Apical Images Research Articles

Using Tissue Doppler and Speckle Tracking Echocardiography to Assess if Ivabradine Improves Right Ventricular Function.

ObjectiveTo evaluate the mid-term effects of ivabradine on right ventricular functions in patients with heart failure.MethodsA prospective study was conducted on 52 patients who had heart failure in normal sinus rhythm (59% male, age: 64.76 ±12.49 years). Right ventricular functions were measured at baseline, after one month and one year by conventional and tissue Doppler echocardiography imaging. The parameters, right ventricular (RV) longitudinal strain (LS), RV systolic longitudinal strain rate (LSRs), RV early diastolic longitudinal strain rate, and late diastolic longitudinal strain rate, were evaluated by apical four-chamber grayscale imaging through the free wall of RV in accordance with the automated function imaging protocol.ResultsDuring the follow-up, the pulmonary artery systolic pressure (PASP), RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), E peak, and A peak values were similar to the basal values. While comparing the basal values of the global longitudinal systolic strain (GLS), LS, LSRs, longitudinal strain rate diastolic early filling (LSRe), and longitudinal strain rate diastolic late filling (LSRa), there were no differences in the first month but a significant increase was observed on one-year follow-up (p<0.001).ConclusionAt the one-year follow-up, the heart failure patients who were given ivabradine treatment showed an improvement in the right ventricular function assessed by the new echocardiographic techniques.

Evaluation of apical transportation and apical root sealing in root canals prepared with mtwo rotary system with and without apical enlargement – an in vitro study

The aim of this study was to evaluate apical transportation and apical root canal sealing after root canal filling in human teeth prepared with MTwo® Rotary System with and without apical foramen enlargement. Twenty mandibular premolars were divided into two groups (n=10). Group 1 had root canals prepared 1mm beyond the apical foramen. Group 2 had root canals prepared 1mm below the root canal length. After chemo-mechanical preparation, samples were submitted to scanning electronic microscopy. Apical foramen images had 75x magnification at standardized positions, allowing measurements from the apical foramen area before and after root canal preparation, and after root canal filling. Apical foramen shape and apical transportation, as well as its level of circumferential filling after root canal preparation were accessed using the Image Subtraction System. Scanning electronic microscopy analysis demonstrated that samples of Group 1 showed larger foraminal diameter than samples of Group 2 (p&lt;0.05). Apical foramen transportation was statistically different between Groups 1 and 2 (p=0.0108). Furthermore, the apical foramen sealing also differed statistically between groups 1 and 2 (p=0.0007) and 100% of samples of Group 1 showed apical root canal sealing. Apical root canal sealing was more effective when the root canal was prepared with apical foramen enlargement, even when the apical transportation was detected.

Effects of Sacubitril/Valsartan Treatment on Left Ventricular Myocardial Torsion Mechanics in Patients with Heart Failure Reduced Ejection Fraction 2D Speckle Tracking Echocardiography.

Background:Left ventricular ejection fraction (LVEF) is calculated from volumetric change without representing true myocardial properties. Strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Sacubitril/valsartan has been shown to improve mortality and reduce hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). The effect of sacubitril/valsartan angiotensin receptor neprilysin inhibitor (ARNI) on left ventricular (LV) ejection fraction (EF) and torsion dynamics in HFrEF patients has not been previously described.Methods:The study involved 73 patients with HFrEF, for all patients Full history was taken, full clinical examination was done. Baseline vital signs, ECG, NYHA classification, conventional echocardiography and STE were done at baseline study and after 6 and 11 months.Basal and apical LV short-axis images were acquired for further off-line analysis. Using commercially available two-dimensional strain software, apical, basal rotation, and LV torsion were calculated.Results:ARNI group of patients showed improvement of symptoms, LV global longitudinal strain (LVGLS)% and diastolic parameters including, E/A, E/e', TV, untwist onset and rate after 6 months of therapy in comparison to the traditionally treated patients. The improvement continued for 11 months with in additional significant improvement of systolic parameters in the form of LVGLS%, EF%, Twist, Apical and basal rotations, main dependent parameters for improvement of EF% was LVGLS% and Apical rotation.Conclusion:To the best of our knowledge, this is the first study to demonstrate that therapy with sacubitril/valsartan in HFrEF patients could create a state of gradual and chronic LV deloading which cause relieving of myocardial wall tensions and decreasing the LV end diastolic pressure this state could cause cardiac reverse remodeling and reestablishment of starling forces proprieties of LV myocardium, which lead to increase of LV EF.

The Mechanics of Apical Rotation in Patients with Myocardial Infarction and Reduced Left Ventricular Function

Background: Traditionally the use of Left ventricular ejection fraction (LVEF) for assessment of left ventricular (LV) systolic. Function is the most widely used method. However, this method is inaccurate after acute MI, this attributed to the development of wall-motion abnormalities after acute MI; Inaddition, the biplane Simpson method calculation is inaccurate, because it relys on geometric assumptions. Recently, the use of two-dimensional speckle-tracking imaging has facilitated noninvasive measurement of LV torsion. Objective: The aim of this study was to use speckle-tracking echocardiography to assess apical rotation in patients with anterior and inferior myocardial infarction (MI). Patients and methods: The present study enrolled 54 patients with anterior or inferior MI, in addition to 20 healthy volunteers (matched for age and sex) as the control group. Using commercially available two-dimensional strain software, apical, basal rotation, and LV torsion were calculated. Basal and apical LV short-axis images were acquired for further off-line analysis. Results: Apical rotation was significantly reduced in the patient group compared with the control group (P<0.001). Consequently, torsion degree (P<0.001), torsion rate, and untwisting rate (P=0.007) were significantly reduced. There was a significant correlation between ejection fraction and apex rotation (r=0.466, P=0.044), torsion degree (r=0.499, P=0.03), and untwisting rate (r=−0.543, P<0.001). Correlation with basal rotation was nonsignificant, and thus measurement of apical rotation alone (rather than calculation of LV torsion) might provide a simple and accurate alternative for assessment of LV contractility. Conclusion: Apical rotation and torsion were decreased in ST-elevation MI, and this was statistically significant in patients with LV dysfunction.

Feasibility, Reproducibility, and Clinical Implications of the Novel Fully Automated Assessment for Global Longitudinal Strain

Despite evidence of its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine, because it requires proficiency and is time consuming. Automated assessment of GLS may be the solution for this situation. The aim of this study was to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semiautomated and manual assessment of GLS. In this validation study, different methods for the assessment of GLS were applied to echocardiograms from 561 asymptomatic subjects (mean age, 71±5years) with heart failure risk factors, recruited from the community. All patients had both data on follow-up outcomes (new heart failure and cardiac death) and interpretable echocardiographic images for strain analysis. Measurement of GLS was repeated using the same apical images with three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semiautomated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator). AutoStrain measurements were technically feasible in 99.5% of patients. Calculation times for automated (0.5±0.1min/patient) and semiautomated assessment (2.7±0.6min/patient) were significantly shorter than for manual assessment (4.5±1.6min/patient; P<.001 for both). Approximately 40% of patients were thought to need manual correction after automatic calculation of GLS. Therefore, there was considerable discordance between automated and semiautomated and manual GLS. Over a median of 12months of follow-up, cardiovascular events (new heart failure and cardiac death) occurred in 66 patients (11.8%). Automated GLS showed the potential to correctly detect normal and abnormal systolic function and predict cardiac events; the predictive value was inferior to that of semiautomated GLS. A novel fully automated assessment for GLS may provide a technically feasible, rapidly reproducible, and clinically applicable means of assessing left ventricular function, but a substantial number of automatic traces still need manual correction by experts. At the present stage, the semiautomated approach using this novel automated software seems to provide a better balance between feasibility and clinical relevance.

Abstract 15974: Non-Invasive Myocardial Work Indices in Normal Adolescents: A Pilot Study

Introduction: Myocardial work may provide a different perspective on LV function and energy consumption. Its non-invasive assessment by echocardiography correlates with invasive measures and there are normal values established in adult patients. We aimed to establish normal values in a healthy adolescent population. Methods: Nineteen healthy subjects (mean age = 15 ± 2 years, 42% male) with normal echocardiograms were prospectively included. Brachial cuff blood pressure was obtained immediately following apical images in the supine position. Post-processing of echocardiograms with speckle tracking echocardiography and derivation of global myocardial work indices from LV pressure-strain loops was done using EchoPAC (General Electric, v203R73.0) (Figure 1). Results: Baseline demographics, echocardiographic measures and global myocardial work indices are reported in Table 1. The mean global work index is 1833 ± 278 mmHg with mean global work efficiency of 95 ± 1.3%. No gender difference in myocardial work indices are found (p&gt;0.05 for all). Correlation between global work indices with age, systolic blood pressure, LV ejection fraction, and global longitudinal strain (GLS) are presented in Table 2. Conclusions: This is a pilot study to begin establishing normal adolescent indices of non-invasive myocardial work. Figure 1. Example

Abstract 14299: Deep Convolutional Neural Network Analysis of Echocardiographic Images Improves Prediction of Genotype Positivity in Patients With Hypertrophic Cardiomyopathy

Introduction: Genotyping may provide valuable insights into family screening strategies and prognosis in patients with hypertrophic cardiomyopathy (HCM). On the other hand, genotyping is expensive. Thus, it is important to identify patients who are more likely to be genotype positive. However, conventional prediction models (e.g., the Mayo score) based on clinical and echocardiographic parameters offer only modest accuracy and are subject to inter-observer variability. Hypothesis: Deep convolutional neural network (DCNN) analysis of echocardiographic images improves the ability to predict genotype positivity in HCM compared to the conventional model. Methods: We included 99 patients with HCM who underwent genetic testing for diagnostic and/or family screening purposes. The age at diagnosis was 46±20 years and 65% were male. In each case, we obtained parasternal short- and long-axis as well as all apical images at end-systole. The DCNN underwent 100 steps to develop the model to predict genotype positivity. In each step, we used 80% of the cohort as the training set and the remaining 20% as the test set (i.e., 5-fold cross-validation). We used the Mayo score as the reference model. We compared the area under the receiver operating characteristics curve (AUC) between a combined model using the reference model plus the DCCN-derived probability and the reference model. We calculated the p value by performing 1,000 bootstrapping. Results: Overall, 45 patients (45%) were genotype positive. The model combining the reference and the DCNN-derived models significantly outperformed the reference model (AUC 0.79 [95% CI 0.69-0.87] with the combined model vs. 0.72 [0.61-0.82] with the reference model; p=0.006; Figure). Conclusion: Compared to a conventional model based on clinical and echocardiographic parameters, our new model combining the conventional and DCNN-derived models demonstrated superior ability to predict positive genotype in patients with HCM.

Feasibility, reproducibility, and clinical implications of the fully automated assessment for global longitudinal strain

Abstract Background Despite of evidence on its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine because it requires proficiency and is time-consuming. Automated assessment of GLS may be a solution to these barriers. This study sought to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semi-automated and manual assessment for global longitudinal strain. Methods In this validation study, different methods for the assessment of GLS were applied to echocardiograms of 561 asymptomatic people (age 71±5 years) with heart failure (HF) risk factors, recruited from the community. All patients were followed up for new-onset of HF and cardiovascular death. Measurement of GLS was repeated using the same apical images on three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semi-automated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator). We defined abnormal GLS for discrimination of LV systolic dysfunction using the cut-off of GLS =18% (absolute value). Results AutoStrain measurements were feasible in 99.5% of patients. Calculation time for automated (0.5±0.1 min/patient) and semi-automated assessment (2.7±0.6 min/patient) were significantly shorter than that for manual assessment (4.5±1.6 min/patient) (both p&amp;lt;0.001), and the automated assessment showed excellent reproducibility. There was considerable discordance between automated and semi-automated/manual GLS (Figure 1), but normal systolic function was reliable identified. The prediction of cardiovascular events was reliable with automated, semi-automated and manual GLS (Figure 2). Conclusion A novel fully automated assessment for GLS is a feasible, rapid, reproducible and clinically applicable means of assessing LV function, and measurements in the normal range predict a favorable outcome. Figure 1 Funding Acknowledgement Type of funding source: None

Echocardiographic assessment of CRT candidates. Does it work equally well in intermediate QRS duration?

Abstract Background The presence of mechanical dyssynchrony – such as apical rocking (ApRock) and septal flash (SF) – on echocardiography is associated with favourable outcome after cardiac resynchronization therapy (CRT). Myocardial scar on the other hand, has a considerable negative impact on CRT response. There is growing evidence that a visual echocardiographic assessment of mechanical dyssynchrony by ApRock, SF and scar predicts CRT response. Little is known however if this works equally well in patients with intermediate QRS duration (120–150ms), where guideline recommendation for CRT is weaker. Methods A total of 400 unselected patients referred for CRT, who fulfil the contemporary guidelines, were enrolled in this multicentre study. Echocardiographic images were visually assessed before CRT implantation, focussing on the presence of ApRock, SF and location and extent of scar segments in the left ventricle (LV), resulting in a CRT response prediction (i.e. Reader Interpretation). Readers were blinded to all patient information other than ischaemic aetiology of heart failure. CRT response was defined as ≥15% reduction in LV end-systolic volume on echocardiography, on average 15 months after device implantation. Results Overall, 321 (80%) patients had a left bundle branch block (LBBB), with an average QRS duration of 166±25ms. Ischemic aetiology of heart failure was found in 131 (33%) patients. Before CRT, ApRock and SF were present in 254 (64%) and 244 (61%) patients, respectively. ApRock and SF alone predicted CRT response with an area under the curve (AUC) of 0.79 (95% CI: 0.74–0.84) and 0.78 (95% CI: 0.73–0.83) (Figure A), while the echocardiographic Reader Interpretation had an AUC of 0.85 (95% CI: 0.81–0.89), with a sensitivity of 89% and a specificity of 82% for the prediction of CRT response (Figure B) (p&amp;lt;0.0001 vs. ApRock and SF alone). A total of 92 patients had a QRS duration of 120–150ms, and 48 of them responded to CRT. In these patients, the AUC of Reader Interpretation was comparable to that of the entire study cohort [0.83 (95% CI: 0.75–0.92)], as was sensitivity and specificity (90% and 79%, respectively, p=0.717 vs. the AUC of the entire cohort) (Figure C). Conclusions A visual assessment of LV function, by means of mechanical dyssynchrony and scar, has an excellent predictive value for CRT response, and requires only apical echocardiographic images. Responders were identified equally well in the challenging subgroup of patients with a QRS duration of 120–150 ms. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): KU Leuven

Texture-based machine learning in LGE-CMRI for automatic scar assessment

Abstract Background Conventional methods for the estimation of infarct size by late-enhanced cardiac magnetic resonance imaging use analyzes from each slice which in turn is added to generate a volume. We present a novel method based on machine learning, called texture based probability mapping (TPM). TPM is based upon expressing the probability of scarring in a pixel based upon analysing textural information in patches around each pixel. Purpose To explore our method and assess its utility as a tool to scar size and compare it with four established methods. Methods In 54 patients with ischemic scars, our method was compared with four 2D methods. 2 patients were excluded due to low image quality and artefacts. The most basal and apical short axis image slices were exclude due to partial volume artefacts. Myocardial infarction (MI) size was estimated manually, and TPM performed. Cardiac segments were defined as myocardial regions with pixel probabilities within a specified range. By varying the lower probability threshold while keeping the upper threshold fixed at 1, different cardiac segments were defined. Using the Sørensen-Dice coefficient the optimal probability range with the highest correlation to manual estimation of infarct size was identified. Results TPM-range 0.341–1.0 is best correlated to manual demarcation (median Dice 0.70). The method demonstrated stronger correlations between scar size and left ventricular remodeling parameters (LV ejection fraction: r=−0.731, p&amp;lt;0.0005; LV end-diastolic volume: r=0.641, p&amp;lt;0.0005; LV end-systolic volume: r=0.672, p&amp;lt;0.0005) compared with manual method. Conclusion Using TPM, infarct size can be measured automatically without using signal intensity as a reference value. It is without the need for manual demarcation of the scar and is less time consuming and less vulnerable to interobserver variability. It has a strong correlation with left ventricular remodeling parameters crucial in guiding further medical therapy. The use of this method is however not primarily dedicated for scar size estimation, but a tool to evaluate different properties of the tissue that cannot be visualized by the naked eye. It's an important step towards better understanding of myocardial damage pattern causing ventricular arrhythmia and SCD. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Helse Vest

Prevalence and prognostic implications of increased apical basal strain ratio in aortic stenosis undergoing transcatheter aortic valve replacement

Abstract Background A substantial number of elderly patients with aortic stenosis (AS) have been reported to have coexisting transthyretin cardiac amyloidosis (ATTR). These patients are characterized by advanced heart failure symptoms and increased NTproBNP. Raising clinical suspicion of ATTR in AS patients seems difficult. Recent data has shown that an increased apical-basal strain ratio (ABr) derived by echocardiography predicts the diagnosis of cardiac amyloidosis (CA) in patients with left ventricular (LV) hypertrophy. However, the prevalence and prognostic value of ABr, a potential marker of ATTR, in patients with symptomatic AS undergoing transcatheter aortic valve replacement (TAVR) is unknown. The aim of this study was to investigate the preoperative prevalence, relation to symptoms and prognostic implications of elevated ABr in patients with symptomatic AS undergoing TAVR. Methods We obtained data including survival status from 499 consecutive AS patients who underwent TAVR in the period 2016–2018 at our institution. From 2D echocardiographic apical images ABr was calculated as mean longitudinal strain of the 5 LV apical segments divided by the mean of the 6 LV basal segments. Patients were stratified according to ABr; 0–1.9 was considered normal, 2–2.9 mildly increased, 3.0–3.9 moderately increased and ≥4 severely increased. Results Median follow-up time was 743 days. Mean age was 80±7 years. The prevalence of ABr ≥4 was 16% (n=78). These patients had higher preoperative NYHA class (77% were NYHA III or IV compared to 59% in ABr 0–1.9, p=0.003). Median preoperative NTproBNP levels for ABr ≥4 were 1781 pmol/l compared to 876 pmol/l in ABr 0–1.9 (p=0.003). NTproBNP levels decreased for all ABr subgroups at three months follow-up but remained considerably elevated in ABr ≥4 (median of ABr ≥4 was 1262 pmol/l compared to 645 pmol/l for ABr 0–1.9, p=0.001). LV ejection fraction (EF) in ABr 0–1.9 and ≥4 was 50% and 46%, p=0.014. The preoperative aortic valve stenosis severity derived by echo Doppler parameters were comparable across ABr subgroups. Overall, increased ABr ≥4 was associated with poor survival (fig. 1). In univariate analysis ABr ≥4 (HR 1.90, p=0.018), preoperative NTproBNP levels above the median of 1226 pmol/l (HR 3.14, p=0.003), increasing age (HR 1.05, p=0.018), TAPSE &amp;lt;19 mm (HR 1.91, p=0.011) and LV EF &amp;lt;50% (HR 1.60, p=0.045) were significant predictors of mortality. Preoperative NTproBNP &amp;gt;1226 pmol/l emerged as the only significant outcome predictor in a multivariate analysis (HR 2.67, p=0.029). Conclusion Increased ABr ≥4 occurs frequently and is associated with significantly higher pre- and postoperative NYHA class, NTproBNP levels and reduced survival in symptomatic AS patients undergoing TAVR. Some of these patients might have undiagnosed CA. The echocardiographic derived ABr could in future studies prove to be a useful tool in raising suspicion of ATTR leading to referral for diagnostic testing for CA. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Danish Independent Research Fund

Prevalence and Prognostic Implications of Increased Apical-to-Basal Strain Ratio in Patients with Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement

The aim of this study was to investigate the preoperative prevalence, relation to symptoms, and prognostic implications of elevated left ventricular (LV) apical-to-basal strain ratio (ABr) in patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement. A total of 499 contemporary consecutive patients with AS treated with transcatheter aortic valve replacement were retrospectively included. Patients were included if they underwent preoperative echocardiography with adequate image quality for assessment of LV global longitudinal strain. Baseline clinical and echocardiographic data were collected and analyzed in ABr subgroups. From two-dimensional echocardiographic apical images, ABr was calculated as mean longitudinal strain of the five LV apical segments divided by the mean of the six basal segments. Median follow-up time was 743days. Mean age was 79.8±7years. The prevalence of severely increased ABr ≥4 was 16% (n=78). Patients with ABr ≥4 had higher preoperative New York Heart Association functional class; 77% of those with ABr ≥4 were in New York Heart Association functional class III or IV compared with 59% of those with ABr of 0 to 1.9 (P<.01). Median preoperative N-terminal pro-brain natriuretic peptide level in patients with ABr ≥4 was 1,781 pmol/L, compared with 876 pmol/L in those with ABr of 0 to 1.9 (P=.003). N-terminal pro-brain natriuretic peptide levels at 3-month follow-up remained considerably elevated in patients with ABr ≥4 (the median in patients with ABr ≥4 was 1,262 pmol/L vs 645 pmol/L in those with ABr of 0 to 1.9, P<.01). AS severity was comparable across ABr subgroup levels. Overall, increased ABr ≥4 was associated with poor survival, as overall 3-year survival was 67% among patients with ABr ≥4 compared with 83% in those with ABr of 2 to 3.9 and 86% in those with ABr of 0 to 1.9 (P=.04). Among patients with increased ABr ≥4, pre- and postoperative New York Heart Association functional class, serum N-terminal pro-brain natriuretic peptide level, and mortality were significantly increased, and ABr may thus serve as a new echocardiographic marker of high mortality risk among patients with AS treated with transcatheter aortic valve replacement.

Left ventricular ejection fraction using manual and semi-automated biplane method of discs in very preterm infants.

Biplane left ventricular ejection fraction (LVEF) is a valuable echocardiographic parameter for assessment of LV systolic pump efficiency in adults and children, but not often reported in preterm infants. The primary aim of this study was to longitudinally measure biplane LVEF in very preterm infants during the neonatal intensive care period. Secondary aim was to compare manual and semi-automatic determination of LVEF for agreement and variability. Stable preterm infants less than 30weeks gestation were scanned on day 3, day 28, and at 36weeks postmenstrual age. The LV endocardium was traced manually and semi-automatically using integrated speckle tracking software in apical 4-chamber and apical 3-chamber images to obtain end-diastolic volume and end-systolic volume, and calculate LVEF. Agreement between methods and variability within and between observers was determined using an interclass correlation coefficient (ICC) and Bland-Altman analysis. Sixty-six preterm infants with a mean birth weight of 1100 (239)g were analyzed. The average manual biplane LVEF was 58 (3)%, 59 (3)%, and 55 (4)% at the three respective time points. Manual LVEF showed good agreement with semi-automatic LVEF (ICC 0.76) with a small bias of -1.5 (3.0)%. Interobserver variability of LVEF improved with semi-automatic tracing of the LV endocardial border (ICC manual 0.68 vs semi-automatic 0.80). Left ventricular systolic pump efficiency in preterm infants remains stable during the neonatal intensive care period. Semi-automatic biplane LVEF has less interobserver variability and can be used interchangeably with manual biplane LVEF.

Transthoracic echocardiography and cardiac biomarkers in healthy captive male and female squirrel monkeys (Saimiri spp.)

BackgroundEchocardiography is the most frequently used non -invasive diagnostic tool to evaluate cardiac anatomy and function in domestic species but increasingly also in non -domestic species, especially since cardiac disease is being recognized as an important cause of death in captive primates. The purpose of this cross -sectional study was to investigate the feasibility of transthoracic echocardiography in healthy squirrel monkeys as well as to provide species specific normal values for standard echocardiographic measurements. A secondary aim was to determine plasma and serum levels of the cardiac biomarkers, N -terminal pro -brain natriuretic peptide (NT -proBNP) and cardiac troponin T (cTnT). Furthermore, a commercial, non -invasive, smartphone -based ECG (AliveCor Vet TM) monitoring device was used to evaluate the heart rate and rhythm and to diagnose possible arrhythmias.ResultsIn this study, transthoracic echocardiography of 14 squirrel monkeys was performed in right and left lateral recumbency. Similar standard right parasternal and left apical images were obtained as in dogs and cats and normal values for routine two -dimensional, time motion mode and Doppler mode measurements were generated. Thirteen animals were considered healthy and one squirrel monkey was identified with significant aortic dilation and regurgitation and consequently values obtained from this animal were not used when species specific normal values were calculated. NT -ProBNP and cTnT concentrations were available for 7 of the 13 healthy monkeys with NT -proBNP concentrations below detection limit in all animals and a mean cTnT concentration of 0.049 ng/mL. Electrocardiography was performed in all squirrel monkeys. The mean heart rate was 172 bpm. Frequent supraventricular premature beats were diagnosed in the squirrel monkey suffering from significant aortic dilation and regurgitation.ConclusionThis study presents echocardiographic normal values and additional cardiovascular data in anaesthetised Saimiri monkeys, fundamental from both the perspective of zoo animal health care as well as scientific research, since the squirrel monkey is often used as an animal model for human disease.

THORACIC RADIOGRAPHY AND TRANSTHORACIC ECHOCARDIOGRAPHY IN CLINICALLY HEALTHY RING-TAILED LEMURS (LEMUR CATTA).

Cardiac disease has been recognized as a major cause of death in captive nonhuman primates, which necessitates diagnostic (imaging) techniques to screen for and diagnose preclinical and clinical stages of possible cardiac conditions. Echocardiography is currently the most commonly used diagnostic tool for evaluation of cardiac anatomy and function. Complete with thoracic radiography and blood levels of two cardiac biomarkers, N-terminal probrain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT), it gives an extensive examination of the cardiorespiratory system. The purpose of this cross-sectional cohort study is to describe normal thoracic anatomy using thoracic radiography, and to provide normal values for echocardiographic measurements in 20 ring-tailed lemurs (Lemur catta). Additionally, cardiac biomarkers were determined. Three radiographic projections of the thoracic cavity and a complete transthoracic echocardiography were performed in 20 clinically healthy ring-tailed lemurs during their annual health examinations. Similar standard right parasternal and left apical echocardiographic images were obtained as described in dogs and cats and normal values for routine two-dimensional (2D-), time-motion (M-) and Doppler mode measurements were generated. Furthermore, a noninvasive smartphone base ECG recording and blood concentrations of cardiac biomarkers were obtained. Other radiographic measurements are provided for the skeletal and respiratory systems such as the trachea to inlet ratio and tracheal inclination. Knowledge of the normal radiographic thoracic and echocardiographic anatomy and function are fundamental for the diagnosis and follow-up of cardiac disease in affected individuals and for species screening, and will be of added value in future research in and conservation of this endangered species.

A demonstration of high field-of-view stability in hands-free echocardiography

BackgroundExercise stress echocardiography is clinically used to assess cardiovascular diseases. For accurate cardiac evaluation, a stable field-of-view is required. However, transducer orientation and position are difficult to preserve. Hands-free acquisitions might provide more consistent and reproducible results. In this study, the field-of-view stability and variability of hands-free acquisitions are objectively quantified in a comparison with manually obtained images, based on image structural and feature similarities. In addition, the feasibility and consistency of hands-free strain imaging is assessed.MethodsIn twelve healthy males, apical and parasternal images were acquired hands-free, using a fixation device, and manually, during semi-supine exercise sessions. In the final ten seconds of every exercise period, the image structural similarity and cardiac feature consistency were computed using a steerable pyramid employing complex, oriented wavelets. An algorithm discarding images displaying lung artifacts was created. Hands-free strain consistency was analyzed.ResultsHands-free acquisitions were possible in 9 of the 12 subjects, whereas manually 10 out of 12 could be imaged. The image structural similarity was significantly improved in the hands-free apical window acquisitions (0.91 versus 0.82), and at least equally good in the parasternal window (0.90 versus 0.82). The change in curvature and orientation of the interventricular septum also appeared to be lower in the hands-free acquisitions. The variability in field-of-view was similar in both acquisitions. Longitudinal, septal strain was shown to be at least as consistent when obtained hands-free compared to manual acquisitions.ConclusionsThe field-of-view was shown to be more or equally stable and consistent in the hands-free data in comparison to manually obtained images. The variability was similar, thus respiration- and exercise-induced motions were comparable for manual and hands-free acquisitions. Additionally, the feasibility of hands-free strain has been demonstrated. Furthermore, the results suggest the hands-free measurements to be more reproducible, though further analysis is required.

P972 Quantitative methods for assessing contractile reserve in patients with diastolic heart failure

Abstract Aim The effectiveness of isometric handgrip exercise on changes of cardiovascular hemodynamics 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 70-85 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 &amp;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 &amp;gt; 0,5) after handgrip maneuvers . On the other hand, LV force (SBP/ ESV ratio) ,MAP and HR decreases significantly (p &amp;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 &amp;lt; 0,001/, MAP /p &amp;lt; 0.01/ and contractile reserve as well as LV force /p &amp;lt; 0, 01/ and GLVLS /p &amp;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.

The impact of catheter ablation of atrial fibrillation on the left atrial volume and function: study using three-dimensional echocardiography

PurposeThe exact correlation between the baseline left atrial (LA) volume (LAV) and atrial fibrillation (AF) radiofrequency catheter ablation (RFCA) outcomes and changes to the LA after AF RFCA has not yet been fully understood. We sought to evaluate the serial changes in the LAV and LA function after RFCA using 3D echocardiography.MethodsConsecutive patients who received RFCA of paroxysmal (PAF) or persistent AF (PeAF) at our center between January 2013 and March 2016 were included. Real-time 3D apical full-volume images were acquired, and a 3D volumetric assessment was performed using an automated three-beat averaging method. The LAV index (LAVI) was calculated and the LA ejection fraction (LAEF) was calculated as [LAVmax − LAVmin]/LAVmax.ResultsNinety-nine total patients were enrolled, and the mean age was 58.0 ± 8.2 years and 75 (74.7%) were male. There were 59 (59.6%) PAF patients and the remaining 40 (40.4%) had PeAF. AF recurred in 5 of 59 (8.5%) PAF and in 10 of 40 (25%) PeAF patients. The LAVImax increased on 1 day, decreased at 3 months, and then increased again at 1 year but was lower than that at baseline. The LAEF changes were similar to the volume changes but were more prominent in PeAF than PAF patients. The baseline 3D LAVImax was an independent predictor of AF recurrence after RFCA and the cut-off value was 44.13 ml/m2.ConclusionIn our study, even after 3 months of scar formation due to ablation, structural remodeling of the LA continued. The changes were more prominent in the non-recurrent, PeAF patients.

Effeciency of Different Injection Obturation Techniques in Pulpectomized Deciduous Teeth Using Radiograph

ABSTRACT Objective: This study aimed to evaluate and compare the quality of different obturation techniques in primary teeth (navitip, endodontic pressure syringe, insulin syringe and reamer as a control) by using peri-apical radiograph. Materials and Methods: Eighty extracted human lower primary second molar teeth with minimum 7 mm root length were randomly divided in to four groups (Group one-navitip, Group two-endodontic pressure syringe, Group three – insulin syringe, Group four- reamer) were included in the study. Peri apical radiograph images were taken after the obturation for each group.To evalute over filling, under filling and optimal filling. Result: The results showed no significant differences between the four groups for the length of obturation (P > 0.05). Navitip and endodontic pressure syringe showed the best results for the length of obturation (50.0% optimal fillings) and insulin syringe showed (45.o% optimal fillings) for the length of obturation. Reamer showed (40.0%). Conclusion: The studies showed that all obturation techniques used didn’t provide ideal obturation with nearly comparable obturation quality for the techniques.

P2477Assessment of intraventricular flow dynamics in acute heart failure studied by Vector Flow Mapping

Abstract Background Although left ventricular (LV) flow dynamics should be closely related to LV morphology and function, little is known about how heart failure (HF) changes it. Pathline Analysis (PA), a recently developed software based on Vector Flow Mapping (VFM, Hitachi), enables us to trace the virtual blood particles entering to the LV in diastole and being ejected in systole. We investigated the change of flow dynamics in HF induced in dogs using PA. Methods In 15 open-chest dogs, HF was induced by intracoronary injection of microspheres. Color Doppler images of apical long-axis view were acquired using Prosound F75 (Hitachi) before and after HF and were analyzed by PA. We calculated the ratio of the numbers of entering particles in diastole and ejected particles in systole (ejection rate) and the distance reached by the particles in diastole corrected by the LV long-axis diameter (propagation distance). Apical and basal short axis images were acquired using GE Vivid E9 and were analyzed for peak rotation and peak twist. Results After inducing HF, LV end-diastolic pressure increased from 6±2 to 15±5 mmHg (p&lt;0.001) and ejection fraction (EF), apical peak rotation and peak twist decreased significantly (EF; 58±5 to 36±8%, apical peak rotation; 14±5 to 3±2 degree, peak twist; 19±5 to 6±3 degree, p&lt;0.05, respectively). PA showed most of the entering particles to the LV were ejected in the following systole at the control stage, but in HF, a significant part of the entering particles were not ejected and remained in the LV (Figure). Ejection rate decreased from 50±11 to 26±11% (p&lt;0.001) and the propagation distance decreased from 85±9 to 66±13% (p&lt;0.001) after inducing HF. There were significant relationships between indices obtained by PA and EF and peak twist (Table). Conclusion A significant part of inflow is not ejected directly to the outflow in the next systole and remains in the LV in HF, suggesting inefficient flow dynamics.