Echocardiography Laboratory Research Articles

Physics-constrained intraventricular vector flow mapping by color Doppler

Color Doppler by transthoracic echocardiography creates two-dimensional fan-shaped maps of blood velocities in the cardiac cavities. It is a one-component velocimetric technique since it only returns the velocity components parallel to the ultrasound beams. Intraventricular vector flow mapping (iVFM) is a method to recover the blood velocity vectors from the Doppler scalar fields in an echocardiographic three-chamber view. We improved our iVFM numerical scheme by imposing physical constraints. The iVFM consisted in minimizing regularized Doppler residuals subject to the condition that two fluid-dynamics constraints were satisfied, namely planar mass conservation, and free-slip boundary conditions. The optimization problem was solved by using the Lagrange multiplier method. A finite-difference discretization of the optimization problem, written in the polar coordinate system centered on the cardiac ultrasound probe, led to a sparse linear system. The single regularization parameter was determined automatically for non-supervision considerations. The physics-constrained method was validated using realistic intracardiac flow data from a patient-specific computational fluid dynamics (CFD) model. The numerical evaluations showed that the iVFM-derived velocity vectors were in very good agreement with the CFD-based original velocities, with relative errors ranged between 0.3% and 12%. We calculated two macroscopic measures of flow in the cardiac region of interest, the mean vorticity and mean stream function, and observed an excellent concordance between physics-constrained iVFM and CFD. The capability of physics-constrained iVFM was finally tested with in vivo color Doppler data acquired in patients routinely examined in the echocardiographic laboratory. The vortex that forms during the rapid filling was deciphered. The physics-constrained iVFM algorithm is ready for pilot clinical studies and is expected to have a significant clinical impact on the assessment of diastolic function.

311 A new color Doppler-based echocardiographic technique for evaluation of intraventricular flow dynamics: first application to normal subjects, athletes, and patients

Abstract Aims A new echocardiographic, color Doppler-based technique, named HyperDoppler, has been recently introduced for non-invasive evaluation of intracardiac flow dynamics. The aim of this study was to verify the feasibility and reproducibility of this technique and its capability to differentiate geometrical and energy measures of vortex flow within the left ventricle (LV) in normal subjects, athletes and patients with heart failure. Methods and results Two Italian cardiology centres enrolled each one 100 unselected, consecutive patients presenting at the echocardiography laboratory for a clinical examination, regardless of the indication to echocardiography. In these patients, the feasibility, repeatability, reproducibility, and inter-centre reproducibility of the HyperDoppler technique were tested using the intraclass correlation coefficient (ICC) and Bland–Altman analysis. In addition, 50 normal subjects, 30 professional athletes, and 50 patients with stabilized chronic heart failure and LV ejection fraction <40% were enrolled. Images were acquired using a MyLab X8 echo-scanner and analysed to provide the following vortex flow measures: vortex area, normalized with the LV area; vortex intensity (i.e. the integral of the vorticity inside the vortex), normalized with the total vorticity; vortex depth (the distance of its centre from the LV base) and length along the base-apex direction, both normalized with the LV length; and the total kinetic energy dissipation (KED). Feasibility of HyperDoppler was very high (94.5%). According to the ICC values, at Centre 1 repeatability and reproducibility of vortex flow measures in unselected patients were good for vortex area (0.82, 0.85), length (0.83, 0.82) and depth (0.87, 0.84) and excellent for vortex intensity (0.92, 0.90) and KED (0.98, 0.98). Results of the Bland–Altman analysis showed no bias nor consistent under/overestimations of flow measures, with 95% of points always lying within the limits of agreement for each flow measure. Centre 2 provided similar repeatability and reproducibility evaluations for all the vortex measures, thus supporting a good-to-excellent inter-centre reproducibility. Athletes had greater vortex area, intensity, and KED compared to healthy subjects while they had smaller vortex length and depth and greater KED compared to patients with heart failure and reduced LV ejection fraction. In comparison with healthy subjects, heart failure patients showed greater vortex area, length, depth, and intensity but smaller KED. Combining vortex flow measures, the LV flow profile of healthy individuals, athletes, and heart failure patients could be differentiated. Conclusions HyperDoppler is a new ultrasound technique which is feasible, reliable, and practical for assessment of LV flow dynamics. It can quantitate several measures of the LV vortex and may distinguish normal subjects and patients. Future studies are needed to clarify how to implement this technique in cardiology clinical practice.

733 Evaluation of pulmonary pressures in patients underwent to MitraClip

Abstract Mitral regurgitation (MR) is the second most frequent valve heart disease in Europe and its underlying mechanism primary-organic (due to disease of the mitral leaflets), or secondary-functional (where valve leaflets and chordae are structurally normal and MR results from alterations in left ventricle and left atrium geometry), determines the therapeutic approach. Transcatheter Edge-to-Edge Repair (TEER) with MitraClip implantation is a minimal-invasive treatment that according to 2021 ESC Guidelines should be considered (class indication IIa) in selected symptomatic patients with severe MR despite optimal medical therapy, not eligible for surgery and fulfilling COAPT trial inclusion criteria, suggesting an increased chance of responding to treatment. Optimal valve morphology features for TEER are central pathology (second scallop), no leaflet calcifications, mitral valve area >4 cm2, mobile length of posterior leaftel >10 mm, coaptation depth <11mm, normal leaflet strength and mobility, flail width <15 mm, flail gap <10 mm. TEER may be considered (class IIb) only in selected cases when the COAPT criteria are not fulfilled with the aim of improving symptoms and quality of life. MR occurs during systole, that at normal heart rates represents 30–50% of the cardiac cycle. As such, marked left atrial (LA) pressure elevation is present only transiently, representing less of a drive to development of secondary pulmonary hypertension compared to chronic LA pressure elevation seen in severe mitral stenosis. Anyway, in patients with severe MR echocardiography often reveals elevated systolic pulmonary artery pressure (PAPs) and MitraClip implantation usually is associated with a slight increase of the trans-mitral gradient with possible repercussions on pulmonary pressures. To better describe the effect of MitraClip implantation on pulmonary pressures and clinical outcomes we did a retrospective study enrolling in the period 2012–2021 25 patients with severe mitral regurgitation treated with TEER. We aimed to evaluate the clinical outcomes (symptoms, signs of heart failure, NYHA functional class) and the pulmonary pressures assessed by an echocardiographic examination before and after the intervention. At 6-month follow-up all patients with repaired mitral regurgitation showed an improvement in the NYHA class (from IV to II) and no need for re-hospitalization. We observed a trend in the reduction of the mean sistolic pulmonary arterial pressure of 2.68 mmHg ± 15 mmHg (P 0.39, 95% C.I. −9.03 to 3.67) with an unchanged left ventricle ejection fraction. Moreover, the echocardiographic exam showed a normalization of the S and D waves pattern in the pulmonary veins at the PW Doppler evaluation. We can assume that the clinical improvement and the reduction of dyspnoea in these patients underwent TEER is related to a reduction of pressures in the pulmonary circulation regardless of the ejection fraction. This finding could be used as a tool that the cardiologist has to evaluate in the echocardiography lab to reveal a new mitral valve disfunction. Considering the small sample, a greater number of patients will be enrolled to highlight the statistical significance.

Fragmented QRS and blood pressure pattern in normotensive individuals with a history of preeclampsia

Background/Aim: Hypertension is well defined in preeclamptic individuals and those with a history of preeclampsia. However, the relationship between blood pressure pattern and fragmented QRS on electrocardiography (ECG) has not been elucidated in normotensive patients with a history of preeclampsia. This study aimed to investigate the frequency of non-dipper blood pressure (BP) patterns in normotensive individuals with a history of preeclampsia and to evaluate the relevance of this pattern to fragmented QRS (fQRS). Methods: Sixty-three normotensive (office BP measurement) patients with a history of preeclampsia were included in this study between August 2020 and January 2021. These individuals underwent 24-hour ambulatory BP monitoring. The patients were divided into two groups as dipper and non-dipper, according to their BP patterns. The two groups were compared in terms of echocardiographic parameters, laboratory values, and QRS fragmentation on ECG. Results: Left ventricular diastolic dysfunction (LVDD) diagnosed by echocardiography (P= 0.015) and fQRS on ECG (P=0.002) were significantly higher in the non-dipper group than in the dipper group. Tricuspid regurgitation velocity (P=0.004) and average E/e' ratio (P

Abstract 9362: A Quality Improvement Project to Optimize TEE Orders and Reduce Hospitalization Cost at a Large Volume Academic Hospital

Introduction: Appropriate use criteria (AUC) for indication of transesophageal echocardiography (TEE) were revised in 2011. Aim: To evaluate the appropriateness of TEEs ordered at Ochsner LSU Health Shreveport based on 2011 AUC guidelines and take necessary steps to optimize the TEE workflow and reduce hospitalization cost. Method: A retrospective analysis of the TEE case requests received by the echocardiography lab at Ochsner LSU Health Shreveport between March 1, 2020 and August 31, 2020 was carried out. Each TEE case request was classified as appropriate (A), inappropriate (I) or uncertain (U) based on the 2011 AUC guideline. TEE case requests were divided based on the ordering specialty as well as indications. Result: Among the total 372 case requests for TEE,189 (50.80%) were ordered by cardiologists and 183 (49.20%) were ordered by non-cardiologists. Out of the 189 orders by cardiologists, 184 (97.35%) were appropriate and 5 (2.65%) were inappropriate. Cardiologists ordered 123 TEEs for Atrial fibrillation/flutter evaluation/management, 33 for valvular evaluation, 10 for evaluation of mass/vegetation, 3 for atrial mass evaluation, 10 for CVA workup and 10 for other reasons. Among the total 183 TEE orders placed by non-cardiologists, 125 (68.31%) were appropriate and 58 (31.69%) were inappropriate. Specialty-wise, Neurology placed 78 TEE orders (54-A, 24-I), Hospital Medicine placed 59 orders (38-A, 21-I) while other specialties placed 46 orders (33-A, 13-I). Most common indications for TEE requests by non-cardiologists were for CVA workup (62-A, 30-I) and infective endocarditis workup (21-A, 13-I). Conclusion: 83% of all the TEE orders (309 out of 372) were appropriate. 97% (184 from 189) of the TEE orders by cardiologists were appropriate compared to 68% (125 from 183) orders by non-cardiologists. Following this result, medical providers were educated about the correct indications of TEE by educational presentation as well as distributing posters and pocket cards. Plan is to also evaluate the appropriateness of TEE orders post intervention phase. We believe that educating the physician providers can optimize the appropriate TEE requests, avoid unnecessary invasive procedures and reduce the hospitalization cost.

Abstract 13253: Prevalence of Preclinical Cardiomyopathy in Patients With Type 2 Diabetes With No Apparent Cardiovascular Involvement

Background: Hyperglycemia is associated with changes in cardiac structure and function, increased atherosclerosis and diabetic cardiomyopathy (1,2). Currently there is scarcity of robust large scale studies evaluating prevalence of asymptomatic left ventricular dysfunction and/or pre-clinical Heart Failure (HF) in patients with T2DM, particularly in India. Therefore, this study was conducted to determine prevalence of pre-clinical cardiomyopathy in Indian patients with T2DM. Methodology: Cross sectional, multi-center study was conducted in India. Institutional ethics committee had approved study protocol. Patients aged ≥ 18 years, T2DM with duration of ≥1 year and willing to provide informed consent were included. Patients with coronary artery or valvular disease, previously diagnosed with HF stage III/IV, chronic kidney disease, peripheral artery disease, arrhythmias, diabetes other than T2DM or currently under treatment with digoxin or loop diuretics were excluded. Two-dimensional echocardiography and natriuretic peptide estimation were conducted. Results: This is an interim analysis of 569 patients. Mean HbA1c was 8.3%. Total subjects with LVD were 52% (95% CI 0.48,0.56). Diastolic dysfunction was 20% (95% CI 0.17,0.24) and systolic dysfunction was 42% (95% CI 0.38,0.46) (Table 1). Prevalence of HF according to BNP levels >105 pg/ml was 9% (95% CI 0.07,0.11). Correlation analysis between HbA1c and prevalence of LVD was statistically significant for systolic LVD, while it was not statistically significant for diastolic LVD. Patients in the age group of 51 to 60 were more vulnerable to LVD at 35% (95% CI 0.30,0.41). Conclusion: Using suitable echocardiographic indexes and laboratory investigations LVD is detectable in almost half of the T2DM patients and has a direct correlation with older age and HbA1c. Thus, we conclude that HF goes undetected and early intervention to diagnose and treat LVD can improve outcome.

Quality improvement initiative in paediatric echocardiography laboratory in a low- to middle-income country.

To determine the impact of a quality improvement (QI) initiative in the area of paediatric echocardiography (echo) in a low- to middle-income country (LMIC).Care for patients with congenital heart disease is challenging, especially in LMICs. Collaborative learning through QI projects is imperative to ensure improvement in delivery processes leading to better patient outcomes. This QI initiative was taken by a team consisting of physicians and sonographers. Problems were identified, a key driver diagram (KDD) was created, and simple process re-engineering was done using interventions based on the KDD. Metrics (five process and one outcome) were assessed to determine the effectiveness of the QI project. The process metrics assessed were comprehensiveness of exam, timeliness of reporting, diagnostic accuracy and error, and sedation adverse event rates of transthoracic echocardiograms, while a novel comprehensive echo laboratory (lab) quality score was developed as an outcome metric. Data were collected quarterly and analysed in the post-implementation phase. Significant improvement was seen in comprehensive mean score (20.4-29.7), timeliness (40-95%), and diagnostic accuracy rate (91-100%), while a decrease was seen in the diagnostic error rate (7.5-3.5%) and the sedation adverse event rate (6.8-0%), pre- vs. post-implementation. The overall quality outcome score improved from 7 to 19 and the echo lab was able to achieve adequate quality. This QI initiative produced improvement in all the processes, and the overall quality of the echo lab without any substantial increase in resources or cost.

Predictors of Ascending Aorta Enlargement and Valvular Dysfunction Progression in Patients with Bicuspid Aortic Valve.

Bicuspid aortic valve (BAV) patients are at high risk of developing progressive aortic valve dysfunction and ascending aorta dilation. However, the progression of the disease is not well defined. We aimed to assess mid-long-term aorta dilation and valve dysfunction progression and their predictors. Patients were referred from cardiac outpatient clinics to the echocardiographic laboratories of 10 tertiary hospitals and followed clinically and by echocardiography for >5 years. Seven hundred and eighteen patients with BAV (median age 47.8 years [IQR 33–62], 69.2% male) were recruited. BAV without raphe was observed in 11.3%. After a median follow-up of 7.2 years [IQR5–8], mean aortic root growth rate was 0.23 ± 0.15 mm/year. On multivariate analysis, rapid aortic root dilation (>0.35 mm/year) was associated with male sex, hypertension, presence of raphe and aortic regurgitation. Annual ascending aorta growth rate was 0.43 ± 0.32 mm/year. Rapid ascending aorta dilation was related only to hypertension. Variables associated with aortic stenosis and regurgitation progression, adjusted by follow-up time, were presence of raphe, hypertension and dyslipidemia and basal valvular dysfunction, respectively. Intrinsic BAV characteristics and cardiovascular risk factors were associated with aorta dilation and valvular dysfunction progression, taking into account the inherent limitations of our study-design. Strict and early control of cardiovascular risk factors is mandatory in BAV patients.

Impact of cardio-oncology strategies in the management of breast cancer patients

Abstract Background Cardio-oncology has arisen as one of the most rapidly expanding fields of cardiovascular medicine. The accumulated evidence on the possibilities of early diagnosis of cardiotoxicity provided by imaging techniques as well as on the benefits of preventive and therapeutic interventions is also increasing. Objective This study reported our echocardiography lab's initial experience of a cardio-oncology follow-up program. Methods We prospectively studied the outcomes of 107 patients diagnosed with breast cancer who attended our follow-up program between 2017 and 2020. An echocardiographic monitoring were realised according to the chemotherapy protocol. Cancer therapy-related cardiac dysfunction (CTRCD) is defined, according to the european society of cardiology (ESC) guidelines of 2016, as a drop of left ventricular ejection fraction (LVEF) by >10 percentage points from baseline to a value <50%. A new entity named subclinical systolic dysfunction, is defined by a drop of global longitudinal strain (GLS) by >15% from baseline, however, LVEF remains >50%. The diagnosis should be confirmed by a second echocardiogram after 2–3 weeks. Results We enrolled 107 patients diagnosed with breast cancer and receiving anthracycline and/or trastuzumab. 27 patients were excluded for many reasons: 17 patients were lost to follow-up, 10 patients had an inadequate echo-imaging (8 had a follow-up without measurement of GLS and 2 patients were poorly echogenic). Only eighty patients were finally retained. The average age of our patients was 49.9±10.8 years. The mean left ventricular ejection fraction (LVEF) was at 64±4.4%. The incidence of CTRCD was 6%. the mean delay of diagnosis from the onset of chemotherapy was 174 days. It was reversible in 60% of cases after the initiation of a cardioprotective treatment which allowed the anti-cancer treatment pursuit. The incidence of subclinical cardiac dysfunction was 25%. The mean delay between the initiation of anti-cancer treatment and the diagnosis was 314.5 days. A cardioprotective treatment with Bblockers and angiotensin-converting enzyme (ACE) inhibitors was prescribed and all these patients recovered a normal GLS with a mean delay of three months and pursuied their chemotherapy. Conclusion We showed that timely cardiovascular evaluation, intervention and close monitoring in the context of a structured service allowed the majority of patients (99%) to pursue their anti-cancer treatment and to avoid the evolution to CTRCD in patients diagnosed with subclinical cardiac dysfunction. Funding Acknowledgement Type of funding sources: None. Treated subclinical cardiac dysfunction

Editorial introductions.

Editorial introductions.

2011 appropriate use criteria audit of an echocardiography lab in South Western Nigeria

Cardiovascular diseases are the major cause of death worldwide. Since its discovery in the 20th century, Echocardiography (ECHO) has become one of the pivotal tools in assessing cardiac structure and function. With the increase in requests for ECHO, there has risen an unwanted problem - inappropriate requests for ECHO. There has therefore arisen the need to audit ECHO labs for the appropriateness of ECHO requests. The patients referred from the outpatient clinics and in-patient wards for ECHO from June 1st, 2015 till September 30th, 2016 were recruited. Their request form data, clinical information, and ECHO results were analyzed as appropriate. The 2011 appropriate use criteria for Transthoracic ECHO was utilized. The most common indication out of the 2174 ECHOs reviewed was hypertension (16%), closely followed by hypertensive heart disease (12.4%). The percentage of appropriate, inappropriate, and uncertain indications according to the 2011 appropriate use criteria (AUC) for transthoracic echocardiography were 41.4%, 31.1%, and 0.1% respectively. Less than ten percent (9.3%) of the indications could not be classified by the 2011 AUC while 18.1% of the ECHOs had no indication. When indications of Hypertension, Hypertensive Heart Disease (HHD) and heart failure were compared, heart failure was significantly associated with eccentric Left Ventricular Hypertrophy (LVH), larger LV mass, lower BMI, larger cardiac dimensions, reduced ejection fraction, lower trans mitral A velocities than the other two indications. Concentric LVH was showed a trend towards being most in those with HHD (p= 0.072). The percentage of appropriate indications was low in this study as compared to others, largely because of large inappropriate indications. There is a need to ensure appropriate indications are filled for ECHO request forms. The 2011 AUC may need to be reviewed to expand the appropriate group of indications.

Detecting jellyfish sign in a patient with systemic lupus erythematosus: An added value of the echocardiography

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects nearly every organ of the body. Cardiopulmonary manifestations are common in SLE, almost in the form of serositis, and include pleural and pericardial effusions. In these patients, echocardiography is an excellent non-invasive tool for detecting pericardial effusion and may provide a hint about pleural effusion. We report the case of a 20-year-old woman with SLE who had been experiencing dyspnea for 1 month and had no prior history of cardiovascular or pulmonary disease. A rheumatologist referred her to our echocardiography lab for a cardiac evaluation. In the echocardiographic examination, pleural mass depended from the left visceral pleura was discovered, surrounded by massive pleural effusion that induced left lung atelectasis (Jellyfish sign, and complete atelectasis of a lung lobe floats above a massive pleural effusion).

Features and behavior of valvular abnormalities in adolescent and adult patients in mucopolysaccharidosis: an echocardiographic study.

Mucopolysaccharidoses, a rare inherited disorder of lysosomal storage, account for less than 0.1% of all genetic diseases. The penetrance is highly variable and clinically it varies from severe fetal-neonatal forms to attenuated diseases diagnosed in adult individuals. The majority of the patients have been reported to show cardiac abnormalities since pediatric age, however, there is a minority of patients with attenuated disease diagnosed in the adolescent and adult age. The haematopoietic stem cell transplantation and enzyme replacement therapy are the current therapies for these disorders. Thanks to these treatments, Mucopolysaccharidoses patients live longer than in the past. Even though enzyme replacement therapy has been demonstrated to reduce left ventricular mass in patients with cardiomyopathy, the efficacy on valve abnormalities has not been clearly demonstrate yet. Furthermore, thanks to the current therapy, to better understanding and to the advent on new technologies, an increasing number of adolescent and adult patients diagnosed with MPS are followed up in the adult echocardiographic laboratory. Indeed, a systematic descriptive study describing the echocardiographic features of valvular involvement and their evolution in adolescent and adult patients lacks of medical literature and this was the aim of our investigation. Our results showed that all the valves are affected, mainly the mitral valve with a higher prevalence compared to the pediatric age. The echocardiographic features of MPS differs from other valvular disease of adolescent and adult age, and knowing them can avoid misdiagnosis. Our observations also suggest that the progression of cardiac involvement slows after the initiation of the therapy in our group of age. Further studies on larger population are required to confirm our results.

Reshaping of Italian Echocardiographic Laboratories Activities during the Second Wave of COVID-19 Pandemic and Expectations for the Post-Pandemic Era.

Background: Cardiology divisions reshaped their activities during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to analyze the organization of echocardiographic laboratories and echocardiography practice during the second wave of the COVID-19 pandemic in Italy, and the expectations for the post-COVID era. Methods: We analyzed two different time periods: the month of November during the second wave of the COVID-19 pandemic (2020) and the identical month during 2019 (November 2019). Results: During the second wave of the COVID-19 pandemic, the hospital activity was partially reduced in 42 (60%) and wholly interrupted in 3 (4%) echocardiographic laboratories, whereas outpatient echocardiographic activity was partially reduced in 41 (59%) and completely interrupted in 7 (10%) laboratories. We observed an important change in the organization of activities in the echocardiography laboratory which reduced the operator-risk and improved self-protection of operators by using appropriate personal protection equipment. Operators wore FFP2 in 58 centers (83%) during trans-thoracic echocardiography (TTE), in 65 centers (93%) during transesophageal echocardiography (TEE) and 63 centers (90%) during stress echocardiography. The second wave caused a significant reduction in number of echocardiographic exams, compared to November 2019 (from 513 ± 539 to 341 ± 299 exams per center, −34%, p < 0.001). On average, there was a significant increase in the outpatient waiting list for elective echocardiographic exams (from 32.0 ± 28.1 to 45.5 ± 44.9 days, +41%, p < 0.001), with a reduction of in-hospital waiting list (2.9 ± 2.4 to 2.4 ± 2.0 days, −17%, p < 0.001). We observed a large diffusion of point-of-care cardiac ultrasound (88%), with a significant increase of lung ultrasound usage in 30 centers (43%) during 2019, extended to all centers in 2020. Carbon dioxide production by examination is an indicator of the environmental impact of technology (100-fold less with echocardiography compared to other cardiac imaging techniques). It was ignored in 2019 by 100% of centers, and currently it is considered potentially crucial for decision-making in cardiac imaging by 65 centers (93%). Conclusions: In one year, major changes occurred in echocardiography practice and culture. The examination structure changed with extensive usage of point-of-care cardiac ultrasound and with lung ultrasound embedded by default in the TTE examination, as well as the COVID-19 testing.

Prognostic Value of Minimal Left Atrial Volume in Heart Failure With Preserved Ejection Fraction.

BackgroundMaximal left atrial (LA) volume is reported by most echocardiography laboratories and is associated with clinical outcomes in patients with heart failure (HF). Recent studies suggest that minimal LA volume may better reflect left ventricular filling pressure and may be more prognostic than maximal LA volume. This study assessed the prognostic value of indexed minimal LA volume (LAVImin) in patients with HF with preserved ejection fraction.Methods and ResultsWe assessed the relationship of LAVImin with a primary composite end point of cardiovascular death, aborted cardiac death, or HF hospitalization in 347 patients with HF with preserved ejection fraction enrolled from the Americas region in TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial). We compared LAVImin with indexed maximal LA volume with respect to their prognostic values. In addition, we assessed if LA functional parameters provide additional prognostic information over LAVImin. During a median follow‐up of 2.5 years, 107 patients (31%) experienced a primary composite end point. LAVImin was associated with increased risk of a primary composite outcome (hazard ratio [HR], 1.35; 95% CI, 1.12–1.61) and HF hospitalization alone (HR, 1.42; 95% CI, 1.17–1.71) after adjusting for clinical confounders and ejection fraction. In contrast, indexed maximal LA volume was not related to the primary composite outcome, but related to HF alone (HR, 1.25; 95% CI, 1.02–1.54). In comparison with indexed maximal LA volume, LAVImin was significantly more prognostic for primary composite outcome (P for comparison=0.032). Both LA emptying fraction and LA strain were prognostic of primary outcome independent of LAVImin (all P<0.05).ConclusionsIn patients with HF with preserved ejection fraction, LAVImin was more predictive of cardiovascular outcome than indexed maximal LA volume, suggesting this measure may be more physiologically relevant and might better identify patients at high risk for cardiovascular events. LA functional parameters provide prognostic information independent of LAVImin.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT00094302.

Central and Branch Retinal Artery Occlusion-Do They Harbor the Same Risk of Further Ischemic Events?

Purpose: Retinal artery occlusion (RAO) is associated with an increased risk of cardiovascular events such as ischemic stroke and myocardial infarction, but whether different RAO subtypes such as central retinal artery occlusion (CRAO) or branch retinal artery occlusion (BRAO) carry similar risk of these events is unclear. Our aim was to determine whether the risk of cardiovascular events differs between CRAO and BRAO. Methods: This single-center, retrospective study included 131 patients hospitalized in our clinic in 2010–2020 with CRAO or BRAO confirmed by ophthalmic examination. Data on demographics, previous ischemic stroke and myocardial infarction, comorbidities, the results of echocardiographic and ultrasound carotid artery examinations and laboratory tests were assessed. Data on ischemic stroke, myocardial infarction, and all-cause mortality occurring after RAO were obtained from the Polish National Health Service, which collects data on all publicly funded hospitalizations. Using these data, Kaplan-Meier analyses and Cox proportional hazard regression were performed. Results: Ischemic stroke occurred in 9.9% of patients after RAO: 10.6% in the CRAO group and 8.1% in the BRAO group (p = 0.662). Myocardial infarction occurred in 2.3% of patients after RAO: 2.1% in the CRAO group and 2.7% in the BRAO group (p = 0.843). All-cause mortality occurred in 22.9% of patients after RAO: 25.5% in the CRAO group and 16.2% in the BRAO group (p = 0.253). The composite endpoint of ischemic stroke, myocardial infarction, and all-cause mortality after RAO occurred in 28.2% of patients: 30.9% in the CRAO group and 21.6% in the BRAO group (p = 0.338). There was no difference between CRAO and BRAO in median time to ischemic stroke (32 vs. 76.4 months; p = 0.352), all-cause mortality (35.9 vs. 36.3 months; p = 0.876) or composite endpoint (37.5 vs. 41.5 months; p = 0.912) after RAO. The Kaplan-Meier analysis showed no differences between CRAO and BRAO in ischemic stroke, myocardial infarction, all-cause mortality, or the composite endpoint; similar results were obtained in analyses of patients with and without cardiovascular events before RAO. Conclusions: The prognosis for ischemic stroke, myocardial infarction, and all-cause mortality is similar in patients with CRAO and BRAO. Ischemic strokes occur with a similar frequency before and after RAO. Myocardial infarctions are observed significantly more frequently before an episode of RAO than after. The results of our study indicate that both CRAO and BRAO require expanded diagnostics to assess the risk of recurrent cardiovascular events, especially ischemic strokes, to implement appropriate prophylaxis and reduce mortality.

Prenatal sonography of the foramen ovale predicts urgent balloon atrial septostomy in neonates with complete transposition of the great arteries

Hypoxia caused by inadequate intracardiac mixing owing to a restrictive foramen ovale is a potentially life-threatening complication in neonates with dextro-transposition of the great arteries. An urgent balloon atrial septostomy is a procedure of choice in such cases, but dependent on the availability of a 24-hour interventional cardiology facility. The prenatal identification of predictors for an urgent balloon atrial septostomy at birth would help in optimizing the management of these neonates, minimizing the risk of hypoxic damage. This study aimed to predict with prenatal echocardiography the need of urgent balloon atrial septostomy in neonates with dextro-transposition of the great arteries. This was a retrospective cohort study of patients with a prenatal diagnosis of transposition of the great arteries that were delivered in our center between 2010 and 2019, for whom fetal ultrasound echocardiograms obtained at less than 3 weeks before delivery were available. The following parameters were systematically obtained at fetal echocardiography: size and appearance of the foramen ovale, septum primum excursion (foramen ovale flap angle at the maximal excursion), diameters of the atria, and size of the ductus arteriosus. Balloon atrial septostomy was defined as urgent if performed within 12 hours from birth in neonates with restrictive foramen ovale. Neonatal follow-up was obtained through medical records analysis. From November 2007 to April 2019, 160 fetuses with complete transposition of the great arteries were referred to our echocardiography laboratory and 60 of these were included in the analysis; 27 underwent urgent balloon atrial septostomy, 11 elective balloon atrial septostomy, and 22 no balloon atrial septostomy. The size of the foramen ovale was the best predictor of an urgent balloon atrial septostomy. A measurement of >6.5 mm had a sensitivity of 100% and a false positive rate of 45%. Fetal echocardiography predicts the need of an urgent balloon atrial septostomy in fetuses with dextro-transposition of the great arteries although with a limited precision. In our experience, a measurement of the foramen ovale within 3 weeks of delivery had the greatest accuracy.

Higher Copeptin Levels are Associated with the Risk of Atrial Fibrillation in Patients with Rheumatic Mitral Stenosis.

Correlations between increased copeptin levels and various cardiovascular diseases have been described. In this study, we aimed to investigate the correlation between increased copeptin levels and paroxysmal atrial fibrillation (PAF) in rheumatic mitral stenosis (MS). Patients with mild/moderate rheumatic MS and sinus rhythm were consecutively recruited from an echocardiography laboratory. Patients with a history of PAF and those with PAF on 24-48-hour ambulatory electrocardiography (ECG) monitoring constituted the study group, and those without PAF on ambulatory ECG monitoring constituted the control group. Clinical characteristics, echocardiographic parameters and levels of copeptin, plasma N-terminal proBNP (NT-proBNP) and high-sensitivity C-reactive protein (hs-CRP) were evaluated. Twenty-nine patients with PAF and 124 control MS patients were studied. Patients in the PAF group were older, but the mitral valve areas and transmitral gradients were not different between the groups. In the PAF group, hs-CRP (1.2 vs. 0.8 mg/L, p < 0.001), NT-proBNP (335 vs. 115 pg/mL, p < 0.001) and copeptin (6.9 vs. 4.0 pmol/L, p < 0.001) levels were significantly higher than in the control group. Multivariable logistic regression analysis revealed that age [odds ratio (OR) 1.19, 95% confidence interval (CI) 1.04-1.38; p = 0.024], left atrial volume index (OR 1.23, 95% CI 1.06-1.41; p = 0.032), copeptin levels (OR 2.81, 95% CI 1.30-5.29; p < 0.001) and hs-CRP levels (OR 15.5, 95% CI 1.41-71.5; p = 0.012) were independent predictors of PAF. In patients with mild/moderate rheumatic MS, higher copeptin and hs-CRP levels predicted a higher risk of developing atrial fibrillation.

2-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study.

This study reports 2-year outcomes from the multicenter, prospective, single-arm CLASP study with functional mitral regurgitation (FMR) and degenerative MR (DMR) analysis. Transcatheter repair is a favorable option to treat MR. Long-term prognostic impact of the PASCAL transcatheter valve repair system in patients with clinically significant MR remains to be established. Patients had clinically significant MR≥3+ as evaluated by the echocardiographic core laboratory and were deemed candidates for transcatheter repair by the heart team. Assessments were performed by clinical events committee to 1 year (site-reported thereafter) and core laboratory to 2 years. A total of 124 patients (69% FMR, 31% DMR) were enrolled with a mean age of 75 years, 56% were male, 60% were New York Heart Association functional class III to IVa, and 100% had MR≥3+. At 2 years, Kaplan-Meier estimates showed 80% survival (72% FMR, 94% DMR) and 84% freedom from heart failure (HF) hospitalization (78% FMR, 97% DMR), with 85% reduction in annualized HF hospitalization rate (81% FMR, 98% DMR). MR≤1+ was achieved in 78% of patients (84% FMR, 71% DMR) and MR≤2+ was achieved in 97% (95% FMR, 100% DMR) (all p<0.001). Left ventricular end-diastolic volume decreased by 33ml (p<0.001); 93% of patients were in New York Heart Association functional class I to II (p<0.001). The PASCAL repair system demonstrated sustained favorable outcomes at 2 years in FMR and DMR patients. Results showed high survival and freedom from HF rehospitalization rates with a significantly reduced annualized HF hospitalization rate. Durable MR reduction was achieved with evidence of left ventricular reverse remodeling and significant improvement in functional status. The CLASP IID/IIF randomized pivotal trial is ongoing.

Left Atrial Volume as A Parameter of The Ventricular Function in Patient with Non-Valvular Atrial Fibrillation

Background: Remodeling of the left atrium (LA)is a reflection of chronicity of the underlying, often occult cardiovascular disease. The presence of left atrial enlargement indicates clinically significant risk of adverse cardiovascular consequences for the patient. Left atrial volume provides a more sensitive assessment of left atrial enlargement, which is an important predictor of AF, providing incremental information beyond that afforded by the clinical risk factors and conventional M mode LA dimension. Objective: Assessment of left atrial volume as a parameter of ventricular function in patients with non-valvular atrial fibrillation. Patients and methods: The study was conducted on convenient sample of 50 patients with non-valvular AF and 50 normal control group who presented to Damietta Cardiology Center Outpatient Echocardiography Laboratory for a resting transthoracic study.The eligible patients were adults aged from 26 to 67 years, who had no history of pacemaker implantation, valvular heart disease (except mild degree), congenital heart disease and ischemic or dilated cardiomyopathy. Results: our study revealed that there was a strong direct significant graded relationship between the severity of diastolic dysfunction and left atrial volume index (LAVI) in patients of non-valvular AF. There was limited significance regarding Tei index and global longitudinal strain (GLS). Therefore, LAVI can be considered a sensitive and specific echocardiographic indicator for left ventricular diastolic dysfunction. We can consider LAVI the A1c of the heart. Conclusion: Diastolic dysfunction in non-valvular AF patient can be assessed using LAVI with limited significance of Tei index and GLS. Regarding systolic function in those patients, it can be assessed using GLS as it is considered sensitive index of early systolic dysfunction.