Echo Screening Research Articles

Combination of Tele-Cardiology Tools for Cardiovascular Risk Stratification in Primary Care: Data from the PROVAR+ Study.

Tele-cardiology tools are valuable strategies to improve risk stratification. We aimed to evaluate the accuracy of tele-electrocardiography (ECG) to predict abnormalities in screening echocardiography (echo) in primary care (PC). In 17 months, 6 health providers at 16 PC units were trained on simplified handheld echo protocols. Tele-ECGs were recorded for final diagnosis by a cardiologist. Consented patients with major ECG abnormalities by the Minnesota code, and a 1:5 sample of normal individuals underwent clinical questionnaire and screening echo interpreted remotely. Major heart disease was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, or wall-motion abnormalities. Association between major ECG and echo abnormalities was assessed by logistic regression as follows: 1) unadjusted model; 2) model 1 adjusted for age/sex; 3) model 2 plus risk factors (hypertension/diabetes); 4) model 3 plus history of cardiovascular disease (Chagas/rheumatic heart disease/ischemic heart disease/stroke/heart failure). P-values < 0.05 were considered significant. A total 1,411 patients underwent echo; 1,149 (81%) had major ECG abnormalities. Median age was 67 (IQR 60 to 74) years, and 51.4% were male. Major ECG abnormalities were associated with a 2.4-fold chance of major heart disease on echo in bivariate analysis (OR = 2.42 [95% CI 1.76 to 3.39]), and remained significant after adjustments in models (p < 0.001) 2 (OR = 2.57 [95% CI 1.84 to 3.65]), model 3 (OR = 2.52 [95% CI 1.80 to3.58]), and model 4 (OR = 2.23 [95%CI 1.59 to 3.19]). Age, male sex, heart failure, and ischemic heart disease were also independent predictors of major heart disease on echo. Tele-ECG abnormalities increased the likelihood of major heart disease on screening echo, even after adjustments for demographic and clinical variables.

Agreement between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren from High-Prevalence Settings (Agreement between Screening and Standard Echo for RHD).

Introduction: Handheld echocardiography (echo) is the tool of choice for rheumatic heart disease (RHD) screening. We aimed to assess the agreement between screening and standard echo for latent RHD diagnosis in schoolchildren from an endemic setting. Methods: Over 14 months, 3 nonphysicians used handheld machines and the 2012 WHF Criteria to determine RHD prevalence in consented schoolchildren from Brazilian low-income public schools. Studies were interpreted by telemedicine by 3 experts (Brazil, US). RHD-positive children (borderline/definite) and those with congenital heart disease (CHD) were referred for standard echo, acquired and interpreted by a cardiologist. Agreement between screening and standard echo, by WHF subgroups, was assessed. Results: 1390 students were screened in 6 schools, with 110 (7.9%, 95% CI 6.5-9.5) being screen positive (14 ± 2 years, 72% women). Among 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline, and 1 to normal. Among 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) reclassified as definite RHD, and 2 had mild CHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criterion was B (isolated mitral regurgitation, 64%), followed by A (2 mitral valve morphological features, 31%). In 1 patient with definite RHD reclassified to normal, the WHF criterion was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3-4.2). Conclusions: Although practical, RHD screening with handheld devices tends to overestimate prevalence.

Abstract 14701: Agreement Between Handheld and Standard Echocardiography for Diagnosis of Latent Rheumatic Heart Disease in Brazilian Schoolchildren From High-Prevalence Settings

Background: Handheld echocardiography (echo) is the tool of choice for Rheumatic Heart Disease (RHD) screening, based on the 2012 World Heart Federation (WHF) Criteria. We aimed to assess the agreement between screening and standard echo for diagnosis of latent RHD in schoolchildren from an endemic setting. Methods: Over 14 months, 3 non-physicians used handheld machines (GE, VSCAN) and the 2012 WHF Criteria to determine RHD prevalence in low-income public schools in Minas Gerais, Southeast Brazil. Consented children were eligible for participation. Studies were interpreted remotely using a telemedicine cloud-server by 2 experts in Brazil and the US. RHD-positive children (borderline and definite) and those with congenital heart disease (CHD) were referred for standard echo with portable devices (GE, Vivid IQ), with acquisition and interpretation by an expert cardiologist. Agreement between screening and standard echo, by category and according to the WHD criteria, was assessed, and the kappa statistic was applied. Results: A total of 1,390 students were screened in 6 schools and, among these, 110 (7.9%, 95% CI 6.5 - 9.5) were screen-positive and referred for standard echo, with mean age of 14±2 years, 80 (72%) women. Among the 16 cases initially diagnosed as definite RHD, 11 (69%) were confirmed, 4 (25%) reclassified to borderline and 1 to normal. Among the 79 cases flagged as borderline RHD, 19 (24%) were confirmed, 50 (63%) reclassified to normal, 8 (10%) to definite RHD and 2 had mild CHD. Among 11 children with CHD in screening, 4 were confirmed, 5 were reclassified to normal and 2 to RHD. Considering the 4 diagnostic categories, kappa was 0.18. In patients with borderline RHD reclassified to non-RHD, the most frequent WHF criteria was B (isolated mitral regurgitation): 64%, followed by A (2 morphological features of the mitral valve): 31%. In the only patient with definite RHD reclassified to normal, WHF criteria was D (borderline RHD in aortic and mitral valves). After standard echo, RHD prevalence was 3.2% (95% CI 2.3 - 4.2). Conclusions: Although practical, RHD screening with handheld devices tend to overestimate prevalence. Even in endemic settings, continuous education for detection, and application of risk stratification for management are crucial.

Abstract 14693: Combined Tele-Cardiology Tools for Cardiovascular Risk Stratification in Primary Care: Data From the PROVAR+ Study

Introduction: Tele-cardiology tools are valuable strategies to improve risk stratification, especially in low-resourced settings. We aimed to evaluate the accuracy of tele-electrocardiography (ECG) in remote sites to predict abnormalities in screening echocardiography (echo) in primary care (PC). Methods: In 17 months, 6 healthcare workers at 16 PC units were trained on simplified handheld (GE VSCAN) echo protocols. Tele-ECGs were recorded with dedicated software with measurement and magnification tools, with final diagnosis by a cardiologist. Consented patients with major ECG abnormalities by the Minnesota code, and a 1:3 sample of individuals without abnormalities underwent a clinical questionnaire and screening echo interpreted remotely. Major heart disease (HD) was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. Association between major ECG and echo abnormalities was assessed by logistic regression, in 4 models: 1): unadjusted, 2): model 1 adjusted for age and sex; 3): model 2 plus cardiovascular risk factors (hypertension and diabetes); 4: model 3 plus history of cardiovascular disease (Chagas, Rheumatic Heart Disease, ischemic heart disease, stroke and heart failure). Results: At total 1,411 patients underwent echo; 1,149 (81%) with major ECG abnormalities. Mean age was 67 (IQR 60-74) years, 51.4% were males; 76.3% had hypertension, 37.7% diabetes and 22.3% ischemic heart disease. Among those with major ECG abnormalities, 78% had abnormal echo. Major ECG abnormalities were associated with a 2.2 higher chance of major HD in echo in bivariate analysis: OR=2.15; (95%CI: 1.76 - 3.39), and remained significant after adjustments in models (p&lt;0.001) 2: OR=2.57 (95%CI 1.84 - 3.65), model 3 (OR=2.52 (95%CI 1.80 - 3.58), and model 4 (OR=2.23 (95%CI 1.59 - 3.19). Age (OR=1.07 (95%CI 1.06 - 1.09), p&lt;0.001) and heart failure (OR=5.18 (95%CI 2.43 - 11.87), p&lt;0.001 were also independent predictors of major HD on echo. Conclusions: Tele-ECG abnormalities increased likelihood of major HD on screening echo, even after adjustments for demographic and clinical variables. The combination of tele-cardiology tools and clinical data may improve risk stratification in PC.

Cardiac dysfunction (CD) among breast cancer survivors (BCS): Role of cardiotoxic therapy and cardiovascular risk factors.

12078 Background: CD is the leading cause of mortality in BCS. Limited information regarding the long-term risk of CD after exposure to cardiotoxic agents (anthracyclines, trastuzumab/pertuzumab and left breast/chest wall radiation) and additional factors that place BCS at highest risk has precluded development of surveillance guidelines for early detection of CD in BCS. Methods: Patients, who survived ≥1y after BC and received potentially cardiotoxic therapy, underwent q2y echocardiographic (echo) screening at a single center. All echos from BC diagnosis to CD or last follow-up were processed in Python via automated text analysis. New-onset CD was defined as left ventricular ejection fraction (LVEF) &lt;50% or fractional shortening (FS) &lt;28%. Treatment exposures, demographics and cardiovascular risk factors (CVRFs: diabetes, hypertension, dyslipidemia, obesity, smoking) were abstracted from medical records. Cumulative incidence of CD described the magnitude of risk in the entire cohort and among those who received anthracyclines (±radiation), trastuzumab/pertuzumab (±radiation), and radiation alone (without anthracyclines/trastuzumab/pertuzumab). Cox proportional hazards models estimated hazard ratios (HRs) and 95%CIs of associations between CD and treatment, adjusting for CVRFs (time varying) and demographics. Longitudinal echocardiographic analyses (adjusted for covariates) estimated trends in cardiac function prior to CD. Results: We evaluated 2,540 echos in 847 BCS exposed to potentially cardiotoxic therapy (median age at BC: 54.4y; median follow-up: 7.6y). Overall, 39% of BCS received anthracyclines, 17% received trastuzumab/pertuzumab, 5% received anthracyclines + trastuzumab/pertuzumab, and 39% received radiation alone. The cumulative incidence of CD in the entire cohort was 12.3% at 2y, increasing to 29.7% by 10y after BC. Multivariable analysis revealed the following to be independently associated with CD: treatment (anthracyclines: HR=2.72, 95%CI=1.9-3.9; trastuzumab/pertuzumab: HR=1.92, 95%CI=1.1-3.2; ref: radiation alone), presence of CVRFs before CD diagnosis (hypertension: HR=1.77, 95%CI=1.3-2.4; obesity: HR=1.82, 95%CI=1.4-2.4; and dyslipidemia: HR=1.63, 95%CI=1.3-2.1). Adjusted longitudinal echo analyses revealed a statistically significant decline in SF over 20y from BC diagnosis (but prior to CD onset) for the entire cohort (p=0.0007), trastuzumab/pertuzumab (p=0.006), anthracyclines (p=0.037), and radiation alone (p=0.01). Conclusions: In this large cohort of BCS followed longitudinally for an extended period, exposure to potentially cardiotoxic therapy results in a substantial burden of CD; the risk increases over time, and with CVRFs. These results provide evidence for close surveillance of BC survivors at increased risk of CD for extended periods, and aggressive management of CVRFs before, during and after BC.

Utility of Echocardiography Screening for Cancer Therapy-Related Cardiac Dysfunction

Availability of echocardiography resources in New Zealand is under pressure due to workforce shortages. This study examined real-world utility of echocardiogram (echo) as a screening tool for cancer therapy-related cardiac dysfunction (CTRCD), changes in patient treatment, and outcome because of CTRCD detected by echocardiography. A retrospective audit was undertaken of all patients dispensed with trastuzumab, pertuzumab, and/or doxorubicin chemotherapy, with serial echocardiography performed, at Lakes and Bay of Plenty District Health Boards between January 2018 and January 2021. Two-dimensional ejection fraction (EF), three-dimensional (3D) EF, and global longitudinal strain (GLS) were used to classify patients with CTRCD based on current guidelines. Changes in patient management were examined. A total of 407 echos were performed in 107 patients. Of 25 (23%) patients with CTRCD, 11 had a change in cancer treatment and seven started cardiac medications. Fifteen (60%) patients showed recovery in EF/GLS measurements over time and eight (32%) showed spontaneous recovery. Patients were more likely to have a change in cancer treatment based on a change in left ventricular ejection fraction than GLS (p<0.001). The use of 3D EF and GLS was limited by 43% of the population who were obese, which was performed in 14% and 62% of studies, respectively. Cancer therapy-related cardiac dysfunction was associated with mortality in univariate (p=0.02) but not multivariate (p=0.06) analysis. Detection of CTRCD remains a priority. However, echo screening requires many resources and did not result in consistent changes in management approach. It is worth examining whether the use of biomarkers would be effective and resource sparing.

High Rates of Progression From Screening to Requiring Investigation: Early Report From the Te Kūiti Access to Cardiology Pilot Study

The Te Kūiti Access to Cardiology Pilot Study (TKACPS) was designed to assess, in a high Māori proportion general practitioner (GP) population (Te Kūiti) with increased cardiovascular risk (CVR), whether a simple local screening protocol followed, if indicated, by more definitive cardiology tests performed locally would identify people for treatment or tertiary referral earlier than a normal care control group. Progression from screening to investigation phase and early echocardiography data are provided. Te Kūiti GP patients aged 35–74 years, with a 5-year CVR of ≥10% (PREDICT CVD) were eligible for inclusion. Current cardiology patients (or those seen within 2 years), were excluded. Screening (Phase 1: symptom questionnaire, electrocardiogram, and plasma Troponin T, N-terminal prohormone of brain natriuretic peptide, and ST2) was followed by, if the cardiologist and GP felt indicated, Phase 2 (locally performed screening echo, Holter monitor or exercise tolerance test). For Māori patients, a hospital Kaitiaki (very well known in the community) made first contact, organised appointments, and met patients upon arrival. Of 119 patients approached so far, 23 (19.3%) were uncontactable, 18 (15.2%) declined to be involved, and 78 (65.5%) agreed to participate. Thirteen (10.9%) patients did not attend (three Tangi, one COVID) but will be rescheduled.Table 1Sex and ethnicity of patients and progression from Phase 1 to Phase 2 for the TKACPS (early data).ParticipantsN (%) of totalN (%) progress to Phase 2Māori male32 (49.2)16 of 32 (50.0)Māori female17 (26.2)10 of 17 (59.2)Non-Māori male8 (12.5)4 of 8 (50.0)Non-Māori female8 (12.5)4 of 8 (50.0)Total6534 of 65 (52.3) Open table in a new tab Table 2Preliminary data from screening echocardiography (15 patients).ParticipantsNeed referral for echo or clinicClinical advice/no actionMāori male 4 of 154 of 4 (MR3+, MR2+, fast AF, aortic root 4.8 cm)Māori female 4 of 153/1Non-Māori male 5 of 154 of 5 (LVEF 30%–35%, aortic root 4.8 and 4.5 cm, fast AF)2/0Non-Māori female 2 of 152Total8 of 15 (53.3%)6 (40.0%)/1 (6.7%) Open table in a new tab A high proportion (52.3%) of these GP patients in Te Kūiti with 5-year CVR ≥10% were judged to require further investigation after Phase 1 symptom questionnaire, electrocardiogram, and blood tests. Early Phase 2 echocardiography data suggest high rates of pathology that need follow-up (53.3%) or generated clinical advice for the GPs (40.0%).

PO-03-175 COST-EFFECTIVENESS OF TRANSESOPHAGEAL ECHOCARDIOGRAM PRIOR TO ATRIAL FIBRILLATION ABLATION.

With universal adoption of uninterrupted anticoagulation (AC) it is suggested that transesophageal echo (TEE) screening for LA (left atrial) thrombus prior to AF ablation procedure could be omitted. Observational studies suggest that post-procedure stroke might not be completely prevented by TEE. Accumulating data on safety of AF ablation on uninterrupted AC together with a risk of TEE complications raise the question of indications for TEE in all AF ablation patients. We estimated the cost-effectiveness of TEE before AF ablation. Cost-effectiveness ratio was defined as the net costs of TEE including the cost of TEE complications and reduction of lifetime stroke costs divided by net health benefit gain. Health effect was quality-adjusted life-years (QALYs) due to post-ablation stroke or TEE complications. Costs and QALYs were discounted at 3%. Lifetime cost of stroke was assessed according to the modified Rankin Scale (mRS) at 1 year follow up. One way sensitivity analyses were performed for the incidence of TEE complications, stroke rate and severity. We assumed double the rate and half the rate of TEE complications. For stroke severity sensitivity analysis we redistributed severity towards non-mild strokes having more weight. For the stroke rate we added the LA thrombus detection rate by TEE (2%) to the literature reported incidence of post ablation stroke. Given the rarity of stroke after AF ablation, and the uncertainty of TEE effectiveness in preventing it, we reviewed cost-effectiveness analysis based on hypothetical stroke reduction by TEE of 25%, 50%, 75% and 100%. When TEE does prevents no strokes, TEE is dominated, adding $434,802,162 in costs and reducing health by 768 QALYs in 240,000 procedures per year. When TEE prevents all peri-procedural strokes, the cost-effectiveness ratio is $45,620 per QALY gained. TEE remains a dominated strategy in sensitivity analyses if it doesn’t prevent any strokes. When strokes are reduced by 50%, the cost effectiveness ratio exceeds $100,000 Our study found that when TEE prior to AF ablation on uninterrupted AC doesn’t prevent any strokes, TEE is dominated. Cost-effectiveness of TEE screening is sensitive to the level of stroke prevention it accomplishes. For TEE to be cost effective it must reduce the risk of stroke at least by 50%. RCTs are needed on effectiveness of TEE at preventing strokes in patients on uninterrupted AC to fully resolve the utility of TEE.

The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices

A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic images, holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of nonexperts to obtain diagnostic-quality images in patients with RHD using AI guidance with color Doppler. Novice providers without prior ultrasound experience underwent a 1-day training curriculum to complete a 7-view screening protocol using AI guidance in Kampala, Uganda. All trainees then scanned 8 to 10 volunteer patients using AI guidance, half RHD and half normal. The same patients were scanned by 2 expert sonographers without the use of AI guidance. Images were evaluated by expert blinded cardiologists to assess (1) diagnostic quality to determine presence/absence of RHD and (2) valvular function and (3) to assign an American College of Emergency Physicians score of 1 to 5 for each view. Thirty-six novice participants scanned a total of 50 patients, resulting in a total of 462 echocardiogram studies, 362 obtained by nonexperts using AI guidance and 100 obtained by expert sonographers without AI guidance. Novice images enabled diagnostic interpretation in >90% of studies for presence/absence of RHD, abnormal MV morphology, and mitral regurgitation (vs 99% by experts, P ≤ .001). Images were less diagnostic for aortic valve disease (79% for aortic regurgitation, 50% for aortic stenosis, vs 99% and 91% by experts, P<.001). The American College of Emergency Physicians scores of nonexpert images were highest in the parasternal long-axis images (mean, 3.45; 81%≥3) compared with lower scores for apical 4-chamber (mean, 3.20; 74%≥3) and apical 5-chamber images (mean, 2.43; 38%≥3). Artificial intelligence guidance with color Doppler is feasible to enable RHD screening by nonexperts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.

Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study : Disagreement between screening and standard echo.

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

Usefulness of supplemental parasternal block for sternal keloid excision under general anesthesia in a child status post multiple cardiac surgeries

Sir A 12-year-old boy weighing 60 kg, with history of tricuspid atresia, had undergone right modified Blalock–Thomas–Taussig shunt, and patent ductus arteriosus ligation on day 1 of life. One year later he underwent bidirectional Glenn shunt, and extra cardiac Fontan surgery was done at 6 years. He presented now with a thick keloid in the midline sternotomy scar for keloid excision. Current screening echo showed tricuspid atresia, normally related great arteries with normal ventricular flow and unobstructed Glenn and Fontan flow profiles. Intravenous midazolam 1 mg, fentanyl 100 mcg and ketamin 60 mg were given and incremental bolus of propofol 10 mg (total 20 mg) was given till loss of response to verbal commands and relaxation of jaw. Airway was then secured with size 3 proseal laryngeal mask airway (PLMA) and correct placement was ensured with regular endtidal carbon dioxide (ETCO2) waveforms. Parasternal block was then given under ultrasound guidance at third and fifth intercostal spaces 2 cm lateral to midline bilaterally. Spread of injected solution causing separation of pectoralis major muscle from the rib and external intercostal muscle confirmed deposition of drug in the correct plane (Fig. 1). Ten milliliter of 0.25% bupivacaine was injected at each site.Figure 1: Superficial parasternal-intercostal plane block.Anesthesia was maintained with sevoflurane (1.5–2%) in air oxygen mixture under spontaneous ventilation. Intraoperatively patient remained stable with heart rate 86-98/min, systolic blood pressure 90–100 mmHg, oxygen saturation 96–98% and ETCO2 32-40 mmHg and had received 500 ml of Ringer lactate. At the end of surgery, which lasted for 2 h, PLMA was removed when patient was awake. He had good postoperative analgesia. Anesthetic goals in a child post-Fontan surgery include adequate hydration, avoidance of hypoxia, hypercabia, and acidosis and preservation of spontaneous ventilation whenever possible. If general anesthesia is mandated, low inspiratory pressures and minimal positive end expiratory pressures are to be used [1,2]. Sternotomy produces considerable pain which increases with chest wall movement and reduces pulmonary function with higher risk of development of postoperative hypoxia, atelectasis, and pneumonia [3]. Parasternal block is commonly advocated to provide supplemental anaesthesia intraoperatively and for postoperative analgesia following median sternotomy, breast surgery and cardioverter-defibrillator implantation [4,5]. The nerve targeted is the anterior branches of intercostal nerves which enters intercostal and pectoralis major muscles and innervates the antero-medial region of chest wall. Local anesthetic is injected deep to pectoralis major muscle and superficial to intercostal muscles or between internal thoracic muscle and transverses thoracis muscle. Therefore, these blocks are essentially described as superficial or deep parasternal-intercostal plane blocks, depending on where the target nerves are blocked. The anatomical injection site differentiates these techniques though both techniques provide analgesia to the antero-medial chest wall [5]. Supplemental regional block helps to reduce dose requirement of anesthetic agents intraoperatively. Use of supplemental parasternal block enabled us to keep the child spontaneously breathing under general anaesthesia using PLMA with use of lesser doses of anesthetic agents, thereby minimising drug adverse effects which could be deleterious in the presence of cardiac diseases. It is concluded that supplemental parasternal block provides good intraoperative and postoperative analgesia following anterior midline chest wall surgeries.

Abstract 15026: The Use of Artificial Intelligence Guidance for Rheumatic Heart Disease Screening by Novices

Introduction: A novel technology utilizing artificial intelligence (AI) to provide real-time image-acquisition guidance, enabling novices to obtain diagnostic echocardiographic (echo) images holds promise to expand the reach of echo screening for rheumatic heart disease (RHD). We evaluated the ability of non-experts to obtain diagnostic quality images in patients with RHD using AI guidance (Caption Health) with color Doppler. Methods: This study was performed in Kampala, Uganda at the Uganda Heart Institute. Nurses and nursing students with no prior echo experience underwent one-day training in the use of AI guidance, which included a 7-view screening protocol with 2D and color Doppler images. Following training, all participants scanned 8-10 patients using AI guidance, half RHD and half normal. The same patients were scanned by two expert sonographers without the use of AI guidance. Each echo was evaluated by a panel of 4 expert echocardiographers blinded to the identity of the scanner (novice/exert) and diagnosis of the patient to provide quality assessment including (1) diagnostic quality to determine presence/absence of RHD, (2) more detailed valvular assessment, and (3) ACEP score 1-5 for each view. Results: Thirty-six novice scanners scanned a total of 50 patients, 25 with RHD and 25 controls. A total of 462 echocardiogram studies were obtained, 351 obtained by non-experts using AI guidance and 111 obtained by expert sonographers without AI guidance. Preliminary analysis of 394 interpretations showed that 95% of non-expert studies were of diagnostic quality to assess for RHD and mitral valve disease (vs 100% by experts, p=0.03), but only 56% of non-expert studies were of diagnostic quality to assess aortic valve disease (vs 97% by experts, p&lt;0.0001). The ACEP scores of non-expert images were highest in the parasternal long axis images (mean 3.62, 84% ≥ 3) compared to lower scores for apical 4 (mean 3.28, 73% ≥3), and apical 5 images (mean 2.52, 46% ≥ 3). Conclusions: AI guidance with color Doppler is feasible to enable rheumatic heart disease screening by non-experts, performing significantly better for assessment of the mitral than aortic valve. Further refinement is needed to optimize acquisition of color Doppler apical views.

Abstract 11455: Outcomes of Latent Rheumatic Heart Disease: External Validation of a Simplified Score in Patients With And Without Secondary Prophylaxis

Background: Secondary antibiotic prophylaxis reduces progression in children with latent rheumatic heart disease (RHD). However, nearly half of children show improvement with or without prophylaxis. Improved risk stratification could refine prophylaxis recommendations following positive screening echo. We aimed to validate a previously developed echo risk score to predict mid-term RHD outcomes among children with latent RHD. Methods: Our population included children who completed the GOAL Trial, a randomized controlled trial of secondary antibiotic prophylaxis among children with latent RHD in Uganda. These children underwent echo at enrollment and study completion, with rigorous blinded adjudication by a 4-member panel to establish diagnosis. We applied a point-based risk score developed from prior Brazilian and Ugandan cohorts, consisting of 5 variables (mitral valve (MV) anterior leaflet thickening (3 points), MV excessive leaflet tip motion (3), MV regurgitation jet length ≥2 cm (6), aortic valve focal thickening (4) and any aortic regurgitation (5)) to predict unfavorable outcome, defined as progression of diagnostic category (borderline to definite, definite mild valvular disease to definite moderate/severe disease) or remaining with definite RHD. Results: At total 801 patients (626 borderline and 175 definite RHD, mean age 12.5±2.9 years) were included, with median follow-up of 24 months. RHD progression was observed in 3 patients in the Penicillin group, vs. 33 in the control group, and overall, 386 patients regressed and 377 remained stable. The echo score was strongly associated with unfavorable outcome (OR: 1.25, 95% CI 1.15 - 1.36, p&lt;0.001). Unfavorable outcome rates in low (≤6 points), intermediate (7 - 9) and high-risk (≥10) children at follow-up were 12.2%, 31.1%, and 42.2%, (p&lt;0.001) respectively, with area under the ROC curve of 0.64 (95% CI 0.59 - 0.69). Among children without prophylaxis, the score had a similarly good performance: OR: 1.24 (95% CI 1.12 - 1.39), area under the ROC curve: 0.64 (95% CI 0.58 - 0.70). Conclusions: The simple risk score provided an accurate prediction of RHD status at 2-years, showing a good performance in a population with milder RHD phenotypes, with a potential value for global risk stratification.

Abstract 212: Artificial Intelligence To Predict Late Onset Cardiomyopathy Among Childhood Cancer Survivors Using Electrocardiogram, Echocardiogram, And Clinical Data

Objectives: Applying machine learning to predict the 10-year cardiomyopathy risk among adult survivors of childhood cancer. Methods: The St. Jude Lifetime Cohort Study (SJLIFE) is an ongoing study of adult survivors of childhood cancer with in-person clinical evaluations. ECG and ECHO data were obtained on participants who did not have cardiomyopathy (defined as left ventricular ejection fraction &lt; 50% or absolute drop from baseline ≥ 10%) at initial SJLIFE evaluation and who had at least two evaluations with ECHO screening. Predictors including ECG-AI based risk (cardiomyopathy risk from our previously develop AI model using ECG-alone), ECHO parameters, age, race, sex, BMI, primary cancer diagnosis, heart rate, respiratory rate, systolic and diastolic blood pressures, smoking, diabetes, hypertriglyceridemia, hypertension, or hypercholesterolemia. Light gradient boosting machines (LGBM) were applied to predict risk for cardiomyopathy using training (60%) and validation (20%) data. The hold-out (20%) data was used to evaluate predictive performance as sensitivity, specificity, precision, negative predictive value (NPV) and AUC. Shapley Additive exPlanations method (SHAP) was used to uncover predictors’ importance. Findings: The study population included 1,046 survivors with mean age±std of 32.2±8.0. The median time between baseline and follow-up evaluations was 5.2 years (0.5-9.5). In the hold out set, a model using ECHO parameters-only yielded an AUC of 0.68 (CI: 0.55-0.81), ECG-AI based risk alone yielded a hold-out test AUC of 0.87 (CI: 0.79-0.95), and an AUC of 0.89 (CI: 0.82-0.96) was obtained on LGBM model when ECG, ECHO, and clinical risk factors were used together. The final model classified cardiomyopathy with 80% sensitivity, 82% specificity, precision of 32%, and NPV of 98%. SHAP results showed that ECG-AI based risk, LV Global Longitudinal Peak Strain, LV Diastolic Volume, LV systolic volume, and cumulative anthracycline dose (&gt;200 mg/m 2 ) were associated with an increased risk, and LVOT Peak gradient was associated with decreased risk. Conclusion: Artificial intelligence-based analyses with ECG and ECHO images may aid in cardiomyopathy risk prediction for at-risk survivors of childhood cancer.

Chylothorax After Orthotopic Heart Transplant - A Rare Complication

<h3>Introduction</h3> A high output chylothorax is a therapeutic challenge and a cause of major morbidity due to persistent drainage of lymph, resulting in immune suppression, malnutrition and electrolyte abnormalities. Postop. chylothorax is rare (0.42% after general thoracic surgery). Chylothorax after thoracic organ transplant is very rare and mostly reported after lung transplant (1.38%) while after heart transplant it is extremely rare with only a handful of case reports. <h3>Case Report</h3> A 53yr old lady with Arrhythmogenic right ventricular dysfunction underwent orthotopic heart transplantation. She had multiple past ablations for VT and paroxysmal AF for which she was on Amiodarone. She also had a CRT device which was explanted at the time of transplant. Hypothyroidism& renal dysfunction were the other significant problems. Her transplant was complicated by primary graft dysfunction and bleeding from the right lower lobe of lung. Bronchoscopy did not reveal any cause. She was weaned off support and mobilised by the end of the 1st week. Immunosuppression and infection prophylaxis were as per institutional protocol. The chylothorax presented as large pericardial effusion and right pleural effusion on screening Echo and CXR done on postop day 7. This was confirmed on CT scan. Sub xiphoid drainage of pericardial effusion and intercostal drainage was done. The fluid was confirmed to be chyle with a triglyceride level of 8 mmol/l. The fluid was sterile. Low fat diet was started, in spite of which there was persistent drainage more than 500 ml /day. She was put on a more aggressive fat free, fruit only diet and s/c octreotide 100mcg 8 hrly. Drain output was closely monitored and surgery deferred considering the risks. Close monitoring of the nutritional status and dietary input was done. Slow but progressive decline in drainage permitted drain removal in three weeks. The dietary restrictions were eased over 3 to 4 months with no recurrence of leak. <h3>Summary</h3> Chylothorax is rare after heart transplantation. Prompt diagnosis and treatment are of paramount importance. Chyle leak is a challenge in these immunosuppressed patients given the concern for infection and the requirements of rigorous dietary modification. The risks of surgery have to be balanced against nutritional depletion and deconditioning. Close monitoring and multidisciplinary input is required for a successful outcome by conservative treatment.

Investigation of the Familial Risk of Rheumatic Heart Disease with Systematic Echocardiographic Screening: Data from the PROVAR+ Family Study.

We aimed to use echocardiographic (echo) screening to evaluate the risk of Rheumatic Heart Disease (RHD) among the relatives of patients with advanced RHD, who were enrolled in the University Hospital’s outpatient clinics from February 2020 to September 2021. Consenting first-degree relatives were invited for echo screening using handheld devices (GE VSCAN) by non-physicians, with remote interpretation. Matched controls (spouses, neighbors) living in the same household were enrolled in a 1:5 fashion. A standard echo (GE Vivid-IQ) was scheduled if abnormalities were observed. In 16 months, 226 relatives and 47 controls of 121 patients were screened, including 129 children, 77 siblings and 20 parents. The mean age was 40 ± 17 years, 67% of the patients were women, and 239 (88%) lived with the index case for >10 years. Echo findings suggestive of RHD were confirmed in zero controls and 14 (7.5%) relatives (p = 0.05): 11 patients had mild/moderate mitral regurgitation, and four were associated with mitral stenosis and abnormal morphology. Two patients had mild aortic regurgitation and abnormal morphology, which were associated with mild aortic and mitral stenosis, and two patients with advanced RHD had bioprostheses in the mitral (2) and aortic (1) positions. In conclusion, first-degree relatives of individuals with clinical RHD are at greater risk of having RHD, on top of socioeconomic conditions.

Echocardiographic surveillance of rheumatic heart disease in West and North Darfur compared with Kassala State: socioeconomic or genetic differences?

Rheumatic heart disease (RHD), a preventable complication of group A beta-haemolytic streptococcal infection, is highly prevalent in Sudan. Echocardiographic (echo) screening has an established role in disease surveillance. This study aims to measure the echo prevalence of RHD using handheld echo (HHE) in West and North Darfur and Kassala states and initiate control programs. School children 10-18 years of age were selected from the three states and HHE screening was performed by trained paediatric residents supervised by cardiologists using a pre-tested protocol. Health worker training and public awareness sessions were carried out. The study was conducted between November 2020 and December 2021. In West Darfur, 1,547 children were screened, echo prevalence was found to be 17.4/1,000, and 22% had moderate to severe disease. In North Darfur, 800 children were screened and echo prevalence was 16.2/1,000, 23% had moderate to severe disease while in Kasala 2,225 children were screened and the prevalence was 3.1/1,000 and all cases were mild. One hundred and fifty-eight health workers were trained and 20,150 people benefited from health education sessions. The prevalence of RHD in Darfur is 5 times more than in Kassala. This may reflect socioeconomic and genetic differences between the two regions. RHD control in Darfur needs to be consolidated, and echo surveillance is an important tool for early detection and the institution of secondary prophylaxis.

Echocardiography Screening for Diagnosis of Latent RHD Using Nurses: Is the Project Feasible for Nepal?

Rheumatic Heart Disease (RHD) is a preventable disease which occurs years or decades after the onset of Acute Rheumatic Fever (ARF) in childhood. The prevalence of RHD is still high in Nepal, with most cases of latent RHD concentrated in the rural, resource-limited setting. The sequelae of latent RHD cases often manifest decades later, causing a significant burden on the health system. Training of non-experts with simple protocols in such remote setting for screening of latent RHD is showing promising results worldwide. Screening of latent RHD is advocated in RHD endemic areas where early detection by echo screening can alleviate a massive burden on morbidity and mortality in the future. More research is needed to explore this possibility in the context of an endemic country like Nepal to tackle the burden of RHD.

Abstract 11802: Evaluation of Family Risk of Rheumatic Heart Disease With Systematic Echocardiographic Screening: Data From the Provar+ Study

Introduction: Rheumatic Heart Disease (RHD) is determined by a complex interaction between socioeconomic environment and host susceptibility. Relatives of patients with advanced RHD share both, and may be at high-risk. We aimed to use echocardiographic (echo) family screening to evaluate the risk of RHD among 1 st degree relatives of patients with advanced RHD. Methods: From Feb 2020 - Jun 2021 patients with advanced RHD were consecutively enrolled in the University Hospital’s outpatient clinics. Consented 1 st degree relatives were invited for echo screening (2012 World Heart Federation Criteria) utilizing handheld devices (GE VSCAN) by non-physicians, with telemedicine interpretation by 2 experts. Matched controls (spouses, neighbors) living in the same household were also enrolled in a 1:5 fashion. A confirmatory full echo (GE Vivid IQ) was scheduled if abnormalities were observed, and all positive RHD cases were referred for follow-up. Results: In 16 months, 202 relatives and 42 controls of 117 patients were screened, including 114 children, 68 siblings and 20 parents. Mean age was 41±18 years, 62% were women and 214 (88%) lived with the index case for &gt;10 years. At total 51 (21%) individuals had hypertension, 17 (7%) diabetes, 5 reported a previous stroke and only 5 (all relatives) had personal history of RHD. Among index cases, 73% reported current or past prescription of Penicillin. Echo findings suggestive of RHD were observed in 0 controls and 14 (7%) relatives (p=0.08), being 11 with mitral valve (MV) disease and 3 with mixed (mitral and aortic valve (AV)) disease. Eleven patients had mild/moderate MV regurgitation, 4 with associated MV stenosis and abnormal morphology. Two patients had mild AV regurgitation and abnormal AV morphology, associated with mild AV and MV stenosis, and 1 patient had bioprostheses in the MV and AV. One case of mild left ventricular dysfunction was observed, and 1 patient had indication of commissurotomy for MV stenosis at the time of diagnosis. Conclusions: First-degree relatives of individuals with clinical RHD are at greater risk of having RHD and family screening should be considered. Genotyping studies are warranted to better understand individual and family susceptibility to RHD, in addition to socioeconomic conditions.

Determining the Risk of Developing Rheumatic Heart Disease Following a Negative Screening Echocardiogram.

Background: Screening echocardiograms can detect early-stage rheumatic heart disease (RHD), offering a chance to limit progression. Implementation of screening programs is challenging and requires further research. This is the first large-scale study assessing the risk of RHD among previous screen-negative children.Methods: This retrospective cohort study, conducted in Gulu, Uganda, performed school-based echo screening on children ages 5–18 years. Surveys were used to determine which children underwent initial screening 3–5 years prior. Age, gender, and disease severity were compared between cohorts. Relative risk (RR) of RHD was calculated for those with a prior screen-negative echo (exposed cohort) compared to those undergoing first screening (unexposed cohort).Results: Echo screening was completed in 75,708 children; 226 were excluded, leaving 1,582 in the exposed cohort and 73,900 in the unexposed cohort. Prevalence of new RHD was 0.6% (10/1,582) and 1% (737/73,900), in the exposed and unexposed cohorts, respectively. The RR of RHD was 0.64 (95% CI 0.3–1.2, p = 0.15), a nearly 40% reduced risk of RHD in those with a prior negative echo. There was no difference in age or gender between RHD cohorts. All cases in the exposed cohort were borderline/mild; 2.6% of cases in the unexposed cohort had moderate/severe disease.Conclusion: There was no statistical difference in RHD prevalence between previous screen-negative children and children with no prior echocardiogram, however, there was a trend toward decreased risk and severity. This information has important implications for the design of screening programs and the use of screening echocardiograms in endemic RHD regions.