Right Ventricular Strain Research Articles

Assessment of CMR Feature-Tracking Age- and Sex-Dependent Right Ventricular Strain in a Healthy Caucasian Cohort.

Right ventricular (RV) strain offers crucial diagnostic insights in cardiovascular and pulmonary disorders. Nonetheless, the absence of established reference values impedes its clinical implementation. Utilizing CMR-feature tracking, age- and gender-dependent RV strains were systematically assessed in 175 heart-healthy Caucasians, 97 females, median 32.5years. RV global longitudinal strain (GLS) was greater in females than males (median -26.8% (-28.3;-24.1) vs. -24.4 ± 3.0%; p < 0.001), whereby radial and circumferential strain remained comparable. Age subgroups exhibited increased RV-GLS for group B (30-50years) (-26.0 ± 3.1% vs. -24.4 ± 3.2%; p = 0.011) and group C (> 50years) (-26.7 ± 2.3% vs. -24.4 ± 3.2%; p < 0.001) compared to group A (< 30years). High intra-class correlation coefficients (ICC) were exhibited by intrarater variability (ICC = 0.86-0.95) and moderate levels for interrater variability (ICC = 0.50-0.73). CMR-feature tracking provides a fair quantification method of age- and gender-specific normal RV strain values, demonstrating that higher RV-GLS is linked to female gender and advancing age within a healthy Caucasian cohort.

Right ventricular dyssynchrony predicts outcome in pulmonary arterial hypertension when assessed in multiple CMR views

BackgroundRight ventricular (RV) dyssynchrony or post systolic contraction (PSC) cause inefficient pumping and have not been investigated as prognostic markers in pulmonary arterial hypertension (PAH). ObjectivesTo investigate if RV dyssynchrony and PSC are prognostic markers of transplantation-free survival in PAH and if multiple RV views improve the prognostication. MethodsPatients with PAH undergoing cardiac magnetic resonance (CMR) between 2003-2021 were included. For strain analysis, endocardial end-diastolic RV contours were delineated in RV 3-chamber (RV3ch), 4-chamber (4ch) and midventricular short axis slice (SAX). RV dyssynchrony was defined as standard deviation of time to peak strain in the walls from one (4ch), two (4ch and SAX) or three views (4ch, SAX and RV3ch). PSC was defined as peak strain occurring after pulmonary valve closure. Outcome was defined as death or lung transplantation. ResultsOne hundred-one patients (58±19 years, 66% women) were included. Median follow-up was 37 [51] months. There were 60 events (55 deaths and 5 lung transplantations). Outcome was associated with RV dyssynchrony from three views and with RV strain in 4ch. An increase of RV dyssynchrony - from 3 views - by 1% was associated with a 10% increased risk of lung transplantation or death. There was no association between outcome and RV dyssynchrony in one or two views nor with PSC. ConclusionRight ventricular dyssynchrony from three views were associated with outcome in PAH, whereas assessing dyssynchrony from one or two views and PSC were not. This implies that assessment of multiple instead of single RV views potentially could be used for prognostication in PAH.

Right Ventricular Strain With 4-Dimensional Computed Tomography Identifies Pulmonary Hypertension in Adults With Repaired Tetralogy of Fallot.

This study evaluated right ventricular (RV) volume, strain, and morphology using cardiac 4-dimensional computed tomography (4D-CT) to detect pulmonary hypertension (PH) in adults with repaired tetralogy of Fallot (TOF) scheduled for transcatheter pulmonary valve implantation (TPVI). Using cardiac 4D-CT data, we calculated RV strain in 3 different geometries and RV outflow tract (RVOT) mass in 42 patients with repaired TOF. We compared RV strain and RVOT mass between patients with and without PH. Receiver operating characteristic (ROC) analysis was conducted to evaluate the diagnostic performance of these measurements for identifying PH. Four-chamber (4ch) strain was significantly smaller for patients with (n=10) than without (n=32) PH (8.8±1.7% vs. 11.1±2.4%, respectively; P<0.01), whereas RVOT mass was significantly larger in the PH group (12.5±3.5 vs. 9.2±3.2 cm2; P<0.01). ROC analysis of the diagnostic performance revealed that the respective sensitivity and specificity was 70% and 84% (area under the curve [AUC]=0.784) for 4ch strain of 8.8%; 80% and 69% (AUC=0.766) for RVOT mass of 10.7 cm2; and 80% and 81% (AUC=0.844) for a 4ch strain/RVOT mass ratio of 0.97. RVOT mass and 4ch strain obtained from cardiac 4D-CT may be helpful for identifying PH in patients with repaired TOF.

Invasive Mechanical Ventilation Is Associated with Worse Right Ventricular Strain in Acute Respiratory Failure Patients.

Right ventricular (RV) dysfunction is associated with poor prognosis in acute respiratory failure (ARF). Our study evaluates the efficacy of RV strain in detecting RV dysfunction in ARF patients requiring invasive mechanical ventilation (IMV) compared to tricuspid annular plane systolic excursion (TAPSE). In this retrospective study involving 376 patients diagnosed with ARF and requiring IMV, we extracted clinical and outcome data from patient records. RV global longitudinal strain (RVGLS), free wall longitudinal strain (FWLS), and TAPSE were measured retrospectively using speckle tracking echocardiography (STE) and traditional echocardiography, respectively. We divided the cohort into three groups: TTE during IMV (TTE-IMV, 223 patients), before IMV (TTE-bIMV, 68 patients), and after IMV (TTE-aIMV, 85 patients). Multivariable regression analysis, adjusted for covariates, revealed significantly higher RVGLS and FWLS in the groups not on IMV at the time of TTE compared to the TTE-IMV group. Specifically, the TTE-bIMV group showed higher RVGLS (β = 7.28, 95% CI 5.07, 9.48) and FWLS (β = 5.83, 95% CI 3.36, 8.31), while the TTE-aIMV group exhibited higher RVGLS (β = 9.39, 95% CI 6.10, 12.69) and FWLS (β = 7.54, 95% CI 4.83, 10.24). TAPSE did not reveal any significant differences across the groups. Our study suggests an association between IMV and lower RVGLS and FWLS in ARF patients, indicating that IMV itself may contribute to RV dysfunction. RVGLS and FWLS appear to be more sensitive than TAPSE in detecting changes in RV function that were previously subclinical in patients on IMV. Prospective studies with TTE before, during, and after IMV are necessary to assess the primary driver of RV dysfunction and to prognosticate STE-detected RV dysfunction in this population.

Assessment of right ventricular systolic function using speckle tracking strain imaging in patients with severe tricuspid regurgitation: a validation study with cardiac magnetic resonance

BackgroundRight ventricular (RV) systolic dysfunction is an established prognostic factor in patients with severe tricuspid regurgitation (TR). However, accurate assessment of RV systolic function using conventional echocardiography remains challenging. We investigated the accuracy of strain measurement using speckle tracking echocardiography (STE) for evaluating RV systolic function in patients with severe TR.MethodsWe included consecutive patients with severe TR who underwent echocardiography and cardiac magnetic resonance imaging (CMR) within 30 days between 2011 and 2023. Two-dimensional STE was used to measure RV free wall longitudinal strain (RVFWLS) and global longitudinal strain (RVGLS). These values were compared with the RV ejection fraction (RVEF) from CMR. RV systolic dysfunction was defined as a CMR-derived RVEF < 35%.ResultsA total of 87 patients with severe TR were identified during the study period. Among echocardiographic RV strain measurements, RVFWLS was the best correlate of CMR-derived RVEF (r = –0.37, P < 0.001), followed by RVGLS (r = –0.27, P = 0.012). Receiver operating characteristic (ROC) curve analysis revealed that RVFWLS provided better discrimination of RV systolic dysfunction, yielding an area under the ROC curve (AUC) of 0.770 (95% confidence interval [CI], 0.696–0.800) than RV fractional area change (AUC, 0.615; 95% CI, 0.500–0.859).ConclusionsIn patients with severe TR, STE-derived RVFWLS showed the best correlation with RVEF on CMR and displayed superior discrimination of RV systolic dysfunction compared with the RV fractional area change. This study suggests the potential usefulness of STE in assessing RV systolic function in this population.

Feasibility, reproducibility, and accuracy of echocardiographic right ventricular systolic function assessments in childhood cancer survivors at risk for heart failure.

We sought to assess the feasibility, reproducibility, and accuracy of conventional and newer echocardiographic measures of right ventricular (RV) systolic function in adolescent and young adult childhood cancer survivors treated with anthracyclines. Echocardiography and cardiac magnetic resonance imaging (CMR) were acquired ≤60 days apart in prospectively recruited survivors and RV functional measures were quantitated by blinded observers. Repeat quantitation was performed in a subset to evaluate reproducibility. For each echocardiographic measure, Spearman correlations with CMR measures were calculated, and values in participants with CMR RV ejection fraction (RVEF) ≥48% and RVEF <48% were compared using two sample Wilcoxon rank-sum tests. Among 58 participants, mean age was 18.2 years (range 13.1-25.2) and five participants had CMR RVEF <48%. Intra- and inter-observer coefficients of variation were 8.2%-10.1% and 10.5%-12.0% for adjusted automated strain measures, and 5.2%-8.7% and 2.7% for 3D RVEF, respectively. No echocardiographic measures were significantly correlated with CMR RVEF; only tricuspid annular plane systolic excursion was correlated with CMR RV stroke volume (r=.392, p=.003). Participants with RV dysfunction had worse automated global longitudinal strain (-20.3% vs. -23.9%, p=.007) and free wall longitudinal strain (-23.7% vs. -26.7%, p=.09). Echocardiographic strain and 3D RV function measurements were feasible and reproducible in at-risk childhood cancer survivors. Although not associated with CMR RVEF in this population with predominantly normal RV function, automated strain measurements were more abnormal in participants with RV dysfunction, suggesting potential clinical utility of these measures.

Tissue-Based Predictors of Impaired Right Ventricular Strain in Coronary Artery Disease: A Multicenter Stress Perfusion Study.

Right ventricular (RV) dysfunction is known to impact prognosis, but its determinants in coronary artery disease are poorly understood. Stress cardiac magnetic resonance (CMR) has been used to assess ischemia and infarction in relation to the left ventricle (LV); the impact of myocardial tissue properties on RV function is unknown. Vasodilator stress CMR was performed in patients with known coronary artery disease at 7 sites between May 2005 and October 2018. Myocardial infarction was identified on late gadolinium enhancement-CMR, and infarct transmurality was graded on a per-segment basis. Ischemia was assessed on stress CMR based on first-pass perfusion and localized by using segment partitions corresponding to cine and late gadolinium enhancement analyses. RV function was evaluated by CMR-feature tracking for primary analysis with a global longitudinal strain threshold of 20% used to define impaired RV strain (RVIS); secondary functional analysis via RV ejection fraction was also performed. A total of 2604 patients were studied, among whom RVIS was present in 461 patients (18%). The presence and magnitude of RVIS were strongly associated with LV dysfunction, irrespective of whether measured by LV ejection fraction or wall motion score (P<0.001 for all). Regarding tissue substrate, regions of ischemic and dysfunctional myocardium (ie, hibernating myocardium) and infarct size were each independently associated with RVIS (both P<0.001). During follow-up (median, 4.62 [interquartile range, 2.15-7.67] years), 555 deaths (21%) occurred. Kaplan-Meier analysis for patients stratified by presence and magnitude of RV dysfunction by global longitudinal strain and RV ejection fraction each demonstrated strong prognostic utility for all-cause mortality (P<0.001). RVIS conferred increased mortality risk (hazard ratio, 1.35 [95% CI, 1.11-1.66]; P=0.003) even after controlling for LV function, infarction, and ischemia. RVIS in patients with known coronary artery disease is associated with potentially reversible LV processes, including LV functional impairment due to ischemic and predominantly viable myocardium, which confers increased mortality risk independent of LV function and tissue substrate.

3D regional evaluation of right ventricular myocardial work from cineCT.

Regional myocardial work (MW) is not measured in the right ventricle (RV) due to a lack of high spatial resolution regional strain (RS) estimates throughout the ventricle. We present a cineCT-based approach to evaluate regional RV performance and demonstrate its ability to phenotype three complex populations: end-stage LV failure (HF), chronic thromboembolic pulmonary hypertension (CTEPH), and repaired tetralogy of Fallot (rTOF). 49 patients (19 HF, 11 CTEPH, 19 rTOF) underwent cineCT and right heart catheterization (RHC). RS was estimated from full-cycle ECG-gated cineCT and combined with RHC pressure waveforms to create regional pressure-strain loops; endocardial MW was measured as the loop area. Detailed, 3D mapping of RS and MW enabled spatial visualization of strain and work strength, and phenotyping of patients. HF patients demonstrated more overall impaired strain and work compared to the CTEPH and rTOF cohorts. For example, the HF patients had more akinetic areas (median: 9%) than CTEPH (median: <1%, p=0.02) and rTOF (median: 1%, p<0.01) and performed more low work (median: 69%) than the rTOF cohort (median: 38%, p<0.01). The CTEPH cohort had more impairment in the septal wall; <1% of the free wall and 16% of the septal wall performed negative work. The rTOF cohort demonstrated a wide distribution of strain and work, ranging from hypokinetic to hyperkinetic strain and low to medium-high work. Impaired strain (-0.15≤RS) and negative work were strongly-to-very strongly correlated with RVEF (R=-0.89, p<0.01; R=-0.70, p<0.01 respectively), while impaired work (MW≤5 mmHg) was moderately correlated with RVEF (R=-0.53, p<0.01). Regional RV MW maps can be derived from clinical CT and RHC studies and can provide patient-specific phenotyping of RV function in complex heart disease patients. Evaluating regional variations in right ventricular (RV) performance can be challenging, particularly in patients with significant impairments due to the need for 3D spatial coverage with high spatial resolution. ECG-gated cineCT can fully visualize the RV and be used to quantify regional strain with high spatial resolution. However, strain is influenced by loading conditions. Myocardial work (MW) - measured clinically derived as the ventricular pressure-strain loop area - is considered a more comprehensive metric due to its independence of preload and afterload. In this study, we sought to develop regional RV myocardial work (MW) assessments in 3D with high spatial resolution by combining cineCT-derived regional strain with RV pressure waveforms from right heart catheterization (RHC). We developed our method using data from three clinical cohorts who routinely undergo cineCT and RHC: patients in heart failure, patients with chronic thromboembolic pulmonary hypertension, and adults with repaired tetralogy of Fallot.We demonstrate that regional strain and work provide different perspectives on RV performance. While strain can be used to evaluate apparent function, similar profiles of RV strain can lead to different MW estimates. Specifically, MW integrates apparent strain with measures of afterload, and timing information helps to account for dyssynchrony. As a result, CT-based assessment of RV MW appears to be a useful new metric for the care of patients with dysfunction.

Right Ventricular and Right Atrial Strain Are Associated with Kidney Dysfunction in Acute Heart Failure.

In acute heart failure (HF), low cardiac output and venous congestion are pathophysiological mechanisms that contribute to renal function impairment. This study investigated the association between advanced echocardiographic measures of right ventricular and atrial function and renal impairment in patients with acute HF. A total of 377 patients hospitalized for acute HF were prospectively evaluated. Estimated glomerular filtration rate (eGFR) on admission was measured using the 2021 Chronic Kidney Disease Epidemiology Collaboration creatinine equation. Advanced echocardiographic assessment was performed on admission. Patients with eGFR < 45 mL/min/1.73 m2 were more likely to have chronic heart failure, chronic atrial fibrillation, and type 2 diabetes mellitus compared to patients with eGFR ≥ 45 mL/min/1.73 m2. Patients with lower eGFR had lower cardiac output, higher mean E/e' ratio, larger right ventricular (RV) size, worse RV free wall longitudinal strain, more impaired right atrial (RA) reservoir strain, and more frequent severe tricuspid regurgitation. RV free wall longitudinal strain and RA reservoir strain were the only independent echocardiographic associates of low eGFR, whereas cardiac output was not. Impaired RV and RA longitudinal strain were independently associated with eGFR < 45 mL/min/1.73 m2 in acute HF, while reduced cardiac output was not. This suggests that RV and RA dysfunction underlying venous congestion and increased renal afterload are more important pathophysiological determinants of renal impairment in acute HF than reduced cardiac output.

Right atrial and right ventricular strain: prognostic value depends on the severity of tricuspid regurgitation.

Assessing right heart function is challenging, particularly when significant tricuspid regurgitation (TR) is present. Among available echocardiographic techniques for assessment, literatures suggests that strain imaging may be more reliable and less susceptible to loading conditions. Thus, we aimed to assess the validity of RA and RV strain relative to conventional metrics as well as their utility in predicting patient outcomes in TR. We studied 262 consecutive patients (mean age 74 ± 11.2 years, 53% male) who underwent same-day echocardiography and right heart catheterization between 2018 and 2023. We compared right heart strain to traditional metrics of RV function and subsequently correlated RA and RV strain to heart failure (HF)-related death or hospitalization, whichever came first. Over a mean follow-up of 34 ± 15 months, there were 103 deaths and HF hospitalizations. Both RA and RV strain were correlated with echocardiographic and invasive measures of right heart function. Across all patients, preserved RA strain was associated with lower risk of adverse outcomes (HR 0.763, 95% CI 0.618-0.943). Similarly, preserved RV strain was correlated with better outcomes, though this was only statistically significant in patients without severe TR or pulmonary hypertension (HR 2.450, 95% CI 1.244-4.825). Moreover, abnormal ratios of RV strain to pulmonary pressures and RV size were significantly correlated with adverse outcomes (p < 0.05 each). RA and RV strain are independently correlated with echocardiographic and invasive measures of cardiac function. Moreover, preserved RA and RV strain are likely associated with better clinical outcomes.

Three-Dimensional Feature Tracking Study of Healthy Chinese Ventricle by Cardiac Magnetic Resonance.

Myocardial strain, as a crucial quantitative indicator of myocardial deformation, can detect the changes of cardiac function earlier than parameters such as ejection fraction (EF). It has reported that cardiac magnetic resonance(CMR) and post-processing software possess the ability to obtain the stability and repeatability strain values. Recently, the normal strain values range of people are debatable, especially in the Chinese population. Therefore, we aim to explore the ventricular characteristics and the myocardial strain values of the Chinese people by using the cardiac magnetic resonance feature tracking (CMR-FT). Additionally, we attempted to use the myocardial and chordae tendineae contours to calculate the ventricular volumes by the CMR-FT. This study may provide valuable insights into the application of CMR-FT in tracking the ventricular characteristics and myocardial strain for Chinese population, especially in suggesting an referable myocardial strain parameters of the Chinese. A total of 109 healthy Chinese individuals (age range: 18 to 58 years; 52 males and 57 females) underwent 3.0T CMR to acquire the cardiac images. The commercial post-processing software was employed to analyse the image sequence by semi-automatic processing, then the biventricular morphology (End-Diastolic Volume, EDV; EDV/Body Surface Area, EDV/BSA), function(EF; Cardiac Output, CO; Cardiac Index, CI) and strain(Radial Strain, RS; Circumferential Strain, CS; Longitudinal Strain, LS) values were obtained.The biventricular myocardial strain values were stratified according to the age and gender. The Left Ventricular( LV base, mid, apex) and myocardial strain values of three coronary artery areas were calculated based on the the strain value of LV American Heart Association(AHA) 16 segments. It was shown that the females had larger LV globe strain values compared with the males (LVGPRS: 42.0 ± 8.5 versus 33.6 ± 6.2%, P < 0.001; LVGPCS: -21.2 ± 2.1 versus - 19.7 ± 2.3%, P < 0.001; LVGPLS: -16.4 ± 2.6 versus - 14.6 ± 2.2%, P < 0.001;). Moreover, the differences in RS, CS, and LS among the LV myocardium 16 segments were obvious. However, the right ventricle (RV) strain values showed non-normal distribution in the volunteers of this research. Here, we successfully tracked the characteristics of bilateral ventricles in healthy Chinese populations through using the 3.0T CMR. We confirmed that there was a gender difference in LV Globe Strain values. In addition, we obtained strain values for each myocardial segment of the LV and different coronary artery regions based on the AHA 16 segments method, Our results also showed that the RV strain values with a non-normal distribution, and RV global strain values were not related to the gender and age. Furthermore, LVGPRS, LVGPLS, and RVGPRS were significantly correlated with BMI, CO, CI, and EDV in the Chinese population.

Risk Stratification Using Right Ventricular Longitudinal Strain Ratio Derived from 13N-Ammonia PET in Patients with Ischemic Heart Disease.

Purpose To investigate whether right ventricular (RV) myocardial strain ratio (RVMSR) assessed using nitrogen 13 ammonia (13N-NH3) PET can predict cardiovascular events in patients with ischemic heart disease (IHD). Materials and Methods This retrospective study included 480 consecutive patients (mean age, 66 years ± 12 [SD]; 334 males and 146 females) with IHD who underwent 13N-NH3 PET. RVMSR was defined as the ratio of RV strain during stress to that at rest. The primary end point was major adverse cardiac events (MACEs), defined as cardiac death or heart failure hospitalization. The ability of RVMSR to predict MACE was assessed using receiver operating characteristic (ROC) curve and Kaplan-Meier analyses. Cox proportional hazards regression analysis was used to calculate hazard ratios (HRs) with 95% CIs. Results ROC curve analysis identified a sensitivity and specificity of 84% and 82%, respectively, for predicting MACE from RVMSR. Patients with reduced RVMSR (<110.2) displayed a significantly higher rate of MACE than those with a preserved RVMSR (34 of 240 vs four of 240; P < .001). Cox proportional hazards regression analysis of imaging parameters, including myocardial flow reserve, indicated that RVMSR was an independent predictor of MACE (HR, 0.94 [95% CI: 0.92, 0.97]; P < .001). Conclusion RVMSR was an independent predictor of MACE and has potential to aid in the risk stratification of patients with IHD. Keywords: Right Ventricular Myocardial Strain Ratio, Myocardial Flow Reserve, Ischemic Heart Disease, 13N-Ammonia Positron Emission Tomography Supplemental material is available for this article. © RSNA, 2024.

The role of vascular surgery and suction thrombectomy in a community hospital's pulmonary embolism response team

IntroductionNumerous pulmonary embolism response teams (PERT) have emerged to direct management of pulmonary embolism in hospitalized patients; few of these teams consist of vascular surgeons. MethodsThis study presents a single-center retrospective review aimed at evaluating the outcomes of patients who underwent suction thrombectomy by vascular surgeons within the timeframe of 2022 to 2023. Differences in preoperative and postoperative outcomes were compared using a samples t-test for continuous data. Statistical analyses were performed using JASP Team 2022, JASP (Version 0.16.3) [Computer software]. A p value < 0.05 was considered significant. Results50 patients were assessed that underwent suction thrombectomy. The majority of patients were female (64 vs 36 %). Ages ranged from 26 to 94 and the mean was 65 years old. The majority of patients were Black or African American (62 %). The majority of patients (52 %) had moderate right heart strain (RHS) preoperatively. There were no postoperative wound infections or bleeding complications. All-cause mortality within 30 days was 2 %; procedure-related or pulmonary embolism-related mortality was 0 %. ConclusionSuction thrombectomy remains a safe option for management of pulmonary embolism; a PERT can successfully comprise vascular surgeons as the primary proceduralists.

A novel method for the evaluation of right ventricular dysfunction in acute pulmonary embolism: Myocardial work indices.

The presence of right ventricular dysfunction indicates a higher risk status in patients with pulmonary embolism (PE). The RV strain evaluated by speckle-tracking echocardiography seems to be more reliable method in the evaluation of RV dysfunction as compared to standard echocardiographic measures. In this study, we aimed to determine the value of myocardial-work indices in evaluating serial changes of RV function in acute PE. Our study comprised 83 consecutive acute PE patients who admitted to our tertiary cardiovascular hospital. Echocardiography was performed within the first 24-hours of hospitalization, and RV and LV myocardial-work parameters were obtained along with standard echocardiographic parameters. The change in the RV/LVr detected on tomography was selected as the primary outcome measure, and its' predictors were analyzed with classical linear regression and a generalized additive model (GAM). Among the LV-RV strain and myocardial work parameters, the RV global longitudinal strain (GLS) has borderline statistical significance in predicting the RV/LVr change whereas the RV global work efficiency (RV-GWE) strongly predicted RV/LVr change (p: 0.049 and <0.001, respectively). In this study, classical linear regression and GAM analyses showed that RV-GWE seems to offer a better prediction of RV/LVr change in patients with acute PE.

A CASE OF RIGHT HEART FAILURE: WHEN IT IS NOT PULMONARY EMBOLISM

Abstract A 66–year–old patient, showing exertional dyspnea and atypical chest pain, came to our attention with instrumental findings at echocardiogram of right ventricular failure and was hospitalized due to worsening signs and symptoms of right heart failure. Signs of right ventricular strain and the McGinn–White sign (S1Q3T3 pattern) were seen on the ECG, leading to the suspicion of pulmonary thromboembolism (PE). Pulmonary CT angiography confirmed bilateral PE involving the main pulmonary artery. Oral anticoagulant therapy was initiated with initial partial benefit and relief of symptoms. However, after four weeks, the patient was readmitted for severe heart failure and signs of low cardiac output. Echocardiography showed the presence of a conspicuous, mobile, isoechoic mass occupying most of the main pulmonary artery, suggesting thrombosis. The patient underwent urgent surgical thromboendoarterectomy extended to the third segmental left branches and to the second segmental right branches of the pulmonary artery; a severe pulmonary valve regurgitation was observed and therefore the valve was replaced with a Edwards–Magna pericardial bioprosthetic valve. ECMO (Extracorporeal Membrane Oxygenation) was initiated due to haemodinac instability. In the postoperative period, the severe heart failure worsened, unresponsive to pharmacological treatments and mechanical support, leading to the patient passing away in the following days. Unexpectedly, histological analysis of the surgical specimen revealed neoplastic cells with vascular/endothelial differentiation; fluorescence in situ hybridization (FISH) detected the MDM2 gene (cfr.23–F–00275), involved in the p53 protein regulation mechanisms, which is consistent with a diagnosis of angiosarcoma. Pulmonary–artery angiosarcomas are extremely rare (few anecdotical cases are described in literature) and resemble the CT–signs and clinical features of PE, seriously delaying the diagnosis. They are usually associated with a worse prognosis than PE, one and a half months survival time when inoperable. Radical surgery, associated with thirty six and a half months survival time, is often unfeasible because of locally advanced disease or metastatic disease already present at diagnosis. The main differences with PE are the more proximal and almost–occluding involvement of the pulmonary artery, the absence of peripheral vein thrombosis and the absence of response to anticoagulant therapy.

Cardiac amyloidosis is not a single disease: a multiparametric comparison between the light chain and transthyretin forms.

Systemic amyloidosis represents a heterogeneous group of diseases resulting from amyloid fibre deposition. The purpose of this study is to establish a differential diagnosis algorithm targeted towards the two most frequent subtypes of CA. We prospectively included all consecutive patients with ATTR and AL evaluated between 2018 and 2022 in two centres in a score derivation cohort and a different validation sample. All patients had a complete clinical, biomarker, electrocardiographic, and imaging evaluation. Confirmation of the final diagnosis with amyloid typing was performed according to the current international recommendations. The study population included 81 patients divided into two groups: ATTR (group 1, n=32: 28 variant and 4 wild type) and AL (group 2, n=49). ATTR patients were younger (50.7±13.9 vs. 60.2±7.3years, P=0.0001), and significantly different in terms of NT-proBNP [ATTR: 1472.5ng/L (97-4218.5) vs. AL 8024ng/L (3058-14069) P=0.001], hs-cTn I [ATTR: 10ng/L (4-20) vs. AL 78ng/L (32-240), P=0.0002], GFR [ATTR 95.4mL/min (73.8-105.3) vs. AL: 68.4mL/min (47.8-87.4) P=0.003]. At similar left ventricular (LV) wall thickness and ejection fraction, the ATTR group had less frequently pericardial effusion (ATTR: 15% vs. AL: 33% P=0.0027), better LV global longitudinal strain (ATTR: -13.1%±3.5 vs. AL: -9.1%±4.3 P=0.04), RV strain (ATTR: -21.9%±6.2 vs. AL: -16.8%±6 P=0.03) and better reservoir function of the LA strain (ATTR: 22%±12 vs. AL: 13.6%±7.8 P=0.02). Cut-off points were calculated based on the Youden method. We attributed to 2 points for parameters having an AUC>0.75 (NT-proBNP AUC 0.799; hs-cTnI AUC 0.87) and 1 point for GFR (AUC 0.749) and TTE parameters (GLS AUC 0.666; RV FWS AUC 0.649, LASr AUC 0.643). A score of equal or more than 4 points has been able to differentiate between AL and ATTR (sensitivity 80%, specificity 62%, AUC=0.798). The differential diagnosis score system was applied to the validation cohort of 52 CA patients showing a sensitivity of 81% with specificity of 77%. CA is a complex entity and requires extensive testing for a positive diagnosis. This study highlights a series of non-invasive checkpoints, which can be useful in guiding the decision-making process towards a more accurate and rapid differential diagnosis.

HALF DOSE THROMBOLYSIS IN INTERMEDIATE – HIGH RISK PULMONARY EMBOLISM WITH TRICUSPID VALVE MOBILE MASS: A BAIL OUT STRATEGY

Abstract A 82–year–old previously healthy male was referred to the emergency department complaining sudden onset dyspnea and witnessed syncope complicated by head trauma. Recurrent dizziness occurred previously. No history or drug consumption noted. On admission: heart rate 90 beats/min, blood pressure 110/60 mmHg, respiratory rate 25 breaths/min, oxygen saturation 87% in room air, normal body temperature. No lower extremities tenderness or swelling reported. Consistent with peripheral blood oxygen saturation levels, arterial blood gas analysis showed hypoxemia and respiratory alkalosis. Laboratory exams were significant for thrombocytopenia (89.000 cells/L), elevated cardiac troponin T levels (222 ng/L) and natriuretic peptide (NT pro–BNP 3944 pg/mL). Head CT excluded acute cerebral hemorrhage. At the electrocardiogram, signs of RV strain were present (biphasic T–waves in V1–V3 leads, S1–Q3–T3). Transthoracic echocardiography (TTE) showed dilated RV with hypokinetic free wall, “D–shaped” LV, “60/60” sign and a mobile filiform mass crossing the tricuspid valve plan in the right atrium (fig. 1). The patient did not present structural valvular abnormalities or endocarditis–related risk factors. CT pulmonary angiography detected a “saddle” PE and extensive thrombosis in inferior vena cava. After unfractioned heparin (UFH) bolus, the patient was transferred to our intensive care unit and balancing risks and benefits the chosen treatment option consisted in half dose systemic thrombolysis (50 mg rtPA in 60’’; 10 mg as loading dose in 2’). Because of potential harmful effects in thrombocytopenia and recent head trauma, UFH was temporarily withheld and started again after 1 hour. The day after, a beside TTE showed complete tricuspid thrombus resolution, a significant decrease in RV/LV ratio and systolic pulmonary artery pressure (fig. 2). Apart from small hematomas, no bleedings were reported. The patient was shifted to the ward on the next day and following course was uneventful. On day 4 a direct oral anticoagulant (Dabigatran 110 mg) was started. Abdominal and inferior limb–deep–venous ultrasound were both negative for pathological reports. A total body CT was scheduled to exclude silent malignancies at discharge. Take home message: in intermediate–high risk PE, half dose systemic fibrinolysis strategy is controversial since its potential benefit is counterbalanced by concerns about major bleedings, but increasing data suggest its efficacy with low risk profile.

Recombinant bivalent subunit vaccine combining truncated VP4 from P[7] and P[23] induces protective immunity against prevalent porcine rotaviruses.

Porcine rotaviruses (PoRVs) cause severe economic losses in the swine industry. P[7] and P[23] are the predominant genotypes circulating on farms, but no vaccine is yet available. Here, we developed a bivalent subunit PoRV vaccine using truncated versions (VP4*) of the VP4 proteins from P[7] and P[23]. The vaccination of mice with the bivalent subunit vaccine elicited more robust neutralizing antibodies (NAbs) and cellular immune responses than its components, even at high doses. The bivalent subunit vaccine and inactivated bivalent vaccine prepared from strains PoRVs G9P[7] and G9P[23] were used to examine their protective efficacy in sows and suckling piglets after passive immunization. The immunized sows showed significantly elevated NAbs in the serum and colostrum, and the suckling piglets acquired high levels of sIgA antibodies from the colostrum. Challenging subunit-vaccinated or inactivated-vaccinated piglets with homologous virulent strains did not induce diarrhea, except in one or two piglets, which had mild diarrhea. Immunization with the bivalent subunit vaccine and inactivated vaccine also alleviated the microscopic lesions in the intestinal tissues caused by the challenge with the corresponding homologous virulent strain. However, all the piglets in the challenged group displayed mild to watery diarrhea and high levels of viral shedding, whereas the feces and intestines of the piglets in the bivalent subunit vaccine and inactivated vaccine groups had lower viral loads. In summary, our data show for the first time that a bivalent subunit vaccine combining VP4*P[7] and VP4*P[23] effectively protects piglets against the diarrhea caused by homologous virulent strains.IMPORTANCEPoRVs are the main causes of diarrhea in piglets worldwide. The multisegmented genome of PoRVs allows the reassortment of VP4 and VP7 genes from different RV species and strains. The P[7] and P[23] are the predominant genotypes circulating in pig farms, but no vaccine is available at present in China. Subunit vaccines, as nonreplicating vaccines, are an option to cope with variable genotypes. Here, we have developed a bivalent subunit candidate vaccine based on a truncated VP4 protein, which induced robust humoral and cellular immune responses and protected piglets against challenge with homologous PoRV. It also appears to be safe. These data show that the truncated VP4-protein-based subunit vaccine is a promising candidate for the prevention of PoRV diarrhea.

McConnell's sign predicts normotensive shock in patients with acute pulmonary embolism

Abstract Funding Acknowledgements None. Background Patients with intermediate-risk acute pulmonary embolism (PE) have mortality rates ranging from 3-15%, with incidence of normotensive shock occurring in up to 30% of patients.1-3 Existing risk models often fall short in accurately identifying those at heightened risk of normotensive shock and those who might derive benefit from advanced therapeutic interventions including catheter based therapies. Diagnosis of normotensive shock typically necessitates invasive right heart catheterization, however, McConnell's sign has been associated with higher risk PEs.4 Consequently, our objective was to assess the relationship between McConnell's sign, a readily available bedside point-of-care tool, and its predictive value in identifying normotensive shock in patients diagnosed with acute intermediate-risk PE. Methods All patients with intermediate-risk PE who underwent percutaneous mechanical thrombectomy (MT) between August 2020 and April 2023 at a large academic public hospital were included in the study. Normotensive shock was defined as patients with systolic blood pressure (SBP) ≥ 90mmHg in the absence of vasopressor support with pre-procedural invasive measures of CI £ 2.2 L/min/m2 and clinical evidence of hypoperfusion (i.e. elevated lactate, oliguria). The primary outcome was the association between McConnell’s sign and normotensive shock. Results A total of 49 patients with intermediate-risk PE underwent MT, 9 patients had incomplete data, resulting in a final cohort of 40 patients (mean age: 57 ± 13 years; 45% female). A total of 29/40 (72.5%) patients had McConnell’s sign. Patients with McConnell’s sign had higher rates of obesity (59% vs 18% p=0.02), higher heart rate (114 vs 99 beats/min, p=0.008), higher rates of elevated lactate (86% vs 55%, p=0..038), lower cardiac index (1.9 vs 3.1 L/min/m2, p=0.003), and higher rates of normotensive shock (76% vs 27%, p=0.005). There was no statistically significant difference in age, sex, race, rates of saddle emboli, left ventricular ejection fraction, pulmonary artery systolic pressure, presenting blood pressure, sPESI and composite pulmonary embolism shock score scores in patients with or without McConnell’s sign. In patients with normotensive shock, 22/25 (88%) had McConnell’s sign and only 53.3% had McConnell’s sign without shock (Figure 1). Patients with McConnell’s sign had an increased odds (OR 8.38, CI: 1.73-40.53; p=0.008, AUC 0.70, 95% CI: 0.56-0.85) of normotensive shock. Conclusion This is the first study to suggest that McConnell’s sign can effectively identify those in the intermediate-risk group who are at risk for normotensive shock. Further studies are needed to validate this non-invasive technique that can be rapidly performed at bedside with high reproducibility and whether it can help risk-stratify patients who may benefit from advanced PE therapies.

A COVID-19 specific multiparametric and ECG-based score for the prediction of in-hospital mortality: ELCOVID score.

We aimed to develop and validate a COVID-19 specific scoring system, also including some ECG features, to predict all-cause in-hospital mortality at admission. Patients were retrieved from the ELCOVID study (ClinicalTrials.gov identifier: NCT04367129), a prospective, multicenter Italian study enrolling COVID-19 patients between May to September 2020. For the model validation, we randomly selected two-thirds of participants to create a derivation dataset and we used the remaining one-third of participants as the validation set. Over the study period, 1014 hospitalized COVID-19 patients (mean age 74years, 61% males) met the inclusion criteria and were included in this analysis. During a median follow-up of 12 (IQR 7-22) days, 359 (35%) patients died. Age (HR 2.25 [95%CI 1.72-2.94], p < 0.001), delirium (HR 2.03 [2.14-3.61], p = 0.012), platelets (HR 0.91 [0.83-0.98], p = 0.018), D-dimer level (HR 1.18 [1.01-1.31], p = 0.002), signs of right ventricular strain (RVS) (HR 1.47 [1.02-2.13], p = 0.039) and ECG signs of previous myocardial necrosis (HR 2.28 [1.23-4.21], p = 0.009) were independently associated to in-hospital all-cause mortality. The derived risk-scoring system, namely EL COVID score, showed a moderate discriminatory capacity and good calibration. A cut-off score of ≥ 4 had a sensitivity of 78.4% and 65.2% specificity in predicting all-cause in-hospital mortality. ELCOVID score represents a valid, reliable, sensitive, and inexpensive scoring system that can be used for the prognostication of COVID-19 patients at admission and may allow the earlier identification of patients having a higher mortality risk who may be benefit from more aggressive treatments and closer monitoring.