Apical Images Research Articles

Performance of an automated echocardiographic artificial intelligence model. to detect subclinical heart failure with preserved ejection fraction (HFpEF) in community-dwelling older adults

Abstract Background Heart failure (HF) with preserved Ejection Fraction (HFpEF) is common among older adults and associated with a high burden of morbidity and mortality. Early identification of subclinical HFpEF, defined by abnormalities in cardiac structure and function without symptoms of HF, can prompt early initiation of evidence-based therapies to prevent HFpEF. However, scalable strategies for the identification of subclinical HFpEF are lacking. Purpose To evaluate the performance of a validated, automated echocardiographic artificial Intelligence algorithm (Ultromics, UK) to identify subclinical HFpEF among community-dwelling individuals without HF. Methods The study included participants of the Dallas Hearts and Minds Study without HF who underwent cardiovascular phenotyping with resting and exercise echocardiography and maximal cardiopulmonary exercise testing. The resting apical 4C echocardiographic images were analyzed by the AI echo algorithm to identify the HFpEF phenotype (AI-HFpEF). Subclinical HFpEF was defined by E/e’ >14 and Peak exercise oxygen uptake (VO2peak) <25th percentile for the cohort. The performance of the AI algorithm to detect subclinical HFpEF was determined using the area under the receiver operating curve and decision curve analysis and was compared with the previously validated H2FpEF score. The association between the AI-HFpEF phenotype and the presence of subclinical HFpEF, VO2peak, exercise E/e’, left ventricular strain, and left atrial strain was assessed using multivariable-adjusted logistic and linear regression models. Results The study included 511 participants (mean age: 61 y, 57% women, mean VO2peak = 16.9 ml/kg/min). Using the AI echo algorithm, subclinical HFpEF was detected in 10% of participants (n=76), and 10% were non-diagnostic. The participants with (vs. without) AI-HFpEF phenotype were older and had a higher burden of CVD risk factors, left ventricular hypertrophy, and left atrial dilation. Subclinical HFpEF, as defined by the gold standard criteria, was present in 5.3% of participants. The AUROC for diagnosis of subclinical HFpEF using the AI-HFpEF algorithm was 0.85 vs. 0.78 by the H2FpEF score (see Figure). In the adjusted analysis, the AI-HFpEF phenotype was significantly associated with greater odds of subclinical HFpEF by exercise and echocardiographic phenotyping criteria, higher E/e’ with exercise, lower VO2 peak, and worse LV and LA strain (see Table). In decision curve analysis, the AI-HFpEF algorithm identified 23 additional cases of subclinical HFpEF per 1000 screened participants compared with the H2FpEF score. Conclusion The AI-HFpEF algorithm can reliably identify community-dwelling individuals with subclinical HFpEF characterized by diastolic dysfunction at rest or exercise and impaired exercise capacity. Future studies are needed to assess the utility of the AI-HFpEF algorithm in screening for subclinical HFpEF in health systems.

Donor-derived cell-free DNA versus left ventricular global longitudinal strain in noninvasive detection of heart allograft injury

Abstract Introduction Invasive endomyocardial biopsy (EMB) is still considered the gold standard method for monitoring heart transplant (HTx) rejection. However, it is associated with potentially serious complications, and its histopathologic interpretation has high interobserver variability. Thus, noninvasive methods for surveillance of the transplanted organ remains of great interest. The noninvasive donor-derived cell-free DNA is a marker of graft injury which can indicate acute rejection, even before the histopathological diagnosis of rejection detected by EMB. The assay has a high negative predictive value for acute rejection. Left ventricular global longitudinal strain (LV GLS) is an emerging marker of subclinical myocardial injury which plays a crucial role in the evaluation of several cardiac diseases; however, its role in HTx injury has so far been poorly investigated. Purpose We aimed to investigate the efficacy of a local laboratory-run dd-cfDNA assay-based heart transplant rejection surveillance programme, and the prognostic and discriminatory performance of LV GLS for subsequent heart allograft injury. Methods HTx recipients without a history of allograft rejection requiring intensification of immunosuppressive therapy were transitioned from our EMB-based surveillance protocol to dd-cfDNA-based rejection surveillance. We assessed the percentage of dd-cfDNA to total cell-free DNA. Injury cut-off was defined by a dd-cfDNA level ≥0.20%, while the severe injury threshold was at ≥0.35%. LV ejection fraction was calculated using 2D Simpson’s method. To derive LV GLS, we analyzed apical 4-chamber, 2-chamber, and long-axis images by 2D speckle tracking echocardiography. Results A total of 244 dd-cfDNA samples were analyzed from 46 patients in fifteen runs performed monthly between October 2022 and December 2023. The dd-cfDNA fraction remained below the injury cut-off in most patients (81%). There were no missed rejection episodes. 88% of routine EMBs that would have otherwise been performed were safely avoided. Eighteen for-cause EMBs were performed based on dd-cfDNA levels suggesting injury. One EMB verified moderate cellular rejection (ISHLT grade 2R) that required steroid pulse therapy. Two EMBs proved mild cellular rejection, one EMB confirmed mild antibody-mediated rejection, while one EMB proved mixed rejection. Thirteen EMBs found no rejection. Mean LVEF was preserved (57.6%±7.6%). Mean LV GLS was -15.1%±2.5% in the whole cohort, while -15.6%±4.7% in recipients with HTx rejection on indication EMB. There was no significant correlation between dd-cfDNA and LV GLS (n=159). Conclusion The noninvasive dd-cfDNA assay is effective in ruling out acute rejection and safely decreases the necessity of invasive surveillance EMBs after HTx. LV GLS is less sensitive in comparison with the dd-cfDNA assay for detection of myocardial injury in the early stages of graft rejection in HTx recipients at low risk for rejection.

Differences in left ventricular contraction in left bundle branch block with preserved and reduced ejection fraction: an evaluation using 2-dimensional speckle tracking echocardiography

Abstract Background Left ventricular (LV) contraction in left bundle branch block (LBBB) is characterized by early septal contraction and delayed contraction of the lateral wall, but the process may differ depending on myocardial contractility in addition to the degree of conduction block. Purpose This study aimed to evaluate LV contraction in patients with LBBB by analysis of longitudinal strain (LS) and to compare it between patients with preserved LV ejection fraction (pEF: EF>50%) and reduced LV EF (rEF: EF<40%). Methods We studied 87 patients with LBBB. Fifty had pEF (EF 59±7%) with a mean QRS duration of 144±12ms, and 38 had rEF (EF: 29±4%) with a mean QRS duration of 147±12ms (p=0.32 vs. pEF). We also studied 43 patients without conduction block (Narrow-QRS; pEF, n=23; rEF, n=20). Patients with a heart rate less than 60 or greater than 80 beats/min during echocardiography or with a history of myocardial infarction were excluded. Three standard apical images were recorded, and the LS of one heartbeat starting at the beginning of the QRS was evaluated in 18 LV segments. When the strain waveform showed a negative peak during the pre-ejection period, it was identified as early systolic contraction (ESC), and the first negative peak that appeared after aortic valve opening (AVO) was identified as late systolic contraction (LSC). The time from the beginning of QRS to the peak of the LSC (Q-Peak) and the strain value at the end of the QRS were measured in each segment. Results In patients with LBBB, the septum contracted early, and ESC was seen mainly in the early contracted area. The lateral wall contraction was delayed, and the difference between the maximum and minimum Q-Peak was greater than the Narrow-QRS in the same EF category. Patients with rEF and LBBB had a larger number of segments with ESC and a smaller minimum Q-Peak than those with pEF. The difference between the maximum and minimum Q-Peak was greater for patients with rEF than for patients with pEF. Conclusions Although patients with LBBB had significant dyssynchrony due to conduction block even those with pEF, LV contractile properties were altered in patients with rEF and associated with further increased dyssynchrony.

Investigation of the effect of intravitreal bevacizumab treatment on left heart function using speckle tracking echocardiography

Introduction and objectivesVascular endothelial growth factor (VEGF) inhibitors are widely used in oncology and ophthalmology. Although these agents have been shown to increase the risk of cardiovascular events in systemic use, the effect of local applications is unclear. In our study, we aimed to investigate the effects of anti-VEGF agents on left heart functions after intravitreal injection using speckle tracking echocardiography. MethodsIn this prospectively designed study, 44 patients who were going to start intravitreal anti-VEGF treatment were included in the study. Patients were evaluated with speckle tracking echocardiography before the first anti-VEGF administration and at three months of anti-VEGF treatment. ResultsGlobal longitudinal strain (GLS) values at three months were lower in the patients who participated in the study and this was statistically significant (−18.77±2.17, −18.60±2.01, p=0.001). Also, there was a statistically significant decrease in the mean values of GLS (GLS4CH) obtained from apical four space image, GLS (GLSAPLAX) obtained from apical long axis image and GLS (GLS2CH) obtained from apical 2 space image at month 0 and month 3 (−19.08±2.39, −18.93±2.26, p=0.004; −18.81±2.29, −18.60±2.12, p=0.001; −18.44±2.31, −18.27±2.12, p=0.013, respectively). ConclusionThe slight decrease in GLS in our study suggests that the use of intravitreal anti-VEGF agents may have cardiac effects.

Evaluation of right ventricle functions in acute pulmonary thromboembolism using tissue doppler imaging

Aims: Right ventricular (RV) systolic and diastolic functions are impaired in a significant proportion of patients with acute pulmonary thromboembolism (PTE). In these cases, knowledge of RV function is of great importance both in the diagnosis and in the choice of treatment. Our aim was to evaluate RV systolic and diastolic functions by standard pulse Doppler and tissue Doppler imaging (TDI) in normotensive patients with PTE without hemodynamic disturbances. Methods: A total of 48 subjects, including 28 acute PTE patients (14 M, 14 F) with a mean age of 41 ± 13 years and 20 healthy subjects (10 M, 10 F) with a mean age of 40 ± 9 years, were included in our study. At the level of the tricuspid and mitral valve cusps, pulse Doppler echocardiography evaluated diastolic filling parameters. With the TDI technique, the diastolic function of the RV lateral wall and septum were analyzed in segments in the apical four-cavity image. Diastolic early and late velocities (e', a'), e'/a' ratio, e'dt, isovolumetric relaxation time (IVRT), systolic velocity (s'), and systolic duration (s' duration) were evaluated by TDI. Results: Among the RV standard Doppler parameters, a significant decrease in E velocity and E/A ratio and a significant increase in A velocity were observed compared to the control group (p=0.042; p=0.002; p=0.001, respectively). A non-significant prolongation in E’dt was detected. RV ejection fraction was significantly lower in PTE patients compared to the control group (51.1% vs. 69.7%) (p=0.001). TDI was used to look at the RV systolic function, and it was found that all segments had higher systolic (Sa-m) velocities than the control group. However, systolic velocities in patients with DHB in the RV were found to be lower in the annular regions and RV-free wall. Increased s' velocities were observed in annular regions and RV-free walls. However, no statistical significance was found in s' velocity values. Conclusion: RV systolic and diastolic functions may be impaired in normotensive patients with PTE without hemodynamic disturbances.

Abstract 13419: Transient Coronary Artery to Left Ventricular Fistula With Diastolic Mitral Regurgitation

Introduction: A fistula from a coronary artery to the cardiac chamber is incidentally found in 0.08% to 0.3% of patients undergoing coronary angiography. Case Presentation: A 73-year-old woman with hypertension, diabetes mellitus, chronic renal failure, and nephrosis visited our department due to dyspnea. The patient’s physical examination revealed a blood pressure of 191/109 mmHg and a pulse rate of 77 beats per min. The blood sampling results revealed a plasma brain natriuretic peptide level of 2,001 pg/mL. A 12-lead electrocardiogram showed poor R wave progression in leads V1 to V4. Chest radiography revealed left pleural effusion. Parasternal transthoracic echocardiography showed left ventricular hypertrophy. Left ventricular (LV) ejection fraction was 41%. A pulsed-wave Doppler echocardiography at the mitral inflow showed diastolic mitral regurgitation and a fusion of E and A waves. An unusual myocardial flow was noted in the apical myocardium. It was directed toward the apical surface during systole (Fig. 1a), and directed toward the LV lumen during diastole (Fig. 1b), suggesting coronary artery to LV fistula through sinusoid. Global strain obtained from apical long axis imaging showed myocardial shortening continued to diastole, suggesting post-systolic shortening (PSS). After treatment for hypertension, both of myocardial flow and diastolic MR disappeared. A longitudinal global strain imaging revealed disappearance of PSS. Conclusion: This is a rare case of diastolic MR due to PSS at the fistula from the coronary artery to the left ventricle.

Contractile asymmetry and survival in patients with left bundle branch abnormality treated with cardiac resynchronization therapy.

Currently, electrical rather than mechanical parameters of delayed left ventricular (LV) activation are used for patient selection for cardiac resynchronization therapy (CRT). However, despite adhering to current guideline-based criteria, about one-third of heart failure (HF) patients fail to derive benefit from CRT. This study sought to investigate the prognostic survival significance of a recently introduced index of contractile asymmetry (ICA) based on the deformation of entire opposing LV walls in the context of selecting patients with HF and left bundle branch abnormality (LBBB) for CRT. We analysed 367 patients with HF and LBBB undergoing CRT (31.6% females, 69 ± 9 years, ischaemic aetiology in 50.7%, LV ejection fraction 27 ± 6%). ICA was calculated using LV strain rate values from curved anatomical M-mode plots of apical 2D echocardiography images. The predictive value of ICA was assessed using Kaplan-Meier analysis and Cox proportional hazards models. During a median follow-up time of 5.54 years, death or cardiac transplantation occurred in 105 (28.6%) cases. Higher baseline ICA values in all apical views, particularly in the two-chamber view (ICA-2ch), were associated with increased event-free survival, and the unadjusted hazard ratio was 0.28 (95% confidence interval 0.18-0.46). Higher ICA-2ch (>0.319 s-1) consistently predicted survival across clinical subgroups and remained significant after covariate adjustment, while the event rate sharply increased in low ICA-2ch cases. Additionally, including ICA-2ch improved the predictive value of the multivariate risk model containing the typical LBBB pattern. Pre-implant ICA suggests a quantitative prognostic threshold for both long-term survival and adverse outcomes following CRT implantation.

Incremental predictive utility of a radiomics signature in a nomogram for the recurrence of atrial fibrillation.

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) remains a challenge today. Although it is believed that evaluating the structural and functional remodeling of the left atrium (LA) may be helpful in predicting AF recurrence, there is a lack of consensus on prediction accuracy. Ultrasound-based radiomics is currently receiving increasing attention because it might aid in the diagnosis and prognosis prediction of AF recurrence. However, research on LA ultrasound radiomics is limited. We aim to investigate the incremental predictive utility of LA radiomics and construct a radiomics nomogram to preoperatively predict AF recurrence following CA. A training cohort of 232 AF patients was designed for nomogram construction, while a validation cohort (n = 100) served as the model performance test. AF recurrence during a follow-up period of 3-12 months was defined as the endpoint. The radiomics features related to AF recurrence were extracted and selected to create the radiomics score (rad score). These rad scores, along with other morphological and functional indicators for AF recurrence, were included in the multivariate Cox analysis to establish a nomogram for the prediction of the likelihood of AF recurrence within 1 year following CA. In the training and validation cohorts, AF recurrence rates accounted for 32.3% (75/232) and 25.0% (25/100), respectively. We extracted seven types of radiomics features associated with AF recurrence from apical four-chamber view echocardiography images and established a rad score for each patient. The radiomics nomogram was built with the rad score, AF type, left atrial appendage emptying flow velocity, and peak atrial longitudinal strain. It outperformed the nomogram building without the rad score in terms of the predictive efficacy of CA outcome and showed favorable performance in both cohorts. We revealed the incremental utility of a radiomics signature in the prediction of AF recurrence and preliminarily developed and validated a radiomics nomogram for identifying patients who were at high risk of post-CA recurrence, which contributed to an appropriate management strategy for AF.

Usefulness of automatic assessment for longitudinal strain to diagnose wild-type transthyretin amyloid cardiomyopathy

BackgroundLeft ventricular (LV) apical sparing by transthoracic echocardiography (TTE) has not been widely accepted to diagnose transthyretin amyloid cardiomyopathy (ATTR-CM), because it is time consuming and requires a level of expertise. We hypothesized that automatic assessment may be the solution for these problems. Methods-and-ResultsWe enrolled 63 patients aged ≥70 years who underwent 99mTc-labeled pyrophosphate (99mTc-PYP) scintigraphy on suspicion of ATTR-CM and performed TTE by EPIQ7G, and had enough information for two-dimensional speckle tracking echocardiography at Kumamoto University Hospital from January 2016 to December 2019. LV apical sparing was described as a high relative apical longitudinal strain (LS) index (RapLSI). Measurement of LS was repeated using the same apical images with three different measurement packages as follows: (1) full-automatic assessment, (2) semi-automatic assessment, and (3) manual assessment. The calculation time for full-automatic assessment (14.7 ± 1.4 sec/patient) and semi-automatic assessment (66.7 ± 14.4 sec/patient) were significantly shorter than that for manual assessment (171.2 ± 59.7 sec/patient) (p < 0.01 for both). Receiver operating characteristic curve analysis showed that the area under curve of the RapLSI evaluated by full-automatic assessment for predicting ATTR-CM was 0.70 (best cut-off point; 1.14 [sensitivity 63%, specificity 81%]), by semi-automatic assessment was 0.85 (best cut-off point; 1.00 [sensitivity, 66%; specificity, 100%]) and by manual assessment was 0.83 (best cut-off point; 0.97 [sensitivity, 72%; specificity, 97%]). ConclusionThere was no significant difference between the diagnostic accuracy of RapLSI estimated by semi-automatic assessment and that estimated by manual assessment. Semi-automatically assessed RapLSI is useful to diagnose ATTR-CM in terms of rapidity and diagnostic accuracy.

Long postcovid injury on left ventricle function

Abstract Funding Acknowledgements Type of funding sources: None. Post COVID19 condition occurs in individuals with a history of probable or confirmed SARS Cov2 infection, usually 3 months from the onset of COVID19 with symptoms that last for up to at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction, but also arterial hypertension and generally have an impact on everyday function. Symptoms may be new onset following initial recovery from an acute COVID 19 episode or persist from the initial illness. Aim COVID 19 pneumonia initiates new onset arterial hypertension (AH) and aggravates the structural and functional myocardium remodeling in the long term after hospitalization. Methods The study population /initially questioned 1500 patients for symptoms after acute COVID 19 pneumonia / included 220 patients without history of any disease, mean age of 45±12 years, male 145 (43±10 years) female 75 ( 52± 14 years).We used Speckle tracking echocardiography to analyze the global longitudinal strain (GLS). GLS was extracted by 3, 4 and 2 chamber apical view images on 70 fr/s for left ventricle ( LV ) and right ventricle( RV ).CMR with LGE was performed at 3rd (3mFU) and 12th months (12mFU) also to confirm our resulst. AMBP analysis, MAP and HR were performed at baseline /30–40 days after acute infection/ 3rd and 12th months follow up. Results From initial population /1500 pts/ self-reported symptoms at 12mFU are 1265 ( 84.6 % ) and 235 (15.4 % ) are symptom free at 12mFU. AH presence at 3mFU in 143( 65% of patients )up to 161 patients (73% at 12mFU). Symptoms of heart failure with preserved EF were found at 3mFU in 91 pts (41%) and in 99 pts (45%) at 12mFU Despite normal EF, GLS / minus 18.5 %, p&amp;lt;0.01) and segmental LS in all apical and mid anteroseptal, inferoseptal and basal anteroseptal and inferoseptal levels ( minus 16% to minus 18%, p &amp;lt;0.01) and RV ( 22.3% to 24%) at 12mFU shown diminished and still preserved values, even in 3 level layers. Performed CMR confirmed injured segments. Conlusions New onset AH is one of major symptoms after COVID 19 and remains at 12mFU. Despite of satisfactory improvement of conventional parameters for LV and RV function, GLS indicate worsening of the LV systolic function. In pts with COVID-19 pneumonia echocardiography showed predominantly decrease of the load on the right heart at 3mFU. LV function showed slightly improvement at 12mFU.

Left atrial strain measured by the new speckle tracking dedicated software: feasibility and reproducibility in healthy and pathologic subjects

Abstract Funding Acknowledgements Type of funding sources: None. Background left atrial (LA) strain by speckle tracking echocardiography (STE) is gaining increasing evidence as diagnostic and prognostic tool in several clinical settings. However, the lack of a dedicated software was considered one of its main limitations, although many studies proved a good feasibility and reproducibility of a ventricular-based software. Brand-new fully automated software tools dedicated to the LA have been developed, both for on-line use on the echocardiographic machine and for off-line use on the workstation. Purpose The purpose of our study was to compare LA strain measures acquired by the new fully automated dedicated software with the "traditional" semi-automated ventricular based one in healthy, pressure-overloaded, and volume-overloaded patients. Methods Grey scale apical 4-chamber view echocardiographic images acquired by an experienced operator (GE, Vivid E9, Orthern, Norway) in healthy patients, patients with pressure overload (arterial hypertension, aortic stenosis) and pressure-volume overload (mitral regurgitation, heart failure) were analyzed. STE was performed offline by two independent experienced operators, using both the semi-automated and the fully automated Echopac (Milwaukee,Wisconsin) software, which was then compared using matched-pairs analysis. Both operators were blinded to the other measures and repeated the same measurement on the same images after 10 days. Measurement of LA strain was performed on-line on the echocardiographic machine in a selected group of 20 patients by one of the two operators. Patients with prosthetic valves, heart transplantation, atrial fibrillation were excluded. Results Overall, 100 patients were analyzed (41 healthy patients, 28 with pressure overload, 31 with pressure-volume overload). Peak atrial longitudinal strain (PALS) showed a high reproducibility with both methods. However, the dedicated method had a slightly higher inter-operator reproducibility (intraclass correlation coefficient(ICC)=0.97; 95% CI=[0.87;0.99] vs. ICC=0.96 [9.87;0.99] ) (Fig.1) and intra-operator reproducibility (ICC=0.99 [0.99;0.99] vs. 0.98 [0.98;0.99] (Fig.2); correlation=0.85, p&amp;lt;0.001in operator 1 and 0.97 [0.95;0.98] vs. 0.95 [0.92;0.96]; correlation=0.83, p&amp;lt;0.001 in operator 2) with a slightly lower time consumption (90 s vs. 105 s) than the traditional ventricular-based one. On-line software showed a nearly perfect reproducibility with offline software [ICC=0.99 [0.99;1]] with a further time saving (60 vs. 90 s). Conclusions the new fully automated software for the analysis of LA strain has a high inter-operator and intra-operator reproducibility. Both the automated and the traditionally used semi-automated software calculation provided optimal reproducibility and time-consumption, for different categories of subjects, and could be equally chosen for strain calculation in daily clinical practice. On-line LA strain calculation allows a reliable and time-saving measurement.

The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices

A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic images, holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of nonexperts to obtain diagnostic-quality images in patients with RHD using AI guidance with color Doppler. Novice providers without prior ultrasound experience underwent a 1-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8 to 10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by 2 expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD and (2) valvular function and (3) to assign an American College of Emergency Physicians score of 1 to 5 for each view. Thirty-six novice participants scanned a total of 50 patients, resulting in a total of 462 echocardiogram studies, 362 obtained by nonexperts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in >90% of studies for presence/absence of RHD, abnormal MV morphology, and mitral regurgitation (vs 99% by experts, P ≤ .001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, P<.001). The American College of Emergency Physicians scores of nonexpert images were highest in the parasternal long-axis images (mean, 3.45; 81%≥3) compared with lower scores for apical 4-chamber (mean, 3.20; 74%≥3) and apical 5-chamber images (mean, 2.43; 38%≥3). Artificial intelligence guidance with color Doppler is feasible to enable RHD screening by nonexperts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.

Early diagnosis of coronary microvascular dysfunction by myocardial contrast stress echocardiography.

Coronary microvascular dysfunction (CMD) is one of the basic mechanisms of myocardial ischemia. Myocardial contrast echocardiography (MCE) is a bedside technique that utilises microbubbles which remain entirely within the intravascular space and denotes the status of microvascular perfusion within that region. Some pilot studies suggested that MCE may be used to diagnose CMD, but without further validation. This study is aimed to investigate the diagnostic performance of MCE for the evaluation of CMD. MCE was performed at rest and during adenosine triphosphate stress. ECG triggered real-time frames were acquired in the apical 4-chamber, 3-chamber, 2-chamber, and long-axis imaging planes. These images were imported into Narnar for further processing. Eighty-two participants with suspicion of coronary disease and absence of significant epicardial lesions were prospectively investigated. Thermodilution was used as the gold standard to diagnose CMD. CMD was present in 23 (28%) patients. Myocardial blood flow reserve (MBF) was assessed using MCE. CMD was defined as MBF reserve < 2. The MCE method had a high sensitivity (88.1%) and specificity (95.7%) in the diagnosis of CMD. There was strong agreement with thermodilution (Kappa coefficient was 0.727; 95% CI: 0.57-0.88, p < 0.001). However, the correlation coefficient (r = 0.376; p < 0.001) was not high.

Graph metric learning quantifies morphological differences between two genotypes of shoot apical meristem cells inArabidopsis

AbstractWe present a method for learning ‘spectrally descriptive’ edge weights for graphs. We generalize a previously known distance measure on graphs (graph diffusion distance [GDD]), thereby allowing it to be tuned to minimize an arbitrary loss function. Because all steps involved in calculating this modified GDD are differentiable, we demonstrate that it is possible for a small neural network model to learn edge weights which minimize loss. We apply this method to discriminate between graphs constructed from shoot apical meristem images of two genotypes of Arabidopsis thaliana specimens: wild-type and trm678 triple mutants with cell division phenotype. Training edge weights and kernel parameters with contrastive loss produce a learned distance metric with large margins between these graph categories. We demonstrate this by showing improved performance of a simple k-nearest-neighbour classifier on the learned distance matrix. We also demonstrate a further application of this method to biological image analysis. Once trained, we use our model to compute the distance between the biological graphs and a set of graphs output by a cell division simulator. Comparing simulated cell division graphs to biological ones allows us to identify simulation parameter regimes which characterize mutant versus wild-type Arabidopsis cells. We find that trm678 mutant cells are characterized by increased randomness of division planes and decreased ability to avoid previous vertices between cell walls.

PS-C14-2: QUANTITATIVE METHODS FOR ASSESSING CONTRACTILE RESERVE IN PATIENTS WITH DIASTOLIC HEART FAILURE

Aim: The effectiveness of isometric handgrip exercise on changes of cardiovascular hemodynamical parameter in patients with diastolic heart failure is unknown. We assessed the effect of several hemodynamic parameters and it changes during handgrip maneuvers in patients with different stages of diastolic heart failure during chemotherapy and their improvements after 4 months follow up (4mFU) treatment with single pill combination of ACE inhibitor ACE) and beta blocker(BB). Methods: The study population included 65 patients female / mean age of 45 ± 12 years/ 55 with breast cancer and undergoing chemotherapy / 30 pts with HFpEF and 25 pts with HFmrEF / and 10 pts with HFnEF and without chemotherapy. The effect of handgrip maneuver on hemodynamic parameters were studied by speckle tracking echocardiography. Following maximal squeeze by 100%, during the next 3 minutes patients were instructed to apply pressure at 50%. The global longitudinal strain were extracted by 3, 4 and 2 chamber apical view images on 70 fr/s and MAP and HR were performed at basal level, 1st, 2nd and 3rd minutes during handgrip stress test. The contractility /force/ of LV were also calculate as ratio SBP / ESV. Patients with HFmrEF and HFpEF received for 4 months treatment with single pill combination ACE (perindorpril)/ BB (bisoprolol) 5/5 mg. Results: Heart rate(HR) and mean arterial pressure(MAP) increased significantly after handgrip maneuver / from 75 ± 6 beats /min to 101 ± 12 beats/ min, 109 ± 15 mmHg to 118 ± 19mmHg, p &lt; 0,05 /. Pulmonary artery systolic(s) and diastolic (d) pressure(PAP),pulmonary capillary wedge pressure (PCWP), cardiac index(CI), LVEF did not change significantly(p &gt; 0,5) after handgrip maneuvers. On the other hand, LV force (SBP/ ESV ratio),MAP and HR decreases significantly (p &lt; 0,01) in group with HFmrEF. In same group were found significantly decreased GLVLS at 2nd and 3rd minutes during stress- test comparable with other 2 groups with HFpEF and HFnEF. After 4mFU and treatment with 5/5 mg doses combination of ACE / BB were found improvement in parameters: HR /p &lt; 0,001/, MAP /p &lt; 0.01/ and contractile reserve as well as LV force /p &lt; 0, 01/ and GLVLS /p &lt; 0,001/. Conclusion: Cardiovascular response to handgrip maneuver may be a marker of failure to respond to compensatory mechanisms. Patients with good LV reserve had a rise in stroke work with little or no change in LVEDP. Patients with poor contractile reserve had a fall in stroke work reserve together with a substantial rise in LVEDP. It is concluded that the stress imposed by sustained handgrip provides a simple test for evaluation of LV contractile reserve in patients, who will develop cardiotoxicity during chemotherapy treatment. The treatment with combination with small doses ACE/BB is a big challenge in patients with HFmrEF and HFpEF to improve the contractile reserve.

Hocus POCUS! Parental Quantification of Left-Ventricular Ejection Fraction Using Point of Care Ultrasound: Fiction or Reality?

Point of care ultrasound has become increasingly utilized in pediatric settings. The assessment of cardiac function is one such implementation of this. This study aimed to determine the feasibility of parents in acquiring images to assess function using a handheld ultrasound probe and the correlation of fractional shortening measurements by handheld ultrasound with hospital acquired echocardiography. This was a single-center prospective study of parents of pediatric patients admitted to the hospital. Parents underwent a 25-min education session on how to use the handheld ultrasound probe and then were asked to acquire a parasternal short-axis and apical four-chamber image on their own. Acquired images were reviewed by two physicians to determine adequacy of images to assess systolic cardiac function subjectively and objectively. Fractional shortening was measured using parent-acquired images and then compared to recent hospital acquired fractional shortening. A total of 25 parents of 21 patients enrolled and completed the study. Of the enrolled parents, 96% of both parasternal short-axis and apical four-chamber images acquired were deemed appropriate for subjective assessment of systolic function. Inter-reader variability of fractional shortening was moderate between two readers. Correlation of fractional shortening measured from parent-acquired images versus hospital acquired images was moderate. Parents were able to successfully obtain a parasternal short-axis and apical four-chamber image adequate to assess function and quantify fractional shortening after a 25-min education session. This pilot data demonstrate that further exploration of parent-performed point of care cardiac assessment may be warranted.

Ocupação Apical por Endomiocardiofibrose Associada a Trombo Diagnosticada com Ecocardiografia de Contraste e Resolvida com Tratamento Clínico

Endomyocardial fibrosis (EMF) is a neglected but prevalent disease in underdeveloped countries. Despite its frequency, it is still considered a rare disease. It is marked by the following findings: architectural distortion, ventricular filling changes, and segmental mobility changes affecting not only diastolic and systolic dynamics but also heart valve function. Apical thrombi can be formed in more advanced disease. In this case report, we revisit EMF and present the challenging case of a 52-year-old woman with New York Heart Association (NYHA) functional classification (FC) IV heart failure. Resting electrocardiography revealed sinus rhythm with left ventricular (LV) overload, high voltage vectors, rectified ST-segment depression, and a negative T-wave in the anterolateral region compatible with the strain pattern. The evaluation of echocardiographic images showed marked left atrial dilation, no ventricular dilatation, and hyper-refringent apical occupation within the LV suggestive of a large sessile thrombus superimposed on the endocardial fibrous layer. Although surgery is the most supported approach in the literature in such situations, this patient was treated with oral anticoagulants (OAC) for 1 month and 24 days. The patient progressed well with an improved NYHA FC. Endocavitary contrast echocardiography performed 2 months after OAC initiation showed regression of the apical thrombus image.

1023 FEASIBILITY AND REPRODUCIBILITY OF LEFT ATRIAL STRAIN MEASURED WITH THE NEW DEDICATED SOFTWARE: A SPECKLE TRACKING STUDY

Abstract Background During the last years, left atrial (LA) strain by speckle tracking echocardiography (STE) is gaining increasing evidence as diagnostic and prognostic tool in several clinical settings. However, the lack of a dedicated software was considered one of its main limitations, despite its proven good feasibility and reproducibility of a ventricular-based software. Importantly, brand-new fully automated software tools dedicated to the left atrium have been developed, both for on-line measurement on the echocardiographic machine and for off-line use on the workstation. Aims to compare LA strain measures acquired by the new automated dedicated software with the “traditional” semi-automated ventricular based one, studying its feasibility, time-consumption, and reproducibility for the analysis of healthy, pressure-overloaded, and volume-overloaded patients. Methods Grey scale apical 4-chamber view echocardiographic images acquired by an experienced operator (GE, Vivid E9, Orthern, Norway) in healthy patients, patients with pressure overload (arterial hypertension, aortic stenosis) and pressure-volume overload (mitral regurgitation, heart failure) were analyzed. STE was performed offline by two independent experienced operators, using both the semi-automated and the fully automated Echopac (Milwaukee,Wisconsin) software, which was then compared using matched-pairs analysis. Both operators were blinded to the other measures and repeated the same measurement on the same images after 10 days. Measurement of LA strain was performed on-line on the echocardiographic machine in a selected group of 20 patients by one of the two operators. Patients with prosthetic valves, heart transplantation, atrial fibrillation were excluded. Results Overall, 100 patients were analyzed (41 healthy patients, 28 with pressure overload, 31 with pressure-volume overload). Peak atrial longitudinal strain (PALS) showed a high reproducibility with both methods. However, the dedicated method had a slightly higher inter-operator reproducibility (intraclass correlation coefficient(ICC)=0.97; 95% CI=[0.87;0.99] vs. ICC=0.96 [9.87;0.99]) (Fig.1) and intra-operator reproducibility (ICC=0.99 [0.99;0.99] vs. 0.98 [0.98;0.99] (Fig.2); correlation=0.85, p&amp;lt;0.001in operator 1 and 0.97 [0.95;0.98] vs. 0.95 [0.92;0.96]; correlation=0.83, p&amp;lt;0.001 in operator 2) with a slightly lower time consumption (90 s vs. 105 s) than the traditional ventricular-based one. On-line software showed a nearly perfect reproducibility with offline software [ICC=0.99 [0.99;1]] with a further time saving (60 vs. 90 s). Conclusions the new fully automated software for the analysis of LA strain has a high inter-operator and intra-operator reproducibility. Both the automated and the traditionally used semi-automated software calculation provided optimal results in terms of reproducibility and time-consumption and could be equally chosen for strain calculation in daily clinical practice. LA strain calculation on-line on the echocardiographic machine proved to be reliable and time-saving. Fig. 1 Fig. 2

Abstract 12457: Usefulness of Automatic Assessment for Longitudinal Strain to Diagnose Wild-Type Transthyretin Amyloid Cardiomyopathy

Introduction: Despite obvious diagnostic usefulness, left ventricular (LV) apical sparing has not been widely accepted to diagnose transthyretin amyloid cardiomyopathy, because it is time consuming and requires a level of expertise. Automatic assessment may be the solution for these problems. Methods and Results: We enrolled 69 patients aged ≥ 70 years who underwent 99m TC-PYP scintigraphy and transthoracic echocardiography (TTE) by EPIQ7G, and had enough information for two-dimensional speckle tracking echocardiography at Kumamoto University Hospital from January 2016 to December 2019. LV apical sparing was diagnosed as relative apical longitudinal strain (LS) index (RapLSI) &gt;1.0. Measurement of LS was repeated using the same apical images with three different measurement packages as follows: (1) full-automatic assessment, (2) semi-automatic assessment, and (3) manual assessment. The calculation time for full-automatically assessment (14.8±1.5 sec/patient) and semi-automatically assessment (67.3±14.1 sec/patient) were significantly shorter than for manual assessment (211.1±60.5 sec/patient) (p&lt;0.01 for both). Receiver operating characteristic curve analysis showed that the area under curve (AUC) of the RapLSI evaluated by full-automatically assessment for 99m Tc-PYP scintigraphy positivity was 0.656 (best cut-off point; 1.12 [sensitivity 63%, specificity 68%]), by semi-automatic assessment was 0.806 (best cut-off point; 1.00 [sensitivity, 61%; specificity, 100%]) and by manual assessment was 0.806 (best cut-off point; 1.00 [sensitivity, 71%; specificity, 96%]). Conclusion: The diagnostic accuracy of semi-automatically assessed RapLSI to predict 99m Tc-PYP scintigraphy positivity was as same as that of manual assessed RapLSI. Semi-automatically approach using novel automated software was useful to diagnose ATTR-CM in the terms of rapidity, reproducibility and diagnostic accuracy.

Abstract 14787: Quantification of Flow and Biomechanics by Echocardiography (echo) in the Fetal Single Ventricle (sv)

Introduction: Echo-based ventricular flow and biomechanical analysis provides novel measurements of SV function that can be assessed serially. However, this analysis has not been applied to clinical studies. This study demonstrates a new workflow to measure ventricular flow and biomechanics from apical 4-chamber imaging for hypoplastic left heart syndrome [HLHS] patients and age-matched controls. Methods: We retrospectively collected echos at 33 weeks gestation prenatally and 7 days post-birth postnatally. Color Doppler echo of the LV/RV were evaluated using an in-house vector flow reconstruction algorithm, quantifying energy loss [EL] and vortex strength [VS]. B-mode echo of the LV/RV were evaluated for parameters including cardiac output [CO] and global longitudinal strain [GLS]. Results: 9 HLHS subjects and 11 age-matched controls were included. Prenatal HLHS patients exhibited elevated CO, EL, and VS (p&lt;0.01) but proportional GLS compared to the control LV/RV. The parameters serially increased postnatally (p&lt;0.01), consistent with transitional physiology. GLS in HLHS was differentiable from the normal RV only in postnatal studies, resembling normal LV values. Conclusions: Altered ventricular flow and biomechanics were observed for HLHS patients compared to controls during early life. These novel parameters can be serially evaluated using conventional echo imaging. We will perform longitudinal studies of this HLHS cohort as they progress through surgical palliation to fully understand how our integrated workflow can better inform SV patient care. Figure 1: Left – Comparison of ventricular flow and biomechanical markers between HLHS and control subjects, for prenatal (fetal) and postnatal (neonatal) ages. Right – Ventricular flow patterns for HLHS and control subjects for different ages.