Heart Murmur Research Articles

Heart morphology and function evaluation by transthoracic echocardiography in six captive crested gibbons (Nomascus spp.)

Cardiovascular diseases are one of the leading causes of morbidity and mortality in captive apes. Transthoracic echocardiography is the most comprehensive cardiovascular imaging technique used to diagnose and monitor cardiopathies in mammals. However, there are currently no baseline data of heart morphology and function in hylobatid primates. Conventional transthoracic echocardiograms were performed on six clinically healthy crested gibbons of three species (Nomascus siki, N. leucogenys and N. gabriellae) under general anesthesia using sevoflurane without premedication. Each echocardiogram included the evaluation of 11 variables in bidimensional mode, 8 variables in M-Mode and 6 variables in Doppler mode. Most functional parameters evaluated, like left ventricular ejection fraction (range, 49.3 to 72.4%), shortening fraction (SF; range, 18.9 to 34.5%), left atrium/aorta ratio (range, 0.8 to 1.2), and maximal velocity of aortic, pulmonic, and mitral flows had similar values as those described in gorillas, dogs, and humans. Valvular insufficiencies were detected in two of the six individuals evaluated: one adult female N. siki was diagnosed with a discrete aortic regurgitation and one young male N. leucogenys with a mild mitral valve insufficiency. The mitral valve regurgitation was associated with a low-grade systolic heart murmur, but no further morphological changes of heart chambers were identified in these animals. Finally, a decreased heart contractility (SF = 18.9%) was diagnosed in one female N. gabriellae. This study is the first database transthoracic echocardiography in gibbons undergoing general anesthesia.

Unveiling the Complexity of Medical Imaging through Deep Learning Approaches

Recent advancements in deep learning, particularly convolutional networks, have rapidly become the preferred methodology for analyzing medical images, facilitating tasks like disease segmentation, classification, and pattern quantification. Central to these advancements is the capacity to leverage hierarchical feature representations acquired solely from data. This comprehensive review meticulously examines a variety of deep learning techniques applied across diverse healthcare domains, delving into the intricate realm of medical imaging to unveil concealed patterns through strategic deep learning methodologies. Encompassing a range of diseases, including Alzheimer’s, breast cancer, brain tumors, glaucoma, heart murmurs, retinal microaneurysms, colorectal liver metastases, and more, the analysis emphasizes contributions succinctly summarized in a tabular form.The table provides an overview of various deep learning approaches applied to different diseases, incorporating methodologies, datasets, and outcomes for each condition.Notably, performance metrics such as accuracy, specificity, sensitivity, and other crucial measures underscore the achieved results. Specifically, an in-depth discussion is conducted on the Convolutional Neural Network (CNN) owing to its widespread adoption as a paramount tool in computer vision tasks. Moreover, an exhaustive exploration encompasses deep learning classification approaches, procedural aspects of medical image processing, as well as a thorough examination of key features and characteristics. At the end, we delve into a range of research challenges and put forth potential avenues for future improvements in the field.

Atrial Fibrillation after COVID-19 Vaccination in an Adolescent: A Case Report

Several cases of cardiac arrhythmia after coronavirus disease 2019 (COVID-19) vaccination have been reported in adults. However, the Centers for Disease Control and Prevention do not list cardiac arrhythmias as a possible side effect of the COVID-19 vaccines. A previously healthy 18-year-old man presented at the Soonchunhyang University Bucheon Hospital with complaints of palpitations, acute chest tightness, and dyspnea. Two days before presentation, he had received the COVID-19 vaccine, BNT162b2 (Comirnaty, Pfizer-BioNTech; Pfizer, New York, NY, USA). His vital signs were stable; however, physical examination revealed irregular heartbeats without a cardiac murmur. A 12-lead electrocardiography showed atrial fibrillation. The patient received several medications for 6 months, without improvement. Eventually normal sinus rhythm was restored with cardioversion. The patient has remained asymptomatic for 1 year. We report the case of an adolescent with atrial fibrillation after receiving a messenger RNA COVID-19 vaccine. Atrial fibrillation should be considered a cardiovascular side effect of the COVID-19 vaccine in adolescents.

A case study on right ventricular-myxoma: An unusual presentation

Myxomas originating from the right ventricle are even less common in pediatric patients. It's important to note that right ventricular myxomas are rare, and the symptoms and complications can vary from person to person. Prompt diagnosis and treatment are crucial to prevent potentially life-threatening complications. Treatment typically involves surgical removal of the tumor, and in some cases, additional measures may be necessary to address any associated complications or damage caused by the tumor. Objective: This case study aims to present a rare and noteworthy case of right ventricle myxoma in a 15-year-old boy, emphasizing the challenges in diagnosis, treatment, and the successful outcome achieved. Methods: Detailed clinical, imaging, and surgical data were collected and analyzed for a 15-year-old male patient presenting with atypical cardiac symptoms. Diagnostic procedures included 2D ECHO, X-RAY, HRCT-Thorax along with pulmonary Angio leading to the identification of a right ventricle myxoma. Incidences: Primary tumors of the heart are rare with an incidence of 0.02–0.05%. Cardiac MYXOMAS are rare BENIGN TUMORS that account for nearly 50% of all adult primary Cardiac tumors. Approximately 75–80% of myxomas are in the LEFT ATRIUM,10–20% are in the RIGHT ATRIUM, and 5–10% are in both ATRIA or either VENTRICLE. Myxomas arising from the RIGHT-VENTRICLE are extremely rare and characterized by the presence of a gelatinous mass in the right ventricle. The exact incidence of right ventricular myxoma is not well established, as it is a rare condition and limited data is available. The condition is often diagnosed incidentally during investigations for other cardiac conditions or when patients present with symptoms such as chest pain, shortness of breath, palpitations, or heart murmurs. Results: The patient, initially presenting with palpitation, underwent successful surgical excision of the right ventricle myxoma. Postoperative recovery was uneventful, and the patient demonstrated significant improvement in symptoms. Conclusion: Right ventricle myxomas are exceptionally rare in pediatric patients, posing unique diagnostic challenges. This case underscores the importance of considering cardiac tumors even in younger populations when presented with unexplained cardiac symptoms. Timely diagnosis and surgical intervention contributed to a favorable outcome, highlighting the successful management of right ventricle myxoma in adolescents.

Spontaneous closure of perimembranous ventricular septal defect in a cat

We discuss the case of a 5-month-old male British Shorthair referred to our hospital following the detection of a heart murmur during a routine vaccination appointment. Two-dimensional echocardiography revealed a 1.18 mm ventricular septal defect (VSD) located immediately below the aortic valve, without signs of secondary cardiac remodeling. Given the absence of cardiac dysfunction, no treatment was administered, and the cat was periodically monitored over the next 2 years. Echocardiography at 29 months of age revealed no signs of the VSD. Future studies are needed to increase the evidence base for spontaneous VSD closure in small animals.

VALVULAR HEART DISEASE MANAGED WITH AYURVEDA TREATMENT - A CASE STUDY

Aortic stenosis (AS) is one of the heart's most common and severe valve diseases. Narrowing of the valve more commonly develops during aging. It influences genetic factors, hormones, lipid infiltration, inflammation, and calcification on valves, resulting in a restricted amount of blood flow through the valve. Patients of AS become prostrated and suffer from breathlessness, angina, syncope, palpitations, heart murmur, and other symptoms de-pending on their severity grade. It is a burning health issue, with more than one million new cases per year in India. Yet, there is no solace for AS in the contemporary medicinal system, and surgery has many more limita-tions in older adults. Time-trusted Ayurveda treatment modalities are merited in senior management by trimming down degenerative processes and enhancing the quality of health. Presenting a geriatric, severe AS case report, who otherwise was suggested to undergo valve replacement surgery, was treated with oral medications of Hrudroga chikitsa, which significantly improved the functional ability of the heart and quality of life.

Cardiac murmur grading and risk analysis of cardiac diseases based on adaptable heterogeneous-modality multi-task learning.

Cardiovascular disease (CVDs) has become one of the leading causes of death, posing a significant threat to human life. The development of reliable Artificial Intelligence (AI) assisted diagnosis algorithms for cardiac sounds is of great significance for early detection and treatment of CVDs. However, there is scarce research in this field. Existing research mainly faces three major challenges: (1) They mainly limited to murmur classification and cannot achieve murmur grading, but attempting both classification and grading may lead to negative effects between different multi-tasks. (2) They mostly pay attention to unstructured cardiac sound modality and do not consider the structured demographic modality, as it is difficult to balance the influence of heterogeneous modalities. (3) Deep learning methods lack interpretability, which makes it challenging to apply them clinically. To tackle these challenges, we propose a method for cardiac murmur grading and cardiac risk analysis based on heterogeneous modality adaptive multi-task learning. Specifically, a Hierarchical Multi-Task learning-based cardiac murmur detection and grading method (HMT) is proposed to prevent negative interference between different tasks. In addition, a cardiac risk analysis method based on Heterogeneous Multi-modal feature impact Adaptation (HMA) is also proposed, which transforms unstructured modality into structured modality representation, and utilizes an adaptive mode weight learning mechanism to balance the impact between unstructured modality and structured modality, thus enhancing the performance of cardiac risk prediction. Finally, we propose a multi-task interpretability learning module that incorporates an important evaluation using random masks. This module utilizes SHAP graphs to visualize crucial murmur segments in cardiac sound and employs a multi-factor risk decoupling model based on nomograms. And then we gain insights into the cardiac disease risk in both pre-decoupled multi-modality and post-decoupled single-modality scenarios, thus providing a solid foundation for AI assisted cardiac murmur grading and risk analysis. Experimental results on a large real-world CirCor DigiScope PCG dataset demonstrate that the proposed method outperforms the state-of-the-art (SOTA) method in murmur detection, grading, and cardiac risk analysis, while also providing valuable diagnostic evidence.

Increasing detection of heart valve disease in Farnborough Primary Care Network using auscultation artificial intelligence in the community pharmacy setting

Abstract Introduction Cardiovascular disease causes a quarter of all deaths in the UK, making it a top NHS priority1. One such cardiovascular disease, heart valve disease (HVD), is serious with worse outcomes than many cancers2. Yet diagnosed early, before a patient deteriorates, HVD can be treated effectively with valve replacement or repair. A large proportion of patients however are estimated to be undiagnosed or untreated each year in England (≤53% with severe symptomatic aortic stenosis, ≤41% with moderate/severe mitral valve regurgitation, ≤81% with moderate or greater tricuspid valve regurgitation)3. HVD is often detected when GPs identify a heart murmur upon cardiac auscultation. Patients are referred to echocardiography to confirm diagnosis and severity. By using digital stethoscope to perform auscultation, community pharmacists have the potential to assist with and increase the detection of HVD. Aim To determine if community pharmacists can identify undiagnosed HVD using digital auscultation with eMurmur® stethoscope artificial intelligence (AI), and compare subsequent echocardiography referrals against those from GPs. Methods A community echocardiography service and pharmacy within a single PCN were identified based on interest, capacity, and infrastructure to undergo the service evaluation (SE). Pharmacy patients aged >75 years, or with type 2 diabetes, angina/myocardial infarction, atrial fibrillation or high blood pressure, were invited for HVD assessment by the pharmacist. Patients with known HVD or who had an echocardiogram in the past 10 years were excluded. The pharmacist carried out digital stethoscope auscultation and where systolic murmur was detected, patients were referred to a community clinic for full compensation echocardiography. Patient demographic, comorbidity, auscultation, and echocardiography results were collected. Clinic referrals from the community pharmacy were contrasted with referrals from GP practices to compare the number of appropriate referrals over the same period. Results Community pharmacy detected murmur in 39/86 (45%) patients, who were then referred to community echocardiography (mean age 77.8 years). Echocardiography identified: 8 (21%) moderate/severe HVD, 9 (23%) mild HVD, 22 (56%) ‘normal’ or ‘trivial’ HVD. During the SE, 24 referrals were received from GP practices (mean age 65 years): 2 (8%) moderate/severe HVD, 8 (33%) mild HVD, 14 (58%) ‘normal’ or ‘trivial’ HVD. Pharmacy referred 70% more patients with non-trivial HVD than GP practices (17 vs 10 patients). Discussion/Conclusion This SE demonstrates that community pharmacists can identify undiagnosed HVD, in this case referring more patients with non-trivial HVD to echocardiography than GPs. The rapid data sharing enabled by this technology supports quick decision-making for patients with critical disease requiring immediate treatment. Pharmacists can therefore play an important role as a gateway to accessing potentially lifesaving treatment. Patients appeared comfortable attending a digital auscultation service in a community pharmacy setting. Such a proactive service may help reduce the number of people with severe HVD who go undiagnosed and untreated. Limitations of this SE include the small sample size, rendering statistical analysis inappropriate. Additionally, the analysis indicated the number of GP referrals for echocardiography but not how many patients underwent auscultation overall. Therefore we were unable to compare efficiency of murmur detection.

Fatty Liver Index as a proxy for non-alcoholic fatty liver disease and the risk of stroke and coronary heart disease: The Suita Study

BackgroundNon-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in developed countries, but its role in predicting cardiovascular disease (CVD) needs further investigation. Herein, we studied the association between NAFLD and the risk of CVD, stroke, and coronary heart disease (CHD) among Japanese people. MethodsThis prospective cohort study analyzed data from 2,517 men and 3,958 women, aged 30-84 years, who were registered in the Suita Study. NAFLD was defined as Fatty Liver Index (FLI) ≥ 60. Cox proportional hazard models were applied to calculate the hazard ratios (HRs) and 95% confidence intervals (95% CIs) of incident CVD, stroke, and CHD events by baseline FLI. The results were adjusted for age, smoking, alcohol consumption, hypertension, diabetes, lipid profile, chronic kidney disease, and cardiac murmur or valvular diseases. ResultsWithin 16.6 years of median follow-up, 590 participants developed CVD (346 stroke events and 244 CHD events). Women with NAFLD (FLI ≥ 60) showed a higher risk of CVD and stroke: HRs (95% CIs) = 1.69 (1.16, 2.46) and 2.06 (1.31, 3.24), respectively. Besides, women in the fourth and fifth (highest) FLI quintiles showed a higher risk of CVD and stroke than those in the third (middle) quintile: HRs (95% CIs) = 1.60 (1.08, 2.36) and 1.67 (1.13, 2.45) for CVD and 1.73 (1.07, 2.79) and 1.90 (1.18, 3.05) for stroke, respectively. No corresponding associations were detected in men. NAFLD was not associated with CHD risk in either sex. ConclusionsNAFLD, diagnosed by FLI, was associated with a higher risk of CVD and stroke in Japanese women. From a preventive perspective, women with NAFLD should be targeted for CVD screenings and interventions.

Leveraging School Health Programs in Africa: Integrated Screening for Rheumatic Heart Disease and Dental Caries.

Rheumatic heart disease (RHD) and dental caries (DC) disproportionately affect children and young adults in sub-Saharan countries, with major impact on schoolchildren's health and education. DC in children with RHD constitutes an important risk for fatal complications. Our study aimed at assessing the feasibility of simultaneous RHD and DC screening in school environment. March 20-24, 2022, we performed an observational descriptive study of schoolchildren in a public school in Maputo City, Mozambique. RHD screening involved two stages: first, a physical examination (including cardiac auscultation and direct observation of the oral cavity), and second, an abbreviated echocardiography performed by a cardiologist. Rapid testing for group A Streptococcus (GAS) was done to every eighth child in the classroom and for those with signs suggesting recent infection, in accordance with the study protocol developed for screening. A multidisciplinary team collected the data. Data were analyzed using descriptive statistics. A total of 954 students (median age 9; range 6-15) were screened. One hundred and twenty-five participants were eligible for a rapid antigen test, of which 6 (4.8%) tested positive. On clinical evaluation 52 children (5.3%) presented a heart murmur. Echocardiography on 362 children showed borderline RHD in 35 children and definite RHD in 2 (0.6%); 1 child had a ventricular septal defect. Dental cavities were present in 444 (48.4%), despite 904 out of 917 students reporting brushing of their teeth once to three times daily (98.6%). School-based integrated oral and cardiovascular screenings and use of rapid tests for GAS carriage provide crucial information to create customized preventive strategies for rheumatic fever (RF) and RHD in low- and middle-income countries (LMICs), in addition to detecting children at very high risk of bacterial endocarditis. The sustainability of such interventions and acceptability by health providers needs to be assessed.

Les complications cardiaques du rhumatisme articulaire aigu et ses facteurs de risque : étude de 50 observations

IntroductionAcute rheumatic fever (ARF) is a multi-systemic disease, in which cardiac involvement is the most serious major manifestation of disease. The aim of this study was to analyse cardiac involvement in children with ARF and his risk factors. Materials and methodsIt were a retrospective study including all children under the age of 14 years who were hospitalized for ARF in the pediatric department of the CHU Hédi Chaker of Sfax, during a period of twelve years (2010–2022). ResultsWe collected 50 cases (31 boys and 19 girls). Twenty-two patients (44%) developed cardiac lesions. The mean age at diagnosis was 9.6 years [5–14 years]. A pathological heart murmur was detected in 14 cases (n = 14/22) was classified as mild carditis in 15 cases, moderate carditis in 5 cases and severe in 2 cases.The median follow-up time was 3,3 years. Nineteen patients developed valvular sequelae Risk factors of cardiac lesions was: age more than 8 years, heart murmur, allonged PR, CRP > 100 mg/l and VS > 100 mm. ConclusionCR is still a public health problem in Tunisia. It is a serious pathology that can cause serious increases in morbidity rates. Thus, we must strengthen preventive strategies.

Novel mutation in ELN gene causes cardiac abnormalities and inguinal hernia: case report

BackgroundElastin-driven genetic diseases are a group of complex diseases driven by elastin protein insufficiency and dominant-negative production of aberrant protein, including supravalvular aortic stenosis (SVAS) and autosomal dominant cutis laxa. Here, a Chinese boy with a novel nonsense mutation in the ELN gene is reported.Case presentationWe report a 1-year-old boy who presented with exercise intolerance, weight growth restriction with age, a 1-year history of heart murmur, and inguinal hernia. Gene sequencing revealed a novel nonsense mutation in the ELN gene (c.757 C > T (p.Gln253Ter), NM_000501.4). Due to severe branch pulmonary artery stenosis, the reconstruction of the branch pulmonary artery with autologous pericardium was performed. The inguinal hernia repair was performed 3 months postoperatively. After six months of outpatient follow-up, the child recovered well, gained weight with age, and had no special clinical symptoms.ConclusionWe identified a de novo nonsense mutation in the ELN gene leading to mild SVAS and severe branch pulmonary artery stenosis. A new phenotype of inguinal hernia was also needed to be considered for possible association with the ELN gene. Still, further confirmation will be necessary.

Feasibility of remote screening for high risk valve disease using a new wearable cardiac monitoring patch with synchronized phonocardiogram and electrocardiogram in communities

Abstract Background The 2010 census data showed that the weighted prevalence rate of valvular disease was 3.8% in China. For many elderly people, COVID-19 pandemic has caused the situation that they have not received medical examination for years. Since many patients with moderate aortic/mitral stenosis/regurgitation do not have significant symptoms, early detection of high-risk groups of valve disease is essential. A new wearable cardiac monitoring patch with synchronized phonocardiogram(PCG) and electrocardiogram(ECG) function is introduced in this study. Unlike handheld auscultation, it minimizes the interference of the environment and the operator, and is not demanding for the operator. Methods We enrolled 3170 patients of over 65 years old. Patients with diagnosed moderate or severe aortic/mitral stenosis/regurgitation, congenital heart disease, hypertrophic cardiomyopathy were excluded. Data acquisition was done by social workers following strict instructions. The patch was attached to the mitral and aortic auscultation area on the patients. ECG and PCG signals can be detected simultaneously and sent to a phone or tablet via Bluetooth. The data would then be auto-uploaded to a cloud-based center for further analysis. The end-to-end algorithm for S1 and S2 heart sounds detection involves a CNN-LSTM model for R-peak detection and a 1-D CNN-based U-Net model for fine-grained segmentation based on the detected heartbeat. The segmentation network takes multi-modal PCG and ECG signals as inputs and applies Contrastive Learning as a pretraining technique for enhancement to a real-world problem: detecting heart murmur from high-risk valve disease. If the results indicate positive, the patient is recommended by family doctors to do ultrasonic cardiogram (UCG) and seek further medical advice (Figure 1). Results 3170 participants were recruited from March 2022 to December 2022 in different communities of Huangpu District in Shanghai(Figure 2). In total, 43.98% were men, and 85.81% of age distribution were among 65-79 years. Among 3170 participants, 119(3.8%) were suspected positive by ECG and PCG. Among 119 patients, 65.55% were among 65-79 years. After telephone follow-up 29(24.3%) patients finished clinical visit and UCG. About 66% were diagnosed as mild aortic/mitral stenosis/regurgitation, 24% were diagnosed as moderate aortic/mitral stenosis/regurgitation, 10% were diagnosed as hypertrophic cardiomyopathy. Conclusions This study demonstrated the feasibility of remote screening for high risk valve disease using a new wearable cardiac monitoring patch in community visit by social workers with no medical background. This technology may improve the efficacy of clinical diagnosis and reduce unnecessary examination, particularly in the absence of doctors' auscultation and UCG. Unfortunately, three quarters of the suspected positive patients lost contact or refused to do UCG due to COVID-19 pandemic. Further investigations are necessary to increase accuracy.Flow chart of community screeningbaseline and disease distribution

Abstract 18891: Frequency of Abnormal Cardiac Screens in US High School Athletes: Analysis of a National Cardiac Youth Registry

Introduction: Sudden cardiac arrest affects thousands of children annually, and many heart conditions go undetected by standard child health screens. Cardiac screening of adolescents can identify symptoms suggestive of abnormal cardiac conditions. Despite this, the benefit of cardiac screens in healthy adolescents remains equivocal. Question: At what rate do guideline based cardiac screens identify symptoms suggestive of cardiac abnormalities in the physically active youth? Methods: From 2014 to 2021, Simon’s Heart performed guideline-based heart screenings in youth athletes in Southeastern Pennsylvania. Cardiac screens included a health questionnaire, physical exam (height, weight, blood pressure, cardiac murmur findings), a 12-lead echocardiogram (ECG) read by cardiologists utilizing the international criteria, and echocardiography where recommended. An abnormal cardiac screen was classified as having any of the three abnormalities of hypertension (systolic ≥130 or diastolic >80), heart murmur, or ECG abnormality. Results: 7425 students were screened during a seven-year period. Ages ranged from 12-20 (median of 15) and 61% were male. 1073 of the screened youth athletes (14.5%) had abnormal cardiac screens, 461 (6.2%) had hypertension, 268 (3.6%) had a murmur, 412 (5.5%) had an ECG abnormality and 234 were referred to cardiology for follow up (3.2%). Conclusions: This registry provides evidence that judicious youth athlete screening can uncover significant abnormalities which may require lifelong monitoring. Large registry data are needed to assess the efficacy of such programs.

Abstract 18142: A Silent Heart Break: An Uncommon Case of Silent Mitral Valve Perforation Secondary to Infective Endocarditis

Introduction: Infective Endocarditis (IE) is an endocardial surface infection of the heart which may lead to valve damage and if severe, this may even lead to valve perforation which can cause significant regurgitation and cardiac function compromise. We present an uncommon case of IE complicated by mitral valve perforation. Case presentation: A 46-year old male with AIDS and polysubstance use was brought to the ED from a shelter after exhibiting erratic behavior with confusion. On exam, he was febrile and tachycardic. Lab data pertinent for lacticaemia and leukocytosis. Blood cultures grew Streptococcus Pneumoniae. MRI Brain was unremarkable. Echocardiography was unremarkable. Antibiotic was initiated leading to marked improvement in patient’s mental status. Despite clinical improvement, days into hospital course, a new holosystolic murmur was audible with left axillary radiation necessitating a repeat echocardiogram which revealed moderate-to-severe mitral eccentric jet regurgitation concerning for anterior leaflet perforation. He remained euvolemic without symptoms of heart failure and was subsequently transferred to a tertiary facility where a mitral valve surgery replacement was scheduled. Discussion: Most patients with infective endocarditis have no preceding valvular abnormality. This case is unusual as there was valvular perforation with no evidence of valvular involvement on prior imaging which could possibly be as a result of invasive streptococcus pneumonia IE potentially coexisting with bacterial meningitis which carries a high mortality rate. Invasive streptococcus pneumonia is an unusual cause of IE since wide availability of antibiotics and vaccines. This case reminds us of the need of thorough physical exam and sequential imaging in such immunocompromised patient groups. Conclusions: A high suspicion for mitral valve perforation should be maintained in patients with invasive streptococcus pneumoniae and new cardiac murmur.

Abstract 17665: School Electrocardiography Screening Program Prompts the Detection of Otherwise Unrecognized Atrial Septal Defect in Children in Japan

Background: Atrial septal defect (ASD) is a congenital heart disease that often presents without symptoms or murmurs. If left untreated, children with ASD can develop comorbidities in adulthood. In Japan, school electrocardiography (ECG) screening has been implemented for all 1st, 7th, and 10th graders. However, the impact of this program in detecting children with ASD is unknown. Hypothesis: School ECG screening program prompts the detection of otherwise unrecognized ASD in children in Japan. Methods: This is a retrospective study that analyzed consecutive patients with ASD who underwent catheterization for surgical or catheter closure at ≤18 years of age during 2009-2019 at a tertiary referral center in Japan. Results: Of the overall 116 patients with ASD (median age of 3.0 years at diagnosis and 8.9 years at catheterization), 43 (37%) were prompted by the ECG screening (Screening group), while the remaining 73 (63%) were by other findings (Non-screening group). Of the 49 patients diagnosed at ≥6 years of age, 43 (88%) were prompted by the ECG screening, with the 3 corresponding peaks of the number of patients at diagnosis. Compared with the non-screening group, the screening group exhibited similar levels of hemodynamic parameters but had a lower proportion of audible heart murmur (Levine 2/6 or higher) and coexisting diseases at catheterizarion (p=0.016), which were mainly prompted by the health care and health checkups in infancy or preschool period. Patients positive for a composite parameter (iRBBB, inverted T in V4, or ST depression in the aVF lead) accounted for 79% of the screening group at catheterization, each of which was correlated with hemodynamic parameters in the overall patients (p<.05). Conclusions: The present study showed that school ECG screening detected otherwise unrecognized ASD, which prompted the diagnosis of the majority of patients at school age and > one-third of overall patients in Japan. These findings suggest that ECG screening program could be valuable for detecting hemodynamically significant ASD in students, who are asymptomatic and murmurless.

Abstract 12143: Hearing is Believing: A Case of a Ruptured Sinus of Valsalva Aneurysm

A 36-year-old previously active and healthy male was referred to our Adult Congenital Heart Disease clinic with worsening exertional dyspnea and intermittent palpitations over the past 6 months. He had recently been diagnosed with a membranous ventricular septal defect (VSD) and membranous septal aneurysm at another hospital, although images were not available for review.On physical exam, a continuous cardiac murmur was noted which prompted reconsideration of the diagnosis, with highest suspicion of ruptured sinus of Valsalva aneurysm (SVA). An urgent cardiac CT was obtained, which showed a large, mobile right SVA protruding into and partially obstructing the right ventricular outflow tract (RVOT), with pulmonic regurgitation and dynamic closure of a supracristal VSD (Figure 1A). A margin of the SVA was ill-defined and suspicious for rupture, although no definite communication was seen. An expedited TTE showed findings consistent with SVA rupture (Figure 1B), and he was admitted for surgery soon thereafter. Intra-operatively (Figure 1C), SVA rupture into the RVOT was confirmed by direct inspection; the SVA tissue was resected, the defect closed with a fresh autologous pericardial patch, and the VSD was closed with pledgeted sutures. Post-operatively, there was no leakage around the patch margin and only trace aortic regurgitation.A ruptured SVA causes continuous shunting from the aorta into an adjacent cardiac chamber and if left unrecognized, can lead to right heart failure, arrhythmia, and potentially sudden death, emphasizing the need for early identification. Echocardiography may show an aneurysmal sinus of Valsalva with a continuous (with accentuation in diastole) high-velocity, turbulent flow-jet into an adjacent cardiac chamber, and holodiastolic aortic flow reversal; a VSD is often present. Cross-sectional imaging is also important for diagnosis and surgical planning. A comprehensive physical exam is crucial to mitigate the risk of misdiagnosis.

Abstract 13244: Real World Evaluation of an Artificial Intelligence Enabled Digital Stethoscope for Detecting Undiagnosed Valvular Heart Disease in Primary Care

Background: Clinically significant valvular heart disease (VHD) affects 1 in 10 adults over 65. Cardiac auscultation, the current point of care clinical standard, has shown a 44% sensitivity for detecting VHD, leaving most patients undiagnosed. A deep learning based artificial intelligence (AI) platform that detects cardiac murmurs associated with clinically significant VHD (moderate severity or higher, confirmed by echocardiogram) was used to assess its real-time impact on the point of care. Hypothesis: Use of AI during point of care auscultation may lead to higher discovery rates and earlier diagnosis of VHD compared to conventional practice. Aim: Evaluate real world performance of AI vs. primary care physician (PCP) auscultation in identifying previously undiagnosed VHD. Methods: This blinded, prospective study enrolled 369 patients aged 50 and older without a prior VHD diagnosis or history of murmur from three different primary care clinics. Four-point cardiac auscultation was performed on each patient by (1) PCP with a standard stethoscope, and (2) coordinator with an Eko digital stethoscope to collect phonocardiogram (PCG) data for analysis by the AI. Each patient received an echocardiogram to confirm whether clinically significant VHD was present, and their PCG recordings were reviewed by an outside expert panel to confirm whether audible murmurs were present. PCP and expert panel were blinded to AI and echocardiogram results. Performance metrics were calculated for both PCP auscultation and the AI in detecting audible VHD. Results: The AI showed over twofold improvement in sensitivity vs. PCP auscultation for detecting audible VHD (94.1% vs. 41.2%) with limited impact on specificity (84.5% vs. 95.5%). The AI identified 22 patients with moderate-or-greater VHD who were previously undiagnosed, while PCPs identified eight previously undiagnosed patients with VHD. Conclusion: When applied in a primary care setting, a digital stethoscope with structural murmur detection AI showed meaningful impact on new discovery of VHD as compared to conventional practice. These results suggest that AI-powered auscultation at the point of care may significantly increase earlier VHD discovery, facilitate appropriate patient care, and improve outcomes.

An edge-device-compatible algorithm for valvular heart diseases screening using phonocardiogram signals with a lightweight convolutional neural network and self-supervised learning

Background and objectivesDetection and classification of heart murmur using mobile-phone-collected sound is an emerging approach to the scale-up screening of valvular heart disease at a population level. Nonetheless, the widespread adoption of artificial intelligence (AI) methods for this type of mobile health (mHealth) application requires highly accurate and lightweight AI models that can be deployed in consumer-grade mobile devices. This study presents a lightweight deep learning model and a self-supervised learning (SSL) method to utilise unlabelled data to improve the accuracy of valvular heart disease classification using phonocardiogram data. MethodsThis study proposes a lightweight convolutional neural network (CNN) that consists of ten times fewer parameters than other deep learning models to classify phonocardiogram data. SSL is applied to harness a large collection of unlabelled data as pre-training to enhance the accuracy and robustness of the model and reduce the number of epochs required to converge. A mobile application prototype that encapsulates the model is developed to perform in-device inference and fine-turning. ResultsThe proposed lightweight model achieves an average accuracy of 98.65% in 10-fold cross-validation. When coupled with SSL using unlabelled data, the pre-trained model can reach an average accuracy higher than 99.4% in 10-fold cross-validation. Furthermore, SSL-trained models have a 4–20% improvement in classification accuracy over non-SSL-trained models when tested with perturbed or noisy data, suggesting that SSL improves robustness of the model. When deployed on common smartphones, in-device fine-tuning and inference of the model can be completed within 0.03–0.37 s, which is considerably faster than 0.22–5.7 s by a standard CNN model that have ten times the number of parameters. Our lightweight model also consumes only a third of the power compared to the larger standard model. ConclusionThis work presents a lightweight and accurate phonocardiogram classifier that supports near real-time performance on standard mobile devices.

Neutrophil-to-lymphocyte ratio is increased in dogs with acute congestive heart failure secondary to myxomatous mitral valve disease compared to both dogs with heart murmurs and healthy controls.

To retrospectively evaluate neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as a biomarker for severity and short-term outcomes of congestive heart failure (CHF) secondary to myxomatous mitral valve disease (MMVD) in dogs. 47 dogs with CHF secondary to MMVD, 47 dogs with presumptive preclinical MMVD, and 47 control dogs. Medical record data (signalment, physical examination findings, medical treatments instituted, American College of Veterinary Internal Medicine MMVD stage, length of hospitalization, outcome, and hospital re-presentation due to CHF) from March 2012 through March 2022 for each dog were collected. Statistical analyses were performed with Mann-Whitney, Spearman correlation, and Fisher exact tests. NLR (but not PLR) was significantly higher in dogs with CHF secondary to MMVD (6.41) compared to presumptive preclinical MMVD dogs (4.66; P < .001) and control dogs (3.95; P < .001). Dogs with higher NLR and PLR received significantly higher cumulative dosages of loop-diuretic therapy during hospitalization (ρ = 0.3, P = .04; and ρ = 0.4, P = .02, respectively). There was a positive association between NLR and duration of oxygen supplementation within the CHF group (ρ = 0.4; P = .01). The increased diuretic dose and time receiving oxygen supplementation may represent increased disease severity for which NLR (and to a lesser extent PLR) may serve as a readily available marker. The data presented provide information regarding some of the systemic inflammatory changes seen in CHF secondary to MMVD in dogs. Future research should include prospective, longitudinal studies to provide insight into the long-term prognostic value of NLR and PLR in dogs with CHF.