Comprehensive Echocardiographic Evaluation Research Articles

The prognostic value of right ventricular outflow tract velocity time integral in patients with pulmonary hypertension.

Right ventricular (RV) failure is one of the leading causes of death in patients with pulmonary hypertension (PH). Conventional echocardiographic parameters are not included in risk stratification and follow-up for prognostic assessment due to PH's diverse nature and the RV's complex geometry. RV outflow tract velocity time integral (RVOT VTI) is a simple, non-invasive estimate of pulmonary flow and an echocardiographic surrogate of RV stroke volume. In this study, we aimed to define the prognostic value of RVOT VTI in PH patients. Sixty-three subjects with idiopathic PAH (IPAH) (n=23), connective tissue disease-associated PAH (CTD-associated PAH) (n=19) and chronic thromboembolic pulmonary hypertension (CTEPH) (n=21) were retrospectively included. A comprehensive two-dimensional echocardiographic evaluation, including RVOT-VTI measurement, was performed during the follow-up and the New York Heart Association functional class (NYHA FC), 6min walk distance (6MWD) and brain natriuretic peptide (BNP) levels were recorded. The median age of the whole cohort was 63years (52-68), and 47 (74.6%) of the patients were women. The median follow-up period was 20months (11-33), and 20 (31.7%) patients died in this period. BNP values were higher [317 (210-641) vs 161 (47-466), P=0.02], and 6MWD values were lower [197.5±89.5 vs 339±146.3, P<0.0001] in the non-survivor group, and the non-survivor group had a worse NYHA-FC (P=0.02). Among echocardiographic data, tricuspid annular plane systolic excursion (TAPSE) (15.4±4.8 vs 18.6±4.2, P=0.01) and RVOT VTI (11.9±4.1 vs 17.2±4.3, P<0.0001) values were lower whereas right atrial area (RAA) (26.9±10.1 vs 22.2±7.1, P=0.04) values were higher in the non-survivor group. The area under curve of the RVOT VTI for predicting mortality was 0.82 [95% confidence interval (CI) 0.715-0.940, P<0.0001], and the best cut-off value was 14.7cm with a sensitivity of 80% and specificity of 77%. Survival was significantly lower in subjects with RVOT VTI≤14.7cm (log-rank P<0.0001). Survival rates for patients with RVOT VTI≤14.7cm were 70% at 1year, 50% at 2years, %29 at 3years and 21% at 5years. The univariate determinants of all-cause mortality were BNP [hazard ratio (HR) 1.001 (1.001-1.002), P=0.001], 6MWD [HR 0.994 (0.990-0.999), P=0.012] and NYHA-FC III-IV [HR 3.335 (1.103-10.083), P=0.03], TAPSE [HR 0.838 (0.775-0.929), P=0.001], RAA [HR 1.072 (1.013-1.135), P=0.016] and RVOT VTI [HR 0.819 (0.740-0.906), P<0.0001]. RVOT VTI was found to be the only independent determinant of mortality [HR 0.857 (0.766-0.960), P=0.008]. The decreased RVOT VTI predicts mortality in patients with PH and each 1mm decrease in RVOT VTI increases the risk of mortality by 14.3%. This parameter might serve as an additional parameter in the follow-up of these patients especially when 6MWD and NYHA-FC could not be determined.

Comprehensive echocardiographic evaluation in CTEPH: the impact of TAPSE/sPAP and RVOT acceleration time on the diagnostic performance of peak tricuspid regurgitation velocity

Abstract Introduction The hemodynamic definition of pulmonary hypertension (PH) has been updated, with lowering of the mean pulmonary arterial pressure (mPAP) threshold from 25 to 20 mmHg according to the new 2022 ESC/ERS Guidelines. Peak tricuspid regurgitation velocity (PTRV) remains the key variable for assigning the echocardiographic probability of PH, but a comprehensive echocardiographic evaluation also includes detecting additional signs suggestive of PH. Since the cut-off for PTRV remained the same (&amp;gt;2.8m/s), the potential impact of other echocardiographic variables in the diagnosis of PH according to the new criteria has not been extensively evaluated. Objectives To evaluate the screening power of the standard echocardiographic parameters to detect PH according to the new guidelines and to establish the sensitivity and specificity of adding tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure ratio (TAPSE/sPAP) and right ventricular outflow tract acceleration time (RVOT AT) to PTRV in the diagnosis of PH. Methods Prospective registry of consecutive intermediate-high- and high-risk PE pts submitted to CDT in a single tertiary center. 3 months after the procedure, patients were submitted to a right heart catheterization and echocardiogram to screen chronic thromboembolic pulmonary hypertension (CTEPH). According to new PH criteria, patients were divided in two groups, and echocardiographic parameters were analyzed. ROC curve was performed to evaluate the sensitivity and specificity of each variable. Results 17 pts (60% women, mean age 59 ± 16 years) were included. Among these, 7 pts (41,2%) were diagnosed with pre-capillary PH by RHC at 3 months of follow-up. Among echocardiographic parameters, PTRV (p 0.015), presence of tricuspid regurgitation (0.034) and TAPSE/sPAP (p 0.041) were significantly different between groups. Other parameters did not show significant differences (Fig 1). Regarding PTRV, the cut-off of 2.8 m/s achieved a low sensitivity of 28.6%, although 100% of specificity (AUC 0.643) for the diagnosis of PH. Adding TAPSE/sPAP &amp;lt; 0,55 mm/mmHg (recommended cut-off) to the screening, increased the sensitivity to 42,9% without losing specificity (AUC 0,714). When adding RVOT AT &amp;lt; 105 ms (recommended cut-off) to the analysis, meaning, using three echocardiographic variables combined, it achieved a sensitivity of 85,7%, although the specificity was lower – 80% (AUC 0,829) (Fig 2). Conclusion PTRV and TAPSE/sPAP ratio are the only conventional echocardiographic parameters to be significantly different when comparing patients with and without PH. However, with the recent update in PH criteria, the use of the PTRV recommended cut-off leads to a significant underdiagnosis in our population. Although PTRV did not seem to predict accurately the presence of PH when used alone, when combined with TAPSE/sPAP and RVOT AT, our data suggests a growth in the screening power, without a major loss in specificity.Figure 1Figure 2

Structural and functional abnormalities of cardiac chambers in Barlow disease without significant mitral regurgitation

Abstract Background Limited and conflicting data have been reported on the existence of an early chamber remodelling in patients with Barlow disease (BD) without significant mitral regurgitation (MR). Purpose To explore the presence of left ventricular (LV) and left atrial (LA) morphological and functional abnormalities, evaluated by conventional and speckle-tracking echocardiography, in patients with BD and without significant MR; in addition, potential determinants of MR progression in these patients have been investigated. Methods We retrospectively identified consecutive patients with BD evaluated in two tertiary centers between 2010 and 2021. Only patients with MR graded from trivial to mild-to-moderate, as defined by an integrated multiparametric echocardiographic assessment, were selected. BD patients were matched with healthy controls with similar demographic characteristics and prevalence of cardiovascular risk factors, in a 1:1 ratio. A comprehensive echocardiographic evaluation, including LV and LA strain assessment by speckle-tracking analysis, was performed in all patients. Follow-up echocardiograms, when available, were reviewed in BD patients to evaluate the MR progression. Results A total of 231 patients with BD were included, of which 109 (56%) had trivial or mild MR and the remaining 122 (44%) had mild-to-moderate MR. As showed in Figure 1, patients with BD showed increased LV dimensions and indexed LV mass (LVMi), as compared with controls (all p&amp;lt;0.001); LV remodelling worsened with higher degree of MR (trivial-mild vs mild-to-moderate) and was accompanied by an increased prevalence of eccentric LV hypertrophy (eLVH). Conversely, parameters of LV systolic performance, including LV strain, were similar to controls and between the two groups. In addition, BD patients had larger LA volumes and more impaired LA reservoir strain than controls (p&amp;lt;0.001), without differences in the latter according to MR severity. Multivariable linear regression analyses in the overall population identified BD and MR grade as independent predictors of remodelling markers (LV dimensions, LVMi and LA volumes), and BD as independent correlate of LA reservoir strain. Progression to moderate-to-severe or greater MR was observed in 51 subjects (on 172 with available follow-up) after a median time of 38 (range: 24-68) months. On multivariable Cox regression analysis, LVMi (or alternatively eLVH), together with age, MR grade and the presence of mitral annular disjunction emerged as independent predictors of MR progression (Figure 2). Conclusions Patients with BD and no significant MR show an early LV and LA remodeling, together with a mild impairment of LA reservoir strain, but not of LV function. LV remodelling, and the presence of eLVH in particular, portends a higher risk of MR progression.Comparative echocardiographic analysisMultivariable Cox regression analyses

Electromechanical Window and Spontaneous Ventricular Tachyarrhythmias in Takotsubo Syndrome

QT interval prolongation is common in patients hospitalized with Takotsubo syndrome (TTS), however, only a minority experience ventricular tachyarrhythmias. Our aim was to characterize the electromechanical window (EMW) in patients with TTS and to evaluate its association with ventricular tachyarrhythmias. We preformed aretrospective analysis of 84 patients hospitalized with TTS in the Tel-Aviv Medical Center between 2013 and 2022. All patients underwent a comprehensive echocardiographic evaluation and the EMW was calculated by subtracting the QT interval from the QRS onset to the aortic valve closure obtained from a continuous-wave Doppler for the same beat. Of the 84 patients with TTS, 74 (88%) were female and the mean age was 70 ± 11 years. The mean left ventricular ejection fraction was 42 ± 8%. The EMW was negative in 81 patients (96%), and the mean EMW was -69 ± 50 ms. Ventricular tachyarrhythmias occurred in 7 patients (8%). The EMW of patients who experienced ventricular tachyarrhythmias was more negative than patients who did not (-133 ± 23 ms vs -63 ± 48 ms, p = 0.001). In the univariate analysis, EMW and QT were associated with ventricular tachyarrhythmias (univariate odds ratio [OR]EMW1.03, 95% confidence interval [CI] 1.01 to 1.05, p = 0.003 and univariate ORQTc1.02, 95% CI 1.01 to 1.03, p = 0.02); however, only EMW remained significant in the multivariate analysis (OREMW1.03 95% CI 1.03 to 1.05, p = 0.023). EMW was more effective than corrected QT interval in identifying patients who had ventricular tachyarrhythmias (AUCEMW: 0.89, 95% CI 0.82 to 0.97 vs AUCQTc0.77, 95% CI 0.61 to 0.93, p = 0.02), and a cut-off value of -108 ms was predictive of ventricular tachyarrhythmias with a sensitivity of 86% and a specificity of 79%. In conclusion, EMW is negative in patients with TTS and is associated with increased risk for ventricular tachyarrhythmias. The role of EMW in the risk stratification of patients with TTS warrants further investigation.

Cardiac Function Evaluation after SARS-CoV-2 mRNA Vaccination in Children and Adolescents: A Prospective Speckle-Tracking Echocardiography Study.

Possible cardiac impairment after SARS-CoV-2 mRNA vaccination is a common driver of parental vaccine hesitancy. We performed a comprehensive echocardiographic evaluation of biventricular function in vaccinated children with or without previous COVID-19 compared to healthy controls. We conducted a single-center, prospective, case-control study enrolling children and adolescents aged 5-18 years attending the pediatric clinic of the University Hospital of Padua from April to June 2022. Three months after receiving the primary mRNA vaccination or booster dose, the patients underwent a cardiac assessment, including standard echocardiography and speckle-tracking echocardiography (STE). A pre-pandemic historical cohort of age- and gender-matched healthy children were used as a control. A total of 39 post-VACCINE cases (24, 61% female), mean age 12.6 ± 2.6 years (range 8-17), were enrolled in the study. Ninety percent (N = 35) of patients were previously healthy. No differences in left ventricular diameters, left ventricular ejection fraction (LVEF), and tricuspid annular plane systolic excursion (TAPSE) were observed between cases and controls. Global longitudinal strain (GLS) was in the normal range in all individuals, with no differences between post-VACCINE cases and controls (-21.7 ± 2.3% vs. 21.2 ± 1.8%; p = 0.338). However, GLS was found to be slightly but significantly reduced in post-VACCINE children with a previous COVID-19 compared to naïve-vaccinated individuals (post-VACCINE+COVID-19: -19.9 ± 1.1% vs. post-VACCINE-only: -22.0 ± 2.3%; p = 0.002). We did not observe an impairment in GLS or in other indices of LV structure or function after mRNA COVID-19 vaccination.

Effective echocardiographic parameters for predicting cardiac tamponade in patients with large amount of pericardial effusion

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac tamponade is life-threatening medical condition that needs rapid diagnosis and pericardiocentesis. For diagnosing cardiac tamponade, comprehensive and complex doppler echocardiographic evaluation is necessary. The aim of this study was to evaluate the echocardiographic parameters for differentiating cardiac tamponade in patients with large amount of pericardial effusion. Methods From March 2003 to January 2020, 392 patients with large amount of PE with TTE evaluation were enrolled. We divided the patients into two groups; group A: patients performed subsequent drainage (n=197), group B: patients who are not performed drainage (n=195). Quantitative echocardiographic parameters were compared between two groups and analyzed which parameters were related with cardiac tamponade. Results The patients in group A showed low left ventricular end-diastolic diameter/body surface area (LVEDD/BSA) (25.44 ± 7.75 vs. 28.86 ± 6.10 mm/m2, p&amp;lt;0.001), left atrium volume index (LAVI) (24.08 ± 13.53 vs. 42.69 ± 28.69 ml/m2, p&amp;lt;0.001), early diastolic mitral inflow velocity (E velocity) (0.63 ± 0.18 vs. 0.88 ± 0.31 m/s, p&amp;lt;0.001), right ventricular systolic pressure (RVSP) (31.23 ± 9.47 vs. 39.16 ± 16.49 mmHg, p&amp;lt;0.001), early diastolic mitral inflow velocity/early diastolic mitral annular tissue velocity (E/e’) (11.62 ± 5.07 vs. 16.56 ± 7.75, p&amp;lt;0.001) compared with group B. In the multivariable analysis, E velocity was the most statistically significant parameter (Odds ratio=0.034, 95% CI=0.003–0.470, p = 0.012) and LAVI was the second one (Odds ratio=0.952, 95% CI=0.913–0.993, p = 0.022) related with cardiac tamponade. The ROC curve showed the cutoff value of E velocity was 0.678 m/s (sensitivity=0.675, specificity=0.673) and that of LAVI was 26.62 ml/m2 (sensitivity=0.681, specificity=0.679) for no need of pericardial drainage. Conclusion In patients with large amount of PE, E velocity and LAVI can be simple and useful echocardiographic parameters to differentiate the patients with cardiac tamponade who need pericardial drainage.

Effect of patisiran on myocardial deformation parameters in patients with hereditary transthyretin amyloidosis

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Hereditary transthyretin amyloidosis (ATTRh) is a rare autosomal dominant disease caused by transthyretin (TTR) gene mutations. It can involve several systems on the basis of ATTR gene variant, age, duration of symptoms before diagnosis. Some TTR gene variants have a predominant cardiological or neurologic or mixed phenotype, therefore patients can have only cardiac amyloidosis or only polyneuropathy or both. Recently several advances have been performed in the diagnosis and treatment of cardiac amyloidosis, especially ATTRh amyloidosis using RNA-targeting and gene editing therapies. Particularly, patisiran is a small interfering RNAs that can be used only in patients with ATTRh polyneuropathy with or without concomitant cardiac amyloidosis (stage 1 or 2). Apollo A trial sub analysis demonstrated protective effects of patisiran on the heart. Purpose To assess the effects of patisiran on cardiac function in patients with ATTRh amyloidosis treated with patisiran. Methods a prospective study was carried out enrolling 31 subjects with ATTRh (20 men, 11 women, median age 61,7 ± 10,45 years old). 7 patients (22,6%) had cardiac amyloidosis plus polyneuropathy; 13 patients (41,9%) had only polyneuropathy without cardiac involvement; 11 patients were carriers without clinical manifestations. All patients except carriers were treated with patisiran. Cardiological evaluation including electrocardiogram and echocardiogram was performed in all patients at the time of enrollment and after an average period of 20 months of patisiran therapy. Comprehensive echocardiographic evaluation included the measurement of left ventricular global longitudinal strain (GLS), relative apical sparing, apical/basal strain ratio, myocardial work index expressed as global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE), left atrial reservoir strain (PALS) and atrial stiffness (LASi). Results the group of patients with only polyneuropathy remained clinically stable over time and all echocardiographic parameters didn’t change significantly. In patients with cardiac amyloidosis, we found a significant improvement in GLS (−12,39±3,31% at baseline vs − 16,32 ± 2,84%, p value 0,03) and in LASI (1,6±0,30 vs 1±0,5, p value 0,01). GWI, GWE and GCW increased during follow-up, GWW reduced but not significantly. Also a reduction in the relative apical sparing (1,08±0,36 vs 1,05±0,25, p value 0,85) and in apical/basal strain ratio (2,5±1,4 vs 2,37±1,59, p value 0,87) was observed. No other significant changes in echocardiographic parameters were found. Conclusion Patisiran seems to be effective in stabilizing cardiac disease in ATTRh, significantly improving GLS and LASI. These new echocardiographic parameters should be used to monitor response to therapy in cardiac amyloidosis. The main limitation of our study is represented by the small sample size and to confirm our results wider studies are awaited.

Association of Depression and Anxiety with Cardiac Structural and Functional Characteristics in Heart Failure with Reduced and Mildly Reduced Ejection Fraction.

Heart failure and mental health conditions frequently coexist and have a negative impact on health-related quality of life and prognosis. We aimed to evaluate depression and anxiety symptoms and to determine the association between psychological distress and cardiac parameters in heart failure with reduced and mildly reduced ejection fraction. A total of 43 patients (33 male, mean age 64 ± 10 years) with heart failure and left ventricular systolic dysfunction (29 with HFrEF, 14 with HFmrEF) underwent comprehensive echocardiographic evaluation. All study participants completed questionnaires for the assessment of depression (PHQ-9), anxiety (GAD-7), and health-related quality of life (MLHFQ). Ten (34%) patients with HFrEF and two (14%) participants with HFmrEF had moderate-to-severe depression symptoms. Significant anxiety symptoms were more frequent in HFrEF (10 vs. 2 patients; 34% vs. 14%). Poor quality of life was also more common among patients with HFrEF (17 vs. 5 patients; 59% vs. 36%), showing higher MLHFQ scores (p = 0.009). Moreover, PHQ-9, GAD-7, and MLHFQ scores showed significant correlations between NYHA class severity and the presence of peripheral edema. The symptoms of dyspnea correlated with both PHQ-9 and MLHFQ scores. Significant correlations were observed between MLHFQ scores and a large number of clinical features, such as exercise capacity, 6MWT distance, the need for furosemide, echocardiographic parameters (LVEDVI, LVESVI, LVEF, LVGLS, SVI), and laboratory variables (albumin, GFR, NT-proBNP). In the multiple linear regression analysis, dyspnea proved to be a significant predictor of higher PHQ-9 and MLHFQ scores, even after adjusting for potential confounders. High symptom burden due to psychological distress is common among patients with HFrEF and HFmrEF. More efficient control of congestion may improve depression, anxiety symptoms, and health-related quality of life.

Phasic left atrial strain to predict worsening of diastolic function: Results from the prospective Berlin Female Risk Evaluation follow-up trial.

The predictive value of maximum left atrial volume index (LAVI), phasic left atrial strain (LAS) and other standard echocardiographic parameters assessing left ventricular (LV) diastolic function to discriminate a future worsening of diastolic function (DD) in patients at risk is unclear. We aimed to prospectively assess and compare the clinical impact of these parameters in a randomly selected study sample of the general urban female population. A comprehensive clinical and echocardiographic evaluation was performed in 256 participants of the Berlin Female Risk Evaluation (BEFRI) trial after a mean follow up time of 6.8 years. After an assessment of participants' current DD status, the predictive impact of an impaired LAS on the course of DD was assessed and compared with LAVI and other DD parameters using receiver operating characteristic (ROC) curve and multivariate logistic regression analyses. Subjects with no DD (DD0) who showed a decline of diastolic function by the time of follow-up showed a reduced LA reservoir (LASr) and conduit strain (LAScd) compared to subjects who remained in the healthy range (LASr 28.0% ± 7.0 vs. 41.9% ± 8.5; LAScd -13.2% ± 5.1 vs. -25.4% ± 9.1; p < 0.001). With an area under the curve (AUC) of 0.88 (95%CI 0.82-0.94) and 0.84 (95%CI 0.79-0.89), LASr and LAScd exhibited the highest discriminative value in predicting worsening of diastolic function, whereas LAVI was only of limited prognostic value [AUC 0.63 (95%CI 0.54-0.73)]. In logistic regression analyses, LAS remained a significant predictor for a decline of diastolic function after controlling for clinical and standard echocardiographic DD parameters, indicating its incremental predictive value. The analysis of phasic LAS may be useful to predict worsening of LV diastolic function in DD0 patients at risk for a future DD development.GRAPHICAL ABSTRACT.

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography.

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

The Impact of Cystic Fibrosis- and Noncystic Fibrosis-Bronchiectasis on Pulmonary Artery Wall Thickness and Right Heart Functions Assessed by Speckle-Tracking Echocardiography.

Right heart functions are affected in patients with bronchiectasis as a result of pulmonary hypertension induced by chronic hypoxemia. Pulmonary artery wall thickness has recently been introduced as a sign of intensive and prolonged inflammation. The aim of this study was to analyze right ventricular and right atrial functions and to mea-sure pulmonary artery wall thickness in patients with cystic fibrosis-bronch iecta sis in comparison to those with noncystic fibrosis-bronchiectasis and healthy individuals. We studied 36 patients with cystic fibrosis-bronchiectasis, 34 patients with noncystic fibrosis-bronchiectasis, and 32 age- and sex-matched control subjects. Lung function tests were performed. All subjects underwent comprehensive echocardiographic evaluation including conventional, tissue Doppler, speckle-tracking, and pulmonary artery wall thickness measurements. Right ventricular global longitudinal strain and global longitudinal right atrial strain during ventricular systole decreased in cystic fibrosis-bronchiectasis group compared with noncystic fibrosis-bronchiectasis and control groups (P <.001, both). Conversely, pulmonary artery wall thickness was increased in cystic fibrosis-bronchiectasis group in comparison to other groups (P <.001). Moreover, right ventricular global longitudinal strain was lower and pulmonary artery wall thickness was higher in patients with airflow obstruction (P <.001 and P =.025, respectively) than in those without. Only right ventricular global longitudinal strain was significantly correlated with pulmonary function test parameters. The negative effect of cystic fibrosis on right ventricular and right atrial functions was independent of age, gender, and disease duration. Our study showed that right ventricular and right atrial functions were deteriorated and pulmonary artery wall was thickened in cystic fibrosis-bronchiectasis patients more than noncystic fibrosis-bronchiectasis patients. Right ventricular global longitudinal strain detected subclinical right ventricular dysfunction and was associated with the severity of pulmonary disease.

A validated score to predict one-year and long-term mortality in patients with significant tricuspid regurgitation.

Most patients with significant (defined as ≥ moderate) tricuspid regurgitation (TR) are treated conservatively. Individual mortality rates are markedly variable. We developed a risk score based on comprehensive clinical and echocardiographic evaluation, predicting mortality on an individual patient level. The cohort included 1701 consecutive patients with significant TR, half with isolated TR, admitted to a single hospital, treated conservatively. We derived a scoring system predicting 1-year mortality and validated it using k-fold cross-validation and with external validation on another cohort of 5141 patients. Score utility was compared with matched patients without significant TR. One-year mortality rate was 31.3%. The risk score ranged 0-17 points and included 11 parameters: age (0-3), body mass index ≤ 25 (0-1), history of liver disease (0-2), history of chronic lung disease (0-2), estimated glomerular filtration rate (0-5), haemoglobin (0-2), left-ventricular ejection fraction (0-1), right-ventricular dysfunction (0-1), right atrial pressure (0-2), stroke volume index (SVI) (0-1) and left-ventricular end-diastolic diameter (0-1). One-year mortality rates increased from 0 to 100%, as the score increased up to ≥16. Areas under the receiver operating curves were 0.78, 0.70, and 0.73, for the original, external validation, and external validation with SVI measured cohorts. The score remained valid in subpopulations of patients with quantified RV function, quantified TR and isolated TR. Significant TR compared to no TR, affected 1-year mortality stronger with higher scores, with a significantly positive interaction term. We suggest a robust risk score for inpatients with significant TR, assisting risk stratification and decision-making. Our findings underscore the burden of TR providing benchmarks for clinical trial design.

Association between right ventricular longitudinal strain and cardiovascular events in patients with cardiac sarcoidosis

BackgroundWhile right ventricular (RV) involvement is commonly observed in patients with cardiac sarcoidosis (CS), the utility of strain imaging to detect RV involvement is unclear. We aimed to investigate the association between RV free wall longitudinal strain (RVFWLS) and cardiovascular events in patients with CS. MethodsWe studied 51 patients with CS who were diagnosed between 2012 and 2020. All patients underwent comprehensive echocardiographic evaluation, and RVFWLS was assessed using 2-dimensional speckle tracking echocardiography. The primary outcome was major adverse cardiovascular events (MACEs). ResultsDuring a median follow-up duration of 548 days, 11 patients exhibited MACEs. In the univariable Cox proportional hazards model, the baseline RVFWLS was associated with MACEs (hazard ratio: 1.29, p = 0.008). The addition of RVFWLS to the conventional echocardiographic parameters exhibited a significant incremental value associated with MACEs. Patients with reduced RVFWLS showed a higher prevalence of late gadolinium enhancement on cardiac magnetic resonance imaging in RV wall (p = 0.02) and trends toward higher prevalence of fluorodeoxyglucose uptake in RV (p = 0.06). A serial echocardiographic evaluation revealed that patients with events showed a worsening in RVFWLS, while others showed a trend toward improvement. ConclusionsImpaired RVFWLS at baseline was associated with MACEs in patients with CS. RVFWLS could be an important surrogate of disease activity and prognosis by detecting active RV involvement in CS.

Clinical, Biochemical, and Echocardiographic Characteristics of Severe SARS-COV-2 Infection: Correlates of In-hospital Morbidity and Mortality

Background: Patients with cardiovascular disease are more susceptible to coronavirus disease 2019 (COVID-19) and have worse outcomes when infected. While multiple studies have reported an association between biochemical myocardial injury and consequent adverse events, these studies have been limited by a lack of echocardiographic data. This study reports a comprehensive echocardiographic evaluation of patients with severe COVID-19 at a large quaternary care hospital in New Jersey. Methods: Clinical, biochemical, and echocardiographic features of consecutive patients with severe COVID-19 undergoing echocardiography were studied. Clinical outcomes data including length of stay, requirement of mechanical ventilation, and in-hospital mortality were collected. Results: 987 patients with confirmed COVID-19 infection were treated at our institution of which 197 consecutive patients (20%) underwent echocardiographic evaluation. The median age of the cohort was 64 years. 38% of these patients were females, 23% had known CAD, and 21% had CKD. 55% of patients required mechanical ventilation and 49% required vasopressors, representing a critically-ill patient population with significant mortality of 44% during the index hospitalization. There was a high prevalence of echocardiographic abnormalities including right ventricular dilation (30%) or dysfunction (23%), left ventricular dysfunction (24%), and pericardial effusion (14%). Multiple biomarkers including troponin T, pro-BNP, D-dimer and CRP were strongly associated with echocardiographic abnormalities and in-hospital mortality. On Cox regression analysis, age (HR 1.03/year),pre-existing CAD (HR 2.7), and mechanical ventilation (HR 2.64) were the strongest independent predictors of in-hospital mortality. Conclusions: Severe COVID-19 infection is accompanied by a significant burden of echocardiographic abnormalities that are strongly correlated with higher degrees of inflammation and biomarker elevation. Additional investigation is warranted in assessing the role of a biomarker-guided approach for early cardiac surveillance using echocardiography to further risk stratify patients and tailor adjunctive therapy.

QT Interval Prolongation Is a Novel Predictor of 1-Year Mortality in Patients With COVID-19 Infection.

BackgroundQT interval prolongation is common in critically ill patients and is associated with increased mortality. However, the predictive value of a prolonged corrected QT interval (QTc) for myocardial injury and long-term mortality among patients hospitalized with COVID-19 infection is not well known.PurposeTo evaluate the association of prolonged QTc with myocardial injury and with 1-year mortality among patients hospitalized with COVID-19 infection.Materials and MethodsA total of 335 consecutive patients hospitalized with COVID-19 infection were prospectively studied. All patients underwent a comprehensive echocardiographic evaluation within 48 h from admission. Using the Bazett formula, the QTc interval was calculated from the first ECG tracing recorded at the ER. QTc ≥ 440 ms in males and ≥450 ms in females was considered prolonged. Patients with elevated cardiac biomarkers and/or echocardiographic signs of myocardial dysfunction were considered to have myocardial injury. The predictive value of QTc prolongation for myocardial injury was calculated using a multivariate binary regression model. One-year mortality rate of patients with and without QTc prolongation was compared using the log-rank test, and a multivariate Cox regression model adjusting for multiple covariates was performed to evaluate the 1-year mortality risk.ResultsOne-hundred and nine (32.5%) patients had a prolonged QTc. Compared to patients without QTc prolongation, patients with prolonged QTc were older (70 ± 14.4 vs. 62.7 ± 16.6, p < 0.001), had more comorbidities, and presented with a more severe disease. Prolonged QTc was an independent predictor for severe or critical disease (adjusted HR 2.14, 95% CI 1.3–3.5; p = 0.002) and myocardial injury (adjusted HR 2.07, 95% CI 1.22–3.5; p = 0.007). One-year mortality of patients with prolonged QTc was higher than those with no QTc prolongation (40.4% vs. 15.5; p < 0.001). Following adjustment to multiple covariates including myocardial injury and disease severity, QTc prolongation was found to be associated with increased 1-year mortality risk (HR 1.69, 95% CI 1.06–2.68, p = 0.027).ConclusionProlonged QTc is associated with disease severity, myocardial injury and 1-year mortality among patients hospitalized with COVID-19 infection.

Transcatheter Occluder Devices for the Closure of Atrial Septal Defect in Children: How Safe and Effective Are They? A Systematic Review.

Atrial septal defect (ASD) is a hole in the interatrial septum (IAS) of the heart that is one of the most common congenital heart diseases (CHD). Percutaneous transcatheter device occlusion is one of the techniques that have been developed for the closure of atrial septal defects. The primary objective of this study is to assess the safety and efficacy of septal occluder devices in the management of atrial septal defect in children. We searched PubMed, Science Direct, and Google Scholar databases to collect relevant articles according to a predetermined eligibility criteria and included 21 papers of different study designs in this systematic review. We found that transcatheter closure is safe and effective in most children with ASD. The major complications reported could be avoided by comprehensive clinical assessment and echocardiographic evaluation to determine appropriate device size and implantation strategy per individual child. Further research involving more clinical trials with larger sample size and longer duration of followup is required to improve the safety of existing devices for their use in all children with ASD despite their weight and defect size, and also the efficacy of newer devices such as biodegradable septal occluders.

QT interval prolongation is a novel predictor of one year morality in patients with coronavirus disease-19 infection

Funding AcknowledgementsType of funding sources: None.BackgroundQT interval prolongation is common in critically ill patients and is associated with increased mortality. However, the predictive value of a prolonged corrected QT interval (QTc) for myocardial injury and long-term mortality among patients hospitalized with COVID-19 infection is not well known.PurposeTo evaluate the association of prolonged QTc with myocardial injury and with 1-year mortality among patients hospitalized with COVID-19 infection.MethodsA total of 335 consecutive patients hospitalized with COVID-19 infection were prospectively studied. All patients underwent a comprehensive echocardiographic evaluation within 48 hours from admission. Using the Bazett formula, the QTc interval was calculated from the first ECG tracing recorded at the ER. QTc ≥440 msec in males and ≥450 msec in females was considered prolonged. Patients with elevated cardiac biomarkers and/or echocardiographic signs of myocardial dysfunction were considered to have myocardial injury. The predictive value of QTc prolongation for myocardial injury was calculated using a multivariate binary regression model. One-year mortality rate of patients with and without QTc prolongation was compared using the log-rank test, and a multivariate Cox regression model adjusting for multiple covariates was performed to evaluate the 1-year mortality risk.ResultsOne-hundred and nine (32.5%) patients had a prolonged QTc. Compared to patients without QTc prolongation, patients with prolonged QTc were older (70±14.4 vs 62.7±16.6, p <0.001), had more comorbidities, and presented with a more severe disease. Prolonged QTc was an independent predictor for myocardial injury (adjusted HR 2.07, 95% CI 1.22-3.5; p=0.007). One-year mortality of patients with prolonged QTc was higher than those with no QTc prolongation (40.7% vs 16.9; p <0.001, adjusted HR 1.85[1.2-2.84]; p=0.005). Compared to patient without QTc prolongation and no myocardial injury, the adjusted 1-year mortality risk was highest in patients with prolonged QTc and myocardial injury (HR 6.63, 95% CI 2.28-19.3; p=0.001), followed by patients with QTc prolongation without myocardial injury (HR 6.12 95% CI 1.83-20.49; p=0.003), and patients with myocardial injury without QTc prolongation (HR 4.95 95% CI 1.83-20.49.; p=0.003).ConclusionProlonged QTc is an independent risk factor for both myocardial injury and 1-year mortality among patients hospitalized with COVID-19 infection.

Left ventricular function assessment after aortic and renal intervention in Takayasu arteritis by speckle tracking echocardiography: A pilot study

BackgroundOvert left ventricular (LV) dysfunction and congestive heart failure are known entities in Takayasu arteritis (TA). Subclinical LV dysfunction may develop in these patients despite normal LV ejection fraction (LVEF). Moreover, effect of treatment of aortic or renal artery narrowing in such patients is unknown. MethodsThis study included 15 angiographically confirmed TA patients undergoing aortic and/or renal intervention. A comprehensive clinical, biochemical and echocardiographic (2-dimensional, speckle tracking and tissue doppler imaging) evaluation were done at baseline, 72 h, and six months post intervention. ResultsSix patients (40%) had reduced LVEF (<50%) at baseline while rest 9 (60%) patients had reduced global longitudinal strain (GLS) but normal EF. Diastolic filling pattern was abnormal in all the patients. In patients with baseline reduced EF, mean EF improved from 24.62 ± 12.14% to 45.6 ± 9.45% (p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005) and median NT pro BNP decreased from 1673 pg/ml (970–2401 pg/ml) to 80 pg/ml (40–354 pg/ml) (p = 0.001) at 6 months after interventional procedure. In patients with baseline normal EF, median NT pro BNP decreased from 512 pg/ml (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up. ConclusionLV dysfunction is common in patients with TA and obstructive lesions in aorta or renal arteries. GLS can be used to assess subclinical systolic dysfunction in these patients. Timely intervention can improve LV dysfunction and can even reverse the subclinical changes.

Differentiating typical tako tsubo syndrome from extensive anterior ST-elevation myocardial infarction: look behind the anterior wall

Abstract Funding Acknowledgements Type of funding sources: None. Tako-Tsubo Syndrome (TTS) consists in transient left ventricular dysfunction resembling in its typical form acute anterior ST-elevation myocardial infarction (STEMI). Early non-invasive differential diagnosis, crucial for therapeutic purposes, appears difficult according to available data. Purpose to systematically analyze LV function and ECG changes in patients with acute anterior STEMI and TTS, to identify parameters possibly useful for differential diagnosis. Methods this is a retrospective cohort study, with 2 groups: patients with anterior STEMI and extensive apical involvement at echocardiography (n = 22); patients with TTS (n = 22) and ECG changes diagnostic for anterior STEMI at presentation (n = 22). They underwent a comprehensive clinical and echocardiographic evaluation in acute phase, including 2D speckle tracking longitudinal strain. We created new indexes based on wall motion impairment of inferior and inferior-lateral walls: the Inferior apex ratio (IAR) and inferior-lateral apex ratio (ILAR) (see picture). Results TTS and STEMI patients were similar for age (74.7 ± 9.1 vs 73.4 ± 14.1 y), sex, and main biochemical data except for higher peak troponin I in STEMI (1323 ± 622 vs 377 ± 220 ng/L, p = 0.01). ST segment elevation in V1 (V1e) was significantly less common in TTS (p &amp;lt; 0.001) while increased ratio of ST segment elevation in V4-V6 to V1-V3 (∑Ste V4-V6/∑Ste V1-V3≥1) was more common in TTS (p &amp;lt; 0.001). Among ECG parameters, absence of V1e had the best sensitivity (86%) and specificity (86%) in predicting TTS. LVEF values were similar (means: 45% in both groups) with EDVI greater in TTS (55.5 ±12.3 vs 46.6 ± 11.0 ml/m2, p = 0.02). WMSI was greater in TTS patients (2.2 ± 0.1 vs 1.9 ± 0.1, p &amp;lt; 0.0001), mainly for greater scores of mid segments. Global longitudinal strain was impaired in TTS (-8.1 ± 2.5 %) and in anterior STEMI (-7.9 ± 2.7, p = 0.8). By analyzing the single segments, strain was significantly more compromised in TTS in mid inferior (MI) (-4.3 ± 6.4 vs -9.9 ± 5.5 % in STEMI, p = 0.003) and mid inferior-lateral (MIL) segments (-5.4 ± 5.4 vs -9.6 ± 4.9 %, p = 0.009). Mean IAR was 0.7 ± 0.3 in TTS vs 1.8 ± 0.6 in STEMI, p &amp;lt; 0.0001; mean ILAR was 0.7 ± 0.1 in TTS vs 2.0 ± 0.9 in STEMI, p &amp;lt; 0.0001. ILAR was &amp;lt; I in all TTS patients, and &amp;gt; 1 in all STEMI cases. IAR &amp;lt; 1 showed 90% sensitivity and 95% specificity in predicting TTS. By multivariate linear regression analysis, strain values of MI and MIL segments were significantly associated with TTS (Beta: -0.98 and -0.97 respectively, p &amp;lt; 0.0001), independently from age, sex, and EDVI. IAR and ILAR values were significantly associated with TTS (Beta: -0.81 and -0.76 respectively, p &amp;lt; 0.0001) independently from the same co-variates as above. Conclusions evidence of impaired contractility extending beyond apex to mid inferior and inferior-lateral walls, assed by longitudinal strain or by IAR and ILAR, can help to discriminate TTS from extensive anterior STEMI, more accurately than ECG parameters. Abstract Figure. Examples of ILAR index Abstract Figure. IAR and ILAR distributions

Ecocardiographic comprehensive evaluation of OHCM patients treated with percutaneous ASA

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment. The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure. Methods and results Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a &amp;gt; 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU). 110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively. Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve. During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). Conclusion ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.