Noninvasive Cardiovascular Imaging Research Articles

Noninvasive Atherosclerotic Phenotyping: The Next Frontier into Understanding the Pathobiology of Coronary Artery Disease.

Despite recent advances, coronary artery disease remains one of the leading causes of mortality worldwide. Noninvasive imaging allows atherosclerotic phenotyping by measurement of plaque burden, morphology, activity and inflammation, which has the potential to refine patient risk stratification and guide personalized therapy. This review describes the current and emerging roles of advanced noninvasive cardiovascular imaging methods for the assessment of coronary artery disease. Cardiac computed tomography enables comprehensive, noninvasive imaging of the coronary vasculature, and is used to assess luminal stenoses, coronary calcifications, and distinct adverse plaque characteristics, helping to identify patients prone to future events. Novel software tools, implementing artificial intelligence solutions, can automatically quantify and characterize atherosclerotic plaque from standard computed tomography datasets. These quantitative imaging biomarkers have been shown to improve patient risk stratification beyond clinical risk scores and current clinical interpretation of cardiac computed tomography. In addition, noninvasive molecular imaging in higher risk patients can be used to assess plaque activity and plaque thrombosis. Noninvasive imaging allows unique insight into the burden, morphology and activity of atherosclerotic coronary plaques. Such phenotyping of atherosclerosis can potentially improve individual patient risk prediction, and in the near future has the potential for clinical implementation.

Patient-level explainable machine learning to predict major adverse cardiovascular events from SPECT MPI and CCTA imaging.

Machine learning (ML) has shown promise in improving the risk prediction in non-invasive cardiovascular imaging, including SPECT MPI and coronary CT angiography. However, most algorithms used remain black boxes to clinicians in how they compute their predictions. Furthermore, objective consideration of the multitude of available clinical data, along with the visual and quantitative assessments from CCTA and SPECT, are critical for optimal patient risk stratification. We aim to provide an explainable ML approach to predict MACE using clinical, CCTA, and SPECT data. Consecutive patients who underwent clinically indicated CCTA and SPECT myocardial imaging for suspected CAD were included and followed up for MACEs. A MACE was defined as a composite outcome that included all-cause mortality, myocardial infarction, or late revascularization. We employed an Automated Machine Learning (AutoML) approach to predict MACE using clinical, CCTA, and SPECT data. Various mainstream models with different sets of hyperparameters have been explored, and critical predictors of risk are obtained using explainable techniques on the global and patient levels. Ten-fold cross-validation was used in training and evaluating the AutoML model. A total of 956 patients were included (mean age 61.1 ±14.2 years, 54% men, 89% hypertension, 81% diabetes, 84% dyslipidemia). Obstructive CAD on CCTA and ischemia on SPECT were observed in 14% of patients, and 11% experienced MACE. ML prediction's sensitivity, specificity, and accuracy in predicting a MACE were 69.61%, 99.77%, and 96.54%, respectively. The top 10 global predictive features included 8 CCTA attributes (segment involvement score, number of vessels with severe plaque ≥70, ≥50% stenosis in the left marginal coronary artery, calcified plaque, ≥50% stenosis in the left circumflex coronary artery, plaque type in the left marginal coronary artery, stenosis degree in the second obtuse marginal of the left circumflex artery, and stenosis category in the marginals of the left circumflex artery) and 2 clinical features (past medical history of MI or left bundle branch block, being an ever smoker). ML can accurately predict risk of developing a MACE in patients suspected of CAD undergoing SPECT MPI and CCTA. ML feature-ranking can also show, at a sample- as well as at a patient-level, which features are key in making such a prediction.

Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.

Assessment of intracardiac flow dynamics for the evaluation of patients with aortic stenosis

Abstract Funding Acknowledgements Type of funding sources: None. Background Assessment of intracardiac flows has acquired increasing significance in the past few years, due to the development and introduction of technologies for non-invasive cardiovascular imaging. Recent studies have demonstrated abnormalities in cardiac function, which are related to pathological intracardiac vortical flows. This study investigates the additional information provided by quantifying intracardiac flow dynamics for the evaluation of patients with aortic stenosis (AS), by using an advanced echocardiography vortex-based approach. Methods One hundred twenty patients with severe AS (65 females – 54%), 60 patients with concentric remodelling (VR) (7 females – 12%) and 100 healthy controls (CTRL) (32 females – 32%) were prospectively enrolled to undergo a non-invasive evaluation of intracardiac flow dynamics. Echocardiographic assessments were performed, and apical three chamber views were recorded by means of MyLab™ X8 Platform. The HyperDoppler software adapted to an Esaote echo-scanner without contrast injection was used to assess vortex properties in all the patients. Results Vortex depth, vortex length, vortex intensity and vortex area were all significantly increased in SAo compared to CTRL (p<0.001, p = 0.003, p<0.001 and p = 0,049, respectively). Only vortex depth and vortex intensity (p<0.001 and p = 0.013, respectively) were significantly increased in SAo compared with VR. The mean energy dissipation of SAo group was significantly increased compared to control group (p<0.001) and VR (p = 0.002). Finally, the ROC Curve, generated to assess the capability of vortex depth to discriminate patients with and without severe aortic stenosis, showed an AUC of 0.751 (cutoff value ≥ 0.354; sensitivity, 73%; specificity, 73%). Conclusions There is a significant change of vortex localization, vorticity and energy parameters in patients with Sao. In particular, vortex depth, vortex intensity and energy dissipation are all significantly increased in SAo compared to CTRL and vortex depth can independently differentiate patients with SAo to those with only concentric remodelling and to CTRLs with high accuracy. These findings indicate that the assessment of intracardiac flow dynamics may provide complementary information to standard echocardiography, helping to distinguish within the heterogeneous population of patients with severe AS.

Statins and psoriasis: Position statement by the Psoriasis Task Force of the European Academy of Dermatology and Venerology.

Psoriasis is associated with an increased mortality risk, with cardiovascular disease being the leading excess cause (in a dose-response manner with psoriasis severity). Statins have demonstrated a reduction in all-cause mortality with no excess of adverse events among the general population. The underuse of interventions in cardiovascular prevention, such as statins, for patients with psoriasis may be the result of an insufficient evaluation. To provide the dermatologist with a tool for systematizing the treatment of dyslipidemia in psoriasis, which generally escapes the scope of dermatological practice, and to facilitate decision-making about the referral and treatment of patients. The Psoriasis Task Force of the European Academy of Dermatology and Venereology performed this two-phase study to achieve a consensus and create recommendations on the use of statin therapy in patients with psoriasis. The first phase included a systematic review to identify a list of outline concepts and recommendations according to guidelines. The second phase consisted in a two-round Delphi study to evaluate those recommendations not literally taken from guidelines. A list of 47 concepts and recommendations to be followed by dermatologists involved in the treatment of patients with moderate-severe psoriasis was created. It included six main concepts about cardiovascular risk and psoriasis, six items related with the role of low-density lipoprotein cholesterol (LDL-c) and the benefits of statin treatment in psoriasis patients, eight recommendations about how cardiovascular risk should be assessed, three on the role of non-invasive cardiovascular imaging, three on LDL-c thresholds, eight key points related to statin prescription, 10 on statin treatment follow-up and three on patient referral to another specialist. The application of this position statement (close final list of concepts and recommendations) will help dermatologists to manage dyslipidemia and help psoriasis patients to reduce their cardiovascular risk.

Artificial intelligence in cardiovascular imaging: enhancing image analysis and risk stratification.

In this review, we summarize state-of-the-art artificial intelligence applications for non-invasive cardiovascular imaging modalities including CT, MRI, echocardiography, and nuclear myocardial perfusion imaging.

Cardiac Imaging Biomarkers in Chronic Kidney Disease.

Uremic cardiomyopathy (UC), the peculiar cardiac remodeling secondary to the systemic effects of renal dysfunction, is characterized by left ventricular (LV) diffuse fibrosis with hypertrophy (LVH) and stiffness and the development of heart failure and increased rates of cardiovascular mortality. Several imaging modalities can be used to obtain a non-invasive assessment of UC by different imaging biomarkers, which is the focus of the present review. Echocardiography has been largely employed in recent decades, especially for the determination of LVH by 2-dimensional imaging and diastolic dysfunction by pulsed-wave and tissue Doppler, where it retains a robust prognostic value; more recent techniques include parametric assessment of cardiac deformation by speckle tracking echocardiography and the use of 3D-imaging. Cardiac magnetic resonance (CMR) imaging allows a more accurate assessment of cardiac dimensions, including the right heart, and deformation by feature-tracking imaging; however, the most evident added value of CMR remains tissue characterization. T1 mapping demonstrated diffuse fibrosis in CKD patients, increasing with the worsening of renal disease and evident even in early stages of the disease, with few, but emerging, prognostic data. Some studies using T2 mapping highlighted the presence of subtle, diffuse myocardial edema. Finally, computed tomography, though rarely used to specifically assess UC, might provide incidental findings carrying prognostic relevance, including information on cardiac and vascular calcification. In summary, non-invasive cardiovascular imaging provides a wealth of imaging biomarkers for the characterization and risk-stratification of UC; integrating results from different imaging techniques can aid a better understanding of the physiopathology of UC and improve the clinical management of patients with CKD.

Cardiovascular Disease and Cardiac Imaging in Inflammatory Arthritis.

Cardiovascular morbidity and mortality are more prevalent in inflammatory arthritis (IA) compared to the general population. Recognizing the importance of addressing this issue, the European League Against Rheumatism (EULAR) published guidelines on cardiovascular disease (CVD) risk management in IA in 2016, with plans to update going forward based on the latest emerging evidence. Herein we review the latest evidence on cardiovascular disease in IA, taking a focus on rheumatoid arthritis, psoriatic arthritis, and axial spondylarthritis, reflecting on the scale of the problem and imaging modalities to identify disease. Evidence demonstrates that both traditional CVD factors and inflammation contribute to the higher CVD burden. Whereas CVD has decreased with the newer anti-rheumatic treatments currently available, CVD continues to remain an important comorbidity in IA patients calling for prompt screening and management of CVD and related risk factors. Non-invasive cardiovascular imaging has been attracting much attention in view of the possibility of detecting cardiovascular lesions in IA accurately and promptly, even at the pre-clinical stage. We reflect on imaging modalities to screen for CVD in IA and on the important role of rheumatologists and cardiologists working closely together.

Role of plaque imaging for identification of vulnerable patients beyond the stage of myocardial ischemia.

Chronic coronary syndrome (CCS) is a progressive disease, which often first manifests as acute coronary syndrome (ACS). Imaging modalities are clinically useful in making decisions about the management of patients with CCS. Accumulating evidence has demonstrated that myocardial ischemia is a surrogate marker for CCS management; however, its ability to predict cardiovascular death or nonfatal myocardial infarction is limited. Herein, we present a review that highlights the latest knowledge available on coronary syndromes and discuss the role and limitations of imaging modalities in the diagnosis and management of patients with coronary artery disease. This review covers the essential aspects of the role of imaging in assessing myocardial ischemia and coronary plaque burden and composition. Furthermore, recent clinical trials on lipid-lowering and anti-inflammatory therapies have been discussed. Additionally, it provides a comprehensive overview of intracoronary and noninvasive cardiovascular imaging modalities and an understanding of ACS and CCS, with a focus on histopathology and pathophysiology.

Advances in Digital PET Technology and Its Potential Impact on Myocardial Perfusion and Blood Flow Quantification.

In this review, we explore the development of digital PET scanners and describe the mechanism by which they work. We dive into some technical details on what differentiates a digital PET from a conventional PET scanner and how such differences lead to better imaging characteristics. Additionally, we summarize the available evidence on the improvements in the images acquired by digital PET as well as the remaining pitfalls. Finally, we report the comparative studies available on how digital PET compares to conventional PET, particularly in the quantification of coronary blood flow. The advent of digital PET offers high sensitivity and time-of-flight (TOF), which allow lower activity and scan times, with much less risk of detector saturation. This allows faster patient throughput, scanning more patients per generator, and acquiring more consistent image quality across patients. The higher sensitivity captures more of the potential artifacts, particularly motion-related ones, which presents a current challenge that still needs to be tackled. The digital silicon photomultiplier (SiPM) positron emission tomography (PET) machine has been an important development in the technological advancements of non-invasive nuclear cardiovascular imaging. It has enhanced the utility for PET myocardial perfusion imaging (MPI) and myocardial blood flow (MBF) quantification.

Indications for echocardiography and confirmation rates of cardiovascular diseases: experience of a specialist cardiac outpatient clinic in Kumasi, Ghana.

Transthoracic echocardiography is a very helpful noninvasive cardiovascular imaging technique for the diagnosis and risk stratification in the management of patients with cardiovascular diseases. We aimed to review the clinical indications for transthoracic echocardiography and the confirmation rate of cardiovascular diseases by echocardiography at a specialist cardiac clinic in Ghana. Using a cross-sectional study design, the echocardiography reports of all patients above the age of 15 who were assessed at the clinic were analyzed. Data on patient demographics, clinical history, clinical indication for echocardiography, and the echocardiographic findings were analyzed using version 25.0 of the Statistical Package for Social Sciences (SPSS). A total of 594 participants were studied. The age range of participants was 15-96 years, with a mean (± standard deviation) age of 53.72 (± 17.25) years. There were more females (50.17%) than males (49.83%). Most (54.21%) of the participants had echocardiography for cardiac evaluation. Other indications included hypertension/hypertensive heart disease (HHD) (n = 131; 22.06%), heart failure (n = 69; 11.62%), chest pains (n = 12; 2.02%), and valvular heart disease (VHD) (n = 11; 1.85%). Three hundred and eight-nine (70.30%) of the participants had their clinical diagnoses confirmed by echocardiography; echocardiographic confirmation rates for heart failure, VHD, and HHD were 92.75%, 90.91%, and 88.54%, respectively. Echocardiography showed high confirmation rates for our patients with heart failure, VHD, and HHD. Prompt usage of this noninvasive cardiovascular imaging for the initial evaluation of patients with cardiovascular diseases is highly recommended.

Multimodality Imaging Approach to Spontaneous Coronary Artery Dissection

Spontaneous Coronary Artery Dissection (SCAD) refers to the spontaneous separation of the layers of the vessel wall caused by intramural hemorrhage, with or without an intimal tear. The "typical" SCAD patient is a middle-aged woman with few traditional cardiovascular risk factors, and it's frequently associated with pregnancy. Because of its low incidence, its pathophysiology is not fully understood. SCAD presents as an acute coronary syndrome, with chest pain, dyspnea, syncope, or heartbeat, even if diagnosis and clinical handling are different: coronary angiography is currently the main tool to diagnose SCAD; however, in doubtful cases, the use of both invasive and noninvasive cardiovascular imaging methods such as intravascular ultrasound or optical coherence tomography may be necessary. This paper aims to review the current state of knowledge on SCAD to address its demographic features, clinical characteristics, management, and outcomes, focusing on diagnostic algorithms and main multimodality imaging techniques.

Aortic regurgitation: A multimodality approach.

Aortic regurgitation (AR) is a common valvular pathology. Multimodality noninvasive cardiovascular imaging is routinely used to assess the mechanism of AR, degree, and its hemodynamic impact on the cardiovascular system. Collecting this information is crucial in establishing the prognosis and in guiding patient management and follow-up. While echocardiography remains the primary test to assess AR, a comprehensive assessment of this valvulopathy can be obtained by combining the information from different techniques. This state-of-the-art review is intended to provide an update ed overview of the applications, strengths, and limits of transthoracic echocardiography, cardiac magnetic resonance, and cardiac computed tomography in patients with AR.

Spatio-temporal segmentation of image sequences for non-invasive analysis of cardiovascular structure and function in Whitefish embryos

Label-free quantitative analysis of the cardiovascular structure and function in wild fish is highly important and still unsolved problem. We developed a robust algorithm for bright field microscopy data processing, which allows reliable detection and quantification of circulatory system across the whole animal. We verified this technique by in vivo experiments on broad whitefish (Coregonus nasus) embryos. Calculated morphofunctional features of heart and vessels are quite specific due to low temperature embryonic development of this fish, and correspond well to the reference data obtained by ex vivo techniques. This research highlights the feasibility of non-invasive cardiovascular imaging and measurements valuable for behavioral, environmental, toxicological, drug discovery and many other studies.

Patient and physician preferences for non-invasive diagnostic cardiovascular imaging technologies: a discrete choice experiment

PurposeDiagnostic imaging techniques have to be selected for their accuracy, efficiency, cost-efficiency, and impact on outcome. But beyond that, the choice of non-invasive cardiovascular imaging tests for diagnosing coronary artery disease also has to respect patient safety and comfort. In this study, we investigated patient and physician preference in relation to the choice of cardiovascular imaging tests.ResultsA total of 211 subjects (148 cardiac patients and 63 physicians) were enrolled and completed a discrete choice experiment. Tests and modalities were deconstructed into 6 attributes (risks and side effects, diagnostic accuracy, patient out-of-pocket cost, type of procedure, type of scanner and test duration). A Sawtooth software choice-based conjoint analysis with hierarchical Bayes estimation was performed and showed the risks and side effects attribute was assigned the most relative importance (30%) when considering patients’ preference. Patients gave notably high value to tests with milder side effects, while preferring to avoid exposure to ionizing radiation and risks associated the use of pharmacological agents inducing direct coronary arteriolar vasodilation. Physicians allocated more importance to the patient out-of-pocket cost attribute (29%). Both patients and physicians valued tests’ risks and side effects, diagnostic accuracy, patient out-of-pocket cost as the three most important attributes, but in diverging order. A market simulation comparing current cardiovascular imaging tests revealed breathing maneuver-enhanced cardiac magnetic resonance had the highest shares of preference in both patients (59.6%) and physicians (32.7%).ConclusionA patients’ preference for a particular cardiovascular imaging test was most determined by the risks and side effects, while physicians prioritized less costly tests for their patients. In shared decision-making with patients, physicians should therefore focus on a balanced discussion of risks and side effects associated with cardiovascular imaging tests. Both, patients and physicians would prefer a cardiovascular MR imaging test using a vasoactive breathing maneuver instead of currently used alternatives that require intravenous contrast agents, pharmacological stress, or radiation.

Recommendations in pre-procedural imaging assessment for TAVI intervention: SIC-SIRM position paper part 2 (CT and MR angiography, standard medical reporting, future perspectives).

Non-invasive cardiovascular imaging owns a pivotal role in the preoperative assessment of patient candidates for transcatheter aortic valve implantation (TAVI), providing a wide range of crucial information to select the patients who will benefit the most and have the procedure done safely. This document has been developed by a joined group of experts of the Italian Society of Cardiology and the Italian Society of Medical and Interventional Radiology and aims to produce an updated consensus statement about the pre-procedural imaging assessment in candidate patients for TAVI intervention. The writing committee consisted of members and experts of both societies who worked jointly to develop a more integrated approach in the field of cardiac and vascular radiology. Part 2 of the document will cover CT and MR angiography, standard medical reporting, and future perspectives.

Recommendations in pre-procedural imaging assessment for transcatheter aortic valve implantation intervention: Italian Society of Cardiology (SIC)-Italian Society of Medical and Interventional Radiology (SIRM) position paper part 1 (Clinical Indication and Basic Technical Aspects, Heart Team, Role of Echocardiography).

Non-invasive cardiovascular imaging owns a pivotal role in the preoperative assessment of patients for transcatheter aortic valve implantation (TAVI), providing a wide range of crucial information to select the patients who will benefit the most and have the procedure done safely. Although advanced cardiac imaging with cardiac computed tomography is routinely used for a detailed anatomic assessment before TAVI, echocardiography remains the first imaging modality to assess aortic stenosis severity and to provide essential functional information. This document results from the collaboration between the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), aiming to produce an updated consensus statement about the pre-procedural imaging assessment in patient for TAVI. The writing committee is composed of radiologists and cardiologists, experts in the field of cardiac imaging and structural heart diseases. Part 1 of the document, after a brief overview of the clinical indication and basic technical aspects of TAVI, will focus on the role of echocardiography in TAVI pre-procedural planning.

605 Assessment of intracardiac flow dynamics for the evaluation of patients with cardiac resynchronization therapy

Abstract Aims Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure (HF), reduced left ventricular ejection fraction (EF ≤ 35%) and high-grade intraventricular conduction delays. CRT improves cardiac function, symptoms and well-being, and reduces morbidity and mortality in this setting. However, there are patients unresponsive to CRT. Responders show reverse ventricular remodelling, volumes and diameters reduction, and EF improvement. Noninvasive cardiovascular imaging for visualization and quantitation of intracardiac flows and turbulences has not been assessed thoroughly in CRT. This study seeks to evaluate if the quantitative analysis of intracardiac flow dynamics in HF patients treated by CRT might provide additional information for device optimization and clinical response. Methods and results Fifteen HF patients (five females, age 69.6 ± 9.4 years, NYHA class II/III, EF 29.3 ± 4.6%) were enrolled in the study. Eleven had primitive dilated cardiomyopathy and four had post-ischaemic etiology with completed revascularization. Pacemaker-dependent cases were excluded. MyLab™ X8 platform was used for echocardiographic assessment of intracardiac flow dynamics performed on apical three chamber views. All examinations were realized in baseline (active CRT) and after 5 min of biventricular pacing switch off. The hyperDoppler software was used to assess intracardiac vortexes properties. The analyzed parameters were: vortex area, vortex length, vortex depth, and kinetic of energy dissipation (ΔKE). Categorical variables are expressed as numbers and percentages. Quantitative variables are expressed as mean and standard deviation (SD). Shapiro–Wilk test, D’Agostino Pearson test, and visual inspection of Q–Q-plots were executed to evaluate if variables were normally distributed. Quantitative variables were evaluated with paired sample T-test or Wilcoxon test when appropriate. Clinical features, biochemical parameters, electrocardiograms with and without cardiac pacing, and EF before and after CRT implantation were collected. Although no difference was observed in vortex area/depth/length, a significant increase in KE dissipation after switching OFF the CRT devices (from 1.2 ± 0.9 to 3.5 ± 2.3 J, P < 0.03) was remarkably observed. According to EF improvement after CRT, the patients were divided in responders (5% increase in EF, N = 10) and non-responders (N = 5). Moreover, by analysing the extent of QRS dispersion and the variation of KE dissipation in spontaneous rhythm and after silencing the biventricular pacing, a positive ventricular remodelling (QRS 141.3 ± 29.3 vs. 154.4 ± 24.4ms, P = 0.02; KE dissipation 0.92 ± 0.87 J in responders and 1.53 ± 1.76 J in non-responders, P = 0.006) was detected in responders. Conclusions Noninvasive intracardiac flow dynamics in HF patients represents a complementary tool to standard echocardiography, and provides additional parameters for assessing prognosis and outcomes in CRT recipients. The impact of maladaptation in intracardiac flow dynamic on progressive LV remodelling could be useful to evaluate the prognostic meaning of implanted CRT device and to predict the response to device implantation, based on cardiac flow analysis.

Assessment of intracardiac flow dynamics for the evaluation of patients with aortic stenosis

Abstract Background Assessment of intracardiac flows and turbulence has acquired rising significance in the past few years, due to the development and introduction of technologies for non-invasive cardiovascular imaging. Recent studies have shown that alterations in intracardiac fluid dynamics can be helpful to identify abnormalities in cardiac function. Purpose This study investigates the additional information provided by the quantitative assessment of intracardiac flow dynamics for the evaluation of patients with aortic stenosis (AS), by using an advanced echocardiography vortex-based approach. Methods Sixty-one patients with severe AS (33 females) and 38 healthy sex- and BSA-matched controls (CTRL) (15 females) were prospectively included and underwent echocardiographic assessment of intracardiac flow dynamics. Echocardiographic measurements were performed on apical three chamber views. The HyperDoppler software adapted to the echo-scanner without contrast injection was used to assess intracardiac vortex properties. The following parameters were obtained: vortex area (VA) (the ratio between the total vortex area and the left ventricular (LV) area); vortex length (VL) (the longitudinal length of the vortex relative to the total LV length; vortex depth (VD) (the distance of the vortex center from the LV base relative to the total LV long axis). Inter-rater variability was measured using intraclass correlation coefficients (ICCs) between two independent operators. Results Patients with severe AS (mean gradient: 47,5±13,9 mmHg; aortic valve area: 0.7±0.2 cm2; ejection fraction: 53±7%) had increased LV wall thickness (p<0.001) and mass index (p<0.001) compared with controls. Greater indexed left atrial volume (p<0.001), E/e' (p<0.001) and trans-tricuspid gradient (p<0.001) were also observed in the AS group. The assessment of VA, VL and VD was feasible in the whole population. Their calculation was reliable, as ICCs were very good for VA (0.878, p=0.033), VL (0.960, p=0.004) and VD (0,905, p=0.021). Mean VA was significantly larger in patients with severe aortic stenosis compared with CTRL (p=0.033). VL and VD (p=0.026 and p>0.001, respectively) were significantly higher in AS patients compared with CTRL. Among those who underwent TAVR, we observed a significant difference in the delta values of VA and VL pre-postTAVR in patients with and without significant paravalvular leak (p<0.05). Conclusions The newly defined VA, VL and VD, quantitative indices of vortical flow, were significantly increased in the LV cavity of patients with severe AS compared to normal subjects. These indices, whose measurement was feasible and reliable, might provide complementary information to standard echocardiography, useful for the further diagnostic and prognostic characterization of the heterogeneous population of patients with severe AS. Funding Acknowledgement Type of funding sources: None.

Excerpts from the documents of Mexican positions and recommendations in cardiovascular diseases and COVID-19.

The recommendations in which the Mexican Society of Cardiology (SMC) in conjunction with the National Association of Cardiologists of Mexico (ANCAM) as well as different Mexican medical associations linked to cardiology are presented, after a comprehensive and consensual review and analysis of the topics related to cardiovascular diseases in the COVID-19 pandemic. Scientific positions are analyzed and responsible recommendations on general measures are given to patients, with personal care, healthy eating, regular physical activity, actions in case of cardio-respiratory arrest, protection of the patient and health personnel as well as precise indications in the use of non-invasive cardiovascular imaging, prescription of medications, care in specific topics such as systemic arterial hypertension, heart failure, arrhythmias and acute coronary syndromes, in addition to emphasizing electrophysiology, interventionism, cardiac surgery and in cardiac rehabilitation. The main interest is to provide the medical community with a general orientation on what to do in daily practice and patients with cardiovascular diseases in the setting of this unprecedented epidemiological crisis of COVID-19.