Echocardiographic Left Ventricular Ejection Fraction Research Articles

Mavacamten in Patients With Hypertrophic Cardiomyopathy Referred for Septal Reduction: Week 128 Results from VALOR-HCM

Background: In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), VALOR-HCM trial (Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive HCM Who Are Eligible for Septal Reduction Therapy [URL: https://clinicaltrials.gov; Unique identifier: NCT04349072]) reported that mavacamten reduced the short-term need for septal reduction therapy (SRT). The current report examined the longer-term effect of mavacamten through end of treatment at week 128. Methods: A double-blind randomized placebo-controlled multicenter trial at 19 sites in the United States included symptomatic obstructive HCM patients referred for SRT (enrollment July 2020 through October 2021). The group initially randomized to mavacamten continued the drug for 128 weeks and the placebo to mavacamten group from week 16 to 128 (112-week exposure). Dose titrations were performed using echocardiographic left ventricular outflow tract gradient and left ventricular ejection fraction measurements. The principal end point was proportion of patients proceeding with SRT or remaining guideline-eligible at week 128. Results: At week 128, 17 of 108 (15.7%) patients in the total study sample met the composite end point (7 underwent SRT, 1 was SRT-eligible, and 9 SRT-status unevaluable). Additionally, 87 of 108 (80.5%) patients demonstrated ≥1 New York Heart Association class improvement by week 128, and 52 of 108 (48.1%) demonstrated ≥2, with a sustained reduction in resting and Valsalva left ventricular outflow tract gradients of 38.2 mm Hg and 59.4 mm Hg, respectively. Ninety-five of 108 (88%) patients transitioned to commercial mavacamten. Overall, 15 of 108 (13.8%) patients (5.41 per 100 patient-years) had an left ventricular ejection fraction <50% (2 with left ventricular ejection fraction ≤30%; 1 death). Of these, 12 of 15 (80%) continued treatment. New-onset atrial fibrillation occurred in 11 (10.2%) patients (4.55 per 100 patient-years). Conclusions: In severely symptomatic obstructive HCM patients, sustained freedom from SRT was observed at 128 weeks, with nearly 90% patients remaining on long-term mavacamten.

Imminent risk of LVEF decline in asymptomatic patients with primary mitral regurgitation.

2020 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that the ideal time for mitral valve surgery in primary mitral regurgitation (PMR) is when the LV approaches but has not yet reached echocardiographic LV ejection fraction (EF) < 60% or LV end-systolic dimension (ESD) > 40 mm. However, it is difficult to know the imminent risk of crossing this threshold when the surgical outcome is less optimal. Using machine learning and statistical models, we have shown that cardiac magnetic resonance (CMR) LV sphericity index (SI) and LV mid circumferential strain rate (SRcirc) added to LVEF and LVESD predict LVEF < 50% after mitral valve surgery. Here we test the hypothesis that these CMR features predict LVEF < 60% in asymptomatic PMR patients at 18 months. 33 asymptomatic PMR patients with moderate to severe mitral regurgitation had CMR with tissue tagging at baseline and every 6 months for 18 months. Two types of models were employed to predict LVEF < 60% at 18 months: a model using CMR features at a single time point (e.g., baseline) and a model utilizing repeated measurements over time. CMR LVEF decreased below 60% in 13 patients over 18 months. LVEF varied over time with an inverse relation to mean arterial pressure and mean end-systolic wall stress. Random Forest models utilizing LV SI, LV mid SRcirc, LVESD, and LVEF at a single time point (baseline) had a predictive accuracy of 64%. LV SI, LV mid SRcirc, LVESD and LVEF at baseline, 6, and 12 months achieved a higher predictive accuracy of 79%, improved sensitivity from 57% to 85% than baseline alone and identified a threshold of CMR LVEF 63%-64% signaling LVEF < 60%. The variability of LVEF due to blood pressure dependence may require a longitudinal study that incorporates LVEF, LVESD, SRcirc at multiple time points to identify the threshold at which LVEF is at risk for decline to less than 60%.

Abstract P320: Novel Pulse Waveform Index Obtained by Ambulatory Blood Pressure Monitoring is Associated with Echocardiographic Ejection Fraction in Patients with Heart Failure

Introduction: Simple, non-invasive assessment of cardiac function is useful in the management of heart failure (HF). Hypothesis: We hypothesized that pulse waveform analysis from oscillometric cuff blood pressure (BP) measurement can estimate cardiac function. The aim of this study is to investigate the association of the pulse waveform index we developed from ambulatory BP monitoring, which represents cardiac systolic function in the ambulatory setting, with echocardiographic left ventricular ejection fraction (LVEF) in patients with HF. Methods: A cuff volumetric waveform was obtained from the diastolic phase of each BP measurement with a multisensor ABPM (TM-2441, A&amp;D). The area of the ejection portion is the square forward pulse wave (Sf), which is related to the cardiac ejection. The amplitude (Am) of the waveform represents arterial and cuff compliance. Sf is divided by Am, i.e., Sf/Am, to eliminate the effect of arterial and cuff compliance, which represents left ventricular systolic function ( Figure) . Results: Patients with HF who were clinically stable in the inpatient or outpatient setting (n=195) underwent both measurements of the multisensor-ABPM and echocardiography. LVEF was determined by the modified Simpson’s method. Patient characteristics were as follows: mean age, 72.1±14.7 years; male, 57%; and atrial fibrillation (AF), 39%. Sf/Am was associated with LVEF (r=0.44, p&lt;0.001) ( Figure ). This association was also significant in the multivariable linear regression model including age, sex, body mass index, use of HF medications, coronary artery disease, and AF (β=0.43, p&lt;0.001). Conclusions: Sf/Am, which is obtained by ABPM, is associated with echocardiographic LVEF.

Abstract Mo106: Inhibition of microRNA-200c promotes regeneration of the ischemic injured myocardium through activation of developmental pathways

Ischemic injury and adverse post-infarction myocardial remodeling are major causes of heart failure worldwide. Strategies designed to offset cell death with cardiomyocyte regeneration have, to date, not translated to routine clinical practice. Mir-200c modulates the transcripts of cardiogenic transcription factors (TFs) Tbx5 , Gata4 , Mef2c to promote myocyte maturation. We hypothesized that inhibition of mir-200c activity would result in postnatal myocyte de-differentiation and replication sufficient to ameliorate post-infarction decompensation after ischemic injury. To test this hypothesis, we preformed left coronary ligation on Wild-Type (WT) and transgenic mice expressing an RNA inhibitor against miR-200c ( PMIS-C ). Echocardiographic left ventricular (LV) ejection fraction (EF) fell from 88.41 ± 1.08% (WT) and 90% ± 1.42% ( PMIS-C ) (p=NS) to 28% ± 11.55% (WT) and 36% ± 9.35% at 1 day post injury (DPI) (p =NS). At 21DPI, LVEF was 27% ± 4.31% (WT) and 64% ± 4.25% ( PMIS-C ) [p ≤ 0.0001]. Post-infarction LV chamber dilation was reversed in PMIS-C mice (1.136 ± 0.19 v 0.67 ± 0.06 p ≤ 0.004 LV Vol/mass). By 9 WPI, PMIS-C heart function within non-significantly levels of sham and function prior to injury. These results indicated that inhibiting miR-200c following ischemic injury can recover cardiac function and prevent LV dilation. Moreover, trichrome stain showed a decrease in fibrosis 3 WPI (WT: 57% ± 17.46 v PMIS-C : 12% ± 3.01 p ≤ 0.001) and 9 WPI. To understand the mechanism causing this phenomenon, we analyzed expression of cardiac progenitor markers. Fold change in expression of TFs Tbx5, Gata4, Mef2c, and Isl1 were increased at 1 and 3 DPI in PMIS-C . At 1 WPI, PMIS-C border zone CMs express markers of a “progenitor-like” cell state seen during cardiogenesis. Conclusions: Inhibiting miR-200c abrogates post-infarction LV remodeling and significantly restores LV systolic function. Ongoing studies are investigating the therapeutic use of PMIS-C through delivery via AAV and nanoparticles.

Echocardiographic Predictors of Readiness for Double Switch Operation and Postoperative Ejection Fraction in Patients With Congenitally Corrected Transposition of the Great Arteries Undergoing Left Ventricular Retraining

In patients with congenitally corrected transposition of the great arteries (ccTGA), assessment of readiness for the double switch operation (DSO) after pulmonary arterial band (PAB) placement involves cardiac magnetic resonance imaging (cMRI) to measure left ventricular ejection fraction (LVEF) and mass and cardiac catheterization (catheterization) to assess the ratio of left ventricular to right ventricular pressure (LV:RVp). The aims of this study were to describe the relationships between echocardiographic and catheterization and cMRI measures of readiness for DSO and to develop risk factors for left ventricular (LV) dysfunction after DSO on the basis of echocardiographic measures of ventricular-arterial coupling (VAC). Patients with ccTGA undergoing LV retraining at a DSO referral center were reviewed. LVEF measured by echocardiography was compared with that measured by cMRI, and LV:RVp measured by echocardiography was compared with that measured by catheterization using Bland-Altman analysis. The relationship between preoperative VAC markers and postoperative echocardiography was analyzed using ventricular end-systolic elastance (EES) and a novel marker consisting of the product of LVEF and LV:RVp (EFPR). Thirty-one patients with 56 evaluations for DSO were included, 24 of whom underwent DSO. Echocardiographic LVEF correlated well with cMRI LVEF (r=0.79), and Bland-Altman analysis slightly overestimated cMRI LVEF (mean difference,+3%). Echocardiographic LVEF had a moderate ability to identify normal cMRI LVEF (area under the curve, 0.80) and at an optimal cut point of echocardiographic LVEF threshold of 61%, there was 71% sensitivity and 76% specificity to detect cMRI LVEF≥55%. Echocardiographic LV:RVp correlated well with LV/RVp by catheterization (r=0.77) and slightly underestimated the catheterization value (mean difference, -0.11). Echocardiographic LV:RVp had a good ability to identify adequate LV:RVp by catheterization (area under the curve, 0.95) and at an optimal echocardiography cut point of 0.75 had 100% sensitivity and 85% specificity to detect a catheterization LV:RVp >0.9. Echocardiography-based criteria for DSO readiness (echocardiographic LVEF of 61% and LV:RVp of 0.75) demonstrated specificity of 97% and positive predictive value of 96% for published criteria of DSO readiness (cMRI LVEF of 55% and catheterization LV:RVp of 0.9). EES and EFPR correlated with post-DSO LVEF (ρ=0.72 and ρ=0.60, respectively). EFPR of 0.51 demonstrated 78% sensitivity and 100% specificity for post-DSO LV dysfunction (LVEF<55%). Age at first PAB also strongly correlated with post-DSO LVEF (ρ=0.75). No patient with first PAB at <1year of age exhibited post-DSO LV dysfunction. Echocardiographic measures of LVEF and LV:RVp are reliable indicators of reference standard modalities and can guide management during retraining. The preoperative VAC markers EES and EFPR may be useful markers of post-DSO LV dysfunction. Values of echocardiographic LV:RVp >0.75 are likely to meet pressure-generation criteria for DSO and should be considered for referral to catheterization and cMRI evaluation for DSO. PAB placement before 1year of life may optimize LV outcomes in patients considered for DSO.

Effect of patent complete revascularization on the akinetic myocardial segments.

The aims of the study were (i) to examine the changes in echocardiographic parameters and (ii) to compare the fate of myocardial segments with akinesia and without akinesia on preoperative echocardiography after coronary artery bypass grafting. One hundred one patients who underwent complete revascularization, who were assessed by preoperative, before discharge, postoperative 3- and 12-month echocardiographic examinations, and who showed all patent grafts at postoperative 1-year angiograms were included. Echocardiographic left ventricular ejection fraction was assessed, and a 16-segment model was adopted for regional analysis of the left ventricle. A total of 1616 segments were analysed based on a 6-point scale: 1 = normal (N = 1083), 2 = mild hypokinesia (N = 2), 3 = moderate hypokinesia (N = 74), 4 = severe hypokinesia (N = 150), 5 = akinesia without thinning (N = 259) and 6 = akinesia with thinning (N = 48). The serial left ventricular ejection fraction measured preoperatively, before discharge, at postoperative 3- and 12-months were 0.48 ± 0.14, 0.49 ± 0.12, 0.49 ± 0.10 and 0.54 ± 0.10, respectively. The left ventricular ejection fraction significantly increased over time during the postoperative 12 months (P < 0.001). Wall motion scores tended to decrease over time in both segment groups with akinesia and without akinesia (P < 0.001), and improvement of the wall motion was significantly higher in the segment group with akinesia than in the segment group without akinesia (P < 0.001). The left ventricular ejection fraction and regional wall motion improved over time during the postoperative 12 months, regardless of the presence of an akinetic segment. Complete revascularization including akinetic myocardium should be considered when performing coronary artery bypass grafting.

Artificial Intelligence-Based Electrocardiographic Biomarker for Outcome Prediction in Patients With Acute Heart Failure: Prospective Cohort Study.

Although several biomarkers exist for patients with heart failure (HF), their use in routine clinical practice is often constrained by high costs and limited availability. We examined the utility of an artificial intelligence (AI) algorithm that analyzes printed electrocardiograms (ECGs) for outcome prediction in patients with acute HF. We retrospectively analyzed prospectively collected data of patients with acute HF at two tertiary centers in Korea. Baseline ECGs were analyzed using a deep-learning system called Quantitative ECG (QCG), which was trained to detect several urgent clinical conditions, including shock, cardiac arrest, and reduced left ventricular ejection fraction (LVEF). Among the 1254 patients enrolled, in-hospital cardiac death occurred in 53 (4.2%) patients, and the QCG score for critical events (QCG-Critical) was significantly higher in these patients than in survivors (mean 0.57, SD 0.23 vs mean 0.29, SD 0.20; P<.001). The QCG-Critical score was an independent predictor of in-hospital cardiac death after adjustment for age, sex, comorbidities, HF etiology/type, atrial fibrillation, and QRS widening (adjusted odds ratio [OR] 1.68, 95% CI 1.47-1.92 per 0.1 increase; P<.001), and remained a significant predictor after additional adjustments for echocardiographic LVEF and N-terminal prohormone of brain natriuretic peptide level (adjusted OR 1.59, 95% CI 1.36-1.87 per 0.1 increase; P<.001). During long-term follow-up, patients with higher QCG-Critical scores (>0.5) had higher mortality rates than those with low QCG-Critical scores (<0.25) (adjusted hazard ratio 2.69, 95% CI 2.14-3.38; P<.001). Predicting outcomes in patients with acute HF using the QCG-Critical score is feasible, indicating that this AI-based ECG score may be a novel biomarker for these patients. ClinicalTrials.gov NCT01389843; https://clinicaltrials.gov/study/NCT01389843.

Left ventricular systolic dysfunction predicts clinical prognosis in patients with acute ischemic stroke after intravenous thrombolysis.

Although intravenous recombinant tissue plasminogen activator (rt-PA) thrombolysis is the most effective early treatment for acute ischemic stroke (AIS), outcomes vary greatly among patients. Left ventricular systolic dysfunction (LVSD) is prone to distant organ ischemia and may be a predictor for poor prognosis in AIS patients undergoing intravenous thrombolysis (IVT). Our aim was to investigate the predictivity of LVSD diagnosis (as measured by left ventricular ejection fraction (LVEF)) on 90-day clinical outcomes in AIS patients undergoing thrombolysis. The current prospective cohort study continuously enrolled 273 AIS patients from the National Stroke Prevention and Treatment Engineering Management Special Database who underwent IVT and completed echocardiography within 24 h of admission between 2021 and 2023. LVSD was examined by evaluation of the echocardiographic LVEF values using Simpson's biplane method of discs in line with international guidelines, and defined as a LVEF value < 50%. Multivariable ordinal logistic regression model was performed to analyze the association between LVEF and functional outcome at 3 months. Restricted cubic spline (RCS) was used to examine the shape of the dose-response association between reduced LVEF and poor functional outcomes. Subgroup analysis was also employed to further verify the reliability and practicability of the results. Baseline data analysis showed LVSD patients had more comorbidities including on multivariate analyses, LVSD (OR 2.78, 95% CI 1.23 to 6.24, P=0.014), pre-existing diabetes mellitus (OR 2.08, 95% CI 1.11 to 3.90, P=0.023) and NIHSS on arrival (OR 1.31, 95% CI 1.21 to 1.49, P<0.001) were independent predictors of poor functional outcomes (mRS ≥ 3) at 3 months. Multivariable-adjusted spline regression indicated a linear dose-response association between LVEF after IVT and poor functional outcomes (p for linearity < 0.001), with the optimal cutoff values of LVEF being 0.48. Our finding indicated that AIS patients with LVSD after IVT had poorer outcomes, suggesting the need to monitor and optimize LVEF in stroke management.

Comparison of Echocardiography and Multi-Planar Gated Acquisition Scans for Predicting Cancer-Treatment-Related Cardiovascular Dysfunction

Current guidelines recommend using sequential cardiac imaging to monitor for cancer treatment-related cardiac dysfunction (CTRCD) in patients undergoing potentially cardiotoxic chemotherapy. Multiple different imaging cardiac modalities are available and there are few prospective head-to-head comparative studies to help guide treatment. To perform an exploratory prospective cohort study of "real-world" CTRCD comparing multigated acquisition nuclear ventriculography (MUGA) at the referring cancer specialist's discretion with a novel echocardiographic strategy at an Australian tertiary hospital. Patients were recruited from haematology and oncology outpatient clinics if they were scheduled for treatment with anthracyclines and/or trastuzumab. Patients underwent simultaneous MUGA-based cardiac imaging (conventional strategy) at a frequency according to evidenced-based guidelines in addition to researcher-conducted echocardiographic imaging. The echocardiographic imaging was performed in all patients at time points recommended by international society guidelines. Outcomes included adherence to guideline recommendations, concordance between MUGA and echocardiographic left ventricular ejection fraction (LVEF) measurements, and detection of cardiac dysfunction (defined as >5% LVEF decrement from baseline by three-dimensional [3D]-LVEF). A secondary end point was accuracy of global longitudinal strain in predicting cardiac dysfunction. In total, 35 patients were recruited, including 15 with breast cancer, 19 with haematological malignancy, and one with gastric cancer. MUGA and echocardiographic LVEF measurements correlated poorly with limits of agreement of 30% between 3D-LVEF and MUGA-LVEF and 37% for 3D-LVEF and MUGA-LVEF. Only one case (2.9%) of CTRCD was diagnosed by MUGA, compared with 12 (34.2%) cases by echocardiography. Four (4) patients had >10% decrement in 3D-LVEF that was not detected by MUGA. Global longitudinal strain at 2 months displayed significant ability to predict CTRCD (area under the curve, 0.75, 95% confidence interval, 0.55-0.94). The MUGA correlates poorly with echocardiographic assessment with substantial discrepancy between MUGA and echocardiography in CTRCD diagnosis. Echocardiographic and MUGA imaging strategies should not be considered equivalent for imaging cancer patients, and a single imaging modality should ideally be used per patient to prevent misdiagnosis by inter-modality variation These findings should be considered hypothesis-generating and require confirmation with larger studies.

Donor heart dysfunction and graft survival in liver and kidney transplants-A register-based study from Sweden.

Stress cardiomyopathy in donors can potentially affect graft function and longevity. This study aims to investigate the association between echocardiographic left ventricular ejection fraction (LVEF)<50%, and/or the presence of left ventricular regional wall motion abnormalities (RWMA) in organ donors, and short- and long-term liver and kidney graft survival. Our secondary aim was to link graft survival with donor and recipient characteristics. All donors considered for liver and kidney donation with echocardiographic records at Sahlgrenska University Hospital between 2006 and 2016 were matched with their recipients through the Scandiatransplant register. The studied outcomes were graft survival, re-transplantation, and recipient death. Kaplan-Meier curves were used to plot time to event. Multivariate Cox-regression was used to test independence. There were 370 liver donors and 312 kidney donors (matched with 458 recipients) with echocardiographic records at Sahlgrenska University Hospital between June 2006 and November 2016. Of patients with LV dysfunction by echocardiography, there were 102 liver- and 72 kidney donors. Univariate survival analyses showed no statistical difference in the short- and long-term graft survival from donors with LV dysfunction compared to donors without. Donor age>65 years, recipient re-transplantation and recipient liver tumor were predictors of worse outcome in liver transplants (p<.05). Donor age>65, donor hypertension, recipient re-transplantation, and a recipient diagnosis of diabetes or nephritis/glomerulonephritis had a negative association with graft survival in kidney transplants (p<.05). We found no significant association between donor LV dysfunction and short- and long-term graft survival in liver and kidney transplants, suggesting that livers and kidneys from such donors can be safely transplanted.

Long-term efficacy and safety of tailored immunosuppressive therapy in immune-mediated biopsy-proven myocarditis: A propensity-weighted study.

Standardized immunosuppressive therapy (IS) had been previously investigated in biopsy-proven (BP) lymphocytic myocarditis with heart failure (HF). This study evaluated efficacy and safety of tailored IS in BP immune-mediated myocarditis, irrespective of histology and clinical presentation. Consecutive BP myocarditis patients treated with long-term tailored IS on top of optimal medical therapy (OMT), were compared with OMT non-IS controls using propensity-score weighting. The primary outcome was a composite of death or heart transplant, the secondary outcome was a composite of biventricular function, New York Heart Association (NYHA) class variation, and relapse. IS was managed by a multidisciplinary Cardioimmunology Team, involved a safety checklist and active patients' education. Ninety-one IS patients were compared with 267 non-IS patients. IS patients more frequently had systemic immune-mediated diseases (35% vs. 9.7%), lower baseline echocardiographic left ventricular ejection fraction (35% vs. 43%), lower right ventricular fractional area change (34% vs. 41%) and higher frequency of active lymphocytic, eosinophilic and giant cell myocarditis (71% vs. 58%, 12% vs. 1.1%, and 6.6% vs. 1.5%, respectively). At 5-year follow up, no difference was observed in the primary outcome (survival rate 93% in IS vs. 87% in non-IS), but IS patients had a higher relapse rate. Thus, IS patients, with a lower biventricular function and a higher risk profile at baseline, presented similar biventricular function and NYHA class to non-IS patients at follow-up. Minor adverse drug reactions occurred in 13% of patients, all resolved with therapy switch. Prolonged tailored IS is effective and safe in BP immune-mediated myocarditis irrespective of histology and clinical presentation.

Prognostic and functional importance of both overt and subclinical left ventricular systolic dysfunction in systemic sclerosis

ObjectivesTo quantify the frequency and clinical implications of systemic sclerosis (SSc)-associated left ventricular function (LV) impairment. MethodsAustralian Scleroderma Cohort Study participants meeting ACR/EULAR criteria for SSc with ≥1 echocardiographic LVEF measurement were included. Overt LV dysfunction was indicated by reduced LV ejection fraction (LVEF) and subclinical LV dysfunction was measured using impaired LV global longitudinal strain (LV-GLS>-16 %). Those with secondary causes of LV dysfunction (myocardial ischaemia, valvulopathy and pulmonary arterial hypertension) were excluded. Chi-squared tests, two-sample t-tests or Wilcoxon rank-sum tests were used for between-group comparison as appropriate. Generalised estimating equations(GEE) were used to model longitudinal data. Kaplan-Meier and Cox proportional hazard models were used for survival analyses. ResultsOf 1141 participants with no co-morbid cardiac disease, 2.4 % ever recorded a LVEF<50 %, while only 0.6 % ever recorded a LVEF≤40 %. LV-GLS data were available for 90 % of participants at one centre (n = 218). Impaired LV-GLS was detected in 21 % despite LVEF≥50 %. Those with a LVEF<50 % were more frequently male (p = 0.01) with dcSSc (p < 0.01), higher inflammatory markers (p < 0.02) and skeletal muscle disease (p < 0.05). In multivariable analyses, recording a LVEF<50 % was associated with increased mortality (HR2.3, 95 %CI1.0–4.8, p = 0.04). Impaired LV-GLS was also associated with poorer survival in univariable analyses (HR3.4, 95 %CI1.0–11.8, p = 0.05). Those with a LVEF<50 % more frequently recorded WHO Class III/IV dyspnoea (OR3.5, 95 %CI1.6–7.7, p < 0.01), with shorter six-minute walk distance (p = 0.01), higher Health Assessment Questionnaire-Disability Index scores (p < 0.01) and lower Short Form-36 Physical Component Summary scores (p = 0.02). Increased dyspnoea (WHO Class III/IV dyspnoea; OR3.6, 95 %CI1.4–9.2, p < 0.01) was also seen in those with impaired LV-GLS. ConclusionsBoth overt and subclinical SSc-associated LV dysfunction are associated with worse survival and impaired physical function. The frequency of abnormal LV-GLS in those with consistently normal LVEF suggests an under-appreciated burden of subtle LV systolic dysfunction in SSc that has a significant impact on patient symptomatology.

Development of automated neural network prediction for echocardiographic left ventricular ejection fraction.

The echocardiographic measurement of left ventricular ejection fraction (LVEF) is fundamental to the diagnosis and classification of patients with heart failure (HF). This paper aimed to quantify LVEF automatically and accurately with the proposed pipeline method based on deep neural networks and ensemble learning. Within the pipeline, an Atrous Convolutional Neural Network (ACNN) was first trained to segment the left ventricle (LV), before employing the area-length formulation based on the ellipsoid single-plane model to calculate LVEF values. This formulation required inputs of LV area, derived from segmentation using an improved Jeffrey's method, as well as LV length, derived from a novel ensemble learning model. To further improve the pipeline's accuracy, an automated peak detection algorithm was used to identify end-diastolic and end-systolic frames, avoiding issues with human error. Subsequently, single-beat LVEF values were averaged across all cardiac cycles to obtain the final LVEF. This method was developed and internally validated in an open-source dataset containing 10,030 echocardiograms. The Pearson's correlation coefficient was 0.83 for LVEF prediction compared to expert human analysis (p < 0.001), with a subsequent area under the receiver operator curve (AUROC) of 0.98 (95% confidence interval 0.97 to 0.99) for categorisation of HF with reduced ejection (HFrEF; LVEF<40%). In an external dataset with 200 echocardiograms, this method achieved an AUC of 0.90 (95% confidence interval 0.88 to 0.91) for HFrEF assessment. The automated neural network-based calculation of LVEF is comparable to expert clinicians performing time-consuming, frame-by-frame manual evaluations of cardiac systolic function.

Artificial intelligence-assisted evaluation of cardiac function by oncology staff in chemotherapy patients.

Left ventricular ejection fraction (LVEF) calculation by echocardiography is pivotal in evaluating cancer patients' cardiac function. Artificial intelligence (AI) can facilitate the acquisition of optimal images and automated LVEF (autoEF) calculation. We sought to evaluate the feasibility and accuracy of LVEF calculation by oncology staff using an AI-enabled handheld ultrasound device (HUD). We studied 115 patients referred for echocardiographic LVEF estimation. All patients were scanned by a cardiologist using standard echocardiography (SE), and biplane Simpson's LVEF was the reference standard. Hands-on training using the Kosmos HUD was provided to the oncology staff before the study. Each patient was scanned by a cardiologist, a senior oncologist, an oncology resident, and a nurse using the TRIO AI and KOSMOS EF deep learning algorithms to obtain autoEF. The correlation between autoEF and SE-ejection fraction (EF) was excellent for the cardiologist (r = 0.90), the junior oncologist (r = 0.82), and the nurse (r = 0.84), and good for the senior oncologist (r = 0.79). The Bland-Altman analysis showed a small underestimation by autoEF compared with SE-EF. Detection of impaired LVEF < 50% was feasible with a sensitivity of 95% and specificity of 94% for the cardiologist; sensitivity of 86% and specificity of 93% for the senior oncologist; sensitivity of 95% and specificity of 91% for the junior oncologist; and sensitivity of 94% and specificity of 87% for the nurse. Automated LVEF calculation by oncology staff was feasible using AI-enabled HUD in a selected patient population. Detection of LVEF < 50% was possible with good accuracy. These findings show the potential to expedite the clinical workflow of cancer patients and speed up a referral when necessary.

CMR Predictors of Favorable Outcome in Myocarditis: A Single-Center Experience.

Background: Cardiovascular magnetic resonance (CMR) has emerged as the most accurate, non-invasive method to support the diagnosis of clinically suspected myocarditis and as a risk-stratification tool in patients with cardiomyopathies. We aim to assess the diagnostic and prognostic role of CMR at diagnosis in patients with myocarditis. Methods: We enrolled consecutive single-center patients with 2013 ESC consensus-based endomyocardial biopsy (EMB)-proven or clinically suspected myocarditis undergoing CMR at diagnosis. The pre-specified outcome was defined as NYHA class > I and echocardiographic left ventricular ejection fraction (LVEF) < 50% at follow-up. Results: We included 207 patients (74% male, median age 36 years; 25% EMB-proven). CMR showed the highest sensitivity in myocarditis with infarct-like presentation. Patients with EMB-proven myocarditis were more likely to have diffuse LGE and right ventricular LGE (p < 0.001), which was also more common among patients with arrhythmic presentation (p = 0.001). The outcome was met in 17 patients at any follow-up time point, more commonly in those with larger biventricular volumes (p < 0.001), CMR-based diagnosis of dilated cardiomyopathy (p < 0.001), and ischemic LGE (p = 0.005). Higher biventricular systolic function (p < 0.001) and greater LGE extent (p = 0.033) at diagnosis had a protective effect. Conclusions: In our single-center cohort of rigorously defined myocarditis patients, higher biventricular systolic function and greater LGE extent on CMR at diagnosis identified patients with better functional class and higher left ventricular ejection fraction at follow-up. Conversely, larger biventricular volumes, CMR-based DCM features, and the presence of an ischemic LGE pattern at diagnosis were predictors of worse functional class and LV systolic dysfunction at follow-up. Larger prospective studies are warranted to extend our findings to multi-center cohorts.

Novel Pulse Waveform Index by Ambulatory Blood Pressure Monitoring and Cardiac Function: A Pilot Study

BackgroundA simple ambulatory measure of cardiac function could be helpful for monitoring heart failure patients. ObjectivesThe purpose of this paper was to determine whether a novel pulse waveform analysis using data obtained by our developed multisensor-ambulatory blood pressure monitoring (ABPM) device, the 'Sf/Am' ratio, is associated with echocardiographic left ventricular ejection fraction (LVEF). MethodsMultisensor-ABPM was conducted twice at baseline in 20 heart failure (HF) patients with HF-reduced LVEF or HF-preserved LVEF (median age 66 years, male 65%) and over a 6- to 12-month follow-up after patient-tailored treatment. We assessed the changes in the pulse waveform index Sf/Am and LVEF that occurred between the baseline and follow-up. The Sf/Am consists of the area of the ejection part in the square forward wave (Sf) and the amplitude of the measured wave (Am). We divided the patients into the recovered (n = 11) and not-recovered (n = 9) groups defined by a ≥10% increase in LVEF. ResultsAlthough the ambulatory BP levels and variabilities did not change in either group, the Sf/Am increased significantly in the recovered group (baseline 21.4 ± 4.5; follow-up, 25.6 ± 3.7, P = 0.004). The not-recovered group showed no difference between the baseline and follow-up. The follow-up/baseline Sf/Am ratio was significantly associated with the LVEF ratio (r = 0.469, P = 0.037). The Sf/Am was significantly correlated with the LVEF in overall measurements (n = 40, r = 0.491, P = 0.001). ConclusionsThese results demonstrated that a novel noninvasive pulse waveform index, the Sf/Am measured by multisensor-ABPM is associated with LVEF. The Sf/Am may be useful for estimating cardiac function.

Relationship of Adiponectin and High-Sensitivity CReactive Protein with Left Ventricular Dysfunction among Patients Undergoing Coronary Angiography

Background: Decreased levels of adiponectin (APN) and elevated levels of high-sensitivity C-reactive protein (hs-CRP) have been found as predictors of left ventricular dysfunction and cardiovascular events. Therefore, this study aimed to assess the relationship of APN and hs-CRP with the severity of left ventricular dysfunction among Egyptian patients undergoing coronary angiography (CAG).&#x0D; Methods: A cross-sectional study was conducted among 100 Egyptian patients who underwent clinically indicated CAG at Suez Canal University Hospital in Ismailia - Egypt, from May 2009 to December 2010. The left ventricular ejection fraction (LVEF) scoring system was used to assess left ventricular function based on echocardiographic findings. Pearson correlation was used to determine the relationship of APN and hs-CRP levels with echocardiographic LVEF score, and analysis of variance (ANOVA) was used to compare clinical and biochemical parameters among patients according to left ventricular function at P-value &lt;0.05.&#x0D; Results: The mean hs-CRP level had a significant weak negative correlation with the mean HDL-cholesterol level (r = -0.222; P = 0.048), while the mean APN level had a significant weak negative correlation with BMI (r = -0.269; P = 0.007) but a significant weak positive correlation with the mean hs-CRP level (r = 0.215; P = 0.031) and a significant moderate positive correlation with the mean HDL-cholesterol level (r = 0.302; P = 0.002). Left ventricular function in patients undergoing CAG was normal in 34 (34%), mildly impaired in 41 (41%) patients and moderately impaired in 25 (25%), with significantly different mean hs-CRP levels among the three groups (P = 0.025) that increased from normal to moderately impaired left ventricular function. However, there was no statistically significant difference in left ventricular function according to the mean level of APN.&#x0D; Conclusion: The hs-CRP level is negatively correlated with HDL-cholesterol, while APN is negatively correlated with BMI and hs-CRP but positively correlated with HDL-cholesterol in Egyptian patients undergoing CAG. The hs- CRP level correlates with the severity of left ventricular dysfunction. However, left ventricular function does not appear to correlate with APN levels.

Does sacubitril/valsartan work in children with heart failure?—a pilot study

BackgroundSacubitril/valsartan is an angiotensin receptor neprilysin antagonist (ARNI) approved for adult heart failure (HF). Its safety and efficacy in pediatric HF patients with cardiomyopathy or congenital heart disease are poorly understood. A pilot study was conducted to assess the clinical response, efficacy and safety of sacubitril/valsartan in this population at a tertiary care hospital in China.MethodsClinical parameters of patients who received sacubitril/valsartan from January 2019 to March 2023 were retrospectively collected and analyzed. Children over 1 month with a left ventricular ejection fraction (LVEF) &amp;lt;45% were included. Clinical efficacy was evaluated by echocardiographic LVEF, N-terminal pro-brain natriuretic peptide (NT-proBNP), New York Heart Association (NYHA) HF classification, HF re-admission, and death or transplantation. The initial dose was either 0.2 mg/kg bid or 0.4 mg/kg bid, with a target dose of 2.3 mg/kg bid or 3.1 mg/kg bid.ResultsForty-five patients (60% male) with a median age of 7.86 years were enrolled. Among them, 23 had congenital heart disease and 22 had cardiomyopathies. The median maintenance dose was 0.76 mg/kg. The primary endpoint of LVEF up to 45% was reached by 24 patients (53.3%). The median NT-proBNP was significantly decreased from 5,501.5 pg/ml to 2,241.5 pg/ml (P &amp;lt; 0.001), more in congenital heart disease than in cardiomyopathies (P = 0.032). The NYHA HF class was improved or remained stable in 42 cases (93.3%). During a median follow-up of 1.23 years, 13 patients (28.9%) were re-hospitalized due to HF, and 9 patients (20%) died or underwent transplantation. Hypotension was the main adverse event, occurring in 8 patients.ConclusionsSacubitril/valsartan may be effective in children with HF, but its safety and outcomes may differ depending on the etiology and anatomy of HF. Early post-operative congenital heart disease patients had less tolerance, more hypotension but better recovery and outcomes, while mid- and late- post-operative congenital heart disease patients and cardiomyopathy patients had less side effects but poorer clinical outcomes.

CMR predictors of favourable outcome in myocarditis: a single-centre experience

Abstract Background Cardiovascular magnetic resonance (CMR) has emerged as the most accurate, non-invasive method to support diagnosis of clinically suspected myocarditis and has proved to risk-stratify patients with both ischemic and non-ischemic cardiomyopathies. Purpose We aimed to assess the diagnostic and prognostic role of CMR at diagnosis in patients with clinically suspected or endomyocardial biopsy (EMB) proven myocarditis. Methods We enrolled consecutive single-centre patients with EMB-proven or clinically suspected myocarditis (defined in keeping with the World Health Organization and the European Society of Cardiology (ESC) criteria) undergoing CMR at diagnosis. Extent of late gadolinium enhancement (LGE) was quantified with the full width at half maximum method. Pre-specified outcome was defined as NYHA class &amp;gt; I and echocardiographic left ventricular ejection fraction (LVEF) &amp;lt; 50% at follow-up. Results We included 207 patients (74% male, median age 36 years; 25% EMB-proven). CMR showed the highest diagnostic sensitivity in myocarditis patients with infarct-like presentation. Myocardial oedema was found in 63% of patients and LGE in 93%, with a more diffuse distribution in EMB-proven myocarditis. Right ventricular LGE was more prevalent among EMB-proven myocarditis (8% vs 0, p&amp;lt;0.001) and in patients with arrhythmic presentation (12% vs 1% in patients with infarct-like or heart failure presentation, p=0.001). Outcome was met in 17 patients at any follow-up time point, more commonly in patients with larger biventricular volumes (end-diastolic left HR 1.02, right HR 1.04, p&amp;lt;0.001), CMR-based diagnosis of dilated cardiomyopathy (HR 40.7, p&amp;lt;0.001) and ischemic LGE (HR 56.4, p=0.005), while higher biventricular function (LVEF HR 0.89, p&amp;lt;0.001) and greater LGE extent (HR 0.73, p=0.033) at diagnosis had a protective effect. Conclusions Higher biventricular function and greater LGE extent on CMR at diagnosis predict more favourable outcome in myocarditis; LGE at diagnosis may represent oedema rather than fibrosis.

Cardiac magnetic resonance for prophylactic implantable-cardioVerter defibrillator therapy international registry in patients with ischemic cardiomyopathy

Abstract Background Sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) remains a leading cause of death. Current guidelines provide a class I recommendation for implantable cardioverter–defibrillator (ICD) implantation in ICM patients with transthoracic echocardiographic (TTE) left ventricular ejection fraction (LVEF) ≤35%. and NYHA functional class II or III. The current paradigm is suboptimal in identifying patients who are likely to benefit. In fact, only a relatively small proportion of ICD recipients for SCD primary prevention receive appropriate device therapy and instead there is a not negligible percentage of patients who experienced SCD event despite not fulfilling criteria for implantation. Purpose The DERIVATE-ICM registry sought to evaluate the additional prognostic value for the indication of ICD implantation using cardiac magnetic resonance (CMR) as compared to standard of care based on TTE in a large cohort of ICM patients. Methods We enrolled 861 ICM patients (86% male, mean age 65±11 years) with chronic heart failure and TTE-LVEF&amp;lt;50%. Major adverse arrhythmic cardiac events (MAACE), defined as the combination of SCD, aborted SCD event, and sustained ventricular tachycardia. were the primary endpoint. Independent predictors were used to calculate a CMR risk score for each patient. Risk levels were defined as low (quantile 1 [Q1]), medium (Q2 and Q3) and high (Q4). Results During a median follow-up of 1054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR:1.007, 95%CI:1.000-1.011, p=0.05), CMR-LVEF (HR:0.972, 95%CI: 0.945-0.999, p=0.045) and late gadolinium enhancement (LGE) mass (HR:1.010, 95%CI: 1.002–1.018, p=0.015) were independent predictors of MAACE. Based on the multivariate analysis, CMR weighted risk score was developed according to the following equation [0.005 * EDV/BSA (mL/m2) – 0.029 * LVEF (%) + 0.010 * LGE ischemic mass (g)]. A multiparametric CMR weighted predictive derived score effectively identifies subjects at high risk for MAACE as compared to TTE-LVEF cut-off of 35% with a Continuous NRI: 31.7% (95%CI: 8.6%-54.8%, p=0.007) (Figure 1, Figure 2). Conclusions In this large multicenter registry, a multi-parametric CMR predictive model provides additional prognostic stratification for MAACE predictions in a large cohort of ICM patients as compared to standard of care. This model identifies a large number of patients with TTE-LVEF&amp;lt;35% at low risk of SCD event and on the other side it identifies a subset of patients who are at high risk of MAACE despite TTE-LVEF≥35% (i.e. the population currently not fulfilling the guideline-based criteria for ICD implantation). Further randomized trials to test a CMR guided strategy for ICD implantation versus standard of care are now needed.Kaplan-Meier curvesEvent rate redistribution