed KY, Addetia K, Henry M, Yamat M, ... Mor-Avi V, Lang RM
J Am Soc Echocardiogr: 30 Aug 2020; 33:1087-1094 | PMID: 32651124
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Abstract

Percutaneous coronary intervention of an anomalous coronary chronic total occlusion: The added value of three-dimensional printing.

Young L, Harb SC, Puri R, Khatri J

Three-dimensional (3D) printing has had an evolving role in cardiology, although has been largely reserved for planning of structural heart disease interventions. We present a case whereby multimodality imaging, including 3D printing, played a pivotal role in planning a technically feasible approach for complex percutaneous coronary intervention of a chronically occluded anomalous right coronary artery, with creation of a customized guide catheter.

© 2020 Wiley Periodicals, Inc.

Catheter Cardiovasc Interv: 30 Jul 2020; 96:330-335
Young L, Harb SC, Puri R, Khatri J
Catheter Cardiovasc Interv: 30 Jul 2020; 96:330-335 | PMID: 32233062
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Abstract

Cerebral protection in left atrial appendage closure in the presence of appendage thrombosis.

Boccuzzi GG, Montabone A, D\'Ascenzo F, Colombo F, ... Meincke F, Mazzone P
Background
Presence of thrombus in the left atrial appendage (LAA) remains a severe contraindication to the percutaneous left atrial appendage closure procedure (LAAC), due to increased embolic risk. Recently, the experience developed in cerebral protection device in transcatheter aortic valve implantation (TAVI) procedure was translated in LAAC to address this issue.
Aim
To evaluate efficacy and safety of Sentinel cerebral protection system (CPS) in supporting LAAC in real-world patient with persistent LAA thrombus.
Methods and results
The study retrospectively enrolled consecutive patients with non-valvular atrial fibrillation (NVAF) and thrombus in LAA who underwent LAAC supported by Sentinel CPS in seven European high-volume centres. Twenty-seven patients were included with a median age of 69.1 ± 9.7 years old, with median CHA DS -VASc and HAS-BLEED scores 3 [2-5] and 3 [2.75-4], respectively. Technical and procedural success was achieved in all patients. No periprocedural TIA, stroke, or supra-aortic trunks dissection was recorded.
Conclusions
In this multicenter registry, LAAC supported by Sentinel CPS in patients with LAA persistent thrombus seems to be a safe and efficacious treatment.

© 2020 Wiley Periodicals LLC.

Catheter Cardiovasc Interv: 17 Aug 2020; epub ahead of print
Boccuzzi GG, Montabone A, D'Ascenzo F, Colombo F, ... Meincke F, Mazzone P
Catheter Cardiovasc Interv: 17 Aug 2020; epub ahead of print | PMID: 32808741
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Abstract

Diagnostic utility of right atrial reservoir strain to identify elevated right atrial pressure in heart failure.

Miah N, Faxén UL, Lund LH, Venkateshvaran A
Background
Accurate non-invasive estimation of right atrial pressure (RAP) is essential to assess volume status and optimize therapy in heart failure (HF). This study aimed to evaluate the utility of right atrial reservoir strain (RASr) assessed by speckle-tracking echocardiography to identify elevated RAP in HF and compare diagnostic performance with estimated RAP employing inferior vena cava size and collapsibility (RAP), in addition to RA area.
Method
Association between RASr and invasive RAP (RAP) was examined in 103 HF subjects that underwent standard echocardiography with speckle-tracking strain analysis directly followed by right heart catheterization. The discriminatory ability of RASr to identify RAP > 7 mmHg was evaluated and compared with RAP and RA area.
Results
RASr demonstrated association with RAP (β = -0.41, p < 0.001) and was an independent predictor when adjusted for potential confounders (β = -0.25, p < 0.001). Further, RASr showcased strong discriminatory ability to identify subjects with RAP > 7 mmHg (AUC = 0.78; 95% CI 0.68-0.87; p < 0.001). At a cut-off value of -15%, RASr displayed 78% sensitivity and 72% specificity to identify elevated RAP In comparison, RAP (AUC = 0.71; 95% CI 0.61-0.81; p < 0.001) demonstrated 89% sensitivity and 32% specificity with high false positive rate. RA area (AUC = 0.66; 95% CI 0.55-0.76, p = 0.005) displayed 64% sensitivity and 53% specificity.
Conclusions
RASr demonstrates good ability to identify elevated RAP and relatively stronger diagnostic performance when compared with conventional non-invasive measures. RASr may be useful as a novel noninvasive estimate of RAP in HF management.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 13 Sep 2020; epub ahead of print
Miah N, Faxén UL, Lund LH, Venkateshvaran A
Int J Cardiol: 13 Sep 2020; epub ahead of print | PMID: 32941871
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Abstract

Recovery of atrial contractile function after cut-and-sew maze for long-standing persistent valvular atrial fibrillation.

Jin Y, Wang HS, Han JS, Zhang J, ... Yu Y, Zhao Y
Objective
The recovery of atrial contractile (AC) after maze has been concerned and even questioned. Now, studied the AC recovery degree and its influencing factors .
Method
237 patients with valvular long-standing persistent atrial fibrillation (AF) were retrospectively grouped according to whether sinus rhythm(SR) maintained and AC restored: SR-AC (163 cases), SR-no-AC (41 cases) and AF-no-AC (33 cases). SR-AC were grouped according to Em/Am ratio. Em/Am≤2 showed that the AC recovered well.
Results
The SR maintained rate (161/177, 90.96%) in patients underwent the cut-and-sew maze III (CSM) was significantly higher than that in cryoablation (43/60, 71.7%). Preoperative AF duration had no significant difference among three groups (P = 0.679). Maze methods had significant relationship with whether SR recovered, P < 0.05, but no significant relationship with whether AC recovered in SR maintained patients (P = 0.280). Nearly 80% (163/204) patients can recover AC, among 156 patients (156/204, 76.5%) recovered contractile of left and right atrium, and 63 (63/204, 30.1%) recovered significant left atrial contractile, that is, Em/Am≤2. Whether AC was significantly restored was not related to maze methods, P = 0.370. AC recovered degree in rheumatic heart disease (RHD) patients was worse than that in mitral valve prolapse (MVP) patients, P = 0.004.
Conclusion
To sum up, the CSM is safe and effective, and the atrial contractile function recovery was found in 80%. The key to the success of maze is to form a complete and lasting electrical isolation, and there was no difference in the rate of atrial contractile recovery when postoperative SR was maintained, no matter what maze method is used. MVP patients should be treated with maze more actively than RHD patients.

Copyright © 2020. Published by Elsevier B.V.

Int J Cardiol: 09 Sep 2020; epub ahead of print
Jin Y, Wang HS, Han JS, Zhang J, ... Yu Y, Zhao Y
Int J Cardiol: 09 Sep 2020; epub ahead of print | PMID: 32920067
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Abstract

Left atrial strain as a pre-operative prognostic marker for patients with severe mitral regurgitation.

Mandoli GE, Pastore MC, Benfari G, Bisleri G, ... Mondillo S, Cameli M
Background
In patients with severe mitral regurgitation (MR), additional echocardiographic indices could be helpful to optimize surgical timing before irreversible left heart myocardial dysfunction has occurred. We investigated the correlation of left atrial (LA) strain by speckle tracking echocardiography with prognosis after mitral surgery for severe MR, and its association with LA fibrosis.
Method
71 patients with primary severe MR undergoing pre-operative echocardiographic assessment were initially enrolled. Exclusion criteria were: other valvular disease>moderate, history of coronary artery disease, heart failure (HF), hypertrophic cardiomyopathy, left bundle branch block, previous pacemaker implantation, heart transplantation, poor acoustic window. The primary endpoint was the occurrence of composite events (HF and mortality); the secondary endpoint was post-operative functional capacity (NYHA and Borg CR10 class). LA fibrosis was assessed by atrial biopsy specimens in a subset of patients.
Results
Of 65 eligible patients, the primary endpoint occurred in 30 patients (medium follow-up: 3.7 ± 1 years for event-group, 6.8 ± 1 years for non-event group). After Kaplan-Meier analysis, peak atrial longitudinal strain (PALS) provided good risk stratification (5-year event-free survival:90 ± 5% for PALS≥21% vs 30 ± 9% for PALS<21%, p < 0.0001); it was an independent and incremental predictor of outcome in four multivariate Cox adjusted models. There was also an association between PALS and the secondary endpoint (NYHA: r = 0.11, p = 0.04; Borg CR10: r = 0.10, p = 0.02) and an inverse correlation between PALS<21% and LA fibrosis (r 0.80, fibrosis: 76.6 ± 20.7% vs 31.9 ± 20.8%;p < 0.0001).
Conclusions
Global PALS emerged as a reliable predictor of outcome and functional capacity for severe primary MR, and as a marker of LA fibrosis.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 09 Sep 2020; epub ahead of print
Mandoli GE, Pastore MC, Benfari G, Bisleri G, ... Mondillo S, Cameli M
Int J Cardiol: 09 Sep 2020; epub ahead of print | PMID: 32920069
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Impact:
Abstract

Left ventricular strain and fibrosis in adults with repaired tetralogy of Fallot: A case-control study.

de Alba CG, Khan A, Woods P, Broberg CS
Background
Left ventricular (LV) systolic dysfunction and myocardial fibrosis have prognostic implications in repaired tetralogy of Fallot (rTOF), but their relationship with myocardial strain is not well understood. We evaluated systolic strain and fibrosis (extracellular volume fraction, ECV) of the left ventricle (LV) using feature tracking with magnetic resonance and determine their association with each other and clinical outcome.
Method
Adults with rTOF and age-matched controls underwent CMR to measure LV-ECV. Feature-tracking was used to quantify radial, circumferential, and longitudinal strain in both 2 and 3 dimensions. Clinical events (death, arrhythmia and heart-failure hospitalization) were obtained through chart review. Associations between strain, ECV and clinical events were explored.
Results
48 rTOF subjects (age 40.5 ± 14.3, 42% female) and 20 healthy controls were included. Both LV 2D and 3D global circumferential strain (GCS) and global longitudinal strain (GLS) were lower in rTOF subjects (p ≤0.01 for all). There was no association between strain and LV-ECV. Strain parameters correlated with ventricular volumes and function. After a median follow-up of 8.5 years (range 1-10.9 years) there were 5 deaths, 6 hospitalizations and 9 new arrhythmias. By multivariate Cox-regression, GLS was an independent predictor of both hospitalization and death, whereas LV-ECV was an independent predictor of arrhythmia.
Conclusion
While both LV strain abnormalities and fibrosis are present in rTOF, they are associated with different types of clinical outcome, and not to each other. The findings suggest that these measures reflect different long-term adverse adaptations to abnormal hemodynamics.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Aug 2020; epub ahead of print
de Alba CG, Khan A, Woods P, Broberg CS
Int J Cardiol: 31 Aug 2020; epub ahead of print | PMID: 32882293
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Abstract

Heart failure with preserved ejection fraction or non-cardiac dyspnea in paroxysmal atrial fibrillation: The role of left atrial strain.

Katbeh A, De Potter T, Geelen P, Di Gioia G, ... Van Camp G, Penicka M
Background
Diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with dyspnea and paroxysmal atrial fibrillation (AF) is challenging. Speckle tracking-derived left atrial strain (LAS) provides an accurate estimate of left ventricular (LV) filling pressures and left atrial (LA) phasic function. However, data on clinical utility of LAS in patients with dyspnea and AF are scarce.
Objective
To assess relationship between the LAS and the probability of HFpEF in patients with dyspnea and paroxysmal AF.
Methods
The study included 205 consecutive patients (62 ± 10 years, 58% males) with dyspnea (NYHA≥II), paroxysmal AF and preserved LV ejection fraction (≥50%), who underwent speckle tracking echocardiography during sinus rhythm. Probability of HFpEF was estimated using HFPEF and HFA-PEFF scores, which combine clinical characteristics, echocardiographic parameters and natriuretic peptides.
Results
Patients with high probability of HFpEF were significantly older, had higher body mass index, NT-proBNP, E/e\', pulmonary artery pressure and larger LA volume index than patients in low-to-intermediate probability groups (all p < 0.05). All components of LAS and LA strain rate showed proportional impairment with increasing probability of HFpEF (all p < 0.05). Out of the speckle tracking-derived parameters, reservoir LAS showed the largest area under the curve (AUC = 0.78, p < 0.001) and the strongest independent predictive value (OR: 1.22, 95% CI 1.08-1.38) to identify patients with high probability of HFpEF.
Conclusions
Reservoir LAS shows a high diagnostic performance to distinguish HFpEF from non-cardiac causes of dyspnea in symptomatic patients with paroxysmal AF.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 31 Aug 2020; epub ahead of print
Katbeh A, De Potter T, Geelen P, Di Gioia G, ... Van Camp G, Penicka M
Int J Cardiol: 31 Aug 2020; epub ahead of print | PMID: 32882295
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Abstract

Impact of hypertension on left ventricular function in patients after anthracycline chemotherapy for malignant lymphoma.

Tanaka Y, Tanaka H, Hatazawa K, Yamashita K, ... Minami H, Hirata KI
Background
Hypertension is considered an important risk factors for cancer therapeutics-related cardiac dysfunction (CTRCD) as well as heart failure. However, the impact of hypertension and left ventricular (LV) hypertrophy (LVH), which is associated with hypertension, on LV function in patients treated with anthracycline chemotherapy for malignant lymphoma remains uncertain.
Method
We studied 92 patients with malignant lymphoma and with preserved LV ejection fraction (LVEF). Echocardiography was performed before and two-month after anthracycline chemotherapy. CTRCD was defined as the presence of an absolute decrease in LVEF ≥10% to a final value <53%. LVH was defined as concentric hypertrophy, which was determined as relative wall thickness ≥ 0.42 and LV mass index >95 g/m for females and > 115 g/m for males.
Results
Relative decrease in LVEF after anthracycline chemotherapy in patients with hypertension (n = 23) was significantly higher than that in patients without hypertension (n = 69) (-5.8% [-9.4, -1.3]) vs. (-1.1% [-4.1, 2.5]); P = .005). Moreover, the prevalence of CTRCD in patients with hypertension tended to be higher than in those without hypertension (17% vs. 5%, p = .09). A sequential logistic model for predicting CTRCD, based on baseline clinical variables including major clinical risk factors, was improved by the addition of the complication of hypertension (P = .049), and further improved by the addition of the presence of LVH (P = .023).
Conclusions
Hypertension, especially when complicated by LVH, was found to be associated with LV dysfunction after anthracycline chemotherapy in patients with malignant lymphoma and preserved LVEF. Watchful observation or early therapeutic intervention may thus be needed for such patients by the addition of the presence of LVH.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 12 Aug 2020; epub ahead of print
Tanaka Y, Tanaka H, Hatazawa K, Yamashita K, ... Minami H, Hirata KI
Int J Cardiol: 12 Aug 2020; epub ahead of print | PMID: 32800904
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Impact:
Abstract

Lower left ventricular ejection fraction and higher serum angiotensin-converting enzyme activity are associated with histopathological diagnosis by endomyocardial biopsy in patients with cardiac sarcoidosis.

Komoriyama H, Omote K, Nagai T, Kato Y, ... Ishibashi-Ueda H, Anzai T
Background
The histopathological diagnosis of cardiac sarcoidosis (CS) is challenging because of sampling error in endomyocardial biopsy (EMB) and the determinants of positive EMB are unclear. Reduced left ventricular ejection fraction (LVEF) is a simple parameter of the extent of myocardial damage, and higher serum angiotensin-converting enzyme (ACE) activity would indicate the spread of disease activity in CS patients. Thus, we sought to examine whether these parameters are related to the histopathological diagnosis of CS by EMB.
Methods
A total of 94 consecutive clinically diagnosed CS patients between August 1986 and March 2019 who were admitted to two academic hospitals were examined. We determined EMB as positive if non-caseating epithelioid granulomas were confirmed in the myocardial tissue. Patients were divided into two groups according to positive (n = 37) and negative (n = 57) EMB. We assessed the relationship between LVEF, serum ACE activity and positive EMB.
Results
Multivariable analysis revealed that both LVEF and serum ACE were independently associated with positive EMB (OR 0.83, 95% CI 0.70-0.99; OR 1.39, 95% CI 1.02-1.90, respectively). Moreover, patients with both lower LVEF (<37%, median) and higher ACE activity (≥13.5 IU/L, median) had the highest frequency of positive EMB (p = .003). The combination of lower LVEF and higher serum ACE showed better specificity (91.2%) and positive predictive value (73.7%) than either LVEF or serum ACE alone for positive EMB.
Conclusions
Lower LVEF and higher serum ACE activity were associated with positive EMB, suggesting that these parameters might be useful for predicting positive EMB in CS patients.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 27 Jul 2020; epub ahead of print
Komoriyama H, Omote K, Nagai T, Kato Y, ... Ishibashi-Ueda H, Anzai T
Int J Cardiol: 27 Jul 2020; epub ahead of print | PMID: 32730825
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Impact:
Abstract

Are all left bundle branch blocks the same? Myocardial mechanical implications by cardiovascular magnetic resonance.

Baritussio A, Biglino G, Moharem-Elgamal S, De Garate E, ... Milano EG, Bucciarelli-Ducci C
Aims
Left bundle branch block (LBBB) is usually associated with structural myocardial diseases progressively leading to left ventricular (LV) dysfunction. We sought to determine the mechanical implications of LBBB (as defined based on Strauss\' criteria) by Cardiovascular Magnetic Resonance (CMR).
Method and results
We included consecutive patients referred to CMR to assess the structural cause of LBBB. CMR scans consisted of cine, stress perfusion, and late gadolinium enhancement (LGE) sequences. Myocardial deformation was assessed by tissue tracking analysis; LGE was quantified using the full width at half maximum method. We included 86 patients [63% male, 70 years (60-72)] with mean QRS duration 150 ± 13 msec. A structural disease was identified on CMR in 53% of patients (ischemic heart disease, IHD, 31%; non-ischemic heart disease, NIHD, 22%), while LBBB-related septal dyssynchrony (SD) was the only abnormality in 47%. LGE was found in 42% of patients. LVEF and myocardial deformation were impaired. Despite similar ECG characteristics, myocardial strain differed significantly between IHD, NIHD and SD patients, and patients with SD showed less impaired myocardial deformation. Indexed LV end-systolic volume and LGE extent were independently associated with impaired strain.
Conclusions
Patients with LBBB show different structural and mechanical properties, and LGE extent has an unfavourable effect on myocardial mechanics.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 14 Sep 2020; epub ahead of print
Baritussio A, Biglino G, Moharem-Elgamal S, De Garate E, ... Milano EG, Bucciarelli-Ducci C
Int J Cardiol: 14 Sep 2020; epub ahead of print | PMID: 32941866
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Impact:
Abstract

4D flow cardiac magnetic resonance in children and adults with congenital heart disease: Clinical experience in a high volume center.

Isorni MA, Moisson L, Moussa NB, Monnot S, ... Kara M, Hascoet S
Background
Cardiac magnetic resonance (CMR) imaging with velocity encoding along all three directions of flow, known as 4DFlow CMR, provides both anatomical and functional information. Few data are available on the usefulness of 4DFlow CMR in everyday practice. Here, our objective was to investigate the usefulness of 4DFlow CMR for assessing congenital heart disease (CHD) in everyday practice.
Methods
From 2017 to 2019, consecutive patients who underwent 4DFlow CMR were included prospectively at a single high-volume centre. The parameters recommended by an expert\'s consensus statement for each diagnosis (congenital valvulopathy, septal defect, complex CHD, tetralogy of Fallot, aortic abnormalities) were assessed by two blinded experienced readers. 4DFlow CMRs that provided all recommended parameters were considered successful. Inter-observer and intra-observer agreement were investigated.
Results
We included 187 adults and 60 children covering broad ranges of weight (4.5-142 kg) and age (0.1-67 years). 4DFlow CMR was always the second-line imaging modality, after inconclusive echocardiography, and was successful in 231/247 (91%) patients, with no significant difference between children and adults (54/60, 90%; and 177/187, 95%; respectively; p = .13). Longer time using 4DFlow CMR at our centre was associated with success; in children, older age was also associated with exam success. There was an about 12-month learning curve in children. The success rate was lowest in neonates. Inter-observer and intra-observer agreement were substantial.
Conclusion
Our results suggest that 4DFlow CMR usually provides a comprehensive assessment of CHD in adults and children. A learning curve exists for children and the investigation remains challenging in neonates.

Copyright © 2020 Elsevier B.V. All rights reserved.

Int J Cardiol: 23 Jul 2020; epub ahead of print
Isorni MA, Moisson L, Moussa NB, Monnot S, ... Kara M, Hascoet S
Int J Cardiol: 23 Jul 2020; epub ahead of print | PMID: 32712110
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Abstract

Automated quantitative analysis of CZT SPECT stratifies cardiovascular risk in the obese population: Analysis of the REFINE SPECT registry.

Klein E, Miller RJH, Sharir T, Einstein AJ, ... Berman DS, Slomka PJ
Background
Obese patients constitute a substantial proportion of patients referred for SPECT myocardial perfusion imaging (MPI), presenting a challenge of increased soft tissue attenuation. We investigated whether automated quantitative perfusion analysis can stratify risk among different obesity categories and whether two-view acquisition adds to prognostic assessment.
Methods
Participants were categorized according to body mass index (BMI). SPECT MPI was assessed visually and quantified automatically; combined total perfusion deficit (TPD) was evaluated. Kaplan-Meier and Cox proportional hazard analyses were used to assess major adverse cardiac event (MACE) risk. Prognostic accuracy for MACE was also compared.
Results
Patients were classified according to BMI: BMI < 30, 30 ≤ BMI < 35, BMI ≥ 35. In adjusted analysis, each category of increasing stress TPD was associated with increased MACE risk, except for 1% ≤ TPD < 5% and 5% ≤ TPD < 10% in patients with BMI ≥ 35. Compared to visual analysis, single-position stress TPD had higher prognostic accuracy in patients with BMI < 30 (AUC .652 vs .631, P < .001) and 30 ≤ BMI < 35 (AUC .660 vs .636, P = .027). Combined TPD had better discrimination than visual analysis in patients with BMI ≥ 35 (AUC .662 vs .615, P = .003).
Conclusions
Automated quantitative methods for SPECT MPI interpretation provide robust risk stratification in the obese population. Combined stress TPD provides additional prognostic accuracy in patients with more significant obesity.



J Nucl Cardiol: 13 Sep 2020; epub ahead of print
Klein E, Miller RJH, Sharir T, Einstein AJ, ... Berman DS, Slomka PJ
J Nucl Cardiol: 13 Sep 2020; epub ahead of print | PMID: 32929639
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Abstract

Cardiac fibroblast activation detected by Ga-68 FAPI PET imaging as a potential novel biomarker of cardiac injury/remodeling.

Siebermair J, Köhler MI, Kupusovic J, Nekolla SG, ... Rassaf T, Rischpler C
Background
Fibroblast activation protein (FAP) as a specific marker of activated fibroblasts can be visualized by positron emission tomography (PET) using Ga-68-FAP inhibitors (FAPI). Gallium-68-labeled FAPI is increasingly used in the staging of various cancers. In addition, the first cases of theranostic approaches have been reported. In this work, we describe the phenomenon of myocardial FAPI uptake in patients who received a Ga-68 FAPI PET for tumor staging.
Method and results
Ga-68 FAPI PET examinations for cancer staging were retrospectively analyzed with respect to cardiac tracer uptake. Standardized uptake values (SUV) were correlated to clinical covariates in a univariate regression model. From 09/2018 to 11/2019 N = 32 patients underwent FAPI PET at our institution. Six out of 32 patients (18.8%) demonstrated increased localized myocardial tracer accumulation, with remote FAPI uptake being significantly higher in patients with vs without localized focal myocardial uptake (SUV 2.2 ± .6 vs 1.5 ± .4, P < .05 and SUV 1.6 ± .4 vs 1.2 ± .3, P < .05, respectively). Univariate regression demonstrated a significant correlation of coronary artery disease (CAD), age and left ventricular ejection fraction (LVEF) with remote SUV uptake, the latter with a very strong correlation with remote uptake (R = .74, P < .01).
Conclusion
Our study indicates an association of CAD, age, and LVEF with FAPI uptake. Further studies are warranted to assess if fibroblast activation can be reliably measured and may be used for risk stratification regarding early detection or progression of CAD and left ventricular remodeling.



J Nucl Cardiol: 24 Sep 2020; epub ahead of print
Siebermair J, Köhler MI, Kupusovic J, Nekolla SG, ... Rassaf T, Rischpler C
J Nucl Cardiol: 24 Sep 2020; epub ahead of print | PMID: 32975729
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Abstract

Diagnostic utility of fusion F-fluorodeoxyglucose positron emission tomography/cardiac magnetic resonance imaging in cardiac sarcoidosis.

Okune M, Yasuda M, Soejima N, Kagioka Y, ... Miyazaki S, Iwanaga Y
Background
Although each F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) has been used to diagnose cardiac sarcoidosis (CS), active CS is still misdiagnosed.
Methods
Active CS, diagnosed by PET alone, was defined as focal or focal on diffuse FDG uptake pattern. In fusion PET/CMR imaging, using a regional analysis with AHA 17-segment model, the patients were categorized into four groups: (1) PET-/LGE-, (2) PET+/LGE-, (3) PET+/LGE+, and (4) PET-/LGE+. PET+/LGE+ was defined as active CS.
Results
74 Patients with suspected CS were enrolled. Between PET alone and fusion PET/CMR imaging, 20 cases had mismatch evaluations of active CS, and most had diffuse or focal on diffuse FDG uptake pattern on PET alone imaging. 40 Patients fulfilled the 2016 the Japanese Circulation Society diagnostic criteria for CS. The interobserver diagnostic agreement was excellent (κ statistics 0.89) and the overall accuracy for diagnosing CS was 87.8% in fusion PET/CMR imaging, which were superior to those in PET alone imaging (0.57 and 82.4%, respectively). In a sub-analysis of diffuse and focal on diffuse patterns, the agreement (κ statistics 0.86) and overall accuracy (81.8%) in fusion PET/CMR imaging were still better.
Conclusions
Fusion PET/CMR imaging with regional analysis offered reliable and accurate diagnosis of CS, covering low diagnostic area by FDG-PET alone.



J Nucl Cardiol: 30 Sep 2020; epub ahead of print
Okune M, Yasuda M, Soejima N, Kagioka Y, ... Miyazaki S, Iwanaga Y
J Nucl Cardiol: 30 Sep 2020; epub ahead of print | PMID: 33000410
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Abstract

18F-fluoride PET/MR in cardiac amyloid: A comparison study with aortic stenosis and age- and sex-matched controls.

Andrews JPM, Trivieri MG, Everett R, Spath N, ... Fayad ZA, Dweck MR
Objectives
Cardiac MR is widely used to diagnose cardiac amyloid, but cannot differentiate AL and ATTR subtypes: an important distinction given their differing treatments and prognoses. We used PET/MR imaging to quantify myocardial uptake of 18F-fluoride in ATTR and AL amyloid patients, as well as participants with aortic stenosis and age/sex-matched controls.
Methods
In this prospective multicenter study, patients were recruited in Edinburgh and New York and underwent 18F-fluoride PET/MR imaging. Standardized volumes of interest were drawn in the septum and areas of late gadolinium enhancement to derive myocardial standardized uptake values (SUV) and tissue-to-background ratio (TBR) after correction for blood pool activity in the right atrium.
Results
53 patients were scanned: 18 with cardiac amyloid (10 ATTR and 8 AL), 13 controls, and 22 with aortic stenosis. No differences in myocardial TBR values were observed between participants scanned in Edinburgh and New York. Mean myocardial TBR values in ATTR amyloid (1.13 ± 0.16) were higher than controls (0.84 ± 0.11, P = .0006), aortic stenosis (0.73 ± 0.12, P < .0001), and those with AL amyloid (0.96 ± 0.08, P = .01). TBR values within areas of late gadolinium enhancement provided discrimination between patients with ATTR (1.36 ± 0.23) and all other groups (e.g., AL [1.06 ± 0.07, P = .003]). A TBR threshold >1.14 in areas of LGE demonstrated 100% sensitivity (CI 72.25 to 100%) and 100% specificity (CI 67.56 to 100%) for ATTR compared to AL amyloid (AUC 1, P = .0004).
Conclusion
Quantitative 18F-fluoride PET/MR imaging can distinguish ATTR amyloid from other similar phenotypes and holds promise in improving the diagnosis of this condition.



J Nucl Cardiol: 29 Sep 2020; epub ahead of print
Andrews JPM, Trivieri MG, Everett R, Spath N, ... Fayad ZA, Dweck MR
J Nucl Cardiol: 29 Sep 2020; epub ahead of print | PMID: 33000405
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Abstract

Prognostic value of myocardial perfusion imaging with D-SPECT camera in patients with ischemia and no obstructive coronary artery disease (INOCA).

Liu L, Abdu FA, Yin G, Xu B, ... Xu Y, Che W
Background
Myocardial perfusion imaging (MPI) with a novel D-SPECT camera maintains excellent prognostic value compared to conventional SPECT. However, information about the relationship between D-SPECT MPI and the prognosis in patients with ischemia and no obstructive coronary artery disease (INOCA) is limited. The objective of this study was to evaluate the prognostic value of MPI with D-SPECT in INOCA and obstructive coronary artery disease (CAD) patients.
Methods
All consecutive patients with suspected CAD and without prior CAD who underwent D-SPECT MPI and invasive coronary angiography within 3 months were considered. INOCA and obstructive CAD were defined as < 50% and ≥ 50% coronary stenosis, respectively. Patients were followed-up for the occurrence of major adverse cardiac events (MACE: cardiovascular death, nonfatal myocardial infarction, revascularization, stroke, heart failure and angina-related rehospitalization).
Results
Among 506 patients, 232 (45.8%) were INOCA patients. A total of 33.2% of the INOCA patients had abnormal D-SPECT MPI, whereas 77.7% of the obstructive CAD patients had abnormal D-SPECT MPI. In both groups, patients with abnormal D-SPECT MPI demonstrated higher MACE rates and lower survival free of MACE. In addition, patients with INOCA and abnormal D-SPECT MPI had a poor prognosis similar to that of the obstructive CAD patients. Cox regression analysis showed that the risk-adjusted hazard ratios for abnormal D-SPECT MPI were 2.55 [1.11-5.87] and 2.06 [1.03-4.10] in the INOCA and obstructive CAD patients, respectively.
Conclusions
D-SPECT MPI provides excellent prognostic information, with a more severe prognosis in patients with abnormal D-SPECT MPI. INOCA patients with abnormal D-SPECT MPI experience a poor prognosis similar to that of patients with obstructive CAD.



J Nucl Cardiol: 29 Sep 2020; epub ahead of print
Liu L, Abdu FA, Yin G, Xu B, ... Xu Y, Che W
J Nucl Cardiol: 29 Sep 2020; epub ahead of print | PMID: 33000403
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Abstract

The indications and utility of adjunctive imaging modalities for chronic total occlusion (CTO) intervention.

Allahwala UK, Brilakis ES, Kiat H, Ayesa S, ... Weaver JC, Bhindi R

Coronary chronic total occlusions (CTO) are common in patients undergoing coronary angiography, yet the optimal management strategy remains uncertain, with conflicting results from randomized trials. Appropriate patient selection and careful periprocedural planning are imperative for successful patient management. We review the role of adjunctive imaging modalities including myocardial perfusion imaging (MPI), cardiac magnetic resonance imaging (CMR), echocardiography and computed tomography coronary angiography (CTCA) in myocardial ischemic quantification, myocardial viability assessment, as well as procedural planning for CTO revascularization. An appreciation of the value, indications and limitations of these modalities prior to planned intervention are essential for optimal management.



J Nucl Cardiol: 05 Oct 2020; epub ahead of print
Allahwala UK, Brilakis ES, Kiat H, Ayesa S, ... Weaver JC, Bhindi R
J Nucl Cardiol: 05 Oct 2020; epub ahead of print | PMID: 33025478
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