Echocardiography Research Articles

From blunt chest trauma to broken heart: imaging features of a neglected diagnosis

Abstract Background/Introduction Blunt chest trauma is a leading cause of mortality, with a significant portion of deaths attributed to cardiac injuries. These cardiac injuries can range from mild contusions to life-threatening ruptures. Imaging plays a crucial role in evaluating suspected cardiac injury after chest trauma. This study highlights the importance of a comprehensive imaging approach in this critical setting. Purpose This study aims to investigate the presentations and diagnostic challenges of a wide range of cardiac injuries following blunt chest trauma, emphasizing the crucial role of cardiac imaging in identifying these injuries. Methods This study retrospectively investigates patients' presentations, diagnostic challenges, and imaging finding in diagnosing cardiac injuries following blunt chest trauma. We reviewed medical records of thirteen patients diagnosed with these injuries over a twelve-year period. Results Our study investigated cardiac injuries following blunt chest trauma. We analyzed thirteen patients' cases (Figure 1). Tricuspid valve regurgitation was the most frequent diagnosis, affecting seven patients. The potential for delayed presentation makes diagnosing these cases challenging, as patients with this injury may remain asymptomatic for many years following the trauma. One patient had a left main artery dissection (Figure 2 panel D cardiac 3D computed tomography; red arrow pointing to dissection within the distal left main coronary artery at the site of atheroma, with a small vascular outpouching, representing a false lumen) and another patient had severe mitral regurgitation due to partial rupture of the anterior papillary muscle post chest trauma. Additionally, two patients had ventricular septal defects (Figure 2 Panel C cardiac MRI; red arrow pointing to large muscular ventricular septal defect at the mid - apical segment with left to right shunt; LV: left ventricular, RV: right ventricular, LA: left atrium, RA:Right atrium, AA:ascending aorta). We observed another very rare complication post chest trauma an aortic valve aneurysm causing severe aortic regurgitation. Additionally, another patient with a bicuspid aortic valve developed post chest trauma flail and tear of the aortic valve cusp (Figure 2 Panel A, 2D transthoracic echocardiography, parasternal long axis views red arrow pointing to flail and tear of aortic valve cusp, panel B; 2D transthoracic echocardiography with color, parasternal long axis views red arrow pointing to severe aortic regurgitation jet directed towards the anterior mitral leaflet). Conclusion(s) This study highlights the challenges of diagnosing cardiac injuries after chest trauma. It emphasizes the importance of maintaining a high index of suspicion for these injuries in patients with blunt chest trauma. A focused examination and utilization of imaging can improve diagnostic accuracy, guide optimal patient management, and ultimately prevent complications and improve outcomes. Figure 1 Figure 2

Mitral annulus components in patients with metabolic syndrome and relapse after atrial fibrillation cardioversion

Abstract Background Metabolic syndrome (MetS) is associated with recurrent episodes of atrial fibrillation (AF) due to atrial remodeling. Four-dimensional transesophageal echocardiography (4DTEE) is an ideal imaging technique to evaluate these patients' complex morphology of the mitral valve apparatus (MVA). Purpose The study aimed to find some features of MVA components in patients with MetS and persistent AF and if some of them could be indicative of relapse after cardioversion. Methods The study enrolled 101 patients with persistent AF and mild/moderate functional mitral regurgitation (FMR) before cardioversion. According to the latest guidelines, 46(45,54%) of the patients were diagnosed with MetS. After performing two-dimensional transthoracic echocardiography (2DTTE), the study included only mild/moderate FMR patients. 4D TEE permitted a detailed examination of the MVA components, using an E95 machine for acquisition and an ECHOPAC 204 for image postprocessing with mitral valve quantification (MVQ) software. The studied measured: annulus area (AA)3D, annulus perimeter (AP), antero-posterior diameter (APD), posteromedial-anterolateral diameter (PM-ALD), commissural diameter (CD), inter-trigonal distance (ITd), annular height (AH), non-planar angle (NPa), mitral-aortic angle (MAa), anterior leaflet area (ALA), posterior leaflet area (PLA), anterior leaflet length (ALL), posterior leaflet length (PLL), anterior leaflet angle (ALa), posterior leaflet angle (PLa), tenting height (TH), tenting area (TA), and tenting volume (TV). Results 1. Relapse after cardioversion were 32,6% in MetS (+) patients and 17,85% in MetS (-) group. 2. Features of MA parameters in patients with or without MetS were: AA3D 13.09 vs. 12.18 (p= 0.02), AP 12.89 vs. 12.11 (P = 0.01), APD 3.75 vs. 3.6 (P = 0.07), PM-ALD 4.18 vs. 3.98 (P = 0.04), CD 4.2 vs. 4.04 (P = 0.08), and 2.91 vs. 2.88 (P = 0.7), AH 5.85 vs. 5.32 (P = 0.03), NPa 160.39 vs. 157.89 (P = 0.2), MAa 124 vs. 123.4 (P = 0.7), ALA 6.74 vs. 6.03 (P = 0.006), PLA 7.64 vs. 6.96 (P = 0.03), ALL 2.21 vs. 2.17 (P = 0.4), PLL 1.74 vs. 1.72 (P = 0.7), Ala 18.26 vs 17.56 (P = 0.6), Pla 23.41 vs 22.56 (P = 0.5), TH 1.43 vs 1.01 (P = 0.004), TA 1.85 vs 1.51 (P = 0.03), TV 2.76 vs 2.18 (P = 0.03). 3. Parameters that showed significant differences in patients with relapse with or without MetS were AA3D 15.25 vs. 13.45 (P = 0.03), AP 4.22 vs. 13.02 (p=0.04), PM-ALD 4.61 vs. 3.99 (P = 0.008), CD 4.75 vs. 4.02 (P < 0.0001), AH 6.37 vs. 4.91 (P = 0.004), and for the leaflets ALA 8.25 vs. 7.18 (P = 0.02), PLA 9.31 vs 7.97 (P = 0.04), TA 2.66 vs 1.79 (P = 0.02), TV 4.03 vs 2.27 (P = 0.006). Conclusions 1. Mitral annulus and mitral leaflet remodeling were more evident in patients with MetS with or without relapse. 2. The annular area, annular perimeter, posteromedial to anterolateral diameter, commissural diameter, leaflets area, and tenting parameters are most damaged in patients with MetS and relapse after the first cardioversion. 4DE reconstruction of the mitral valve Mitral valve apparatus evaluation by MVQ

Echocardiography image quality assessment: human subjectivity and artificial intelligence prediction in multi-centre data

Abstract Background Echocardiography image quality is important for precise care, but its assessment is subjective. An image quality metric by artificial intelligence (AI) may permit the optimization of image acquisition and improve analysis. Purpose To investigate (i) the most relevant features of echocardiography images related to perceived quality, (ii) to quantify them with AI and (iii) test their variability among centres. Methods Fifteen thousand anonymized transthoracic echocardiography studies acquired at Vall d’Hebron Hospital (VH) during care were retrieved. The original clinical assessment of study quality was obtained. Via co-creation, three image quality metrics (each with 3 levels, [0, 1, 2]) were identified: (i) the definition of structures borders and the presence of (ii) all expected cardiac structures and (iii) of apical foreshortening. Then, cardiologists annotated image quality of 6831 VH and 1000 CAMUS videos, which provided its own quality metric [1]. Three AI models were trained with 5256 videos from the VH to reproduce the 3 quality metrics. Models were then internally and externally validated in 1424 and 1000 videos from VH and CAMUS, respectively. Results Data from 488 VH patients were available for this analysis (Table 1). Inter-observer agreement in VH data was limited (56, 48 and 46% for border definition, presence of structures and foreshortening, respectively). Borders definition (p<0.001) but not the presence of all expected structures (p=0.862) nor apical foreshortening (p=0.440) was related to clinical study quality. Trained with data from a single rater, AI models demonstrated reasonable performance in the predictions for borders definition (agreement 60%), presence of all expected structures (54%) and apical foreshortening (53%) in VH images, showing slightly better performance when tested with data annotated by the same rater (62%, 58%, 51%). Border definition decreased with BMI (p=0.042), which was reproduced by the model (p=0.001), while annotated (p=0.028) but not predicted (p=0.525) border definition was lower in cardiomyopathy, a potential bias of the model. Age, sex, aortic stenosis and irregular heart rhythm did not show trends with border definition. In CAMUS data, annotated image quality metrics did not compare well with original annotations (agreement of 21% and 35% for border definition and complete structure), which showed lower image quality compared to VH (60 vs 11% of CAMUS videos defined as low quality by VH vs CAMUS raters), highlighting the high subjectivity of image quality. Generalizability to CAMUS images was good for border definition (agreement of 57%) but very limited for structures completeness (19%). Conclusions Echocardiography image quality is subjective and mainly driven by the definition of the borders of cardiac structures. AI models can learn image quality, but generalization to images from other centres may be limited. Demographic and clinical information

Left atrial stiffness and its association to left ventricular geometry in resistance trained athletes using anabolic-androgenic steroids

Abstract Background Anabolic-Androgenic Steroids (AAS) are commonly used in resistance trained (RT) individuals despite the negative impact on left ventricular (LV) structure and function. Purpose Due to the inter-dependence of the left atrium (LA) and the LV, alongside the importance of the atria contributing to LV filling and cardiac output, this study aimed to assess the relationship between LV geometry and LA stiffness in young RT users of AAS. Methods Utilising a cross-sectional design, male (n=99) and female (n=19) RT individuals aged 29±6yrs were grouped based on self-reported AAS user status: current (CU; n=70), past (PU; n=22) and non-users (NU; n=27). All participants underwent transthoracic echocardiography with strain imaging. Left ventricular geometry was defined based on LV mass index and relative wall thickness as per European Association of Cardiovascular Imaging guidelines. Left atrial stiffness index (LASi) was calculated as the ratio of E/E’ to LA reservoir strain (LARes) and concentricity as the ratio of LV mass to end-diastolic volume^0.67. Ejection Fraction (EF) was calculated using Simpsons biplane method. All data was presented as mean ± standard deviation with group differences assessed using a one-way ANOVA with post-hoc Bonferroni adjustment and Kruskal-Wallis test for non-normally distributed indices. A Fishers exact test was used to compare geometry between groups. Relationships between LASi and concentricity were assessed using multi linear regression Results Current users presented greater LV remodelling compared to PU and NU (eccentric hypertrophy (45%, 9% and 0%), concentric remodelling (2%, 0% and 0%) and concentric hypertrophy (8%, 0% and 0% respectively; p<0.001). EF was lower in those with concentric (52±9, p=.006) and eccentric (53±5, p<.001) hypertrophy than with normal geometry (58±5), but no difference between concentric and eccentric hypertrophy. LARes was lower in CU (32.0±7.5) compared to PU (39.1±8.3, p=.001) and NU (40.2±7.7, p<.001). E/E’ and LASi were higher in CU than PU (p=.006, p=.001) and NU (p<.001, p<.001; E/E’: 6.7±1.8, 5.9±1.5, and 5.7±1.4; LA stiffness index: 0.21±0.08, 0.16±0.05, and 0.15±0.05). Concentricity was higher in CU than PU (p<.001) and NU (p<.001; 8.3±2.2; 6.4±1.4 and 5.7±2.2 respectively). Controlling for user status, concentricity predicted LASi (R²=0.23, F(2,109)=16.1, p<.001) with a 0.1 increase in LASi for each 10g.ml^-0.667 increase in concentricity. Conclusions Although current users of AAS presented with more eccentric hypertrophy, those with increased concentricity and concentric hypertrophy had higher LA stiffness index. These data highlight 1) the potential greater negative functional impact of concentric compared to eccentric hypertrophy in young RT individuals using AAS, 2) the added value of LASi above conventional indices such as EF and 3) the possible reversible nature of LV and LA remodelling following cessation of AAS use.

Mechanical dispersion as a marker of the risk of ventricular arrhythmias in patients who have suffered a left ventricular myocardial infarction

Abstract Introduction Purpose. To study the relationship between the indices of mechanical dispersion (MD) of the left ventricle and ventricular arrhythmias (VA) by classification Lown and Wolf in patients who have suffered a left ventricular myocardial infarction Methods The study included 80 patients with chronic CAD aged between 38 and 84 years. All patients underwent the following examinations: physical examination, general clinical and laboratory blood tests, 12-lead ECG, 24-hour holter monitoring; standart transthoracic echocardiography, assessment of left ventricular systolic function, speckle-tracking echocardiography with assessment of global longitudinal strain (GLS) and mechanical dispersion (MD) using the auto CMQ program on the Phillips Affinity 70 ultrasound machine. All patients divided into 5 groups: Group I - 22 patients without VA; Group II – 15 patients without ventricular arrhythmias. Conclusion The study shows that mechanical dispersion of the left ventricle is a marker of the risk of ventricular arrhythmias in patients who have suffered acute myocardial infarction of the left ventricle and the higher the gradation of arrhythmias, the longer the duration of MD

A new vendor-independent software tool allows for reliable measurement of left ventricular, right ventricular and left atrial global longitudinal strain

Abstract Introduction Speckle tracking echocardiography (STE) has become an essential clinical tool. However, its use in everyday practice remains cumbersome due to differences between vendor-specific measurement packages and a lack of compatibility. Vendor-independent software tools can overcome these limitations and allow for more widespread use of STE. Aim To assess the feasibility and accuracy of a new vendor-independent software (VIS) tool for measuring left and right ventricular, as well as left atrial global longitudinal strain using a well-established vendor-specific software (VSS) package as a reference. Methods 110 patients (60 male, mean age 65 ±12,5 years) with various cardiovascular pathologies who underwent transthoracic echocardiography in the cardiology department were included in the study group. All acquired images were sent to an external workstation, where they were analyzed offline using a vendor-specific measurement package and a new vendor-independent software tool. Patients with suboptimal image quality of any myocardial segment were excluded from the study group. The analysis included measurements of left ventricular global longitudinal strain (LV GLS) based on three apical views, as well as right ventricular global longitudinal strain (RV GLS) and right ventricular free wall strain (RV FWS) based on apical four-chamber RV-focused view. Left atrial strain (LAS) measurements were based on a four – and two-chamber apical view and the three phases of the atrial function were analyzed. Results Due to suboptimal image quality, 31 and 36 patients were excluded from the LV and RV analysis groups, respectively. We observed strong correlations between measurement results obtained using VS and VI software tools for the LV (r=0,888, p<0,0001) and RV global strain (r=0,807, p<0,0001) and RV FWS (r=0,836, p<0,0001). Mean LV GLS measured by VIS and VSS were -15,3±3,4% and -14,4±3,5%, respectively (p=NS). Mean RV GLS measured by VIS and VSS were -16,5±4,4% and -17,4±5%, respectively (p=0,NS). Mean RV FWS obtained with VIS and VSS were -18,7±5,5% and -21±6,7%, respectively (p=NS). 51 patients (32 male, mean age 63,5±12 years) had feasible image quality for calculating LAS. In this group, strong correlations between the measurement results using VS and VI software tools were observed for the reservoir (r=0,8956 p<0,0001), conduit (r=0,8168, p<0,0001), and contraction (r=0,8759 p<0,0001) phases. The mean reservoir strain measured by VIS and VSS were 23,04±7,99% and 21,7±7,7%, respectively (p=NS). Mean conduit strain measured by VIS and VSS were 10,07±5,02% and 8,71±3,85%, respectively (p=NS). The mean contraction strains obtained with VIS and VSS were 13,01±5,42% and 13,99±5,49%, respectively (p=NS). Conclusion A new vendor-independent software tool, allows for reliable measurement of left and right ventricular global longitudinal strain, as well as left atrial strain.

Trajectories and determinants of myocardial work indices in patients with acute myocardial infarction after primary percutaneous coronary intervention

Abstract Backgrounds The myocardial work indices (MW indices) are novel echocardiographic parameters that quantify myocardial deformation and concomitant left ventricular pressure. However, there is little current data on trajectories and determinants of MW indices after acute myocardial infarction (AMI). Purpose We aimed to evaluate the trajectories of myocardial work indices and their relationship with left ventricle (LV) functional recovery and remodelling in patients with AMI after primary percutaneous coronary intervention (PCI). Methods Thirty-one prospectively recruited patients (28 men; mean age, 64 ± 9 years) underwent transthoracic echocardiography 7.7±3.8 days after PCI for the first ST-elevation AMI. LV function was evaluated at baseline and the 6-month follow-up. MW index (MWI), constructive MW (CMW), myocardial wasted work (MWW), MW efficiency, and (MWE) were measured globally and segmentally. The myocardial area at risk (AAR) and the remote area were based on the culprit coronary arterial segment, determined from the invasive coronary angiography. Levels of troponin T and NT-proBNP were assessed. Results The mean LV end-diastolic volume (EDV), LV end-systolic volume (ESV), LV ejection fraction (EF), and global longitudinal strain were similar at baseline and the 6-month follow-up (94.7±27.7 vs 93.6±30.1 ml, p=0.7, 42.7±17.1 vs. 40.8±19.1 ml, p=0.4, 55.8±6.9 vs. 57.5±7.3%, p=0.2, and -14.9±4.6 vs. -15.4±3.9%, p=0.3, respectively). The global MWI, MCW, MWW and were significantly improved at the 6-month follow-up (p<0.001, p<0.001, p=0.002, and p=0.03, respectively). Furthermore, in AAR, regional MWI, MCW, and MWW values significantly improved at the 6-month follow-up (all p<0.001), whereas no changes in MWE were observed . MWI and MCW significantly improved in the remote areas (p<0.001, and p=0.02, respectively) , but other indicators remained unchanged (Table 1). The global MWI and MCW values at baseline were inversely correlated with peak levels of troponin T (r= - 0.60, p<0.001, and r= -0.52, p= 0.002, respectively) and NT-proBNP (r= -0.49, p= 0.007, and r= -0.47, p=0.01, respectively). Furthermore, the global MWI and MCW showed a significant positive correlation with EF at baseline (r= 0.66, p<0.001, and r= 0.56, p<0.001, respectively) and 6-month follow-up (r= 0.68, p<0.001, and r= 0.69, p<0.001, respectively), but a negative correlation with ESV (Figure 1). However, there was no significant correlation between MW indices and EDV. Conclusion Patients with AMI who underwent primary PCI showed improved global and regional LV performance 6 months post-infarction, as demonstrated by MW indices. Decreased global MWI and MCW are associated with higher baseline levels of NT-proBNP, higher baseline levels of troponin T, reduced EF, and increased end-systolic volume. These results provide evidence that MW indices are potential markers of the severity of myocardial injury and remodelling after AMI.

Artificial intelligence-enhanced electrocardiogram left ventricular diastolic function assessment for prognostic assessment in mitral annulus calcification

Abstract Background Moderate-severe mitral annulus calcification (MAC) and left ventricular (LV) diastolic dysfunction are both linked to increased risks of heart failure and mortality. Assessing LV diastolic function (LVDF) in moderate-severe-MAC by echocardiography is frequently challenging and unreliable. We recently validated an AI-ECG model for LVDF. We aimed to determine if this tool can predict long-term mortality in patients with moderate-severe-MAC and whether it can help establish MAC-specific echocardiographic LVDF parameter cutoffs. Methods This retrospective study included all patients from the AI-ECG LVDF study test cohort who underwent comprehensive transthoracic echocardiography confirming moderate-severe-MAC and ECG within fourteen days of each other at Mayo Clinic between 09/2001 and 06/2022. AI-ECG LVDF was determined based on the index ECG. Patients were categorized based on AI-ECG into groups representing normal/grade-1 LVDF, grade-2 LVDF, or grade-3 LVDG (DF-1, DF-2, and DF-3, respectively). Results Of 2,506 patients with moderate-severe-MAC [mean age 77, 64.1% females], 709 (28.3%), 1,510 (60.3%), and 287 (11.5%) were classified as DF-1, DF-2, and DF-3, respectively. Worse LVDF grade was associated with older age, male sex, lower LV ejection fraction, and higher rates of noncardiovascular and cardiovascular comorbidities. Over a median follow-up of 2.8 years, 1,059 (42.3%) patients died. In multivariable survival analysis, DF-2 [adjusted hazard ratio (aHR) 1.43, 95% confidence interval (95%CI) 1.21-1.68] and DF-3 (aHR 1.54, 95%CI 1.22-1.93) were independently associated with a higher risk of death (figure). Findings were also consistent after adjusting to mitral inflow gradients. When comparing LVDF echocardiographic parameters in controls without MAC matched by age, sex, left ventricular ejection fraction, and AI-ECG DF grade, significant differences were observed. Patients with moderate to severe MAC generally exhibited lower e' velocities, higher TR velocities, elevated E/e' ratios, and increased LAVi. Interestingly, the E/A ratio between MAC patients and their matched controls across AI-ECG LVDF grades remained consistent. Conclusion AI-ECG LVDF predicts mortality risk in patients with moderate-severe-MAC, regardless of mitral inflow gradients. Utilizing AI-ECG LVDF might aid in the risk stratification of patients with significant MAC.

Comparison of algorithms of left ventricular diastole function assessment in hypertensive individuals with preserved ejection fraction

Abstract The aim of the study was to compare two echo-algorithms of the assessment of the left ventricular diastole function (2016 the American Society of Echocardiography/the European Association of Cardiovascular Imaging and the 2024 British Society of Echocardiography guidelines) in routine clinical practice. Methods We retrospectively enrolled 142 adult hypertensive patients with cardiovascular disease of different aetiologies who underwent transthoracic echocardiography examination (2D imaging, Doppler) for routine clinical indications. It was measured echocardiography parameters for diastolic function evaluation as transmitral Doppler E wave, mitral annular Tissue Doppler Imaging e`septal and e` lateral, average E/e`, left atrium volume index, the velocity of tricuspid regurgitation. Results Overall, a total of 90 subjects were finally included (mean age 61.8 years (95% CI 59.1 to 64.5), 44.4% women) who had preserved left ventricular (LV) ejection fraction (≥50%). By applying the 2024 recommendations, 11% of individuals fulfilled the criteria for impaired diastolic function with elevated filling pressure, 83 % of subjects were diagnosed with normal diastolic function, and only 4.4% had impaired diastolic function with normal filling pressures. Meanwhile, according to the 2016 recommendations, 12 % were diagnosed with diastolic dysfunction, 54% had a normal diastolic function and 34%subjects had indeterminate diastolic function, and required additional examination. Conclusions This study demonstrates that a low number of individuals with impaired diastolic function with normal filling pressures was classified based on British recommendation 2024, however, a high number of patients with indeterminate diastolic function was diagnosed through guideline 2016. The new echocardiographic approach for estimating the left ventricular diastole function presented in 2024 could have higher clinical utility, especially in resource-limited settings for routine examination of hypertensive patients.

Validation of a fully automated AI system for accurate left ventricular mass measurement in echocardiography

Abstract Background Accurate measurement of left ventricular mass (LVM) with 2D transthoracic echocardiography (Echo) provides prognostic information, and aids in tailoring treatment plans. Purpose We sought to validate a fully automated artificial intelligence (AI) system for LVM measurement in Echo against human measurements and computed tomography (CT), considered the gold standard. Methods 101 patients with symptomatic aortic valve stenosis (AS), 48 with mitral valve regurgitation (MR), and 41 with tricuspid valve regurgitation (TR) underwent both Echo and cardiac spiral CT on the same day, the latter for planning interventional valve repair. End-diastolic septal and posterior wall thickness (IVSD, PW), along with end-diastolic diameter (EDD) from LV parasternal long axis views in Echo, were independently measured for 1-dimensional LVM calculation by both an AI and an experienced cardiologist (>10 years) (Figure 1A). Notably, the AI performed fully automated view selection from the entire Echo exam and measured LV diameter and wall thickness on appropriate LV views without operator involvement. LVM results from CT were supervised by an experienced radiologist (>10 years) (Figure 1B). Pearson’s correlation coefficient (r), regression analysis, and mean absolute error (MAE) were used to assess agreement of measurement values between methods. Results The final cohort consisted of 164 patients, with complete LVM calculations by AI, human, and CT (feasibility: 91%, 95%, and 99%, respectively). LVM from AI and human correlated strongly (r=0.83, MAE=22 g), but AI exhibited higher agreement with CT (r=0.69, MAE=28 g) than human LVM measurement (r=0.62, MAE=37 g) (Figures 1C and 1D). AI and human measurements showed good correlation for IVSD (r=0.74, MAE=0.18 cm) and EDD (r=0.73, MAE=0.54 cm), but low correlation for PWD (r=0.48, MAE=0.23 cm). Conclusion The findings highlight the potential use of an AI-based application for fully automated view selection and measurement of LV wall thickness and diameter, demonstrating strong agreement of LV mass with CT and human measurements.

Hypercontractile phenotype of the left ventricle in patients with heart failure with preserved ejection fraction: too strong to be normal?

Abstract Background Hypercontractile phenotype (HP) of the left ventricle (LV) is an actionable therapeutic target in patients with chronic coronary syndromes (CCS), but its prevalence and meaning in patients with heart failure and preserved ejection fraction (HFpEF) remains unclear. Purpose To assess the myocardial work correlates of the HP in patients with HFpEF. Methods In a prospective, observational, single-center, cross-sectional study, we recruited 62 healthy controls (55 ± 7 yrs, 36 males, 58.1%) and 129 patients (58 ± 8 yrs, 70 males, 54.3%) with HFpEF referred for resting transthoracic echocardiography with volumetric echocardiography and assessment of global work efficiency (GWE). We measured systolic blood pressure (SBP) with a cuff sphygmomanometer. We assessed quantitatively LV end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), force (SBP/ESV), stroke volume (SV), arterial elastance (SBP/SV), ventricular-arterial coupling (VAC, as SV/ESV), and cardiac output (CO= SV*heart rate).HP was identified a priori as value >7.87 mmHg/ml, corresponding to a value exceeding > 2SD (95% of values) of the distribution in normals. GWE was assessed with a single vendor together with global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and GWE. Results LVEF and GLS values were similar in normal and HFpEF (EF: 63.3±4.7% vs 67.2±6.3%, p > 0.05; GLS: 21.4±1.4% vs 19.1±2.7%, p > 0.05). However, at individual patient analysis, 42 patients of the HFpEF group showed HP (32.6%). Compared to controls and patients with HFpEF without HP, HP patients showed higher values of heart rate and EF but lower values of SV, LVESV, LVEDV, similar values of GLS, and markedly higher values of GWI, GCW, and GWW with lower GWE. Multivariable linear regression analysis showed that force was independently associated with GWE (β=-0.356, P=0.002) and LVEF (β=0.219, P<0.0001), NTproBNP was independently associated with GWW (β=0.589, P=0.020) and GWE (β=-31.120, P<0.0001). Conclusion A HP of the LV with high force is frequent in HFpEF and is associated with a small heart, reduced SV, and lower mechanical efficiency with higher global work but a disproportionate increase in wasted work. Work analysis is more effective than GLS in identifying HFpEF with HP.

Evolution of cardiovascular imaging surrogate endpoints in heart failure clinical trials: a systematic review

Abstract Background Cardiovascular imaging is commonly used for assessment of surrogate endpoints in early phase clinical trials in heart failure (HF). Treatment-induced change in left ventricular (LV) volumes and ejection fraction (EF) were validated against change in outcomes in a meta-analysis from 2011 [1]. However, cardiovascular imaging has evolved significantly since then with new modalities and endpoints introduced in interventional trials. Purpose To analyse temporal trends in implementation of cardiovascular imaging modalities and endpoints in HF trials in the last 15 years and identify endpoints with existing data on relationship between short-term change in imaging endpoint and long-term change in hard outcomes. Methods Firstly, we performed a systematic review of cardiovascular outcome trials (CVOTs) evaluating treatment effects on outcomes in HF. Secondly, we reviewed remodelling trials (RTs) evaluating effect of drugs identified in CVOTs search on imaging parameters. Results The CVOTs search yielded 64 records. Seventeen CVOTs evaluating effect of 10 different interventions on cardiovascular outcomes were considered eligible and included in the final analysis. The RTs search yielded 80 records, 34 publications were considered eligible (Fig.1). Out of 34 RTs, 29 trials employed transthoracic echocardiography (Echo), 1– low dose Dobutamine stress-Echo, 5– cardiac magnetic resonance (CMR), 1– Dobutamine stress-CMR, 1– Phosphorus CMR spectroscopy, and 1– PET. With exception of one study, Echo was the only imaging modality used in selected RTs until 2020. Four studies utilised >1 imaging modality. Data on relationship between therapy-induced changes in remodelling parameters and changes in clinical outcomes are mostly available for conventional markers of the LV and left atrium (LA) (LV EF, volumes, mass, E/e’, e’, LA volume), followed by LV global longitudinal strain. Data on how the therapy-induced changes in other novel endpoints (LV global circumferential strain, right ventricular function, or surrogates of myocardial fibrosis), can translate into change in clinical outcomes in HF has been investigated for single interventions only (Fig.2). Conclusions While Echo had been dominating the field in interventional HF trials, new imaging modalities and endpoints have been introduced in trials recently. Conventional parameters of LV remodelling and function remain the most validated regarding relationship between change in surrogate endpoint in response to treatment and change in clinical outcomes. More evidence on translatability of changes in imaging markers of LV and LA myocardial deformation, right ventricular function and myocardial tissue characterisation with clinical outcomes need to be generated in future trials. Fig.1. PRISMA Flow chart diagram Fig. 2. Imaging endpoints in HF trials

Association of transaortic flow rate with outcomes in patients with moderate aortic stenosis

Abstract Background In patients with severe aortic stenosis (AS), the transvalvular flow rate (FR) is a key determinant of the prognostic value of the aortic valve area (AVA). However, the prognostic significance of FR in patients with moderate AS remains unclear. Purpose To assess the association with outcomes of FR in patients with moderate AS. Methods 292 outpatients (mean age 80 ± 9 years, 45% female) with moderate degenerative AS (defined as AVA between 1 cm² and 1.5 cm²) underwent transthoracic echocardiography between January 2019 and July 2022 and were retrospectively included in this study. The FR was calculated using the derivation method [FRder= mean jet velocity (cm/s) x AVA(cm²)], and was validated in a random sample of 90 patients. In these patients, FR was also calculated using the direct method [FRdir = stroke volume (mL)/ejection time (s)]. The primary study endpoint was a composite of all-cause mortality and hospitalization for heart failure (HHF). Results After median follow-up of 19.3 (Interquartile-Range 12.3–26.0) months, 73 patients reached the primary endpoint, with 22 experiencing HHF and 51 deaths. Patients who met the combined endpoint had lower values of FRder compared to those who didn’t experience these outcomes (201±47 mL/s vs 225±48 mL/s). The FRder showed excellent correlation with FRdir (R²=0.93, p<0.0001) (Figure 1). The best threshold value for identifying patients at higher risk of experiencing adverse outcomes of FRder was determined to be 210 mL/s through spline curve analysis. Female sex [Odds Ratio (OR) 5.3 (C.I.95% 2.8-10.3), p<0.0001], chronic kidney disease (eGFR<60 ml/min) [OR 3.2 (C.I.95% 1.5-7.0), p=0.003], previous myocardial infarction (OR 3.9 [C.I. 95%1.7-8.6], p=0.001), stroke volume indexed (SVi) [OR 0.8 (C.I.95% 0.8-0.9), p<0.0001] and at least moderate tricuspid regurgitation (OR 2.9 [C.I. 95% 1.2-6.8], p=0.017) resulted independent predictors of FRder less than 210 mL/s. At Cox multivariable regression analysis, FRder less than 210 mL/s resulted associated with events (adjusted Hazard Ratio 2.17 [C.I. 95% 1.14 – 4.12], p=0.018), after adjustment for age, coronary artery disease, left-ventricular ejection fraction, right-ventricular dysfunction and low flow state-defined as SVi <35 mL/m². Conclusion In patients with moderate degenerative AS under medical management, FRder less than 210 mL/s is independently associated with increased mortality and HHF at medium term follow-up. Further research is needed to determine whether patients with moderate AS and impaired flow rates might benefit from more intensive monitoring or earlier aortic valve replacement. Figure 1

Performance of fully automated AI-based left ventricular strain measurement in cancer patients treated with immune checkpoint inhibitors

Abstract Background Immune checkpoint inhibitors (ICIs) have improved clinical outcomes for various types of cancer. However, their use is associated with cardiotoxicity. Left ventricular global longitudinal strain (LV-GLS) is considered the standard of care for detecting early myocardial damage in patients treated with anti-cancer drugs. However, the routine use of LV-GLS is limited by its time-consuming nature, and the need for expert cardiologists. AI-based LV-GLS applications may offer a cost-effective alternative to conventional methods. Purpose To compare standard, semi-automated LV-GLS analysis to a fully-automated AI-based LV-GLS software, and to evaluate its performance in predicting cardiovascular (CV) events in patients treated with ICIs. Methods We retrospectively analyzed consecutive cancer patients who underwent baseline transthoracic echocardiography before the initiation ICIs therapy. All echocardiographic studies were performed by experienced sonographers. LV-GLS analysis was conducted using both standard semi-automated, vendor-independent software (TomTec) and fully-automated AI-based software (Us2.AI). CV events were defined as a composite of myocarditis, acute coronary syndrome, heart failure and arrhythmia. We examined the correlation between the two techniques and their ability to predict future CV events using logistic regression and receiver operating characteristic (ROC) curves. For simplicity, we report LV-GLS as a positive value. Results Out of 183 patients (mean age 65±12 years, 43% females) who underwent echocardiography assessment, 157 (86%) had adequate image quality for strain analysis. During a median follow up period of 48 months (IQR: 34-61), 23 (13%) patients experienced CV events. A significant difference was observed between the baseline mean standard LV-GLS and AI-based LV-GLS (18±2.9 vs. 20±2.9, P<0.001), with a moderate positive correlation between the two techniques (r=0.38, P<0.001). Lower standard LV-GLS was predictive of CV events (OR = 0.83, 95% CI 0.71-0.98, P=0.03), whereas AI-based LV-GLS did not (OR = 0.96, 95% CI 0.82-1.14, P=0.686). In ROC analysis, standard LV-GLS showed superior area under the curve compared to AI-based measurements, but the difference was not statistically significant (AUC 0.62 vs. 0.53, P=0.275). Conclusions Among cancer patients treated with ICIs, fully automated AI-based LV-GLS provided higher values compared to standard, semi-automated LV-GLS, with a moderate correlation between the two techniques. Only standard LV-GLS was predictive of future CV events. Further validation and specific cut-offs are required to enhance the predictive accuracy of AI-based LV-GLS.

Right ventricle pulmonary artery coupling in patients with aortic stenosis.

Abstract Right Ventricle (RV) –Pulmonary Artery (PA) Coupling refers to the relationship between RV contractility and RV afterload. It is estimated as the ratio of RV free wall tissue Doppler imaging (TDi) and Pulmonary Artery Systolic Pressure (PASP) . This index has shown a prognostic value in patients with cardiovascular diseases. The aim of the current study is to investigate the current index in patients with various grades of aortic stenosis. We enrolled 60 subjects to our study (20 with severe aortic stenosis, 20 with symptomatic moderate aortic stenosis without other significant valve pathology, 20 contol group- aged matched). All patients underwent transthoracic echocardiography study. Statistical analysis revealed a significant deference within 3 groups regarding RV –PA Coupling (RV-STDi /PASP, mean ± sd : 0.2595 ± 0.11718 vs 0.4305 ± 0.07416 vs 0.5820 ± 0.04275 , p – value = <0,001) Conclusions RV –PA Coupling index is significally associated with the grade of aortic stenosis. RV PA coupling vs stenosis

Transfer learning for echocardiographic detection of heart failure with preserved ejection fraction: preliminary results of TALE-HFpEF Study

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome with increasing prevalence (1). The diagnosis of HFpEF is a complex one that has not yet reached a consensus in current guidelines, and attempts are being made to diagnose it through various algorithms and scoring systems (2, 3). However, the uncertainties in the diagnostic process and the inherent complexity continue to pose significant barriers to practical implementation. The use of artificial intelligence on single apical 4-chamber transthoracic echocardiograhy video clips for HFpEF detection has shown success (4), but knowledge from readily available models trained for different tasks is not utilized. Purpose This study aims to utilize transfer learning, an artificial intelligence method, to detect HFpEF using echocardiography images. Methods In this preliminary anaylsis, echocardiography video clips were collected from 40 healthy volunteers and 53 HFpEF patients, all over 18 years old. The diagnosis of HFpEF was made in accordance with the current ESC guidelines (3). Apical 4-chamber transthoracic echocardiography images of the patients and volunteers included in the study were obtained and analyzed. Patients with chronic obstructive pulmonary disease, recent myocardial infarction (last 6 months), or recent stroke/cerebrovascular disease (last 3 months) were excluded. Transfer learning was applied using a video ResNet model (6), adapted for left and right ventricle ejection fraction (LVEF and RVEF) prediction tasks, along with a non-medical video classification task (Kinetics 400) (6-8). A 5-fold cross-validation schema was used, and models were compared using balanced accuracy with a right-tailed t-test. Results When comparing with the control group, the HFpEF group shows higher rates of hypertension, diabetes, and atrial fibrillation, as well as higher NT-proBNP levels. The paired one-tailed t-test confirmed significant superiority of all transfer learning models over the baseline model (p < 0.005). The model transferred from the LVEF regression task achieved an AUC of 0.95 ± 0.04 and F1 score of 0.93 ± 0.04 (Figure 1), demonstrating superior performance. Statistical analysis indicated no significant variation in balanced accuracy among models (p > 0.05). Figure 1 also depicts ROC curves of the models initialized with different task weights. Figure-2 illustrates the locations where models focus before and after training using the Grad-CAM method (9). The LVEF model has achieved 92% accuracy in identifying HFpEF patients with 95% sensitivity and 90% specificity. Conclusion The preliminary results of our study are promising in the diagnosis of HFpEF patients through echocardiographic clips with transfer learning. Throughout our study, as the sample size grows, this model could become a key tool in clinical practice for detecting HFpEF patients, potentially enhancing AI's role in diagnosing this challenging patient group.

Elevated left atrial stiffness index is a poor prognostic factor in heart failure with preserved ejection fraction undergoing transcatheter aortic valve replacement

Abstract Background Patients with severe aortic valve stenosis undergoing transcatheter aortic valve replacement (TAVR) present with a high prevalence of heart failure with preserved ejection fraction (HFpEF). An elevated left atrial stiffness index (LASI) has recently been recognized as a potential prognostic factor for worsened outcomes in HFpEF patients. Purpose This study investigates whether the LASI is a prognostic factor for outcomes following TAVR in HFpEF patients. Methods In this single-center retrospective study, patients with severe aortic valve stenosis who underwent TAVR at our center from February 2020 to May 2023 and had left ventricular ejection fraction >40% were included (Figure 1). The LASI was defined as the ratio of E/e’ to the left atrial reservoir strain from transthoracic echocardiography performed before and one week after TAVR. The primary endpoint was a composite outcome of all-cause mortality and cardiovascular events during the follow-up period. Results We analyzed 178 patients with a median age of 84 years, of whom 69% were female. During a median follow-up period of 549 days, 34 cases (19%) experienced the composite outcome. Multivariate Cox proportional hazards analysis using preoperative indices showed that LASI was independently associated with the occurrence of outcomes (HR 1.84 [95% CI; 1.15-2.95, P = 0.011] per 1.0 increase). A sub-analysis excluding cases had left bundle branch block postoperatively revealed a significant association between postoperative LASI and outcomes (HR 3.62 [95% CI; 2.01-6.51, P = <0.001] per 1.0 increase), particularly pronounced in patients with preoperative grade 2 left ventricular diastolic dysfunction (HR 4.38 [95%CI; 2.07-9.26, P=<0.001] per 1.0 increase) (Figure 2). Conclusion There is potential for LASI as a prognostic factor for outcomes following TAVR in HFpEF patients.

Comparing fully automated 3DE quantification and cardiac magnetic resonance imaging for left ventricular volume and function evaluation in patients with dilated cardiomyopathy

Abstract Background Integration of artificial intelligence enhances precision, yielding dependable evaluations of left ventricular volumes and ejection fraction despite image quality variations. Dilated cardiomyopathy patients have low ejection fraction with dilated left ventricular volumes, which affect the diagnostic accuracy of automated 3D echocardiography. Establishing the diagnostic accuracy of fully automated 3DE quantification software, simplify and accelerate the measurement of left chamber volumes and ejection fraction. Objective In this manuscript, we present a cross-sectional study to assess and compare the diagnostic accuracy of automated 3D transthoracic echocardiography (3D TTE) to the standard cardiac magnetic resonance (CMR) imaging in patients with dilated cardiomyopathy. Methods In this cross-sectional study, 30 dilated cardiomyopathy patients with CMR imaging and comprehensive 3D TTE were included. 3D TTE and CMR imaging were performed within 24 hours. All 3D volume analyses were performed with fully automated quantification software using 3D images of 2,3, and 4-chamber views at the end of systole and diastole. Results Excellent Inter- and Intra-observer correlation coefficient was reported for automated 3D TTE software for all indexes. Automated 3D TTE software underestimated the mean value of LVESVI and LVESDI compared to the CMR. On the contrary, LVEF, LV Mass, LV Mass Index, and SV were overestimated. Contour correction was needed in 8 cases. In cases needing contour editing, no statistically significant difference was demonstrated except for LVEF and SV. Semiautomated 3D TTE software showed similar findings as automated, except that SV was underestimated. Correlation analysis demonstrated significant agreement between Automated 3D TTE software and CMR measurements for all indexes. Fully automated measurements exhibited excellent agreement for LVESVI (r=0.918) and LVEDVI (r=0.911), good agreement for SV (r=0.811), and acceptable agreement for LVEF (r=0.744). However, despite being significantly correlated, it did not reveal acceptable agreement for LV Mass (r= 0.498) and LV mass index (r=0.421). Semiautomated 3D TTE software revealed improved correlation for all indexes, except for LVEDVI and SV. Nevertheless, no significant difference was observed between the CMR agreement correlations with automated and semiautomated 3D TTE software measurements. Conclusion Automated 3D TTE software emerges as a rapid and viable imaging approach for evaluating the left ventricle's structure and function. Nevertheless, its volume assessments demonstrate a stronger correlation with CMR imaging compared to its functional assessments. Agreement between 3D TTE and CMR Inter- and Intra-observer correlation

Diastolic function in patients with preserved left ventricle ejection fraction: prognostic value and added role of left atrial strain

Abstract Background Few studies have evaluated the prognostic value of diastolic function in patients with preserved left ventricular ejection fraction (LVEF) according to the 2016 ASE/EACVI guidelines, regardless of the specific type of heart disease. Our aim was to evaluate the ability of diastolic function to predict a composite event of heart failure (HF), atrial fibrillation (AF) or ischemic stroke and to determine the added value of left atrial reservoir strain (LARS). Methods We performed a retrospective analysis of 364 patients with preserved LVEF and sinus rhythm referred for transthoracic echocardiography and categorized them into four groups based on their diastolic function status according to the 2016 ASE/EACVI guidelines: normal diastolic function (NDF), indeterminate diastolic function and diastolic dysfunction with indeterminate filling pressure (IDT), grade 1 diastolic dysfunction (DD1), and diastolic dysfunction with elevated filling pressure (DD-EFP). The primary endpoint was a composite of AF, HF or ischemic stroke. LARS was measured by 2D speckle tracking. Clinical parameters and specific cardiac diseases were also assessed. Results After a mean follow-up of 2.4 years, diastolic function was an independent predictor of events, with patients with DD-EFP having the highest risk (HR 12.73 (95% CI, 1.50-108.17), P=0.02). The addition of LARS improved risk stratification, especially in IDT patients, with a cut-off of ≤24% identifying a high-risk population. Patients at high risk, defined as those with DD-EFP and IDT with LARS ≤24%, had a high event rate of 34% and 46%, respectively. Conclusions In patients with preserved LVEF and sinus rhythm, patients classified with DD-EFP have the highest risk for the composite event. LARS improves risk stratification and also identifies IDT patients with LARS≤24% as a high-risk population. High-risk patients (DD-EFP and IDT with LARS ≤24%) had a high event rate (34% and 46%, respectively). Future studies are needed to further confirm these findings. Survival according to diastolic function Survival (diastolic f and LARS combined)

Challenging sacred cows: does left ventricle end-systolic and end-diastolic diameter change significantly in long term follow up of patients with severe aortic regurgitation ?

Abstract Background American and European valvular heart disease guidelines suggest considering aortic valve surgery in patients with severe aortic regurgitation (AR) and progressive increase in left ventricle (LV) end diastolic diameter (LVEDD) into the severe range or progressive decrease in LV function. Surprisingly, there are almost no studies that actually examined systematically the rate of change over time in these widely used parameters in clinical practice in patients with severe AR. Purpose determine the rate of change in LVEDD, left ventricular end systolic diameter (LVESD) and fractional shortening (FS) in patients with significant AR over a long period of time. Methods we considered all consecutive patients with at least moderate to severe AR on index transthoracic echo study and at least four subsequent echo studies over a follow-up period longer than 1.5 years in a large tertiary hospital registry between April 1994 and April 2024. Exclusion criteria were concomitant greater than mild to moderate aortic stenosis or mitral valve disease, aortic dissection, previous aortic or mitral surgery, hypertrophic cardiomyopathy or complex congenital heart disease on index study. Aortic valve replacement (AVR) or death terminated follow-up in this study. Partial correlation corrected for repeated measures was determined for LVEDD/LVESD/FS and interval period (in days) between repeat studies. Results We included a cohort of 140 patients meeting the inclusion criteria study after excluding 31 patients as per above criteria. Aortic valve was bicuspid in 39 (27.9%) of the patients, and unicuspid in 4 (2.9%) patients. Median follow-up was 4.4 years (interquartile range (IQR) 1.9 to 8.8 years), median interval between consecutive studies was 255 days (IQR 172 to 367 days), 35 (25%) patients died and 61 (43.6%) patients underwent AVR. Partial correlation coefficients and p values for LVEDD, LVESD, and FS were respectively -0.3 (p<0.0001), -0.032 (p=0.24), and -0.18 (p<0.001). Conclusions Contrary to conventional wisdom, we didn’t find a significant trend of dilatation in left ventricular end diastolic and end-systolic LV diameter in patients with ≥ moderate to severe AR over a long follow-up, but a weak trend of fractional shortening decrease over time was noted. These findings cast doubt on the utility attributed to change in these parameters as part of the routine clinical follow up of patients with significant AR. LVEDD and LVESD change over time