American Society Of Echocardiography Guidelines Research Articles

Echocardiographic Outcomes With Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients

BackgroundThe CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). ObjectivesThis study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) ≤1+. MethodsAn independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR ≤1+ were identified using logistic regression. ResultsIn 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4+ in 76.4% and 3+ in 23.6% of patients. All patients achieved MR ≤2+ at discharge. The proportion of patients with MR ≤1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR ≤1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR ≤1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). ConclusionsThe study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR ≤1+ to 6 months. Results demonstrate that MR ≤1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833)

Mitral annular calcification in patients with severe aortic stenosis underwent transcatheter aortic valve implantation: prevalence and association with stenosis severity

Abstract Background Patients with calcific aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) usually have calcification in other cardiac structures, especially mitral annulus. Severity of mitral annular calcification (MAC) and degree of mitral stenosis (MS) may be associated with hemodynamic effects and outcomes. Purpose We sought to investigate the prevalence of MAC in patients with severe calcific AS using mitral annular calcium score with Agatston method from cardiac computerized tomography (CT). We also aim to assess the severity grading of MAC and its association with the severity of MS evaluated by transthoracic echocardiography. Methods We conducted a retrospective cohort analysis of the TAVI registry at King Chulalongkorn Memorial Hospital between May 2013 and December 2021. Clinical information was extracted from medical records. The pre-TAVI echocardiography and cardiac CT were reviewed, as well as the mitral annular calcium score. The severity of MAC (no, mild, moderate, severe) was classified using cardiac CT per the modified Cleveland clinic classification system. The MS grading was based on the 2009 American society of echocardiography guidelines. MAC prevalence was studied. Analysis of the association between MAC and MS was conducted. Results Our cohort included a total of 188 patients (mean age of 81±8 years). 134 patients (71.3%) demonstrated evidence of MAC. 47 patients (25%) had severe MAC evaluated by cardiac CT. Among patients with severe MAC, mean age was 83±8 years, 29 patients (63%) were female, 14 patients (30%) had diabetes, and 11 (23%) of them were associated with moderate or severe MS. Patients with MAC were significantly associated with hemodynamically significant MS (moderate or severe) when compared with patients without MAC (p <0.001). Conclusions One-fourth of patients with severe calcific AS underwent TAVI had severe MAC. The hemodynamically significant MS was more prevalent as the severity of MAC increased. The association between MAC and long-term adverse clinical outcomes needs to be further investigated.Figure 1Figure 2

Abstract 16494: Cardiac Structure and Function Predict Incident Atrial Fibrillation and Flutter in Patients With HFpEF - Lessons From PARAGON-HF

Introduction: Incident atrial fibrillation and flutter (AFF) are common among patients with heart failure with preserved ejection fraction (HFpEF) portending a worse prognosis. Cardiac echocardiographic predictors of incident AFF in patients with HFpEF are not well known. Methods: Patients without history of AFF enrolled in the echocardiographic sub-study of the PARAGON-HF trial with adequate image quality were included in this analysis. Cardiac structure and function parameters were measured per the American Society of Echocardiography guidelines. Incident AFF was ascertained during serial trial visits. Multivariable Cox proportional hazards models were used to identify parameters of echocardiography associated with incident AFF and were adjusted for variables previously known to associate with incident AFF (age, heart rate, body mass index and NT-pro-BNP). Results: Among patients without prior AFF (N=425, 54% women, mean age 71 ± 8 years), 63 developed incident AFF over a median follow-up of 2.8 years (5.4 per 100 person-years). After multivariable adjustment, higher left atrial (LA) volume index (HR: 1.35 per 11.3 ml/m 2 , 95% CI: 1.10-1.66, p=0.004), left ventricular mass index (HR: 1.40 per 25.7 g/m 2 , 95% CI: 1.09-1.80, p=0.008), septal E/e’ ratio (HR: 1.72 per 6.4 units, 95% CI: 1.29-2.28, p<0.001), and lower septal a’ (HR: 0.48 per 2.0 cm/s, 95% CI: 0.33-0.70, p<0.001) were associated with a significantly higher risk of incident AFF. Furthermore, higher (better) LA reservoir strain (LAsr) (HR: 0.66 per 10.8%, 95% CI: 0.48-0.92, p=0.014) and LA contractile strain (absolute LAsct) (HR: 0.71 per 6.7%, 95% CI: 0.51-0.98, p=0.040) predicted lower risk of incident AFF. Conclusions: In the PARAGON-HF echocardiographic sub-study, worse diastolic and LA function, larger LA size and higher LV mass were associated with a higher risk of incident AFF.

Diastolic Dysfunction and Health Status Outcomes After Transcatheter Aortic Valve Replacement

BackgroundBaseline left ventricular diastolic dysfunction (LVDD) is associated with poor health status in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR), but health status improvement after TAVR appears similar across all grades of LVDD. Here, we aim to examine the relationship between changes in LVDD severity and health status outcomes following TAVR. MethodsPatients who underwent TAVR and had evaluable LVDD at both baseline and 1 year in the PARTNER (Placement of Aortic Transcatheter Valves) 2 SAPIEN 3 registries and PARTNER 3 trial were analyzed. LVDD grade was evaluated using echocardiography core lab data and an adapted definition of American Society of Echocardiography guidelines. Health status was assessed using the Kansas City Cardiomyopathy Questionnaire Overall Summary (KCCQ-OS) score. The association between ΔLVDD severity and ΔKCCQ-OS was examined using linear regression models adjusted for baseline KCCQ-OS. ResultsOf 1100 patients, 724 (65.8%), 283 (25.7%), and 93 (8.5%) had grade 0/1, 2, and 3 LVDD at baseline, respectively. At 1 year, LVDD severity was unchanged in 790 (71.8%) patients, improved in 189 (17.2%), and worsened in 121 (11.0%). Among 376 patients with baseline grade 2 or 3 LVDD, 50.3% had improvement in LVDD. In the overall cohort, KCCQ-OS score improved by 21.9 points at 1 year. There was a statistically significant association between change in LVDD severity (improved, unchanged, and worsened) and ΔKCCQ-OS at 1 year (p = 0.007). ConclusionsChange in LVDD grade was associated with change in health status 1 year following TAVR.

Concentric Cardiac Remodeling and Hypertrophy in Pregnant Individuals with Chronic Hypertension.

This study aimed to evaluate rates of superimposed preeclampsia in pregnant individuals with echocardiography-diagnosed cardiac geometric changes in the setting of chronic hypertension. This was a retrospective study of pregnant individuals with chronic hypertension who delivered singleton pregnancies at 20 weeks' gestation or greater at a tertiary care center. Analyses were limited to individuals who had an echocardiogram during any trimester. Cardiac changes were categorized as normal morphology, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy according to the American Society of Echocardiography guidelines. Our primary outcome was early-onset superimposed preeclampsia defined as delivery at less than 34 weeks' gestation. Other secondary outcomes were also examined. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were calculated, controlling for prespecified covariates. Of the 168 individuals who delivered from 2010 to 2020, 57 (33.9%) had normal morphology, 54 (32.1%) had concentric remodeling, 9 (5.4%) had eccentric hypertrophy, and 48 (28.6%) had concentric hypertrophy. Non-Hispanic black individuals presented over 76% of the cohort. Rates of the primary outcome in individuals with normal morphology, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy were 15.8, 37.0, 22.2, and 41.7%, respectively (p = 0.01). Compared with individuals with normal morphology, individuals with concentric remodeling were more likely to have the primary outcome (aOR: 3.28; 95% CI: 1.28-8.39), fetal growth restriction (crude OR: 2.98; 95% CI: 1.05-8.43), and iatrogenic preterm delivery <34 weeks' gestation (aOR: 2.72; 95% CI: 1.15-6.40). Compared with individuals with normal morphology, individuals with concentric hypertrophy were more likely to have the primary outcome (aOR: 4.16; 95% CI: 1.57-10.97), superimposed preeclampsia with severe features at any gestational age (aOR: 4.75; 95% CI: 1.94-11.62), iatrogenic preterm delivery <34 weeks' gestation (aOR: 3.60; 95% CI: 1.47-8.81), and neonatal intensive care unit admission (aOR: 4.82; 95% CI: 1.90-12.21). Concentric remodeling and concentric hypertrophy were associated with increased odds of early-onset superimposed preeclampsia. · Concentric remodeling and concentric hypertrophy were associated with an increased risk of superimposed preeclampsia.. · Concentric hypertrophy was associated with an increased risk of delivery at less than 34 weeks.. · Two-thirds of the individuals in our study had concentric hypertrophy and concentric remodeling..

Left ventricular function assessed with two-dimensional speckle tracking and three-dimensional echocardiography in patients with obstructive sleep apnea

Objective: To investigate left ventricular function by two-dimensional (2D) speckle tracking and three-dimensional (3D) echocardiography in obstructive sleep apnea (OSA) patients. Subject and method: Patients who were diagnosed with OSA based on the results of full polysomnography and had apnea- hypopnea index values &gt; 5 events/hour of sleep were included in the study. All patient underwent polysomnography recording. Comprehensive 2-dimensional echocardiography were performed to all subjects according to American Society of Echocardiography guidelines [5], followed by real-time 3D echocardiography. Result: From June 2021 to June 2022, there were 46 OSA patients were included in the study. Mean age of OSA patients 51.3 ± 11.7 years. Men 63% (29/46), women 37% (15/46). The apnea-hypopnea index, percentage of total sleep time with an oxygen saturation level &lt; 90%, arousal index increased in OSA patients. E/E’ increased (12.6 ± 4.3), GLS mildly reduced (-16.5 ± 3.8%) while other echocardiographic parameters were in normal range. Results of ANOVA showed an increase in the following LA parameters on 3D echocardiography according to the levels of OSA severity: LV mass index, 3D maximum LA volume, 3D maximum LA volume index, E/E’ were significantly higher in the severe OSA group compared with the moderate OSA and the mild OSA (p&lt;0.05 for all). There was a decrease in the E’ velocity and global longitudinal strain (GLS) (p&lt;0.05 for all). Conclusion: In patients with obstructive sleep apnea, the severity of OSA was associated with lower E′ velocity, greater E/E′ ratio, larger 3D LV volume, greater LV mass index, and poorer left ventricular global longitudinal strain.

Assessment of left atrial volume and function by real-time three-dimensional echocardiography in obstructive sleep apnea

Aims: To evaluate the volumetric and functional abnormalities of the left atrium (LA) using real-time three-dimensional echocardiography (RT3DE) in patients with obstructive sleep apnea (OSA) compared with a control group.&#x0D; Methods: Patients with OSA and age-and sex-matched control subjects were recruited to the study in Bach Mai hospital. All patients underwent polysomnography recording. Comprehensive 2-dimensional echocardiographic (2DE) was performed to all subjects according to American Society of Echocardiography guidelines, followed by RT3DE. Maximum LA volume, maximum LA volume indexed for body surface area (BSA), minimum LA volume, and LA volume before contraction were obtained.&#x0D; Results: From June 2021 to June 2022, there were 46 OSA patients and 30 controls were included in the study. Mean age of OSA patients 51.3 ± 11.7. Men accounted for 63% (29/46). The apnea-hypopnea index, percentage of total sleep time with an oxygen saturation level &lt; 90%, arousal index were higher in OSA patients compared with controls. There was a significantly higher 2D LA volume index and E/E’ ratio in the OSA patients compared with the controls (p&lt;0.05). RT3D echocardiography results showed a larger maximum LA volume indexed for BSA, LA volume before atrial contraction, total LA systolic volume, and active LA systolic volume and a higher active LA ejection fraction in the OSA patients compared with controls (p&lt;0.05 for all). There was an increase in the following LA parameters on RT3DE according to the levels of OSA severity: 3D maximum LA volume, 3D maximum LA volume index, 3D LA volume before LA contraction; 3D LA total systolic volume, 3D LA active systolic volume, 3D LA active systolic ejection fraction (p&lt;0.05). On the other hand, 2D maximum LA volume and 2D maximum LA volume index did not differ according to the severity of OSA (p&gt;0.05)&#x0D; Conclusion: There was a significant increase in LA volume and augmentation of LA active systolic function in patients with OSA. The severity of OSA was directly linked with the enlargement of 3D LA volume while this was not seen with 2D LA volume.

Two-dimensional echocardiographic and strain values of the proximal thoracic aorta in a normal sub-Saharan African population

BackgroundThere is limited data regarding reference ranges for aortic dimensions in African populations. This study aims to establish normal reference ranges for echocardiographic dimensions and circumferential strain (CS) of the proximal thoracic aorta in a healthy sub-Saharan African population.MethodsThis was a secondary analysis of data from a prospective cross-sectional study of 88 participants conducted at Chris Hani Baragwanath Hospital (2017–2019). Aortic measurements were obtained as per the 2015 American Society of Echocardiography guidelines using a Philips iE33 system. Circumferential Strain was measured using Philips QLAB version 11.0 software offline semi-automated analysis of speckle-based strain 2-D speckle-tracking software (Amsterdam, The Netherlands).ResultsMean age was 37.22 ± 10.79 years (41% male). The mean diameter at the aortic annulus, sinuses, sino-tubular junction (STJ) and ascending aorta (AAO) were 19.11 ± 2.38 mm, 27.40 ± 6.11 mm, 25.32 ± 3.52 mm and 25.36 ± 3.38 mm, respectively. Males had larger absolute and indexed aortic diameters at all levels when compared to females. The mean aorta CS was 11.97 ± 5.05%. There was no significant difference in CS based on gender (12.19 ± 5.04% vs 11.51 ± 5.02%, P = 0.267). On multivariate linear regression analysis, male sex was the most significant predictor of increased diameter at the level of the aortic annulus (r = 0.17, P = 0.014), body surface area was the most significant predictor at the sinuses (r = 0.17, P = 0.014) and AAO (r = 0.30, P < 0.001), while age was the most significant predictor at the STJ (r = 0.27, P = 0.004). There was a negative correlation between age and aortic CS (r = − 0.12, P < 0.001). The most important predictor of aorta CS was age, on multivariate analysis (r = − 0.19, P = 0.024).ConclusionsThis study provides normal reference ranges for dimensions of the proximal aorta and circumferential strain (CS) in a sub-Saharan African population according to age, sex, and body habitus. It serves as a platform for future larger studies and allows for risk stratification of cardiovascular disease in an African population.

The Role of the Electrocardiogram in Pregnant Individuals with Chronic Hypertension.

The American College of Obstetricians and Gynecologists suggests that an electrocardiogram is an acceptable first-line test. We sought to examine whether an electrocardiogram is a sufficient screening tool to identify echocardiogram-diagnosed left ventricular hypertrophy. We also sought to determine risk factors associated with left ventricular hypertrophy. This was a retrospective cohort study of pregnant individuals with chronic hypertension who delivered at 20 weeks' gestation or greater at a tertiary care center. Analyses were limited to individuals who had both electrocardiogram and echocardiogram during pregnancy. Left ventricular hypertrophy was diagnosed using the American Society of Echocardiography guidelines. Maternal demographics and electrocardiogram results were compared between individuals with left ventricular hypertrophy and those without left ventricular hypertrophy. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the electrocardiogram to identify left ventricular hypertrophy were also calculated. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were calculated, controlling for covariates. Of 172 individuals, 60 (34.9%) had left ventricular hypertrophy. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of the electrocardiogram to identify echocardiogram-diagnosed left ventricular hypertrophy was 18.3% (95% CI: 9.5-30.4), 91.1% (95% CI: 84.2-95.6), 2.05 (95% CI: 0.93-4.56), and 0.90 (95% CI: 0.78-1.02), respectively. Compared with individuals without left ventricular hypertrophy, those with left ventricular hypertrophy were more likely to have hypertension of 4 years' duration or longer (aOR = 4.01; 95% CI: 1.71-9.42), unknown duration of hypertension (aOR = 4.66; 95% CI: 1.28-17.04), and higher body mass index (aOR = 1.04; 95% CI: 1.01-1.07). After adjusting for covariates, left ventricular hypertrophy by electrocardiogram was not associated with actual left ventricular hypertrophy (aOR = 2.59; 95% CI: 0.94-7.10). Electrocardiogram was not a sufficient test for identifying left ventricular hypertrophy in pregnant individuals with chronic hypertension. We suggest an echocardiogram evaluation for all individuals with chronic hypertension. · The first-line test for cardiac evaluation is an electrocardiogram.. · In our cohort, the rate of left ventricular hypertrophy was 35%.. · The electrocardiogram was not sensitive to detect left ventricular hypertrophy..

PSUN52 Patients with Left Ventricular Hypertrophy on Echocardiography are Frequently Evaluated with Renin and Aldosterone

Abstract Background Increased left ventricular (LV) mass is an independent predictor of cardiovascular morbidity and mortality. Primary aldosteronism (PA) is associated with increased LV mass regardless of concomitant essential hypertension. Therefore, we hypothesize that the findings of increased LV mass approximated by left-ventricular hypertrophy (LVH) on echocardiogram relate to renin-independent hyperaldosteronism. Methods We performed a retrospective review of patients who underwent echocardiography at our institution between April of 2013 and September of 2017 (n=98,007 individuals). Of this population, we identified patients who underwent transthoracic echocardiography who met criteria for LVH based on current American Society of Echocardiography guidelines using the interventricular septal thickness in diastole (IVSd) and left ventricular posterior wall thickness in diastole (LVPWd). We excluded patients who underwent isolated transesophageal imaging as well as those who had significant structural cardiac abnormalities other than LVH. This cohort was analyzed with an internal self-service data tool to determine if patients had undergone biochemical evaluation with serum aldosterone and renin, which defined the final analytical cohort. Results We identified 19,664 patients with LVH of whom 5.8% (n = 1132) underwent biochemical evaluation with serum aldosterone and corresponding plasma renin activity (PRA) or direct renin concentration (DRC). In all patients with LVH, the mean IVSd was 11.7 ± 1.2mm in those who underwent biochemical testing and 11.5 ± 1.2 mm in those who did not (p &amp;lt;0.001); the mean LVPWd was 11.4 ± 1.1 mm mm in those who underwent biochemical testing and 11.3 ± 1.1 mm in those who did not (p &amp;lt;0.001). Of African American patients with LVH, 9.8% underwent biochemical testing; 5.0% of Caucasian patients with LVH underwent testing. The median PRA was 0.9 ng/mL/h with a median aldosterone to renin activty ratio (ARR) of 8.9 ng/dL-ng/mL/h. . The majority (54.4%) of individuals who underwent testing with plasma renin activity had a PRA ≤ 1.0 ng/mL/h. Conclusion Patients with LVH are being evaluated with renin and aldosterone at a higher frequency than patients with resistant hypertension and other guideline based indications for PA screening. Individuals evaluated with renin and aldosterone had increased IVSD and LVPWd, suggestive of more extensive LVH, compared with other individuals with LVH. LVH may be a sensitive screening criterion for PA. Additional prospective studies are necessary. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Echocardiographic Features of Longevity: A Cross-Sectional Study of Centenarians.

Centenarians represent an under-studied population within cardiovascular medicine. This study aimed to describe the echocardiographic characteristics of a cohort of centenarians at a tertiary referral center. The institutional Echocardiography database was retrospectively reviewed and identified 100 consecutive centenarians referred for transthoracic echocardiography between January 2009 and December 2020. Cardiac chamber quantification, diastology, and valvular heart disease were assessed according to the American Society of Echocardiography guidelines. Independent t-tests and Mann-Whitney U-tests compared data between males and females. The mean age was 101.5 ± 1.7 years, 78% were female, and the most common co-morbidities were hypertension (77%), coronary artery disease (46%), and congestive heart failure (42%). The mean left ventricular (LV) ejection fraction measured 56.9 ± 11.3% (females vs males, 58.4 ± 9.8 vs 51.6 ± 14.6%, p = 0.01). Males had larger LV end-diastolic (2.8 ± 0.6 vs 2.5 ± 0.5, p = 0.03) and end-systolic diameter (1.9 ± 0.6 vs 1.6 ± 0.4, p = 0.001) indices; a smaller relative wall thickness (0.54 ± 0.18 vs 0.69 ± 0.36, p = 0.06); and a lower E/e' ratio (13.3 [10.3-19.6] vs 17.3 [13.2-23], p = 0.05), when compared with females. The prevalence of severe valvular lesions was 13.5%, and similar between genders. However, in patients with aortic stenosis, the transaortic pressure gradients were significantly higher in females (mean gradient: 32.0 ± 17.7 vs 18.7 ± 9.2 mmHg, p = 0.04). The present study on centenarians affords a cross-sectional evaluation of cardiac structure and function in a growing population, and highlights important differences between male and female patients.

S624 Role of Esophagogastroduodenoscopy Before Transesophageal Echocardiography

Introduction: As per American Society of Echocardiography (ASE) guidelines, esophageal varices, dysphagia, thrombocytopenia, symptomatic hiatal hernia, active esophagitis, are relative contraindications to transesophageal echocardiography (TEE). It is not uncommon for gastroenterologists to get consulted to perform an esophagogastroduodenoscopy (EGD) to determine any lesions that will preclude performing a TEE. The evidence behind this recommendation is scant. We aim to determine whether an upper endoscopy before TEE changes patient management. Methods: This is a retrospective chart review of patients who underwent a diagnostic EGD to assess for clearance before TEE. All the EGDs were done 3 weeks prior to TEE. The primary outcome was preclusion of TEE based on EGD findings. Secondary outcomes were overt GI bleeding or drop in hemoglobin post TEE requiring endoscopic intervention. Results: A total of 26 patients met the inclusion criteria. Bacteremia and fungemia are the indications for TEE in 23 patients and cardioversion for Atrial fibrillation, mitral valve disease are the indications in the others. Variceal screening is the indication in 11 patients and anemia with overt GI bleeding is the indication in the rest. Of the 11 patients in the variceal screening group only 4 were known to have cirrhosis, and the rest were requested to have EGD for variceal screening due to elevated AST and thrombocytopenia with an APRI Score >1. All the consult requests are from cardiology team. 15 patients had EGD due to concerns for GI bleeding in the setting of anemia and overt GI bleeding. Of these 15, 2 patients had Grade D esophagitis and they underwent TEE 2-3 weeks after EGD (Figure). None of the patients experienced primary or secondary outcomes. Conclusion: Based on our findings upper GI endoscopy before TEE for risk stratification has limited utility. However, we agree with ASE guidelines of consulting gastroenterology when there is a question as to whether gastrointestinal symptoms or pathology present poses a risk for TEE. Our study is limited by small sample size, however, adds to the limited literature available on this subject.Figure 1.: Breakdown of indication for EGD and EGD findings.

Aşikâr pulmoner hipertansiyonu olmayan sistemik sklerozlu hastalarda tırnak kapilaroskopi bulguları ve modifiye Rodnan skoru sağ ventrikül fonksiyonlarında bozulma ile ilişkilidir

Objective: Although nailfold capillaroscopy (NC) and modified Rodnan skin score (mRSS) have already been studied in a variety of contexts related to Systemic Sclerosis (SSc) progression, there is limited data about the relationships between NC, mRSS, and right ventricle (RV) function in SSc patients without overt pulmonary arterial hypertension (PAH). In this study, we examined the relationship between RV function and clinical SSc parameters such as NC pattern and mRSS. &#x0D; Material and Method: Thirty two patients with SSc and twenty healthy participants as a control group were enrolled in this study. Patients with SSc were assessed for digital ulcers, Raynaud’s phenomenon, and severity of skin involvement by a rheumatology specialist. Also, all participants underwent echocardiographic examinations by cardiology specialists. The echo parameters were measured considering the criteria of the American Society of Echocardiography guidelines. &#x0D; Results: Systolic pulmonary arterial pressure (sPAP) was statistically higher in the SSc group (26.4±3.2 vs 30.8±3.6 mmHg, p

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

New advances in medical imaging technology for the evaluation of anthracycline-induced cardiotoxicity.

Unsupervised Machine Learning for Assessment of Left Ventricular Diastolic Function and Risk Stratification

The 2016 American Society of Echocardiography guidelines have been widely used to assess left ventricular diastolic function. However, limitations are present in the current classification system. The aim of this study was to develop a data-driven, unsupervised machine learning approach for diastolic function classification and risk stratification using the left ventricular diastolic function parameters recommended in the 2016 American Society of Echocardiography guidelines; the guideline grading was used as the reference standard. Baseline demographics, heart failure hospitalization, and all-cause mortality data were obtained for all adult patients who underwent transthoracic echocardiography at Mayo Clinic Rochester in 2015. Patients with prior mitral valve intervention, congenital heart disease, cardiac transplantation, or cardiac assist device implantation were excluded. Nine left ventricular diastolic function variables (mitral E- and A-wave peak velocities, E/A ratio, deceleration time, medial and lateral annular e' velocities and E/e' ratio, and tricuspid regurgitation peak velocity) were used for an unsupervised machine learning algorithm to identify different phenotype clusters. The cohort average of each variable was used for imputation. Patients were grouped according to the algorithm-determined clusters for Kaplan-Meier survival analysis. Among 24,414 patients (mean age, 63.6±16.2years), all-cause mortality occurred in 4,612 patients (18.9%) during a median follow-up period of 3.1years. The algorithm determined three clusters with echocardiographic measurement characteristics corresponding to normal diastolic function (n=8,312), impaired relaxation (n=11,779), and increased filling pressure (n=4,323), with 3-year cumulative mortality of 11.8%, 19.9%, and 33.4%, respectively (P<.0001). All 10,694 patients (43.8%) classified as indeterminate were reclassified into the three clusters (n=3,324, n=5,353, and n=2,017, respectively), with 3-year mortality of 16.6%, 22.9%, and 34.4%, respectively. The clusters also outperformed guideline-based grade for prognostication (C index=0.607 vs 0.582, P=.013). Unsupervised machine learning identified physiologically and prognostically distinct clusters on the basis of nine diastolic function Doppler variables. The clusters can be potentially applied in echocardiography laboratory practice and future clinical trials for simple, replicable diastolic function-related risk stratification.

Left atrial function index in embolic stroke of undetermined source: A case-control study

Background &amp; Objectives: Previous studies showed left atrial volume index (LAVi) is a precise surrogate of atrial cardiopathy and associated with new-onset atrial fibrillation and embolic stroke undetermined source (ESUS). Recent data suggest that the left atrial functional index (LAFi) is associated with the risk of developing AF recurrence. However, there was no study to show LAFi in ESUS. We aim to compare the performance of different surrogates of atrial cardiopathy (LAVi and LAFi) in a cohort of ESUS patients and healthy adults. Methods: Between Dec 2018 to Feb 2020, consecutive patients diagnosed with ESUS and normal healthy controls (&gt;18 years) were included. Left atrial diameter (LAD), left atrial diameter index (LADi), LAVi and LAFi were measured by transthoracic echocardiogram under American Society of Echocardiography guidelines. Results: A total of 125 patients (43 controls and 82 ESUS patients) were compared. Significant differences of LADi, LAVi, and LAFi were detected between ESUS and control (p=0.04, p=0.002, and p=0.001, respectively). On adjustment for age, sex, hypertension, and diabetes mellitus, LADi and LAVi the association with ESUS and LAFi (aOR decrease, 0.928; 95% CI 0.882–0.976; p = 0.004) remained significant and LAD, LADi, and LAVi were not associated with ESUS in this analysis. Conclusions: LAFi may be a more comprehensive predictor of atrial cardiopathy as compared to LADi and LAVi in risk stratification of ESUS or cryptogenic stroke.

Secondary mitral regurgitation: Maintaining coherence with the American Society of Echocardiography grading guidelines, which proportionality concept best predicts prognosis in the real world?

IntroductionProportionality of secondary mitral regurgitation (sMR) may be a key factor in deciding whether a patient may benefit from mitral intervention. The aim of this study was to evaluate the prognostic value of two different concepts of proportionality and assess their ability to improve MR stratification proposed by the American Society of Echocardiography (ASE) guidelines. MethodsWe conducted a retrospective analysis in patients with reduced left ventricular ejection fraction (LVEF) (<50%) and at least mild sMR. Proportionality status was calculated using formulas proposed by a) Grayburn et al. – disproportionate sMR defined as EROALVEDV >0.14; b) Lopes et al. – disproportionate sMR whenever measured EROA>theoretical EROA (determined as 50%×LVEF×LVEDVMitralVTI). Primary endpoint was all-cause mortality. ResultsA total of 572 patients (69±12 years; 76% male) were included. Mean LVEF was 33±9%, with a median left ventricular end-diastolic volume of 174 mL [136;220] and a median effective regurgitant orifice area of 14 mm2 [8;22]. During mean follow-up of 4.1±2.7 years, there were 254 deaths. There was considerable disagreement (p<0.001) between both formulas: of 96 patients with disproportionate sMR according to Lopes’ criteria, 46 (48%) were considered proportionate according to Grayburn's; and of 62 patients with disproportionate sMR according to Grayburn's, 12 (19%) were considered proportionate according to Lopes’ formula.In multivariate analysis, only Lopes’ definition of disproportionate sMR maintained independent prognostic value (hazard ratio 1.5; 95% confidence interval 1.07–2.1, p=0.018) and improved the risk stratification of ASE sMR classification. ConclusionOf the two formulas available to define disproportionate sMR, Lopes’ model emerged as the only one with independent prognostic value while improving the risk stratification proposed by the ASE guidelines.

New perspective on fatigue in hemodialysis patients with preserved ejection fraction: diastolic dysfunction : Fatigue and diastolic dysfunction.

The relationship between diastolic dysfunction and fatigue in hemodialysis patients with preserved ejection fraction is unknown. In this context, the objective of this study is to assess fatigue using the relevant scales and to demonstrate its relationship with diastolic dysfunction. The patients who underwent hemodialysis were evaluated prospectively. Patients' fatigue was assessed using the Visual Analogue Scale to Evaluate Fatigue Severity (VAS-F). The echocardiographic works were performed as recommended in the American Society of Echocardiography guidelines. A total of 94 patients [mean age 64.7 ± 13.5years, 54 males (57.4%)] were included in the study. The median VAS-F score of these patients was 68.5 (33.25-91.25), and they were divided into two groups according to this value. Peak myocardial velocities during early diastole (e') and tricuspid annular plane systolic excursion (TAPSE) values were found to be significantly lower in the group with high VAS-F scores, whereas the early diastolic flow velocities (E)/e' ratio and pulmonary artery peak systolic pressures (PAP) were found to be significantly higher (p < 0.05, for all). E/e' ratio (r 0.311, p 0.002) and PAP (r 0.281, p 0.006) values were found to be positively correlated with the VAS-F score, as opposed to the TAPSE (r -0.257, p 0.012) and e' (r -0.303, p 0.003) values, which were found to be negatively correlated with the VAS-F score. High fatigue scores in hemodialysis patients may be associated with diastolic dysfunction. In addition, in our study, we determined the correlation of VAS-F score with E/e' ratio, PAP and TAPSE.

IVC measurement for the noninvasive evaluation of central venous pressure.

Central venous pressure (CVP) is one of only a handful of variables that can be used to assess a patient's volume status to attempt to optimize stroke volume. The gold standard method for assessing CVP is though pulmonary artery catheterization, which is invasive and risks severe complications such as pneumothorax and cardiac conduction abnormalities. Current noninvasive methods for estimating CVP such as jugular venous pressure assessment are imperfect with wide inter-examiner variability. The inferior vena cava (IVC) is a highly compliant vessel that uniquely does not constrict in response to hypovolemia, making it an ideal, noninvasive surrogate for the estimation of CVP. A range of IVC indices including minimum and maximum IVC diameter and fraction of IVC collapse with inspiration (known as collapsibility index) have been studied with highly variable results that range from excellent to poor correlation between these values and CVP. Despite this inconsistency in findings, multiple schemes have been proposed to attempt to estimate CVP from IVC measurements, but when prospectively tested, none has been shown to be accurate. Since the most recent 2015 American Society of Echocardiography guidelines, multiple studies have identified unique ways of improving the accuracy of IVC measurement, which could translate into better CVP estimation. The goal of this review is to summarize the many, often conflicting studies that exist in this area, and provide recommendations for future studies based on our findings.

Correlation between standard and adjusted echocardiographic quantitative methods for evaluating tricuspid regurgitation severity

Abstract Funding Acknowledgements Type of funding sources: None. Background Current guidelines advocate for a multi-parametric approach to echocardiographic quantitation of tricuspid regurgitation (TR). The primary quantitative measure of TR severity uses the proximal isovelocity surface area (PISA) method to calculate effective regurgitant orifice area (EROA) and regurgitant volume (RegVol). However, EROA-PISA may underestimate TR severity due to low flow and tethering of the tricuspid leaflets. Purpose The purpose of this study was to compare standard EROA-PISA quantitation of TR to alternative quantitative measures, including quantitative Doppler (EROA-Doppler), flow- and angle-corrected PISA method (EROA-Corrected), and three-dimensional vena contracta area (3D-VCA), in addition to the comparison of calculated RegVol-PISA, RegVol-Doppler, and RegVol-3DVCA. Methods Patients undergoing both transthoracic (TTE) and transesophageal (TEE) echocardiographic evaluation of TR severity for transcatheter treatment were included in this study. Patients were excluded if they had ≥ moderate aortic regurgitation. TTE measurements of EROA-PISA and RegVol-PISA were performed as per American Society of Echocardiography guidelines. EROA-Doppler was performed by quantifying RegVol-Doppler (diastolic stroke volume using biplane annular area, minus left ventricular outflow stroke volume) and deriving EROA. EROA-Corrected was calculated by adjusting for both aliasing velocity and leaflet angle as per published methods. 3D-VCA was measured on TEE performed within 14 days of TTE. Results Of 44 consecutive patients, the median age was 80 ± 9 years, 61% were female, and 89% had atrial fibrillation. Most patients (86%) had functional TR, 71% had a EROA-PISA ≥ 0.4 cm2. Table 1 shows the EROA and RegVol results for each method. EROA-PISA and RegVol-PISA were significantly lower than EROA-Doppler and RegVol-Doppler, as well as 3D-VCA and RegVol-3DVCA (all p &amp;lt; 0.0001). There was no significant difference between EROA-Doppler and 3D-VCA (p = 0.51), and RegVol-Doppler and RegVol-3DVCA (p = 0.66). EROA-Corrected reduced the absolute difference with EROA-Doppler (51% to 33%, p &amp;lt; 0.0001) and 3D-VCA (52% to 32%, p &amp;lt; 0.0001), but remained statistically lower than EROA-Doppler and 3D-VCA. Although EROA-PISA was strongly correlated to EROA-Doppler (r = 0.75, p &amp;lt; 0.0001) and 3D-VCA (r = 0.68, p &amp;lt; 0.0001), the correlation between EROA-Doppler and 3D-VCA was greatest (r = 0.77, p &amp;lt; 0.0001). Adjusting EROA-PISA for angle and flow demonstrated improved correlation to EROA-Doppler without affecting correlation to 3D-VCA (Figure 1). Conclusion Our study demonstrated that EROA-PISA significantly underestimates the severity of TR by EROA-Doppler and 3D-VCA. Although PISA correction methods reduced the underestimation, both EROA-Corrected and RegVol-Corrected remained significantly lower. EROA-Doppler and 3D-VCA and the calculated RegVol by each method, were closely correlated and not significantly different. Abstract Table 1 Abstract Figure 1