Biventricular Function Research Articles

Early cardiac dysfunction in obese adolescents with Down syndrome or autism.

Obesity in adolescents with intellectual and developmental disabilities) occurs at twice the frequency as their typically developing peers. Typically developing adolescents with obesity have abnormal cardiac function (as measured by strain echocardiography) and cardiac mass, but the effects of obesity on cardiac health in adolescents with Down syndrome or autism spectrum disorder are unknown. The purpose of this study was to evaluate the impact of body mass index on cardiac function in adolescents with Down syndrome or autism. Adolescents (age 12-21 years) with Down syndrome (n = 28), autism (n = 33), and age-/sex-matched typically developing controls (n = 15) received an echocardiogram optimised for strain analysis at a single timepoint. Measures of ventricular function, mass, and size were collected. Regression modelling evaluated the impact of body mass index and intellectual and developmental disabilities diagnosis on these cardiac measures. In regression modelling, an elevated body mass index z-score was associated with diminished systolic biventricular function by global strain (left ventricular longitudinal strain β 0.87, P < 0.001; left ventricular circumferential strain β 0.57, p 0.003; right ventricular longitudinal strain β 0.63, P < 0.001). Diminished left ventricular diastolic function by early diastolic strain rate was also associated with elevated body mass index (global longitudinal end-diastolic strain rate β -0.7, P < 0.001). No association was found between traditional (non-strain) measures of systolic and diastolic ventricular function and body mass index z-score. Obesity in adolescents with Down syndrome or autism negatively impacts cardiac function as measured by echocardiographic strain analysis that was not detected by traditional parameters.

Feasibility of clinical and electrocardiographic follow-up of prinzmetal angina using the metaverse

Abstract Background The recent pandemic triggered an acceleration in adopting innovative technologies and telemedicine novelties. The metaverse, representing a merge of digital worlds using augmented reality (AR) and virtual reality (VR), promises disruptive transformation in healthcare. The feasibility of combining the metaverse with cardiovascular telemedicine services empowering remote consultation as well as assisting heart disease prevention and diagnosis, has not been investigated yet in cardiology. Purpose We evaluated the feasibility of combined clinical and electrocardiographic follow-up inside the metaverse on top of standard of care for a patient who presented with prinzmetal angina. Methods A digital consultation room combining AR/VR was created in a metaverse platform (GDPR compliant, CE marked class I medical device). Patient and cardiologist were given a personal and secured login account. Interactions and connections were made via virtual avatars. Patient was instructed to ask for a consultation in case of any cardiac related symptom occurred. The patient was equipped with a previously validated portable hospital-grade 12-lead smartphone-based electrocardiograph device which was directly integrated to the metaverse platform. Results A 30 years old obese active smoker patient presented for recurrent episodes of typical cardiac chest pain at rest. ECG showed sinus rhythm, normal atrioventricular and intraventricular conduction and no repolarization abnormalities. Laboratory test were normal, echocardiography showed a normal biventricular function with no focal abnormalities or valvular disease. Coronary angiogram excluded the presence of coronary artery disease, and the most possible diagnostic scenario was prinzmetal angina from coronary artery spasm. The patient was therefore discharged under treatment with diltiazem 120 mg twice daily, a multiple lead smartphone ECG device as well as the access to metaverse via his avatar, since no ECG were available during the episodes. Ten days later, the patient experienced an episode of palpitation accompanied with general discomfort. He subsequently logged into the metaverse where the cardiologist was available. The anamnesis of the episode was collected as well as the auto-recorded ECG by the patient. Although the clinical and electrocardiographic data were reassuring, the physician proposed to seek for medical attention. Hospital work up was consistent with the diagnosis provided in the virtual consultation. Conclusions To our knowledge, we conducted the first medical act in cardiology inside the metaverse combining VR environment with existing cardiovascular technological innovations as support information to the standard of care. Exploiting the full potential of the metaverse could serve as an unparalleled leap in the way cardiovascular medicine is delivered and could introduce new dimensions to cardiology in terms of health education, disease prevention and diagnosis. Funding Acknowledgement Type of funding sources: None.

The effect of L-thyroxine treatment on ventricular dysfunction and pulmonary arterial stiffness in patients with subclinical hypothyroidism.

In our study, we aimed at evaluating the change in biventricular functions and pulmonary arterial stiffness (PAS) in patients with subclinical hypothyroidism (SH) in whom euthyroidism was achieved with L-thyroxine therapy. 70 SH patients and 75 healthy volunteers were included in our study consecutively. Baseline demographic and echocardiographic data of the participants were recorded. The data obtained in the control evaluation 6 months after the euthyroidism were achieved in the SH group patients started on L-thyroxine treatment and then compared with the baseline measurements. The mean age of patients in the SH group was 44.1 ± 9.4 years and 47.1% were women. Euthyroidism in SH patients was achieved with a mean daily L-thyroxine treatment of 59 µg/day for a mean of 16.1 ± 4.5 weeks. Positive changes in metabolic and hormonal profiles were achieved after L-thyroxine treatment in SH patients. It was determined that left ventricular and right ventricular isovolumetric relaxation and myocardial performance index were higher in SH patients compared to the control group, and these measurements were observed to decrease significantly with L-thyroxine treatment (p < 0.05 for each). While PAS was 16.9 ± 3.1 kHz/ms in the control group, it was 25.2 ± 5.3 kHz/ms in the SH group (p < 0.05). After L-thyroxine treatment, PAS measurements decreased to 17.2 ± 3.2 kHz/ms (p < 0.05) in the SH group and showed a positive change. Thyroid-stimulating hormone (TSH) change (Δ TSH) with Δ E/A ratio (r: -0.407, p < 0.001), right ventricular myocardial performance index (Δ RV MPI) change (r: 0.404, p < 0.001) and PAS change (Δ PAS) (r: 0.458, p < 0.001) found to be correlated. SH is associated with dysfunction in the biventricular and pulmonary vascular bed. Biventricular functions and PAS change positively in SH patients with L-thyroxine treatment.

A randomized controlled trial of positive end-expiratory pressure on pulmonary oxygenation and biventricular function in esophageal cancer patients receiving one-lung ventilation under a lower FiO2

Arterial oxygenation is often impaired during one-lung ventilation (OLV), due to both pulmonary shunt and atelectasis. Lower fraction of inspiration O2 (FiO2) may reduce inflammation and complications, but may increase the risk of hypoxemia. The aim of this randomized controlled parallel trial was to analyze whether higher positive end-expiratory pressure (PEEP) could improve oxygenation and maintain lower levels of inflammation during OLV under a lower FiO2. One hundred and twenty patients with selective thoracotomy for esophageal cancer (EC) were classified randomly into four groups on a ratio of 1:1:1:1 using a computer-generated list, including Group A (FiO2 =0.6, PEEP =0), Group B (FiO2 =0.6, PEEP =5 cmH2O), Group C (FiO2 =1.0, PEEP =8 cmH2O), and Group D (FiO2 =1.0, PEEP =10 cmH2O). The oxygenation and pulmonary shunt were primary outcomes. Haemodynamics, respiratory mechanics, serum IL-6 and IL-10 levels, and complications were taken as secondary outcomes. Follow-up was terminated until discharge. Two patients in Group A and two in Group D were excluded due to hypoxemia and hypotension, respectively. Then the data of 116 patients (Group A =28, Group B =30 Group C =30, and Group D =28) were assessed for final analysis. Compared with Group B, the partial pressure of oxygen (PaO2) and dynamic compliance during OLV in Group D were significantly increased from 15 minutes to 60 minutes, while pulmonary shunt was significantly decreased (P>0.05). Patients in Group D had higher levels of central venous pressure (CVP) and airway pressure (Paw) during OLV and higher levels of IL-6 and IL-10 after OLV compared with Group B (P>0.05). No statistical differences were found in oxygen saturation (SaO2), PvO2 (partial pressure of oxygen in venous blood), partial pressure of end-tidal carbon dioxide (ETCO2), partial pressure of carbon dioxide in artery (PaCO2), heart rate (HR), mean arterial pressure (MAP), and complications among the four groups (P>0.05). Higher PEEP increased the oxygenation under 60% O2 during OLV. However, the haemodynamics and respiratory mechanics changed, and the levels of inflammation increased. A higher PEEP under 60% O2 during OLV is not recommended. Chinese Clinical Trial Registry ChiCTR1900024726.

Comparison of biventricular myocardial strain according to treatment regimens in patients discharged after COVID-19 recovery

Purpose: The effects of different COVID-19 therapeutic strategies on cardiac function are uncertain. Therefore, this study aimed to evaluate the effects of different medical treatments on biventricular function in patients who had recovered from COVID-19.&#x0D; Materials and Methods: Speckle-tracking echocardiography was performed to examine the biventricular myocardial function of patients at follow-up visits after recovery from COVID-19. The patients were divided into two groups based on the medication they used during the active disease: favipiravir (FAV; n = 60) or hydroxychloroquine (HCQ; n = 60). A comparison was made with risk factor–matched controls (n = 41).&#x0D; Results: A total of 161 patients were included in the study. The left ventricular end-diastolic volume, end-systolic volume, end-diastolic diameter, and end-systolic diameter were higher in the HCQ and FAV groups compared to the controls, while the left ventricular ejection fraction was similar between all the groups. The right ventricular diameter was increased, and the systolic pulmonary artery pressure was higher in the HCQ and FAV groups compared to the controls. The left ventricular global longitudinal strain (-18±6.6 vs. -19.7±4.4 vs. -20.4±5, respectively), the right ventricular global longitudinal strain (-19.8±7.5 vs. -22.2±6 vs. -23.4±6.2, respectively), and the right ventricular free wall strain (-16.9±3.6 vs. -18.2±2.4 vs. -19.6±4.7, respectively) were worse in the HCQ group compared to the FAV and control groups.&#x0D; Conclusion: This study found echocardiographic evidence of subclinical cardiac involvement in both the HCQ and FAV groups compared to the controls. However, HCQ treatment was associated with an increased risk of biventricular subclinical systolic dysfunction in COVID-19 survivors compared with FAV treatment.

Double chambered left ventricle-Two chambers are not better than one.

In this month's Journal,1 Ali and colleagues present a case series consisting of two adults who underwent surgical resection for a double chamber left ventricle (DCLV). The first case was an 18-year-old female with several years of progressive chest pain and dyspnea who was ultimately found to have both a double chamber right ventricle (DCRV) and DCLV after transthoracic echocardiography (TTE) and cardiac catheterization. She underwent surgical resection of the fibromuscular bands in both ventricles with an uncomplicated postoperative course. The second case was a 27-year-old male with a history of supravalvular aortic stenosis that had been previously addressed who on TTE was found to have aortic regurgitation, aortic stenosis, and DCLV with elevated left ventricular outflow tract and accessory chamber (AC) gradients. He underwent mechanical aortic valve replacement, ascending aorta replacement, and muscle bundle excision with a course notable for delayed sternal closure and retroperitoneal hematoma. Both patients had technically successful operations with band resection and appropriate biventricular function confirmed on TTE. Both survived their index operations and had resolution of their symptoms, with the second patient dying at 6 months due to complications from anticoagulation. The authors should be congratulated for the successful identification and operative treatment of these patients. DCLV is an incredibly rare diagnosis and is even less common than its counterpart DCRV—which is seen in less than 2% of all congenital cardiac anomalies.2 Ali and colleagues successfully differentiated DCLV from other similar pathologies such as left ventricular aneurysms and left ventricular diverticulum. This is critical given their difference in etiology and overall management. Those with asymptomatic DCLV do not require surgical intervention. Symptoms are rare but can present as fatal tachyarrhythmias or heart failure. Patients can also be found to have mid-ventricular obstructions, particularly those with superior–inferior arrangements according to Bao et al.3 Those who are intervened upon typically undergo resection with patch reconstruction or cardiac transplant for large communications.4 Furthermore, diagnosing DCLV can be a challenge in and of itself. Some patients, including the second case of this study, have previous imaging that does not confirm the presence of DCLV.5 This just reiterates the importance of having a high clinical suspicion. Nevertheless, TTE is typically the first test performed and serves as a fairly reliable starting point. Bao et al.3 showed that in their series of nine patients, eight were correctly diagnosed during their initial TTE. Although a tissue diagnosis would be the best confirmatory test, a second imaging modality is typically used to confirm the diagnosis. The authors used cardiac catheterization and magnetic resonance imaging (MRI) in their first and second case, respectively, as their second modality of choice. The advantages of cardiac MRI are stated throughout the literature. It offers high inherent contrast resolution, good spatial and temporal resolutions, a wide field of view, multiplanar imaging capabilities, and the absence of radiation.4, 6 Gadolinium is particularly useful as a similar enhancement of the AC wall compared to the remainder of the left ventricular myocardium supports the diagnosis of DCLV.7 We (Figure 1) commend the authors on their work with this complex patient population. Both cases presented were unique and challenging. The authors demonstrated the ability to address DCLV in addition to the patient's existing congenital abnormalities. Furthermore, they demonstrate the ability to do so through both a transaortic and transmitral approach. DCLV is an incredibly rare diagnosis, making it difficult to establish practice guidelines. One should always pause when deciding when and how to operate on these patients. Still, Ali and colleagues add to the body of literature that suggests operating on DCLV can be done safely and that patients may derive a meaningful benefit. This work was supported by a research grant from NHLBI/NIH (No. T32HL007849). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health. The authors declare no conflict of interest.

Epicardial adipose tissue thickness is associated with reduced peak oxygen consumption and systolic reserve in patients with type 2 diabetes and normal heart function.

To investigate the impact of epicardial adipose tissue (EAT) thickness on cardiopulmonary performance in patients with type 2 diabetes (T2D) and normal heart function. We analysed EAT thickness in subjects with T2D and normal biventricular systo-diastolic functions undergoing a maximal cardiopulmonary exercise test combined with stress echocardiography, speckle tracking and pulmonary function assessment, as well as serum N-terminal pro B-type natriuretic peptide (NT-proBNP). In the 72 subjects enrolled, those with EAT thickness above the median (> 5 mm) showed higher body fat mass, smaller indexed left ventricular dimensions and marginally reduced diastolic function variables at rest. Higher EAT thickness was associated with lower peak oxygen uptake (VO2peak 17.1 ± 3.6 vs. 21.0 ± 5.7ml/min/kg, P=.001), reduced systolic reserve (ΔS' 4.6 ± 1.6 vs. 5.8 ± 2.5m/s, P=.02) and higher natriuretic peptides (NT-proBNP 64 [29-165] vs. 31 [26-139] pg/ml, P=.04), as well as chronotropic insufficiency and impaired heart rate recovery. Ventilatory variables and peripheral oxygen extraction were not different between groups. EAT was independently associated with VO2peak and linearly and negatively correlated with peak heart rate, heart rate recovery, workload, VO2 at the anaerobic threshold and at peak, and cardiac power output, and was directly correlated with natriuretic peptides. Higher EAT thickness in T2D is associated with worse cardiopulmonary performance and multiple traits of subclinical cardiac systolic dysfunction.

Dissecting Intramyocardial Hematoma Following Mitral Valve Repair

A 67-year-old male patient with a severe mitralinsufficiency presented for reoperation after a failed Mitral Valve (MV) repair. The prior annuloplasty ring was removed and a new 32-mm fully rigid ring was inserted with the affixation of artificial chords to the anterior MV leaflet. Initial post-bypass transesophageal echocardiographic examination demonstratedresolution of mitral regurgitation and normal biventricular function (Figure 1), RV=Right Ventricle, LV=Left Ventricle).

Situación Fallot reparada en la edad adulta: resultados de 3 décadas de experiencia

IntroductionWe define “Fallot situation” as the existence of significant ventricular septal defect and right ventricular outflow obstruction. Survival into adulthood is extremely rare without complete surgical repair. We present our experience operating these adults. MethodsWe consider complete surgical repair in Fallot adult patients if they have pulmonary arteries with adequate size. Retrospective study: 45 Fallot patients operated from 1993 to 2022 in our adult congenital heart unit. Statistical analysis: SPSS® 20.0. ResultsMean age: 37±13 years, 53% male, 18% prior palliation. Principal diagnosis: double chamber right ventricle+ventricular septal defect (60%), tetralogy of Fallot (27%). NYHA functional class: i 31%, ii 38%, iii 31%. Arrhythmia 20%. Mean hematocrit: 48±10%. Associated left pulmonary artery agenesis 7%, severe aortic regurgitation 7%. Main surgical indication was pulmonary stenosis 98%. Additional tests showed high gradients between the right ventricle and pulmonary artery, and good biventricular function. Surgeries were performed by median sternotomy with cardiopulmonary bypass, moderate hypothermia and aortic clamp. Ventricular septal defect was closed through the right atrium (71%). Reconstruction of the right ventricle outflow tract was done by preserving the pulmonary valve (80%), interposing bioprosthesis (16%), and using transannular patch (4%). Associated surgery (18%): tricuspid (one), aortic (6), anomalous pulmonary venous drainage (one). Inhospital mortality: one patient (2,2%). Mean follow-up: 8.9±7.6 years. Late mortality: 2 patients (4.5%). Reintervention: 7 patients (15%) because of residual lesions (3 percutaneous, 5 surgical). Nowadays, functional class: i 68%, ii 28%, iii 4%; sinus rhythm 83%. ConclusionsComplete surgical repair in adulthood of Fallot patients achieves clinical improvement by eliminating the cyanosis, closing intracardiac shunts, and decreasing right ventricular pressure overload. Our results are excellent with good rates of pulmonary annulus preservation, low mortality and acceptable reintervention rate in the follow up.

The effect of placental transfusion on hemodynamics in premature newborns: a randomized controlled trial

Despite of growing evidence of the beneficial effects of placental transfusion techniques, there is no available sufficient data about their effects on vulnerable hemodynamics and myocardium of premature infants. The purpose of this work is to study ventricular functions and hemodynamics after applying different placental transfusion techniques, delayed cord clamping (DCC), cut cord milking (C-UCM), and intact cord milking (I-UCM). Sixty-four infants delivered whether by C-section or vaginal delivery were randomly assigned to undergo C-UCM (20–30 cm), I-UCM (3–4 strippings), and DCC (30–60 s). Functional echocardiography was done on day 1 and day 3 of life for 57 infants. Primary outcome variable was superior vena cava flow measurement in infants having placental transfusion in the first 24 h of life and between 64 and 72 h. Secondary outcomes were other echocardiographic and clinical hemodynamic parameters, and biventricular functions in those infants. Of a total 196 preterm infants ≤ 32 weeks delivered in the study period, from January 2021 to August 2021, 57 infants were eligible and survived till the second examination. They were randomly assigned to the three groups. Neonates randomly assigned to DCC had significantly higher superior vena cava flow and lower right ventricular systolic function in the first 24 h of life. This finding vanished at day 3. Neonates undergone different methods of placental transfusions had similar hemoglobin, admission temperature, and mean blood pressure in the first 24 h of life.Conclusion: Despite their potential benefits, placental transfusions have shown to alter the hemodynamics and adversely affect myocardial function of premature neonates.Trial registration: This trial was registered in the clinical trial gov NCT04811872.What is Known:• Placental transfusion techniques might have benefits regarding prematurity- related morbidities and mortality.What is New:• Placental transfusion might adversely affect the myocardium and alter hemodynamics in premature infants.

Relationship Between Epicardial Adipose Tissue and Biventricular Longitudinal Strain and Strain Rate in Patients with Type 2 Diabetes Mellitus

Epicardial adipose tissue (EAT) has been reported to be increased in patients with type 2 diabetes mellitus (T2DM). EAT thickness may impact left ventricular (LV) diastolic function. However, the association between EAT and right ventricular (RV) function in T2DM is unclear. We hypothesized an association between EAT volume and biventricular longitudinal strain and strain rate in patients with T2DM. A total of 20 controls and 69 T2DM patients with preserved LV ejection fraction (EF) who underwent cardiac magnetic resonance (CMR) were included. Biventricular function was evaluated by CMR Tissue-Tracking derived strain analysis, including LV global peak systolic longitudinal strain (LVGLS), peak diastolic longitudinal strain rate (LVLSR), RVGLS and RVLSR. Compared to controls, patients with T2DM had significantly higher EAT volumes with lower LVGLS, LVLSR, RVGLS and RVLSR (all p<0.05). EAT volume was significantly correlated with LVGLS, LVLSR, RVGLS and RVLSR in T2DM patients (r=-0.45, -0.39, -0.59, -0.50, all p<0.001). Multivariate linear regression analysis revealed that EAT volume was significantly associated with LVGLS (β=0.38, p=0.001), LVLSR (β=-0.35, p=0.003), RVGLS (β=0.64, p<0.001) and RVLSR (β=-0.43, p<0.001) independently of traditional risk factors in patients with T2DM. Patients with T2DM had higher EAT levels and lower biventricular function than controls. EAT volume was independently associated with biventricular longitudinal strain and strain rate in T2DM patients.

The biventricular contribution to chronic pulmonary hypertension of the extremely premature infant.

Evaluate factors associated with significant pulmonary hypertension [PH] (≥2/3 systemic) and its impact on ventricular function at 36 weeks postmenstrual age (PMA). Retrospective cohort of infants born at <29 weeks who survived to their echocardiography screening for PH at 36 weeks PMA. Masked experts extracted conventional and speckle-tracking echocardiography [STE] data. Of 387 infants, 222 were included and 24 (11%) categorized as significant PH. Significant PH was associated with a decrease in tricuspid annular plane systolic excursion (0.79 vs 0.87 cm, p = 0.03), right peak longitudinal strain [pLS] by STE (-19.6 vs -23.1%, p = 0.003) and left pLS (-25.0 vs -22.7%, p = 0.02). The association between biventricular altered function by STE and significant PH persisted after adjustment for potential confounders - LV-pLS (p = 0.007) and RV-pLS (p = 0.01). Our findings are suggestive that premature newborns with significant PH at 36 weeks PMA have a biventricular cardiac involvement to their pathophysiology.

Evaluation of biventricular longitudinal myocardial function in normal fetuses at different gestational ages using ultrasonic velocity vector imaging.

ObjectiveThis study aimed to evaluate biventricular myocardial function and biventricular longitudinal global myocardial function of fetuses at different gestational weeks using ultrasonic velocity vector imaging.MethodsA total of 127 pregnant women were enrolled and divided into five groups according to the gestational age of their fetuses. The velocity, strain, and strain rate of the left and right ventricles were measured, and these biventricular parameters were compared between the groups. The global parameters of the biventricular myocardium were also compared.ResultsA pairwise comparison revealed that the differences in biventricular velocity and strain rate between groups in adjacent gestational weeks were not statistically significant (P > 0.05), but velocity increased with gestational age. A comparison of fetal longitudinal global myocardial parameters revealed that the global velocity, strain, and strain rate of the right ventricle were higher than those of the left ventricle, and the differences were statistically significant (P < 0.05) in all groups.ConclusionThe peak velocities of the fetal left and right ventricles increased with gestational age, but the global strain and strain rate did not, suggesting that fetal myocardial function is mature and constant in the middle and late stages of pregnancy and can more reliably reflect myocardial deformation. The peak systolic velocity, global strain, and peak strain rate of the right ventricle were higher than those of the left ventricle, suggesting that the right ventricle dominates longitudinal systolic movement from the second trimester of pregnancy.

Diagnostic Approach for the Primary Cardiac Angiosarcoma – A Case Report

Background: We report a 25-year-old male who presented to an outside institution with progressive dyspnoea. He had increased jugular venous pressure and muffled heart sounds, suggesting a pericardial tamponade. A diagnosis of a cardiac angiosarcoma was put forward. Primary cardiac tumours are rare, and patients can present with constitutional symptoms, posing a diagnostic challenge. The objective of this report is to suggest a diagnostic standard for early recognition of these fatal tumours. Case presentation: A chest radiograph demonstrated an enlarged cardiac contour and signs of pericardial tamponade. Pericardiocentesis was performed, complicated by a pneumopericardium and the pericardial fluid was haemorrhagic and exudative. Echocardiography confirmed a right atrial mass featured by heterogeneous enhancement in subsequent chest computed tomography and magnetic resonance imaging concerning a sarcoma. No metastatic lesions were found. The tumour was excised completely, and the following echocardiogram indicated normokinetic biventricular function. Histological examination of the tumour cells confirmed the presence of a cardiac angiosarcoma. Patient was scheduled for combined chemotherapy following discharge. Conclusion: Primary cardiac angiosarcomas are difficult to diagnose due to the rarity of the tumour as well as the non-specific symptoms. An early diagnosis may help improve prognosis which emphasizes the importance of establishing a standard diagnostic protocol for such tumours.

Reversal of right ventricular pressure loading improves biventricular function independent of fibrosis in a rabbit model of pulmonary artery banding.

Right ventricular (RV) pressure loading leads to RV and left ventricular (LV) dysfunction through RV hypertrophy, dilatation and fibrosis. Relief of RV pressure load improves RV function. However, the impact and mechanisms on biventricular reverse-remodelling and function are only partially characterized. We evaluated the impact of RV pressure overload relief on biventricular remodelling and function in a rabbit model of reversible pulmonary artery banding (PAB). Rabbits were randomized to three groups: (1) Sham-operated controls (n=7); (2) PAB (NDef, n=7); (3) PAB followed by band deflation (Def, n=5). Sham and NDef animals were sacrificed at 6weeks after PAB surgery. Def animals underwent PAB deflation at 6weeks and sacrifice at 9weeks. Biventricular geometry, function, haemodynamics, hypertrophy and fibrosis were compared between groups using echocardiography, magnetic resonance imaging, high-fidelity pressure-tipped catheters and histology. RV pressure loading caused RV dilatation, systolic dysfunction, myocyte hypertrophy and LV compression which improved after PAB deflation. RV end-diastolic pressure (RVEDP) decreased after PAB deflation, although remaining elevated vs. Sham. LV end-diastolic pressure (LVEDP) was unchanged following PAB deflation. RV and LV collagen volumes in the NDef and Def group were increased vs. Sham, whereas RV and LV collagen volumes were similar between NDef and Def groups. RV myocyte hypertrophy (r=0.75, P<0.001) but not collagen volume was related to RVEDP. LV myocyte hypertrophy (r=0.58, P=0.016) and collagen volume (r=0.56, P=0.031) correlated with LVEDP. In conclusion, relief of RV pressure overload improves RV and LV geometry, hypertrophy and function independent of fibrosis. The long-term implications of persistent fibrosis and increased biventricular filling pressures, even after pressure load relief, need further study. KEY POINTS: Right ventricular (RV) pressure loading in a pulmonary artery banding rabbit model is associated with RV dilatation, left ventricular (LV) compression; biventricular myocyte hypertrophy, fibrosis and dysfunction. The mechanisms and impact of RV pressure load relief on biventricular remodelling and function has not been extensively studied. Relief of RV pressure overload improves biventricular geometry in conjunction with improved RV myocyte hypertrophy and function independent of reduced fibrosis. These findings raise questions as to the importance of fibrosis as a therapeutic target.

Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients.

Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality. We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality. Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

Cardiogenic shock and tumor resection due to cardiac synovial sarcoma: a case report

BackgroundCardiac synovial sarcoma of the heart is a rare, aggressive mesenchymal tumor with poor prognosis, since complete resection is seldom feasible.Case presentationA 23-year-old man was referred in cardiogenic shock. Emergency computed tomography (CT) revealed a large tumor with obstruction of the right atrium (RA) and prolapse into the right ventricle (RV). Resection and pericardial patch plasty were performed. Histology confirmed a G-3 spindle-cell sarcoma. At 21 months postoperatively, CT and cardiac magnetic resonance (MR) angiography showed a tumor emerging from the lateral wall of the superior caval vein (SCV) and the RA. The RA and SCV were completely resected and replaced with a tailored Dacron tunnel prosthesis. Histology confirmed R0 resection of a G-3 spindle-cell sarcoma. Reverse transcription-polymerase chain reaction (RT-PCR) confirmed a monophasic fibrous synovial sarcoma. Echocardiography upon discharge showed normal biventricular function. The heart was tumor-free upon PET-CT 24 months thereafter. A sudden progression with innumerable pulmonary nodules caused only minimal exertional dyspnea, and the patient received palliative monochemotherapy with ifosfamide. Thirty months after the first operation, he succumbed to hemorrhage from a brain metastasis.ConclusionsWe report an unusually long postoperative period of 30 months in our patient after resection of a very large right atrial sarcoma. Early diagnosis, aggressive surgical treatment, adjunctive chemotherapy and radiotherapy affect survival. Systematic inclusion of patients in multicenter initiatives, including biobanking, is necessary. Better knowledge of genetic defects relevant to these cardiac tumors will promote accurate diagnoses and suggest novel and personalized gene-based therapies.

Different Impacts on the Heart After COVID-19 Infection and Vaccination: Insights From Cardiovascular Magnetic Resonance.

IntroductionMyocarditis-like findings after COVID-19 (coronavirus disease 2019) infection and vaccination were reported by applying cardiovascular magnetic resonance (CMR). These results are very heterogenous and dependent on several factors such as hospital admission or outpatient treatment, timing of CMR, and symptomatic load. This retrospective study aimed to identify differences in myocardial damage in patients with persistent symptoms both after COVID-19 infection and vaccine by applying CMR.Materials and MethodsThis study entails a retrospective analysis of consecutive patients referred for CMR between August 2020 and November 2021 with persistent symptoms after COVID-19 infection or vaccination. Patients were compared to healthy controls (HC). All patients underwent a CMR examination in a 1.5-T scanner with a scan protocol including: cine imaging for biventricular function and strain assessment using feature tracking, T2 mapping for the quantification of edema, and T1 mapping for diffuse fibrosis and late gadolinium enhancement (LGE) for the detection and quantification of focal fibrosis. Patients were divided into a subacute COVID-19 (sCov) group with symptoms lasting < 12 weeks, post-COVID-19 (pCov) group with symptoms > 12 weeks, and patients after COVID-19 vaccination (CovVac).ResultsA total of 162 patients were recruited of whom 141 were included for analysis. The median age in years (interquartile range (IQR)) of the entire cohort was 45 (37–56) which included 83 women and 58 men. Subgroups were as follows (total patients per subgroup, median age in years (IQR), main gender): 34 sCov, 43 (37–52), 19 women; 63 pCov, 52 (39–58), 43 women; 44 CovVac, 43 (32–56), 23 men; 44 HC (41 (28–52), 24 women). The biventricular function was preserved and revealed no differences between the groups. No active inflammation was detected by T2 mapping. Global T1 values were higher in pCov in comparison with HC (median (IQR) in ms: pCov 1002ms (981–1023) vs. HC 987ms (963–1009; p = 0.005) with other parings revealing no differences. In 49/141 (34.6%) of patients, focal fibrosis was detectable with the majority having a non-ischemic pattern (43/141; 30.4%; patients) with the subgroups after infection having more often a subepicardial pattern compared with CovVac (total (% of group): sCov: 7/34(21%); pCov 13/63(21%); CovVac 2/44(5%); p = 0.04).ConclusionPatients after COVID-19 infection showed more focal fibrosis in comparison with patients after COVID-19 vaccination without alterations in the biventricular function.

Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review.

Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.

Cardiovascular magnetic resonance in autoimmune rheumatic diseases: a clinical consensus document by the European Association of Cardiovascular Imaging.

Autoimmune rheumatic diseases (ARDs) involve multiple organs including the heart and vasculature. Despite novel treatments, patients with ARDs still experience a reduced life expectancy, partly caused by the higher prevalence of cardiovascular disease (CVD). This includes CV inflammation, rhythm disturbances, perfusion abnormalities (ischaemia/infarction), dysregulation of vasoreactivity, myocardial fibrosis, coagulation abnormalities, pulmonary hypertension, valvular disease, and side-effects of immunomodulatory therapy. Currently, the evaluation of CV involvement in patients with ARDs is based on the assessment of cardiac symptoms, coupled with electrocardiography, blood testing, and echocardiography. However, CVD may not become overt until late in the course of the disease, thus potentially limiting the therapeutic window for intervention. More recently, cardiovascular magnetic resonance (CMR) has allowed for the early identification of pathophysiologic structural/functional alterations that take place before the onset of clinically overt CVD. CMR allows for detailed evaluation of biventricular function together with tissue characterization of vessels/myocardium in the same examination, yielding a reliable assessment of disease activity that might not be mirrored by blood biomarkers and other imaging modalities. Therefore, CMR provides diagnostic information that enables timely clinical decision-making and facilitates the tailoring of treatment to individual patients. Here we review the role of CMR in the early and accurate diagnosis of CVD in patients with ARDs compared with other non-invasive imaging modalities. Furthermore, we present a consensus-based decision algorithm for when a CMR study could be considered in patients with ARDs, together with a standardized study protocol. Lastly, we discuss the clinical implications of findings from a CMR examination.