Cardiac Chambers Research Articles

Abstract 4117922: The Role of Combined Renin Angiotensin Aldosterone System Inhibitors (RAASi) Plus Beta Blocker Therapy For Cardiotoxicity Prevention In Patients Under Chemotherapy For Breast Cancer: A Meta-Analysis of Randomized Controlled Trials

Introduction: Anti-neoplastic agents, including anthracyclines and trastuzumab, frequently employed in breast cancer treatment carry on considerable cardiotoxic effects impairing both cardiac chamber and cardiac fiber parameters leading to incident heart failure. In response to this challenging side effect, numerous randomized controlled trials (RCTs) have investigated the cardioprotective efficacy of RAASi and beta-blockers (BBs) in patients undergoing anthracycline and trastuzumab chemotherapy. We aim to perform an updated meta-analysis to elucidate the potential cardioprotective properties of these medications in patients undergoing chemotherapy for breast cancer. Methods: A comprehensive search of the literature was performed through April 2024 on PubMed, EMBASE and Clinicaltrials.gov. In total, data from 4 randomized studies were extracted and analyzed. The primary analysis was the effect of RAASi and BBs on LVEF as well as global longitudinal strain (GLS). Data were analyzed using a random-effects model to derive weighted mean differences (WMDs) and 95% confidence intervals for both LVEF and GLS. Data was analyzed using Review Manager 5.3 (RevMan 5.3) software. Results: In total, data from 248 patients (N = 124 on cardioprotection; N = 124 without cardioprotection) undergoing treatment with anti-neoplastic agents for breast cancer were included. At the end of treatment, patients undergoing cardioprotective therapy demonstrated improved LVEF preservation compared to the control group, (mean difference 2.14 [0.03, 4.25]; P=0.05; I2 = 79%). In addition, patients undergoing dual RAASi + BB therapy showed better GLS preservation compared to control group (mean difference –1.37 [-2.01, -0.72]; P < 0.0001; I2 = 0%). Conclusion: In breast cancer patients undergoing anti-neoplastic regimens comprising anthracycline and trastuzumab, the concomitant administration of RAASi and BBs demonstrated better LVEF as well as GLS preservation upon completion of treatment over those without cardioprotective therapy. These findings shed light on the potential benefit derived from the synergistic effects of RAASi and BBs therapy in safeguarding both cardiac chamber and fiber functions amidst aggressive anti-cancer regimens, although further investigations still need to be conducted.

Staging Heart Failure with Preserved Ejection Fraction by Assessing Cardiac Chamber Involvement

The management of heart failure with preserved ejection fraction (HFpEF) remains largely unresolved due to our limited understanding of the underlying mechanisms of the pathology and the challenges in accurately phenotyping this heterogeneous syndrome. A paradigm shift is required to personalise care and unify our approaches to HFpEF patients for future clinical trials. Accordingly, we propose a staging classification for HFpEF based on the identification of the involved cardiac chambers by echocardiography.

Rare case of aorto-left atrial tunnel with associated bicuspid aortic valve, large patent ductus arteriosus, and atrial septal defects.

Aorto-cardiac tunnels represent uncommon cardiovascular anomalies connecting the ascending aorta to cardiac chambers and are typically characterized by extra-cardiac tubular channels. Among these, the involvement of the left atrium is exceptionally rare, with only a few cases reported in literature. Here, we describe a case of an aorto-left atrial tunnel in a 6-year-old boy with an associated bicuspid aortic valve, a large patent ductus arteriosus, and atrial septal defects. This case highlights the significance of multimodal imaging in the accurate identification and characterization of rare cardiovascular anomalies.

Cardiac Computed Tomography as a Method of Diagnosing the Type of Cardiac Tumor—Example of Interatrial Septal Lipoma Filling the Right Atrium

Cardiac tumors present substantial diagnostic challenges due to their diverse manifestations and similarity to other cardiac pathologies. Cardiac lipomas are rare tumors that originate from adipose cells and can develop in any location within the heart. Cardiac lipomas account for 2.4% of all primary cardiac tumors. Most lipomas are located within the cardiac chambers. Among the lipomas occurring within the cardiac chambers, the most common localization is the right atrium. Currently, the gold standard for imaging cardiac tumors is cardiac magnetic resonance (CMR). Despite the significant advantages of CMR, cardiac computed tomography angiography (CCTA) continues to be a valuable technique when CMR is either unavailable or contraindicated. In some cardiac tumors, CCTA can identify the type of tumor. A classic example of this type is a lipoma. We present images of a large interatrial septal lipoma filling the right atrium diagnosed by CCTA in a 57-year-old female Caucasian patient. In summary, CCTA effectively identifies lipomas’ characteristic features and provides crucial information for appropriate management.

A novel non-contrast agent-enhanced 3D whole-heart magnetic resonance sequence for congenital heart disease patients: the REACT Study.

The three-dimensional balanced-steady-state-free-precession (3D bSSFP) whole-heart (WH) technique has long been used to depict cardiac morphology in congenital heart disease (CHD) but is prone to banding artifacts. The Relaxation Enhanced Angiography without Contrast and Triggering (REACT) sequence is an alternative method that is resistant to off-resonance effects. To evaluate cardiac structures and great vessels in CHD patients using 3D WH REACT sequence and compare it to 3D WH bSSFP sequence. This study was approved by the Institutional Review Board. Thirty CHD patients were prospectively enrolled. Contrast-to-noise ratio (CNR), image quality, and cross-sectional area (CSA) were analyzed. Categorical data were compared with a Wilcoxon signed-rank test and normally distributed variables with a t-test. Thirty patients (16 females) participated in this study (median age 17, range 5months to 52years). REACT showed higher CNR in all pulmonary veins (all P<0.05), while 3D bSSFP had higher CNR in the right ventricle (P<0.001) and right pulmonary artery, (P=0.04). Image quality favored 3D bSSFP in the right atrium and ventricle (both P<0.001), main pulmonary artery (P=0.02), and coronary arteries (left: P<0.001, right: P=0.01). REACT outperformed 3D bSSFP for the pulmonary veins (all P<0.05) from image quality perspective. CSA measurements were not significantly different between REACT and 3D bSSFP (all P≥0.05). The REACT method is associated with improved image quality and CNR for pulmonary veins, with CSA measurements concordant with 3D bSSFP in CHD patients, while bSSFP shows better performance for imaging cardiac chambers and coronary arteries.

Artificial intelligence applied to coronary artery calcium scans (AI-CAC) significantly improves cardiovascular events prediction

Coronary artery calcium (CAC) scans contain valuable information beyond the Agatston Score which is currently reported for predicting coronary heart disease (CHD) only. We examined whether new artificial intelligence (AI) applied to CAC scans can predict non-CHD events, including heart failure, atrial fibrillation, and stroke. We applied AI-enabled automated cardiac chambers volumetry and calcified plaque characterization to CAC scans (AI-CAC) of 5830 asymptomatic individuals (52.2% women, age 61.7 ± 10.2 years) in the multi-ethnic study of atherosclerosis during 15 years of follow-up, 1773 CVD events accrued. The AUC at 1-, 5-, 10-, and 15-year follow-up for AI-CAC vs. Agatston score was (0.784 vs. 0.701), (0.771 vs. 0.709), (0.789 vs. 0.712) and (0.816 vs. 0.729) (p < 0.0001 for all), respectively. AI-CAC plaque characteristics, including number, location, density, plus number of vessels, significantly improved CHD prediction in the CAC 1–100 cohort vs. Agatston Score. AI-CAC significantly improved the Agatston score for predicting all CVD events.

Effects of systemic ventricular assist in failing Fontan patients: a theoretical analysis using a computational model

Mechanical circulatory support is a potential treatment for failing Fontan patients. In this study, we performed a theoretical analysis using a computational model to clarify the effects of systemic ventricular assist device (VAD) in failing Fontan patients. Cardiac chambers and vascular systems were described using the time-varying elastance model and modified Windkessel model, respectively. A VAD was simulated as a nonlinear function. In systolic and diastolic ventricular dysfunction and atrioventricular valve regurgitation models, systemic VAD increased the cardiac index and decreased the central venous pressure (CVP). However, in the high pulmonary vascular resistance model, CVP became extremely high above 15 mmHg to maintain the cardiac index when the pulmonary vascular resistance index (PVRI) was above 5 Wood units m2. In Fontan patients with ventricular dysfunction or atrioventricular valve regurgitation, systemic VAD efficiently improves the hemodynamics. In Fontan patients with PVRI of > 5 Wood units m2, systemic VAD seems ineffective.

Echocardiographic Assessment of Cardiac Remodeling According to Obesity Class

Evidence supports the existence of cardiac remodeling in obesity, but no standard diagnostic criteria has been proposed or validated.The objective of this study was to identify echocardiographic features of cardiac remodeling according to obesity class and assess the effect of non-surgical weight loss on cardiac structure and function.A total of 120 patients were divided according to their obesity class (Group 1: BMI 18.5-24.9; Group 2: 25-29.9; Group 3: 30-39.9; Group 4: >40) and underwent cross-sectional transthoracic echocardiography. Echocardiographic parameters of cardiac chamber quantification and function were compared between the 4 groups. Echocardiographic parameters were compared pre- and post-non-surgical weight loss in a subgroup of patients. Overall, there was an incremental increase in left ventricular (LV), left atrial (LA), and right ventricular dimensions, LV mass and LV stroke volume (all p<0.0001) across obesity classes. There was no significant difference in LV ejection fraction or right ventricular systolic function as assessed by tricuspid annular plane systolic excursion (TAPSE) but a significant decrease in global longitudinal strain (BMI 18.5-24.9: 22.8%±1.7%; BMI 25-29.9: 22.0%±1.4%; BMI 30-39.9: 20.8%±1.1%; BMI >40: 20.6%±1.3%, p<0.0001) and left atrial strain (BMI 18.5-24.9: 37.7%±2.3%; BMI 25-29.9: 32.8%±2.1%; BMI 30-39.9: 31.5%±1.8%; BMI >40: 29.0%±2.8%, p<0.0001). Allometric height-indexed LV and LA dimensions increased with increasing BMI class (p<0.0001). Echocardiographic parameters did not change significantly after non-surgical weight loss.In conclusion, echocardiographic features can be described according to obesity class. Allometric height indexation may better reflect cardiac remodeling in obesity in comparison to BSA indexation. Non-surgical weight loss was not associated with significant changes in cardiac chamber dimensions and function.

AI-enabled automated cardiac chambers volumetry in non-contrast ECG-gated cardiac scans vs. non-contrast non-gated lung scans

Abstract Introduction We have developed an AI-enabled automated volume measurement of cardiac chambers (AutoChamber) that works on ECG-gated coronary artery calcium scans and correlates well with contrast enhanced coronary CT angiography scans. We have recently reported that increased left atrial volume measured by AutoChamber is a strong predictor of new onset atrial fibrillation (AF) in asymptomatic individuals of Multi-Ethnic Study of Atherosclerosis (MESA). In this study, we compare the volumetry results in ECG- gated CAC scans with those of non-gated full-chest lung cancer screening scans in the same individuals. Methods We have studied 169 cases of paired ECG-gated cardiac CT scans and non-gated lung scans obtained from Harbor UCLA. Mean±SD for age was 62.1±10.0 years with 52% female participants. All cases were asymptomatic and were scanned for preventive health assessment. AutoChamber was run on all cases by an independent operator who was not involved in data analysis. P value was calculated using a two-tailed test of significance with α=0.05. Results AutoChamber in cardiac scans vs lung scans reported volume (Mean±SD) for left atrium (LA) was 63.8 ± 18.5 vs. 65.5 ± 19.4, left ventricle (LV) 102.8 ± 25.3 vs. 105.5 ± 25.2, right atrium (RA) 81.9 ± 20.5 vs. 85.7 ± 21.9 right ventricle (RV), 140.7 ± 34.2 vs. 134.2 ± 33.7, left ventricle wall (LVW) 113.0 ± 26.6 vs. 109.7 ± 27.0 respectively (P &amp;lt; 0.0001). Strong correlation was shown between cardiac and lung scans for each cardiac chamber: LA (R = 0.92), LV (R = 0.93), RA (R = 0.91), RV (R = 0.92), and left ventricular wall (LVW) R = 0.95. Conclusions AutoChamber volumetry results are similar in ECG-gated cardiac scans vs non-gated full-chest lung scans. This AI-enabled automated tool is promising as it can provide added value to patients undergoing coronary calcium and lung cancer screening scans flagging enlarged cardiac chambers at risk of AF and heart failure.

Systemic manifestations of connective tissue abnormalities in patients with Mitral Valve Prolapse assessed by Cardiac Magnetic Resonance

Abstract Background Mitral valve prolapse (MVP) reflects a connective tissue abnormality of the mitral leaflets leading to myxomatous degeneration. Early echocardiography and semeiotic assessment investigations suggested that connective tissue abnormalities might be extended to heart chambers, great vessels, and the skeletal system. Cardiac Magnetic Resonance (CMR) has unique potentials in evaluating MVP, cardiac chambers, aortic dimensions, and Haller Index, an expression of the deformity of the thoracic cage, at one time. Purpose We aimed to investigate the potential phenotypic systemic expressions of connective tissue disease in patients with MVP by CMR assessment. Methods This case-control study included consecutive patients with MVP and a control group of healthy volunteers undergoing CMR at our Institution from September 2020 to November 2023. Patients with more than mild mitral or aortic regurgitation, bicuspid aortic valve, or known systemic connective diseases were excluded. The MVP, cardiac chambers, aortic dimensions, and Haller Index were assessed according to standard practice. Results 103 patients with MVP and 57 healthy volunteers (51± 17 vs. 47±18 years, p=0.2, and 5% females vs. 54.4% females, p=0.8, respectively) were enrolled. Patients with MVP showed greater left ventricular end-diastolic (91±25 vs. 78±17 ml/m2; p=0.005) and end-systolic volumes (36±12 vs. 27±6; ml/m2; p&amp;lt;0.001), aortic annulus (13±2 vs. 12±2 mm/m2; p&amp;lt;0.001), sino-tubular junction (15±3 vs. 14±3 mm/m2; p=0.03), aortic root (19±3 vs. 17±3 mm/m2; p&amp;lt;0.001), and descending aorta (13±2 vs. 12±2 mm/m2; p=0.03), and higher Haller Index (2.8±0.6 vs. 2.6±0.4; p=0.02) than healthy controls. No differences were found in ascending aorta (18±3 vs. 17±3 mm/m2; p=0.3), pulmonary trunk (13±2 vs. 13±2 mm/m2; p=0.5), left atrial volume (38±18 vs. 30±15 ml/m2; p=0.20), right ventricular end-diastolic-volume (86±20 vs. 81±20 ml/m2; p=0.3) were found. At ANCOVA, sex and MVP affected the Haller Index values (p = 0.005 and 0.04). The association between MVP and Haller Index persisted after controlling for sex, age, and body surface area. In multivariate regression analysis, MVP and sex had an independent impact on ventricular and aortic dimensions, with MVP and male patients showing greater values. In particular, MVP was associated with an increase in the aortic annulus (Coefficient=1.2; p&amp;lt; 0.001), aortic root (Coefficient=1.5, p=0.001), descending aorta (Coefficient=0.7, p = 0.026), left ventricular end-diastolic-volume (Coefficient=11.1, p=0.01) and mass (Coefficient=5.7, p=0.02) after controlling for sex, age, and body surface area. Conclusions This pivotal study assessing systemic connective tissue disorders by CMR suggests abnormalities in the aorta and the skeletal system of patients with MVP, paving the way to larger investigations exploring the clinical impact of these findings.CMR findings in the study populationBox plots showing variables distribution

AI-enabled cardiac chambers volumetry in non-contrast coronary artery calcium CT scans vs. contrast-enhanced coronary CT angiography scans in the same patients

Abstract Introduction We have developed an AI-enabled automated volumetry of cardiac chambers (AutoChamber) that works both on non-contrast ECG-gated cardiac CT scans used for coronary artery calcium (CAC) score, and non-contrast non-gated lung cancer screening CT scans. We have recently reported the agreement between AutoChamber measurements vs cardiac MRI measurements. Here we report AutoChamber results on non-contrast CAC scans and contrast enhanced coronary CT angiography (CTA). Methods We have obtained CT images from a previously published study in which 131 cases underwent non-contrast CAC and contrast enhanced CCTA at research institute. The cases consisted of 52.4% women with ages 55.0 ± 10.1 years. The cardiac chambers volume in 131 cases of contrast enhanced CCTA were measured using automated chamber volumetry by Philips Brilliance Volume v 4.5; Philips Healthcare. Results The correlations between Philips’ automated chamber volumetry in contrast enhanced CCTA scans versus AutoChamber automated volumetry in non-contrast CAC scans for left atrium (LA), left ventricle (LV), right atrium (RA), right ventricle (RV), and left ventricular wall (LVW) volume were 0.73, 0.65, 0.85, 0.93, 0.90, respectively (P for all &amp;lt;0.01). Conclusion AI-enabled AutoChamber volumetry based on non-contrast cardiac scans is feasible, and correlates reasonably well with contrast-enhanced cardiac CT scans. Further studies are warranted to reproduce these results and explore the add-on value of AutoChamber to CAC scans.

Predictors of ventricular and atrial feature tracking-derived global longitudinal strain in healthy athletes and volunteers

Abstract Background Feature tracking (FT) strain analysis provides insights into the mechanics of the heart and carries essential prognostic and diagnostic information without prolonging image acquisition during cardiac magnetic resonance (CMR) scans. However, data regarding CMR-derived FT strain in athletes is scarce, especially in the atria. We explored the determinants of FT global longitudinal strain (GLS) values concerning all four cardiac chambers in healthy competitive athletes and less active volunteers. Methods Long- and short-axis cine sequences were analyzed with Medis Suite v4.0 (Leiden, The Netherlands) to assess FT strain. After excluding individuals with preexisting pathologies and images with quality issues, subjects were classified by sport types following the 2020 ESC Sports Cardiology Guidelines. Multiple linear regression models were constructed to assess the impact of age, sex (male=0, female=1), weekly training hours, and sports category (power coded as 0, mixed as 1, endurance as 2) on GLS values. Atrial strain values are positive, and ventricular ones are negative. Intercepts/constants are denoted as "baseline" for easier comprehension. Results Native CMR scans acquired at a tertiary cardiac centre of 596 healthy Caucasian subjects (411 athletes: 145 females, mean age 21±6, range 14-36 years; and 185 volunteers: 86 females, mean age 24±5, range 13-35 years) were included. Athletes had a high exercise load versus the controls who performed no or maximum recreational physical activity (19±7 vs. 3±2 hours/week, p&amp;lt;.001). When assessing athletes (weekly training≥6h), RA GLS (baseline: 34%, p&amp;lt;.001) is increased in females (β=2.0) but is expected to decrease with every one-hour increase in training hours (β=-0.2). LA GLS is notably affected by sex alone (baseline: 37%, β=3.6, p&amp;lt;.001), suggesting markedly higher values for females. RV GLS (baseline: -30%, p&amp;lt;.001) is associated with both age and training hours (β=0.1 for each), making it less negative. Conversely, LV GLS (baseline: -25%, p&amp;lt;.0001) is significantly modulated by all studied factors, with sports category (β=0.5), age, and training hours (β=0.1 each) increasing values and sex decreasing them (β=-0.9). In less active volunteers (weekly training&amp;lt;6h), sex (β=4.7) is the only significant factor for RA GLS (baseline: 33%, p=.04), and sports category (β=2.7, the group included 98 recreational athletes with low training loads) for LA GLS (baseline: 38%, p=.04). No variables were retained in the model for RV GLS, but sex (β=-1.4) remained a predictor in the LV GLS model (baseline: -21%, p=.002). Conclusion GLS shows significant variations influenced by age, sex, sports category, and training hours across all four heart chambers in athletes. These effects appear mostly inconclusive among less active individuals. This data calls for further advanced analyses of athlete's hearts to refine differentiation methods between healthy adaptation and cardiac pathologies.Left atrial FT analysisModel outputs for GLS predictions

Cardiovascular (reverse) remodelling induced by pregnancy: looking at the right side of the heart

Abstract Introduction Many studies have focused on pregnancy-induced left ventricular remodelling, overlooking the changes in right cardiac chambers. Purpose To characterize the right cardiovascular (CV) remodelling and reverse remodelling (RR) induced by pregnancy and postpartum, respectively, and the impact of CV risk (CVR) factors on these processes. Methods This prospective cohort was recruited at two tertiary centers from 2019 to 2022, including 51 healthy and 79 obese and/or hypertensive and/or with gestational diabetes and/or smoking habits pregnant women (cardiovascular risk [CVR] group). Women were evaluated by transthoracic echocardiography at the 1st trimester (1T) and 3rd trimester (3T) of pregnancy, as well as one-month (PP1), six-months (PP2), and one-year postpartum (PP3). Generalized linear mixed-effects models were used for the analysis of right CV remodelling and RR and to evaluate the impact of CVR factors on these processes. Results This study included 130 pregnant women, 60.8% primiparous, with a median age of 33 years. Despite all echocardiographic results being within the normality range, we describe the progression of right heart adaptations throughout pregnancy and postpartum (Table 1), namely: 1) Similar enlargement of the right atrium (RA) and right ventricle (RV) dimensions throughout pregnancy, recovering at PP2 except for RA in the CVR group; 2) Preserved RV systolic function throughout pregnancy in both groups, while the postpartum hemodynamic normalization triggers a reduction of (TAPSE) and tricuspid S' wave velocity; 3) Reduced RA strain in both groups during pregnancy, more evident in CVR group, which had a slower postpartum recovery; 4) Preserved RV global longitudinal strain (GLS) throughout follow-up time, being significantly reduced in 3T of CVR group and recovering at PP2; 5) Reduction of tricuspid E/A ratio from 1T to 3T in both groups with an early recovery at PP1, being these values significantly higher in the healthy group, and 6) Steady pulmonary artery systolic pressure (PASP) values throughout follow-up time, showing consistently higher values in the CVR group. Conclusion This study describes the subclinical right cardiac functional and structural changes within the physiological range, which recover 6 months after delivery. CVR factors impact the magnitude of the subclinical RV diastolic function changes, PASP and myocardial deformation (strain) without any impact on classic RV systolic function.

Cardiac chamber three-dimensional volumes and deformation predict clinical outcomes in chronic mitral regurgitation

Abstract Background In patients with mitral regurgitation (MR), cardiac remodeling assessed by two-dimensional (2D) echocardiographic linear indexes is highly variable and not suitable for individualized risk assessment. Purpose To evaluate whether measurements of myocardial strain and left atrial (LA), left ventricular (LV) and right ventricular (RV) three-dimensional (3D) volumes improve risk assessment in MR. Methods In the prospective 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation study (3D-PRIME), 176 patients with significant (moderate or greater) MR were investigated with 2D/3D echocardiography. Referral criteria for mitral intervention followed current guidelines. LA remodeling was assessed by the maximum and minimum 3D LA volume (3D-LAV), peak reservoir strain (LASr), and stiffness (i.e. the ratio: mitral peak E-wave divided by the annular e’ velocity (E/e´) / LASr). LV and RV were considered dilated in case of increased 3D end-diastolic (LV&amp;gt;=86/74 and RV&amp;gt;=87/74ml/m2 in men/women) and end-systolic volumes indexed for body surface area (LV&amp;gt;=41/33 and RV&amp;gt;=44/36ml/m2 in men/women). Peak global longitudinal strain was measured in the LV (LV-GLS) and the RV free wall (RV-FWS). The primary outcome was a composite of mitral valve surgery, percutaneous mitral edge-to-edge repair and death. Results During a 14 [8-24] months follow-up, the patients (70±13 years, 39% women) experienced 73 events including 14 deaths. In univariate survival analyses, LV and RV dilatation, but not LV-GLS and RV-FWS, were associated with the primary outcome (Figure) and had superior predictive value to 2D volumes and diameters (p&amp;lt;0.05). On contrary, both atrial size and function predicted outcome, with 3D-LAV (HR 1.01, 95% CI 1.00-1.01), LASr (HR 1.03, 95% CI 1.01-1.06) and increased LA stiffness (Figure) all significant predictors of events (p&amp;lt;0.05). In multivariate Cox analysis with adjustment for age, sex, body mass index and MR etiology, dilated LV (HR 2.6, 95% CI 1.5-4.4), dilated RV (HR 2.0, 95% CI 1.1-3.6) and increased LA stiffness ((HR 2.4, 95% CI 1.3-4.6) were independently associated with higher rate of events (p&amp;lt;0.05). Conclusion In patients with moderate or greater MR, increased cardiac chamber 3D volumes and LA stiffness, as well as impaired LA reservoir strain are associated with higher risk of disease progression towards mitral valve intervention and death. Our findings indicate that assessment of both cardiac chamber 3D size and LA deformation can contribute to increased diagnostic and prognostic precision in patients with MR.

An artificial intelligence-based landmark model for early detection of aortic stenosis in Cardiac MRI

Abstract Background The utilisation of ratiometric intensity measures from cardiac magnetic resonance imaging (CMR) offers a promising biomarker for the diagnosis of aortic stenosis (AS)[1]. The Ao:LV ratio, an approximation of AS severity, is determined by comparing the relative blood signal intensity in the aorta and left ventricle (LV) within three-chamber (3Ch) cine sequences[1]. In patients with AS, the blood signal intensity of aortic blood above the valve is diminished compared to that within the LV in steady-state free precession (SSFP) 3Ch CMR cine. Although the Ao:LV ratio serves as a reliable indicator of AS severity, manual computation of this ratio may encounter difficulties due to visual obstructions caused by small LV cavities or prominent papillary muscles. Purpose This study aims to leverage artificial intelligence (AI) to automate the Ao:LV ratio analysis from 3Ch SSFP cine images and introduce the Ao:LA (aorta to left atrium) ratio, thus enhancing the diagnostic accuracy for AS severity. Methods Our methodology extends the ratiometric analysis to include both Ao:LV and Ao:LA ratios in three main steps: first, developing an AI-based algorithm for automated detection and tracking of cardiac landmarks; second, using these landmarks to automatically compute regions of interest (ROIs) in the cardiac chambers; and third, training and validating classification models with 5-fold cross-validation to select the most effective for AS severity classification. The final model's performance is assessed on a holdout test set. Data for model training and evaluation were sourced from CMR scans across three hospitals and two scanner types. Results We analysed 220 patients of which 78 patients had no AS and 122 had AS (mild AS, n = 29; moderate AS; n = 35, severe AS; n = 78). Our model yielded high efficacy in classifying AS, particularly in differentiating any grade of AS from a normal classification, which is clinically relevant. The Ao:LA ratio demonstrated a stronger correlation with AS severity class than Ao:LV, suggesting a more reliable biomarker. The proposed model demonstrated robust performance in AS classification, achieving an Area Under the Curve (AUC) of 0.845 in the automated binary classification of AS at any grade. The model exhibited a precision of 0.889, recall of 0.865, and an F1 score of 0.877 on a holdout set. Conclusion By the integration of AI in automating the analysis of CMR images through a novel ratiometric approach that includes Ao:LV and Ao:LA ratios, our model significantly improves the accuracy of early AS detection. This advancement enhances imaging strategies for AS evaluation, promoting more efficient and effective use of cardiac MRI sequences as a diagnostic tool for aortic stenosis. It has the potential to be implemented in real-time scanning protocols as a clinical decision support system.AI-inferred cardiac landmarks.ROC curve delineating AS prediction.

Impact of cardiovascular risk factors in cardiac (reverse) remodelling induced by pregnancy

Abstract Introduction Haemodynamic overload during pregnancy induces cardiac remodelling, characterised by cardiac hypertrophy and chamber enlargement, associated with deterioration of diastolic function, despite preservation of the systolic function. After delivery, the woman's heart undergoes reverse remodelling(RR), and myocardial function and structure normalise to their pre-gravid state. The impact of cardiovascular risk factors(CRF) in cardiac remodelling and RR, namely, on cardiac function and structure, is variable and remains to be clarified. Purpose To characterise cardiac remodelling and RR during pregnancy and postpartum, respectively, and to investigate CRF's impact in these processes. Methods This prospective cohort study included volunteer pregnant women (healthy [H group] or obese and/or hypertensive and/or with gestational diabetes [CRF group]) recruited in two tertiary centres between 2019 and 2022. Women were evaluated by transthoracic echocardiography at the 1st trimester [1T,10-15 weeks, baseline], 3rd trimester [3T,30-35 weeks, peak of cardiac remodelling] of pregnancy as well as at the 1st, 6th and 12th month after delivery (during RR). Blood samples were collected in each evaluation moment to quantify plasma troponin I (cTnI), procollagen I COOH-terminal propeptide (PICP), ST2/IL33-receptor, C-reactive protein (CRP) and relaxin-2 by ELISA. Generalised linear mixed-effects models were used to evaluate the extent of RR and its potential predictors. Results We included 130 pregnant women with a median age of 33 [30,36] years, 41.5% with at least one CRF. As shown in Table 1, pregnant women developed cardiac hypertrophy with significant atrial and ventricular enlargement from 1T to 3T in both groups. A significant rise in filling pressures was also documented. During postpartum, a significant regression of cardiac hypertrophy and dilation was verified in the two study groups, accompanied by a significant decrease of E/e’ as soon as 1 month after delivery. These cardiac anatomical and functional adaptations induced by pregnancy were accompanied by a significant reduction in plasma cTnI, PICP, ST2/IL33-receptor, CRP and relaxin-2 levels from 3T to 6-months after delivery. Compared to the healthy pregnant women, the CRF group showed higher relative wall thickness (RWT) for all time points of the follow-up period, with similar values of indexed cardiac mass and volumes. Pregnant women with CRF revealed higher E/e’, contrasting with lower ejection fraction and worse global longitudinal strain. Conclusion The significant cardiac reverse remodelling occurred as soon as 1 month after delivery, returning to basal values 6 months postpartum, supported by a significant reduction of levels of plasma biomarkers related to myocardial injury, repair, fibrosis, and inflammation. Pregnant women with CRF showed higher RWT, impaired relaxation and subclinical LV dysfunction when compared with healthy women at all time points of the study.

Unveiling a hide side of the athlete's heart: a CMR focus on the left atrium.

Abstract Background cardiac magnetic resonance (CMR) is the gold standard to evaluate cardiac chambers’ dimensions and function, but data on left atrium (LA) dimensions and function among elite athletes are lacking. Objective to describe LA size and function among a cohort of elite athletes and evaluate eventual differences based on sports discipline and gender. Methods We enrolled 120 Olympic athletes with un-remarkable cardiovascular pre-participation screening tests (mean age 25±5 years, 50% males, 25% skill, 25% power, 25% mixed, 25% endurance). All the athletes underwent CMR without contrast administration. LA dimensions, in terms of absolute and indexed area and volume, were computed using 4- and 2-chamber steady state precession cine-sequences. LA ejection fraction (LAEF) and LA coupling index (LACI index, as the ratio between LA and LV end-diastolic volumes) were calculated. Cine-images were also used to analyse atrial deformation with a dedicated offline software to measure LA global longitudinal strain. LA dimensions and function were compared between males and females and athletes of different sports categories based on European classification. Results Among the entire cohort, endurance athletes showed the greatest remodelling in terms of LA and LV dimensions (Table). There were no significant differences in LAEF and LV-EF between athletes of different sport categories (p=0.121 and p=0.679). A trend in increasing LA volumes and decreasing LA strain consistent with a growing cardiovascular demand was observed, but the only statistically significant difference was between skill athletes and all the other groups for LA volumes (p&amp;lt;0.001), while there were no significant differences in LA strain (p=0.170). LACI did not differ between athletes of different sports categories (p=0.170). Female athletes showed higher LAEF and LA strain than males (respectively 55±5 vs 52±6% p=0.012 and 35±7 vs 32±7%, p=0.009) while LACI did not differ based on gender (19±5% for both females and males, p=0.385). Conclusion Among our cohort of Olympics, LA remodelling was observed in all athletes, being less evident in skill group, as for the LV. Thus, the ratio between LA and LV did not differ between sport categories. LAEF and LA strain were not significantly different between athletes of different sports categories although LA strain was slightly lower in endurance. Female athletes showed higher LAEF and LA strain than males, while LACI was not different based on gender.

Echocardiographic assessment of the right heart pulmonary circulation unit in mitral regurgitation due to mitral valve prolapse

Abstract Background Right ventricular evaluation is essential in the context of chronic mitral regurgitation (MR). Chronic MR is associated with a progressive cardiac remodeling with enlargement and dysfunction of all cardiac chambers, and the development of functional tricuspid regurgitation (TR). Besides, right ventricle (RV) dysfunction and functional TR have been shown to influence patient prognosis. Purpose The aim of this study was to evaluate simple and combined echocardiographic parameters analysing the right heart – pulmonary circulation unit, according to the severity of MR. Methods In this monocentric retrospective study, echocardiographic studies of patients followed for a mitral valve prolapse (with or without MR) were reviewed. Usual parameters analysing RV morphology, load and function were obtained. Combined parameters of RV – pulmonary artery (RV-PA) coupling were calculated: TAPSE/PASP and RVFWS/PASP. Comparison between MR grades were performed with ANOVA or Kruskal Wallis tests as appropriate. Two-by-two post-hoc comparisons of continuous variables across the 5 groups were made using the Bonferroni correction. Results 158 patients with mitral valve prolapse (MVP) were included: 37 without MR, 28 with mild MR, 23 with mild-to-moderate MR, 21 with moderate-to-severe MR and 49 with severe MR. Clinical and echocardiographic results are presented in Table 1. Patients with a higher-grade MR tended to be older and were more likely to be men. They were also significantly more symptomatic. Most echocardiographic parameters were significantly different between grades of MR. RV remodeling, studied with morphologic parameters, started with the first grade of MR and had a linear progression between levels of MR severity (Figure 1A). Load parameters were stable until grade 2 and then showed progressive increase of RV afterload. RV free wall strain slightly increased with MR grade 1, and then decreased with each grade of MR (Figure 1B). RV fractional area change, Tissue Doppler MPI and RV free wall strain rate tended to stagnate between grade 0 and 2, and then they progressively decreased. Combined parameters of RV-PA coupling including load and function, increased with the first grade of MR, and then gradually decreased (Figure 1C). Conclusion In this study, multiparametric assessment of the cardiopulmonary unit in patients with MVP showed that RV morphologic remodeling starts with the first grades of MR, before any significant increase of pulmonary pressure. This remodeling seemed to initially enhance RV function (evaluated with parameters of RV – pulmonary artery coupling) in the first grade of MR and was then followed by a progressive decrease of RV function with the increasing severity of MR.

AI-enabled cardiac chambers volumetry in coronary calcium scans (AI-CAC) predicts heart failure and outperforms NT-proBNP: The Multi-Ethnic Study of Atherosclerosis

Abstract Introduction Coronary artery calcium (CAC) scans contain useful information beyond the Agatston CAC score that is not currently reported. We recently reported that artificial intelligence (AI)-enabled cardiac chambers volumetry in CAC scans (AI-CAC) predicted incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis (MESA). In this study, we investigated the performance of AI-CAC for prediction of incident heart failure (HF) and compared it with 10 known clinical risk factors, NT-proBNP, and the Agatston CAC score. Methods We applied AI-CAC to 5750 CAC scans of asymptomatic individuals (52% women, White 40%, Black 26%, Hispanic 22% Chinese 12%) free of known cardiovascular disease at the MESA baseline examination (2000-2002). We used the 15-year outcomes data and compared the time-dependent area under the curve (AUC) of AI-CAC versus NT-proBNP, Agatston score, and 10 known clinical risk factors (age, gender, diabetes, current smoking, hypertension medication, systolic and diastolic blood pressure, LDL, HDL, total cholesterol, and hs-CRP) for predicting incident HF over 15 years. Results Over 15 years of follow-up, 256 HF events accrued. The AUC for predicting HF with AI-CAC (0.826) was significantly higher than NT-proBNP (0.742) and Agatston score (0.712) (p&amp;lt;.0001), and comparable to clinical risk factors (0.818, p=0.4141). AI-CAC category-free Net Reclassification Index (NRI) significantly improved on clinical risk factors (0.32), NT-proBNP (0.46), and Agatston score (0.71) for HF prediction at 15 years (p&amp;lt;0.0001). Conclusion AI-CAC significantly outperformed NT-proBNP and the Agatston CAC score, and significantly improved the AUC and category-free NRI of clinical risk factors for incident HF prediction.

Surgical reduction of a high-flow dialysis fistula has long-term positive effects of the heart

Abstract Introduction Part of chronic haemodialysis patients develop a high-flow arteriovenous fistula (AVF). The volume overload caused by the presence of a high-flow AVF leads to increased cardiac output, dilation of cardiac chambers, increased pulmonary artery pressure or even to the development of high-output heart failure. Our previous data showed a positive effect of AVF flow-reducing surgery in 6 weeks follow-up. Purpose The purpose of this study was to analyse the long-term effect of AVF blood flow (Qa) reduction on cardiac structure and function. Methods We included patients with high-flow AVFs (defined as Qa over 1500 mL/min) indicated for blood flow reduction surgery for heart failure symptoms or pre-defined echocardiographic changes (left ventricular hypertrophy, severe secondary valvular regurgitations, or pulmonary hypertension). Echocardiography was performed one day before the surgery, the 6 weeks, 6 months, and 12 months thereafter. Qa was measured by ultrasound during the same visits. Results 27 patients were included, 20 men and 7 women, aged 57 ± 13 years. The procedure led to an immediate decrease in Qa. However, we observed failure of the procedure within 1 year in 8 (= 30%) patients defined by increased Qa back to pre-surgery values. Detailed results are displayed in Table 1. Estimated pulmonary arterial systolic pressure and left atrial volume remained significantly lower after 1 year despite the Qa rise. Effective cardiac output (= difference of cardiac output and Qa) rose immediately and remained increased during the follow-up period despite the increase in AVF blood flow. Conclusions We observed a long-time positive effect of AVF blood flow reduction surgery on the heart despite a significant Qa rise. The effective cardiac output remained increased despite the gradual increase of Qa, probably due to the adaptation of systemic arterioles.