Echocardiographic Data Research Articles

Isovolumic relaxation intraventricular pressure difference predicts elevated left ventricular end-diastolic pressure in patients with coronary artery disease.

Current guideline for evaluating diastolic function requires multiple parameters to identify patients with elevated left ventricular end-diastolic pressure (LVEDP). However, the intermediate result still exists and may cause LVEDP undetermined. Previous studies have shown intraventricular pressure difference (IVPDs) are required for normal LV filling, but the relationship between IVPDs and LVEDP is unknown. In this study, we analyzed the relationship between IVPDs and LVEDP in 54 patients with coronary artery disease (CAD). LVEDP was prospectively measured at the time of coronary intervention and LVEDP > 15 mmHg was considered as elevated LV filling pressure. Simultaneous echocardiographic data was collected prior to the intervention. The relative intraventricular pressure was calculated using the vector flow mapping method. The IVPD was defined as the pressure difference from the apex to the base of LV. From 54 patients presenting with CAD, elevated LVEDP occurred in 30(55.6%). To analyze the changing trend of IVPD with LVEDP, CAD patients were further divided into group I with normal LVEDP (12.7 ± 3.1 mmHg) and group II with elevated LVEDP (26.0 ± 7.2 mmHg). In early diastole, both isovolumic relaxation period and rapid filling period showed decreased IVPD in CAD patients, but only the reduction in isovolumic relaxation period (IVPD-IVR) was statistical different between patients with elevated LVEDP and normal LVEDP (1.03 ± 0.42 mmHg vs. 2.25 ± 1.21 mmHg, p < 0.01). IVPD-IVR had the best correlation with LVEDP (r=-0.499, p < 0.01) among IVPDs. Lower IVPD-IVR was associated with higher risk of elevated LVEDP. Evaluating IVPD-IVR might improve the diagnostic algorithm for predicting elevated LVEDP.

Abstract 4137396: Evolution of Tricuspid Regurgitation and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction: Insights from the PURSUIT-HFpEF Registry

Background: Tricuspid regurgitation (TR) is prevalent in patients with heart failure with preserved ejection fraction (HFpEF). However, due to its high vulnerability to hemodynamic loads, the long-term observation may heighten its prognostic values. Purpose: To investigate the evolution of TR and its impact on clinical outcomes in patients with HFpEF. Methods: An analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 1238 patients hospitalized for acute heart failure (HF) (diagnosed by using Framingham criteria) met the inclusion criteria: an LVEF ≥50% and brain natriuretic peptide level ≥100 pg/ml. After excluding patients who died within 1 year, we included 761 patients (age 82 ± 9 years; men, 45%; atrial fibrillation, 37%) whose echocardiographic data at discharge and 1 year were available. Results: At discharge, 165 patients (21.7%) had moderate to severe TR, which increased to 185 patients (24.3%) at 1 year. Patients were categorized into 4 groups based on the TR evolution: no or mild TR that remained unchanged (n = 522 [69%]), no or mild TR that worsened to moderate to severe (n = 74 [9.7%]), moderate to severe TR that improved to no or mild (n = 54 [7.1%]), and moderate to severe TR that remained unchanged (n = 111 [15%]). During a subsequent follow-up of 33 months, patients with persistent moderate to severe TR had significantly higher mortality rates than the other groups (25.7% vs. 27.0% vs. 27.8% vs. 44.1%, log-rank p &lt; 0.001). Even after adjusting for age, sex, body mass index, left atrial diameter, and left ventricular filling pressure, persistent moderate to severe TR was independently associated with subsequent mortality (hazard ratio, 2.06, 95% confidence interval 1.42-2.99, p &lt; 0.001) Conclusions: During a one-year follow-up, changes in the TR severity were not rare in patients with HFpEF. Persistent moderate to severe TR alone was associated with subsequent mortality, highlighting the need to address persistent TR to improve the prognosis.

Abstract 4138611: Impact of SGLT-2 Inhibitor Use on Atrial Fibrillation Incidence Following Heart Failure Hospitalization

Introduction: The development of atrial fibrillation (AF) in patients with heart failure (HF) is associated with increased morbidity and mortality. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have demonstrated cardiovascular benefit in patients with both preserved and reduced ejection fractions. Meta analysis of prospective trials suggest reduced incidence and burden of atrial fibrillation in patients taking SGLT-2 inhibitors, though this has not been specifically addressed in prospective trials. Hypothesis: SGLT-2 inhibitors reduce the incidence of atrial fibrillation in patients with heart failure. Aim: The goal of the study is to assess the impact of SGLT-2 inhibitor on the incidence of atrial fibrillation following heart failure hospitalization. Methods: The study included consecutive patients who were admitted to an academic tertiary care center over a 3 year time period with a primary diagnosis of heart failure exacerbation and no prior diagnosis of AF. The primary outcome was development of AF within 12 months after hospitalization. Demographic, comorbidity, echocardiographic data, and medications were obtained. Cox-regression analysis was performed to identify the predictors of new-onset AF after HF hospitalization. Results: Among the 3,953 patients included in our study, 704 (17.8%) patients were prescribed SGLT-2 inhibitors. Of those taking SGLT-2 inhibitors, 559 (79.4%) patients had diabetes. SGLT-2 inhibitor use is associated with significant reduction of AF at one year ( p&lt;0.001; RR 0.65; 95% CI: 0.51-.81 ). This finding was consistent across patients with reduced ejection fractions (EF&lt;50%) ( p=0.001; RR 0.56; 95% CI: 0.40-.80 ) and preserved ejection fraction (EF&gt;50%)( p=0.001; RR 0.58; 95% CI: 0.42-0.80 ). Conclusion: In patients with reduced ejection fraction and preserved ejection fraction heart failure, use of an SGLT-2 inhibitor is associated with a statistically significant lower risk of new-onset atrial fibrillation at one year following HF hospitalization.

Abstract 4138330: Clinical outcomes in rheumatic mitral stenosis and the novel Yeo’s index

Introduction: Yeo’s index, the product of the mitral leaflet separation index and dimensionless index of mitral valve, was recently described to accurately identify severe rheumatic mitral stenosis (MS). We aimed to study the association between Yeo’s index and clinical outcomes in patients with rheumatic MS. Methods: We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo’s index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, mitral valve intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. Results: After a median follow up of 6.3 years, 145 patients (48.8%) developed the composite outcome. Yeo’s index ( p &lt;0.001), mitral valve area (MVA) by pressure half-time (PHT) ( p= 0.028) and planimetry ( p &lt;0.001), age ( p =0.016), history of diabetes mellitus ( p =0.029), previous HF ( p =0.021), left ventricular ejection fraction ( p =0.022), and pulmonary artery systolic pressure ( p =0.007) were univariately associated with the composite outcome. Yeo’s index remained independently associated ( p &lt;0.001, HR 0.094, 95% CI 0.260-0.340) with the composite outcome in multivariate analysis. In subgroup analysis of patients without pre-existing AF, Yeo’s index was independently associated ( p =0.024, HR 0.354, 95% CI 0.143-0.874) with new onset AF. MVA by PHT and planimetry were not associated with new onset AF. Conclusion: Yeo’s index was independently associated with clinical outcomes in patients with rheumatic MS.

Abstract 4114220: Majority of Patients with New Ventricular Dysfunction After Acute COVID-19 Infection Did Not Have Cardiac Recovery

Background: It is still not well understood whether cardiac injury observed during acute COVID-19 infection extends after recovery from the initial viral infection. The purpose of this study was to determine the incidence of left and right ventricular dysfunction in patients hospitalized with acute COVID-19 and evaluate for cardiac recovery. Methods: A multicenter, retrospective cohort study was conducted. Adult patients were identified by hospitalizations using ICD-10 code U07.1 from March 2020 to October 2021. Patients were included if they had: 1) acute COVID-19 infection confirmed by RT-PCR and 2) a transthoracic echocardiogram (TTE) performed during their hospitalization. Clinical and echocardiographic data were collected and analyzed. Longitudinal TTE parameters were obtained from follow-up studies performed after discharge. Results: A total of 750 patients (mean age 64.3 ± 15.3 years, 60.0% male) were included. The average time to follow-up TTE was 8.7± 7.4 months. 133 patients (17.7%) had new LV dysfunction seen on TTE ( Figure 1 ). LV recovery (defined as normalization of LVEF or improvement of LVEF by &gt; 10% from baseline) was observed in 28 of 74 (37.8%) survivors. 9 of 26 patients (34.6%) who had a follow-up TTE &lt;6 months post-discharge recovered their LV function, while 19 of 48 patients (39.6%) who had a follow-up TTE ≥6 months had LV recovery. 94 of 725 patients (13.0%) with reported RV parameters had new RV dysfunction seen on TTE. RV recovery (defined as normalization of RV function) was observed in 11 of 38 (28.9%) survivors. 6 of 18 patients (33.3%) who had a follow-up TTE &lt;6 months post-discharge recovered their RV function, while 5 of 20 patients (25%) who had a follow-up TTE ≥6 months had RV recovery. Conclusions: Most surviving patients who developed new LV or RV dysfunction did not recover their ventricular function at follow-up, but recovery extended beyond 6 months follow-up.

Abstract 4121812: Longitudinal Trajectory-Based Classification of Heart Failure with preserved Ejection Fraction: A Machine Learning Approach

Background: Heart failure (HF) with preserved ejection fraction (HFpEF) is a complex syndrome characterized by heterogeneous pathophysiology and dynamic changes in cardiac structure and function. Current research predominantly focuses on left ventricular ejection fraction (LVEF) or left ventricular structures with predefined categories. This study hypothesized that applying unsupervised methodologies to longitudinal echocardiography will reveal distinct trajectory patterns in cardiac structure and function related to clinical outcomes in HFpEF patients. Methods: This retrospective cohort study, conducted at UC Davis Medical Center (2014 to 2022), consisted of adult patients with HFpEF. The inclusion criteria included ICD HF codes, a left ventricular ejection fraction (LVEF) ≥50%, and a Brain natriuretic peptide (BNP) ≥100 pg/ml or N-terminal-pro BNP (NT-proBNP) ≥225 pg/ml. Longitudinal data were analyzed using unsupervised machine learning, including UMAP for dimensionality reduction and Gaussian Mixture Models for clustering. Primary and secondary outcomes included all-cause mortality and changes in BNP levels, respectively. Results: The study included 1,626 patients. The cohort had a median age of 69 years, was 57.5% female, and 51.8% white. Three distinct echocardiographic trajectory patterns emerged (p&lt;.05) among the HFpEF cohort. Trajectory #1 (n=568) exhibited a high-stable pattern with the highest mortality rates, Trajectory #2 (n=512) showed a high-decreasing pattern with high mortality rates, and Trajectory #3 (n=546) had a low-increasing pattern with the lowest mortality rates. Trajectories varied significantly in baseline characteristics and longitudinal echocardiographic changes, with Trajectory #3 having a lower baseline left ventricular mass index (p&lt;.001) and a higher mean arterial pressure ( p =.001) compared to the other trajectories. Kaplan-Meier survival analysis indicated significant differences in survival among the trajectories ( p =.004). Conclusion: The study utilized unsupervised analysis of longitudinal echocardiographic data to identify three distinct HFpEF trajectories, each associated with unique clinical features and outcomes. These findings underscore the heterogeneity of HFpEF and highlight the potential trajectory-based patient stratification to improve targeted intervention strategies. Future validation in larger, multicenter cohorts is warranted to enhance HFpEF management and patient prognosis.

Abstract 4136721: Reducing the Use of Transesophageal Echocardiogram Prior to Cardioversion Using Machine Learning

Introduction/Background: Direct current cardioversion (DCC) is used to terminate atrial fibrillation and atrial flutter. Due to increased stroke risk post DCC, a transesophageal echocardiogram (TEE) is performed in selected patients to rule out left atrial appendage thrombus (LAAT) prior to DCC. The prevalence of LAAT is around 2.5% in the era of direct oral anticoagulants. This is a large proportion of patients with no LAAT on TEE and calls for strategies to improve patient selections for TEE before DCC. Research Questions/Hypothesis: In this study we aimed to determine if the use of machine learning could accurately predict the presence of LAAT among patients with nonvalvular atrial fibrillation and atrial flutter. Methods/Approach: We collected demographic, comorbid, and transthoracic echocardiographic data on 795 patients who underwent TEE prior to DCC for nonvalvular atrial fibrillation and atrial flutter. We developed and validated an explainable machine learning model using the eXtreme Gradient Boosting algorithm with 5x5 nested cross-validation. The algorithm used 37 variables to predict the probability of LAAT. Results/Data: The prevalence of LAAT in our cohort was 11.3%. Our model achieved an area under the curve (AUC) of 0.79 in predicting LAAT, figure 1A. In comparison, CHA2DS2-VASc score performed poorly in our cohort with an AUC of 0.48, figure 1B. The ranking of variables most strongly predictive of LAAT is shown in figure 1C, with left ventricle ejection fraction as the most instrumental. Patients were categorized into 10 groups based on the percentile of their predicted probability of having a thrombus. A lower percentile (e.g., 10%) indicates a lower probability of having a thrombus. By utilizing a cutoff point of 0.16, which includes 10.0% of the patients, we can exclude the presence of thrombus with 100% certainty. Conclusion: Machine learning, compared to traditional risk scores, offers enhanced predictive model for identifying LAAT and provides better guidance for TEE and anticoagulation therapy before DCC.

Abstract 4138238: A Tense Race: Correlation of Liver Stiffness with Ultrasound Elastography and Hemodynamics in Fontan Patients.

Background: Ultrasound elastography (USE) is a non-invasive tool to diagnose and monitor liver fibrosis. Patients with Fontan physiology are predisposed to congestive hepatopathy, progressive liver fibrosis, and end-stage liver disease. We sought to determine whether hemodynamics pre- and post-Fontan are associated with increased liver stiffness on USE. Methods: A single-center retrospective study included Fontan patients who had one or more USE between 06/2008-03/2024. Liver stiffness was reported as shear wave elastography (SWE) in m/s. Hemodynamic data pre- and post-Fontan and recent echocardiographic data were collected. Data was analyzed as continuous (linear regression model) and as a dichotomous variable (t-test). Results: A total of 78 post-Fontan USE results in 56 patients were analyzed. Table 1 describes the demographics of our patient population. The spectrum of fibrosis based on USE was normal (3.8%), mild (10.3%), moderate (55.1%) and severe (30.8%). In patients with more than one USE, the average increase in SWE was 0.04m/s per month. Pre-Fontan median Glenn pressure was 12mmHg [IQR 13, 15] (p=0.83). On post-Fontan catheterization, median Fontan pressure was 18mmHg [16, 21] (p=0.86). We did not find a significant correlation between hemodynamics and severity of liver stiffness on USE (Tables 2&amp;3). No correlation was seen between USE and severity of ventricular function or atrioventricular valve regurgitation. SWE as a function of time from Fontan operation (&lt;5 yr, 5-10 yrs, &gt;10 yrs) did not vary significantly. Conclusions: USE as a marker of liver congestion does not correlate with hemodynamics pre- or post-Fontan. Further studies are necessary to determine the clinical utility of USE in Fontan patients.

Persistently low tricuspid annular plane systolic excursion and its prognosis in Japanese hospitalized patients with heart failure with reduced ejection fraction.

In patients with heart failure (HF) with reduced left ventricular ejection fraction (HFrEF), low tricuspid annular plane systolic excursion (TAPSE) on echocardiography is associated with poor prognosis. The significance of TAPSE changes post-HF treatment among HFrEF patients remains unclear. We evaluated the factors associated with persistently low TAPSE and its prognostic impact in Japanese hospitalized patients with HFrEF. We prospectively examined 260 HFrEF patients from the prospective observational HIJ-HF III study of HF patients hospitalized at Tokyo Women's Medical University between 2015 and 2019. Persistently low TAPSE was defined as TAPSE < 17mm on both pre- and 1-year post-discharge echocardiography. The primary endpoint of the study was all-cause mortality or re-hospitalization due to HF. Prognosis and characteristics were compared between patients with and without persistently low TAPSE. Using characteristics and echocardiography data, factors associated with persistently low TAPSE were assessed using logistic regression analysis. We identified the prognostic impact of persistently low TAPSE in HFrEF patients using Cox proportional hazards models. Seventy-eight (30%) of the 260 patients had persistently low TAPSE. They had higher New York Heart Association functional class; lower baseline TAPSE and left ventricular ejection fraction; and fewer angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Significant factors associated with persistently low TAPSE included higher brain natriuretic peptide level at 1year after discharge, lower baseline levels of TAPSE and septal s'. Over a follow-up period of 32months (range 12-69months) after the 1-year echocardiography, the rate of the primary endpoint was significantly higher among patients with persistently low TAPSE than that among others (n = 31 (40%) vs. n = 39 (21%), respectively, log-rank p < 0.001). Cox multivariate analysis revealed that persistently low TAPSE was independently associated with adverse events (Hazard ratio, 1.975; 95% confidence interval 1.183-3.295; p = 0.009). Exactly 30% of hospitalized patients with HFrEF had low TAPSE both pre- and 1-year post-discharge. Persistently low TAPSE had independent predictive value of prognosis in these patients.

Global left ventricular relaxation index in predicting cardiac cellular rejection in paediatric heart transplant patients.

Endomyocardial biopsy remains the gold standard for cardiac cellular rejection surveillance after heart transplantation. We studied a novel non-invasive index of left ventricular relaxation to detect cardiac cellular rejection in paediatric heart transplant patients. This is a single-centre retrospective study of paediatric heart transplant patients who underwent endomyocardial biopsy from June 2014 to September 2021. Left ventricular relaxation index was calculated as the sum of diastolic tissue Doppler imaging velocities (E) of the left ventricular lateral, septal, and posterior walls divided by the percentage of the left ventricular posterior wall thinning by M-mode. Statistical analysis included t-tests and Mann-Whitney tests to compare means and medians between treatment and non-treatment groups. We used the cut-off with the maximum Youden index to compare the sensitivity and specificity of left ventricular relaxation index to detect rejection. The study included 65 patients who underwent 246 cardiac catheterizations and endomyocardial biopsies. Out of 246, 192 procedures were included and 54 were excluded due to recent transplants or lack of echocardiographic data. A total of 114 demonstrated Grade 0R, 68 Grade 1R, 8 Grade 2R, and 2 Grade 3R allograft rejection. The difference in mean left ventricular relaxation index between treatment versus non-treatment groups (2R, 3R vs. 0R, 1R) was not statistically significant (p = 0.917). A left ventricular relaxation index cut-off of 0.73 had the highest Youden index with good sensitivity (100%) and poor specificity (23%) for detecting rejections with grades 2R and 3R. Left ventricular relaxation index, a novel index of left ventricular relaxation, was not a sensitive or specific predictor of cardiac cellular rejection in paediatric heart transplants.

Echocardiographic Assessment in Patients with Vascular Ehlers-Danlos Syndrome: Insights from an Unexplored Field.

Vascular Ehlers-Danlos syndrome (vEDS) is an inherited connective tissue disorder characterized by arterial fragility. Celiprolol is a β1-adrenoceptor antagonist with partial β2 agonist activity that has been shown to reduce rates of vascular events in this setting, though the underlying mechanisms are not yet fully understood. Moreover, very few echocardiographic data are available in patients with vEDS. To perform a comprehensive echocardiographic assessment of a cohort of patients with vEDS with or without celiprolol therapy compared with healthy subjects. Twenty patients with genetically confirmed diagnosis of vEDS followed at our Institution (University Hospital of Brescia, Italy) were divided into two groups according to whether or not they were on celiprolol therapy at the maximum recommended dose (400mg daily) for at least 12 months. Both groups were compared to 10 healthy individuals matched for sex, age, body mass index (BMI), and office blood pressure (BP) values. Each participant underwent transthoracic echocardiography with tissue Doppler analysis (TDI) for a comprehensive evaluation of cardiac structure and function. Mean age was 35 years and mean BMI was 21.6 kg/m2. Female sex was prevalent (60%). Left ventricular (LV) internal diameter values tended to be lower in patients with untreated vEDS than in healthy controls (4.33 vs 4.74cm, respectively), though this difference was not statistically significant. Similar data were observed for LV mass index (56.9 vs 68.6 g/m2), stroke volume (56.6 vs 71.6 mL), and E/A ratio (1.26 vs 1.66), whereas an opposite trend was observed for e' lateral (13.2 vs 12.2cm/s). No statistically significant difference was found between groups in terms of other parameters of LV mass, systolic and diastolic function. A normal LV geometry was found in all the cases. Indices of mechano-energetic efficiency and ventricular-arterial coupling were also similar between groups. No patient presented with aortic root dilation, mitral valve prolapse, valve insufficiency of more than mild degree, or valve stenosis of any degree. Our study suggests that patients with vEDS have normal cardiac mass and geometry, as well as normal systolic and diastolic function. Celiprolol therapy does not seem to significantly influence such aspects. Compared with vascular imaging, less stringent follow-up with echocardiography seems reasonable in this setting. Future studies with prospective design should confirm these aspects.

Supplemental oxygen for pulmonary embolism (SO-PE): study protocol for a mechanistic, randomised, blinded, cross-over study

BackgroundAcute pulmonary embolism (PE) mortality is linked to abrupt rises in pulmonary artery (PA) pressure due to mechanical obstruction and pulmonary vasoconstriction, leading to right ventricular (RV) dilation, increased RV...

Revisiting the Normal Ranges of Aortic Valve Area in 2D Echocardiography and Its Association With Age, Sex, and Anthropometric Characteristics.

Defining normative aortic echocardiographic values in each geographical district is crucial as aortic valve area (AVA) may vary across races, genders, and ages. Notably, variations in normal values can have implications for clinical decision-making, and available data on the Middle East population is also scarce. We sought to establish normal ranges for aortic valve echocardiographic parameters in the Iranian population and assess the effect of age, gender, weight, height, BMI, BSA, and blood pressure on them. Our data were provided from the web-based echocardiographic data registry of Imam Khomeini Hospital Complex (IKHC). A total of 3251 healthy subjects older than 18 years old without any valvular stenosis were included in our study. AVA's normal range was estimated at 1.92-4.52 and 1.67-3.80 cm2 in men and women, respectively. The annulus, AVA, AV VTI, and LVOT VTI were significantly larger in males, and this association remained significant after indexing AVA for weight, height, BMI, and BSA. Also, smaller AVA was associated with lower height, weight, BMI, and BSA in both men and women. Obese and hypertensive subjects had significantly larger AVA and annulus diameters. Our study provided region-specific normal reference values for AV echocardiographic parameters and compared them across genders, ages, BMI, and blood pressure groups in the Iranian population.

Significant regression of left ventricular hypertrophy in patient with arterial hypertension during antihypertensive treatment with perindopril and atorvastatin

Left ventricular hypertrophy (LVH) in arterial hypertension (AH) is one of the modifiable risk factors for cardiovascular events and serves as a justified goal for antihypertensive therapy. The article presents follow-up of a 60-year-old female with AH, hyperlipidemia, and discovered of LVH on the data of electrocardiography and echocardiography. In addition to the SokolowLyon and Cornell voltage criteria, the baseline echocardiographic examination revealed and increase in thickness of the ventricular septum and the left ventricular (LV) posterior wall, an increase in LV myocardial mass and LV myocardial mass index. The patient was recommended to take a drug of the class of angiotensin converting enzyme inhibitors perindopril and atorvastatin. The patient regularly received therapy and periodically underwent repeated echocardiographic examinations. After 40 months follow-up there are a significant decrease in septal hypertrophy (from 1.22 to 0.76 cm, -37.7%), LV posterior wall (from 1.05 to 0.49, -53.3%), as well as LV myocardial mass (from 197.9 to 96 g, -51.5%) and LV myocardial mass index (from 111.18 to 59.11 g/ m2, -51.5%). Thus, during the entire period of follow-up, the LV mass decreased almost twice. There was a decrease in the size of the left atrium, the relative wall thickness, with the same parameters of LV volumes, characteristics of systolic and diastolic function. Among the favorable factors contributing to significant LVH regression, high adherence to treatment, the efficacy of angiotensin converting enzyme inhibitors and the possible antihypertrophic influence of atorvastatin are discussed.

The impact of QRS complex fragmentation status before and after cardiac resynchronization therapy with defibrillator implantation: Is it a predictor of arrhythmic events?

Abstract Introduction Cardiac resynchronization therapy with an implantable cardioverter defibrillator (CRT-D) has demonstrated efficacy in reducing mortality, hospitalization for heart failure (HF), and sudden cardiac death among subgroups of patients with HF with reduced ejection fraction (HFrEF). However, this population is highly heterogeneous, necessitating risk stratification. Several clinical findings, including QRS complex fragmentation (QRSf), have been identified as potential prognostic factors for arrhythmic risk. Nonetheless, evidence supporting the prognostic significance of QRSf in patients undergoing CRT-D remains limited. Purpose The aim of this study is to assess whether alterations in QRSf status, before and after CRT-D implantation, can predict arrhythmic events (AE) in patients with HFrEF. Methods This study included consecutive patients underwent CRT-D implantation at our center from October 2009 to December 2022. Demographic, clinical, electrocardiographic and echocardiographic data were obtained from electronic medical records and telephone interviews. QRSf was defined by the presence of various RSR′ patterns, including additional R waves (R′) or notching of the R and S wave in two contiguous leads corresponding to a primary coronary artery territory on a 12-lead electrocardiogram conducted before and after CRT-D implantation. An AE was characterized by appropriate ICD therapy (antitachycardia pacing or shock) for a ventricular arrhythmia or sustained ventricular arrhythmia without the need for ICD therapy. Results A total of 176 patients were included (mean age 69.9 ± 9.6 years with 80.6% male). Ischemic etiology accounted for 54.6% of cases of LV systolic dysfunction, with a mean baseline LVEF of 23.6%. CRT-D was indicated as secondary prevention in 18 patients. At baseline, 114 patients (64.8%) presented QRSf. Following CRT implantation, 17 patients (9.8%) without previous QRSf developed QRSf, while 26 patients (14.9%) resolved QRSf. The median follow-up was 43.6 months (interquartile range 19.5-81.1). During follow-up, 90 patients died and 29 AE occurred (16.5%). Among these, 23 patients had QRSf before and after CRT, whereas 6 AE occurred in patients without QRSf. Multivariate survival analysis using Cox regression demonstrated that the presence of QRSf before and after CRT-D was an independent predictor of AE (HR 3.56; 95% CI 1.00-12.70). Univariate and multivariate Cox regression analyses are presented in Table 1. Kaplan-Meier curves for AE in relation to QRSf status before and after CRT-D are illustrated in Figure 1. Conclusions Our findings suggest that the presence of QRSf and its persistence following CRT-D implantation appears to be an independent predictor of AE after CRT-D implantation in patients with HFrEF. Therefore, these patients would benefit from closer monitoring as they exhibit a heightened risk of arrhythmic events. Nevertheless, further research is warranted to validate these results.Table 1.Cox Regression Analysis.

The connection site of the Bachmann bundle to the left atrium affects atrial electrical and anatomical remodeling

Abstract Background A common route for the propagation of the conduction system from the right atrium to the left atrium (LA) is via the Bachmann bundle (BB) which is a parallel-aligned muscular structure. It is empirically known that the site of conduction from BB to LA differs depending on the patient. Purposes To clear the clinical significance of differences in the BB conduction sites in patients with atrial fibrillation (AF). Methods We studied 182 patients (90 non-paroxysmal AF, 121 males, and 68.2 ± 10.0 years) who received catheter ablation for AF. Clinical data, echocardiographic data, and blood samples were evaluated. High-density LA mapping during high right atrial pacing was constructed. The site of conduction from BB to LA, the global activation time, LA mean voltage, the abnormal conduction zone (ACZ), and the conduction block (CBZ) were evaluated. The conduction from BB was connected to the region surrounded by the left atrial roof line, the carina of the right pulmonary vein, and the base of the left atrial appendage in all patients (Figure 1). This area was divided into four regions (right-roof, mid-roof, right-anterior, and mid-anterior area), and BB conduction sites were classified into each area by three independent observers who did not know clinical data. Global activation time for the LA was calculated by subtracting the earliest from the latest activation within the LA. Isochronal activation maps were created at a 5-ms interval setting, and ACZ (Figure 2) and CBZ were identified on the activation map by locating a site with isochronal crowding of ≥3 isochrones and ≥8 isochrones, which were calculated as ≤27 cm/s and ≤10 cm/s. Results The conduction from BB was observed in 45 patients in the right-roof area, 24 in the mid-roof, 76 in the right-anterior, 23 cases in the mid-anterior, and 14 in multiple sites. Global activation time (right-roof 108±20, mid-roof 107±16, right-anterior 105±19, and mid-anterior 117±20ms, P=0.0781) was more prolonged and left atrium diameter was larger (42.1±6.6, 42.6±8.5, 42.5±6.6, and 46.4±6.6mm, P=0.0718) in patients with mid-anterior BB connections. LA mean voltage (4.90±1.94, 5.72±2.62, 4.13±1.58, and 4.88±1.96mV, P=0.0032) was higher and plasma brain natriuretic peptide level (139±138, 67±59, 128±139, and 164±197pg/mL, P=0.0861) was lower in patients with mid-roof BB connections. ACZ (41/45 91%, 20/24 83%, 73/76 96%, and 23/23 100%, P=0.0904) and CBZ (1/45 2%, 0/24 0%, 8/76 11%, and 2/23 9%, P=0.0850) appearance rates were lower in patients with mid-roof BB connections. Conclusion The connection site of the Bachmann bundle to the left atrium may affect atrial electrical and anatomical remodeling in patients with atrial fibrillation.

Correlative study to assess the predictive power of the ICOS HF calculator in the prediction of development of HER-2 antagonist induced cardiac dysfunction in a single center in Saudi Arabia in 2023

Abstract Background Over the past 3 decades, there has been a significant increase in cancer survivors supported by the major advances in cancer therapies. However, most of those therapies are cardio-toxic. In 2022, the European Society of cardiology had published, for the first time, a clinical guideline that describes how to manage this cohort of patients, and endorsed the utilization of a risk calculator to predictor likelihood of development of cancer therapy cardiac dysfunction (CRTCD). We did retrospective review of all consecutive patients that have received Trstuzumab (HER-2 antagonist) in the year 2023 in a single tertiary cardiac center. We assessed their demographics and co-morbidities, incidence of CRTCD, evaluated their ICOS-HF score and looked for any CRTCD in this cohort to assess whether the calculated stratification correlated with development of CRTCD. The objective is to assess the utilization of this tool in our patient population. Methods 369 unique individuals were identified from the hospital databas that had received HER-2 antagonists. Basic patient demographics were extracted from the information system along with their clinical, laboratory, and echocardiographic data. Their risk profiles were stratified using the ICOS-HF calculator. Follow up echocardiogrphic studies were reviewed to assess the incidence of CRTCD in patients receiving HER-2 antagonists and the correlation between the risk strata using the ICOS-HF and actual development of CRTCD. Results The average age was 53+/- 11 years. 96.8% were females. At baseline, 20% were diabetic, 26.8% were hypertensive, 10.8% were dyslipidemic, 1.9% had prior cardiomyopathy or heart failure, 1.3% had IHD, 1.1% were smoker, 33.3% were obese, and 3.8% had CKD. Overall, in the year 2023, the incidence of HER-2 induced cardiac dysfunction was 10.6%. At baseline, using the ICOS-HF calculator, 57.9% were stratified as low risk, 21% as moderate risk 14.6% as high risk, and 6.5% as very high risk. Approximately 5% of the patients with low to moderate risk developed CRTCD, which rose to 18.5% in the high risk, and significantly rose to 58% in the very high risk population. Conclusion The risk stratification using the ICOS-HF calculator in consecutive patients receiving Trastuzumab correlated directly with the likelihood of developing CRTCD. 58% of all of the patients in the very high risk category developed CRTCD. This retrospective analysis validates the use of this tool in our patient population and will aid in the identification of patients that would require to have a more aggressive preemptive management, especially in the high and very high risk population using a multidisciplinary cardio-oncology team to optimize their surveillance and reduce their likelihood of cardiac dysfunction.

Autonomous cortisol secretion in patients with primary aldosteronism is associated with left ventricular hypertrophy and diastolic dysfunction

Abstract Background and Aims: Autonomous cortisol secretion (ACS) constitutes a significant portion of patients diagnosed with primary aldosteronism (PA) and is potentially linked to adverse cardiovascular outcomes. This study aimed to explore the impact of ACS on cardiac remodeling and diastolic dysfunction in PA patients. Methods We prospectively enrolled 567 PA patients from March 2000 to March 2023. ACS was defined as a cortisol level &amp;gt;1.8 μg/dL after a 1 mg dexamethasone suppression test (DST). Clinical, biochemical, and echocardiographic data were collected at baseline and during one-year follow-up after targeted treatments including adrenalectomy and mineralocorticoid receptor antagonist administration. Results In this prospective cohort, 21.5% of PA patients had concurrent ACS. PA patients with ACS were older and had a higher prevalence of diabetes. They also exhibited significantly higher left ventricular mass index (LVMI) and worse diastolic function (E/e'). Baseline post-1 mg DST cortisol levels positively correlated with baseline LVMI and E/e' in restricted cubic spline analysis. Multivariable linear regression analysis showed that ACS presence was significantly associated with higher LVMI and worse E/e' after adjusting for significant variables. Among patients who underwent adrenalectomy, both those with and without ACS showed significant improvements in LVMI and E/e'. Patients who received mineralocorticoid receptor antagonist treatment also showed significant improvement in E/e', irrespective of ACS presence. However, significant LVMI improvement was observed only in PA patients without ACS who received mineralocorticoid receptor antagonist treatment. Conclusions The presence of ACS in PA patients was associated with worse left ventricular hypertrophy and diastolic dysfunction. Adrenalectomy and mineralocorticoid receptor antagonist treatment partially reversed cardiac remodeling in PA patients with ACS.

Tricuspid regurgitation in the context of severe concomitant left-sided valvular heart disease: patients characteristics and long-term clinical and interventional outcomes

Abstract Background The clinical features, therapeutical management and outcome of patients with significant tricuspid regurgitation (TR) in the context of multiple valvular disease (VD) are poorly defined. Purpose To assess the characteristics, management and long-term prognosis of a large cohort of patients with multiple VD, focusing on the context of significant TR and concomitant severe mitral or aortic disease. Methods Clinical and echocardiographic data were collected in 1183 patients with ≥moderate TR diagnosed at our centers from January 2012 to June 2020: after propensity score matching for age to create matched cohort with &amp;lt; 10% of absolute difference, 975 patients were included in this study and divided in 4 groups as shown in Figure 1. Primary endpoint was all-cause death (ACD), secondary endpoint was the composite of heart failure (HF) hospitalization+any valvular intervention. Results Patients with isolated TR (356, 37%) had more history of atrial fibrillation and were more often asymptomatic and with preserved left-ventricular ejection fraction (LVEF). TR+ severe MR patients (466, 48%) showed higher rates of concomitant coronary artery disease, NYHA class III/IV symptoms and larger left atrial volumes. The group of TR+ severe AS (131 patients, 13%) was characterized by older age, more comorbidities and lower LVEF. Patients with TR and severe AR (22, 2%) were younger, with larger LV dimensions and higher pulmonary pressures. Overall, in 37(4%) patients tricuspid intervention was performed: no differences were found between groups in term of frequency of concomitant or staged tricuspid valve surgical treatment (p=0.444 and p= 0.624, respectively), while left-valve only surgical treatment was more common among patients with TR and severe MR and left-valve transcatheter treatment among patients with TR and severe AS (both p&amp;lt;0.001). After a median follow-up of 2.8 years, the primary endpoint occured in 374 (38%) of patients, and was significantly more frequent in the group of patients with TR and severe AS (p&amp;lt;0.001, Figure 2). In this group, after multivariate analysis, indexed stroke volume remained independenty associated with ACD (OR 0.96, CI 0.93-0.98, p =0.040). Eventually, the secondary endpoint too was more common in patients with TR and severe AS (p&amp;lt;0.001, Figure 2). Conclusions In the context of significant TR, concomitant severe left-sided VD is common, and each subtype presents with different clinical features and echocardiographic phenotypes; in this scenario, TR was profoundly underteated. Long-term, patients with significant TR+ severe AS have considerable worse prognosis.Figure 1Figure 2

Myocardial work and aortic valve stenosis cardiac damage stages are predictors of all-cause mortality in patients undergoing transcatheter aortic valve replacement

Abstract In aortic stenosis (AS) patients, assessment of left ventricular (LV) systolic function is complicated due to the significant impact of increased afterload on conventional parameters. Myocardial work (MW) analysis, a novel echocardiographic method adjusts myocardial deformation to instantaneous LV pressure which may better reflect the LV contractile state. Importantly, long-term LV pressure overload has marked backward effects beyond the LV: classification of this extravalvular cardiac damage effectively represents the involvement of the cardiopulmonary system in AS. Both MW and cardiac damage staging could hold remarkable prognostic power in the clinically complex population of transcatheter aortic valve replacement (TAVR) candidates. Accordingly, our aim was to assess the prognostic value of MW analysis and cardiac damage staging in patients undergoing TAVR. We enrolled 289 patients (79±6 years, 41% female) prior to TAVR. Echocardiographic measurements were performed one day before the procedure. We calculated LV ejection fraction (EF) and by speckle-tracking echocardiography global longitudinal strain (GLS), as well. Global constructive work (GCW) was quantified with dedicated software and LV pressure was estimated using transaortic mean gradient and systolic blood pressure. Based on the echocardiographic data, we also determined the extent of cardiac damage associated with AS: patients were classified as Stage 0 (no cardiac damage), Stage 1 (LV damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (pulmonary artery vasculature or tricuspid valve damage), or Stage 4 (right ventricular damage). Our primary outcome was all-cause mortality, reached by 68 patients (median follow-up: 26 months). In our cohort, preprocedural EF was 47±13 %, GLS was -12.3±4 %, while GCW was 2043±791 mmHg%. 14 (5%) patients were classified as Stage 0, 61 (21%) as Stage 1, 128 (44%) as Stage 2, 15 (5%) as Stage 3, and 71 (25%) as Stage 4. GCW showed a continuous decline through the AS Stages (from Stage 0-4: 2963±652 vs. 2154±652 vs. 2168±718 vs. 1988±969 vs. 1552±772 mmHg%; p&amp;lt;0.001). Using univariate Cox analysis GCW (HR 0.968 [95% CI 0.938-0.998] per 100 unit change; p=0.034) and AS Staging (HR 1.236 [95% CI 1.015-1.505]; p=0.035) were both associated with all-cause mortality, while EF (HR 0.984 [95% CI 0.966-1.002]; p=0.085) and GLS (HR 1.042 [95% CI 0.984-1.103]; p=0.160) were not. In multivariate Cox regression models, both GCW (HR 0.957 [95% CI 0.922-0.992] per 100 unit change; p=0.018) and AS cardiac damage staging (HR 1.263 [95% CI 1.029-1.549]; p=0.025) were proven to be significant independent predictors of all-cause mortality. In TAVR patients, preoperative GCW values exhibited a persistent decrease across AS Stages. As opposed to EF and GLS, GCW and AS Staging both showed strong association with all-cause mortality in our cohort. Moreover, GCW had higher prognostic value than any other conventional or advanced measure of LV function.