Simpson's Method Research Articles

Detection of Early Cardiac Affection in Post-COVID Syndrome Using Heart Rate Variability and 2D Global Longitudinal Strain Echocardiographic Assessment of the Left Ventricle

Abstract Aim and objectives The aim of our study is to estimate the Heart Rate Variability (HRV) & two-dimensional global longitudinal strain (GLS) by speckle tracking echocardiography (2D STE) in post-COVID-19 patients after mild to moderate acute SARS COV-2 infection. Patients and Methods This study included fifty consecutive subjects between 17 & 82 years of age who were symptomatic after three weeks up to 3 months of experiencing mild to moderate COVID19 illness according to the CDC criteria of severity. Patients enrolled were coming for follow-up clinic visits at Ain Shams University Hospitals between June 2021- Jan2022. All patients had normal LVEF upon enrollment as assessed by M-mode and Modified Simpson's method. 2D Left Ventricular Global Longitudinal Strain (GLS) and 24-hours Holter monitoring were performed for all patients. Results The LVGLS and HRV were significantly impaired in the symptomatic post-COVID-19. LVGLS was below -16 in 20% of the patients while 22% were in the grey zone; between -18 and -16. SDNN was decreased (< 100 msec) in 24% of the patients. RMSSD values favored a mean below 40 msec with prevalence of 58% among the study population. LF/HF ratio was above 2 in 42% of the patients. Our research suggested a highly significant association between LVGLS and HRV; as 66.7% of patients with decreased SDNN had impaired LVGLS, as opposed to 33% who had normal LVGLS (p-value 0.000) Conclusion LVGLS measured by Speckle Tracking Echocardiography (STE) is an important bedside tool, alternative to CMR which is the gold standard, in assessing LV systolic functions post COVID-19. HRV can explain a lot of post- COVID symptoms attributed to dysautonomia. In our study, we targeted the patients having prolonged symptoms after COVID-19 illness, GLS and HRV were assessed trying to explain the cardiac involvement and if it is the cause of the so called" long COVID". We found high incidence of GLS impairment using STE as well as significant prevalence of diminished HRV. HRV (especially SDNN) and GLS were significantly correlated as 80% of the patients with impaired GLS had decreased SDNN (p-value 0.00).

CT coronary angiography as an alternative imaging method to ascertain cardiac output and its correlation with echocardiography

To assess the feasibility and accuracy of cardiac output (CO) obtained using a test bolus in patients scanned with single-source prospective-gated cardiac computed tomography (CT), and comparing it with CO obtained from unenhanced two-dimensional (2D) echocardiography using biplane Simpson's method. In the present study, 100 patients with a mean age of 55±12 years who underwent coronary CT angiography with prospective electrocardiogram (ECG)-gated CT in which the scan delay was evaluated using a test bolus. The time-attenuation curves obtained from the test bolus were used to calculate the CO of the patients. The CO obtained was then compared with that obtained after follow-up 2D echocardiography using biplane modified Simpson method. Linear regression was calculated between the CO and contrast enhancement: CO=-0.16(HUmax)+7.65. The study showed good correlation between the two methods with r=0.77, p<0.001. On Bland-Altman analysis, no significant difference was noted between the two methods. This less researched method for CO estimation appears feasible; however, the clinical usefulness of this parameter is uncertain in absence of further clinical and reference standard validation.

Identification of factors associated with progression of left atrial enlargement in patients with atrial fibrillation.

Left atrial (LA) enlargement frequently occurs in atrial fibrillation (AF) patients, and this enlargement is associated with the development of heart failure, thromboembolism, or atrial functional mitral regurgitation (AFMR). AF patients can develop LA enlargement over time, but its progression depends on the individual. So far, the factors that cause progressive LA enlargement in AF patients have thus not been elucidated, so that the aim of this study was to identify the factors associated with the progression of LA enlargement in AF patients. We studied 100 patients with persistent or permanent AF (aged: 67±2 years, 40 females). Echocardiography was performed at baseline and 12 (5-30) months after follow-up. LA size was evaluated as the LA volume index which was calculated with the biplane modified Simpson's method from apical four-and two-chamber views, and then normalized to the body surface area (LAVI). The deterioration of AFMR after follow-up was defined as a deterioration in severity of mitral regurgitation (MR) by a grade of 1 or more. Multivariate regression analysis demonstrated that hypertension (p=.03) was an independently associated parameter of progressive LA enlargement, as was baseline LAVI. In addition, the Kaplan-Meier curve indicated that patients with hypertension tended to show greater deterioration of AFMR after follow-up than those without hypertension (log-rank p=.08). Hypertension proved to be strongly associated with progression of LA enlargement over time in patients with AF. Our findings provide new insights for better management of patients with AF to prevent the development of AFMR.

Ejection Fraction Estimation from Echocardiograms Using Optimal Left Ventricle Feature Extraction Based on Clinical Methods.

Echocardiography is one of the imaging systems most often utilized for assessing heart anatomy and function. Left ventricle ejection fraction (LVEF) is an important clinical variable assessed from echocardiography via the measurement of left ventricle (LV) parameters. Significant inter-observer and intra-observer variability is seen when LVEF is quantified by cardiologists using huge echocardiography data. Machine learning algorithms have the capability to analyze such extensive datasets and identify intricate patterns of structure and function of the heart that highly skilled observers might overlook, hence paving the way for computer-assisted diagnostics in this field. In this study, LV segmentation is performed on echocardiogram data followed by feature extraction from the left ventricle based on clinical methods. The extracted features are then subjected to analysis using both neural networks and traditional machine learning algorithms to estimate the LVEF. The results indicate that employing machine learning techniques on the extracted features from the left ventricle leads to higher accuracy than the utilization of Simpson's method for estimating the LVEF. The evaluations are performed on a publicly available echocardiogram dataset, EchoNet-Dynamic. The best results are obtained when DeepLab, a convolutional neural network architecture, is used for LV segmentation along with Long Short-Term Memory Networks (LSTM) for the regression of LVEF, obtaining a dice similarity coefficient of 0.92 and a mean absolute error of 5.736%.

Diagnostic challenges of heart failure with preserved ejection fraction: focus on echocardiography

Aim. To assess the features of diagnosing heart failure with preserved ejection fraction (HFpEF) using echocardiographic markers and diastolic stress test (DST) according to a survey of ultrasound and functional diagnostics specialists in the Russian Federation.Materials and methods. As part of the study, an anonymous survey of 155 ultrasound and functional diagnostic specialists from various Russian regions was conducted. We proposed to answer whether they routinely assess certain echocardiographic parameters necessary for diagnosing HFpEF. The specialists also indicated whether they conduct DST and whether they have the opportunity to refer the patient to this study.Results. A frequency analysis of the responses received was carried out. In routine practice, 83,2% of specialists measure the left ventricular (LV) ejection fraction by Simpson method, 76,1% — by Teichholz method. In addition, 80% of responders analyses LV mass index, 76,1% — relative LV wall thickness, 60% — tricuspid annular plane systolic excursion, 56,8% — left atrial volume index, 51.6% — E/e´ ratio, 94,8% — pulmonary artery systolic pressure, left ventricular global longitudinal strain — 16,1%, 7,7% — left atrial longitudinal strain. Also, 9,7% of specialists conduct DST on their own, while 41,3% have the opportunity to refer patients.Conclusion. The low assessment rate of some ultrasonic HFpEF mar­kers and DST among functional diagnostics specialists in the Russian Federation reduces the detection rate of HFpEF. It is necessary to develop diagnostic algorithms based mainly on clinical and anam­nestic data and available for use by doctors of any specialty.

#6067 GUT MICROBE-DERIVED UREMIC TOXIN TRIMETHYLAMINE N-OXIDE CONTRIBUTES TO CARDIAC REMODELING IN PATIENTS ON HEMODIALYSIS

Abstract Background and Aims It is well established that cardiovascular pathology is the leading cause of increased morbidity and mortality in chronic kidney disease patients, especially in the terminal stage. This is explained by high prevalence of both traditional and non-traditional cardiovascular risk factors, among which inflammation, intestinal dysbiosis and microbe-derived uremic toxins such as indoxyl sulfate, p-cresyl sulfate, trimethylamine-N-oxide (TMAO) are recently considered the most significant. However, the potential underlying mechanisms of these findings have not been fully elucidated. Here we aimed to investigate the association of serum TMAO with echocardiographic parameters of cardiac remodeling in patients receiving hemodialysis treatment. Method One hundred and forty (85M, 55F) clinically stable patients on dialysis were studied. The median (interquartile range) age was 56,5 (46,2-60,5) years, median duration of dialysis treatment – 48 (14,5-97) months, 39 (27,9%) were diabetic, 109 (77,9%) had high blood pressure, 39 (27,9%) – previous history of ischemic heart disease, including 8 (5,7%) suffered a myocardial infarction. All patients underwent transthoracic echocardiography (General Electric Vivid E95 device) with the registration of standard parameters. The determination of TMAO in serum was performed by LC/MS using a Shimadzu-8060 system combined with a Shimadzu LC-20AD liquid chromatograph. Statistical analysis was performed with STATISTICA 14.0 program. Non-parametric Spearman's rank correlation method was used to evaluate the associations between serum TMAO level and echocardiographic parameters. Value of p&amp;lt;0.05 was considered statistically significant in all analyses. Results Median serum TMAO was 5244 (3588-8701) ng/ml. Echocardiography data: end-systolic left ventricular (LV) size is 38,2±0,6 mm, end-systolic LV volume – 62,0±4,4 ml, end-diastolic LV size – 55,8 ±1,3 mm, end-diastolic LV volume – 111,5±19,7 ml, ejection fraction (according to Simpson method) – 53,2±7,2%, shortening fraction – 28,9±4,4%, inter-ventricular septum thickness – 11,6±0,2 mm, posterior wall thickness – 11,9 ± 0,1 mm, LV mass index – 142,8±4,6 g/m2, LV mass – 298,6±8,8 g, relative wall thickness – 0,43±0,3, number of patients with LV remodeling or hypertrophy – 98 (70%). LV diastolic function parameters (n = 113): E – 0,69±0,2 m/s, A – 0,79±0,2 m/s, E/A (early (E) to late (A) ventricular filling ratio) – 0,89±0,2, deceleration time (DT) – 211±52 ms, number of patients with diastolic disfunction – 104 (74,3%). Statistically significant correlation was fount between TMAO concentration and end-diastolic LV volume (r = 0,315; р = 0,028), LV mass (r = 0,409; р = 0,011) and DT (r = 0,272; р = 0,041). TMAO levels in individuals with LV myocardial hypertrophy and diastolic dysfunction was significantly higher than without these abnormalities (Mann–Whitney U-test р = 0,037 and р = 0,043, correspondingly). Conclusion Our results suggest that elevated TMAO may contribute to cardiac remodeling in hemodialysis patients through the myocardial fibrosis and hypertrophy. The pathophysiological mechanisms of TMAO must be investigated further for a better understanding of its role in cardiovascular disease progression and to develop therapeutic interventions against uremic toxicity.

Significant dependency of left atrial strain on left ventricular longitudinal motion.

The effects of left ventricular longitudinal function on the left atrial strain, including the left atrial reservoir function, have not been adequately quantified. A total of 124 patients who underwent echocardiography were enrolled in this study. Left atrial strain analysis was performed using two-dimensional speckle tracking echocardiography, and the left atrial volume was derived using the modified Simpson's method. The peak left atrial strain (LAS) and left atrial expansion index (LAEI), as indices of left atrial reservoir function, were measured. The global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE), which are indices of contractile motion toward the left ventricular apex, were also measured. The correlation between LAS and candidate determinants, including left ventricular systolic longitudinal function, was evaluated, and multivariate regression analysis was performed. A significant correlation was found between LAS and left ventricular systolic longitudinal functions, GLS (r = 0.63, p < 0.001), and MAPSE (r = 0.65, p < 0.001). Two models, which were selected by multiple regression analyses for LAS, included GLS or MAPSE as independent determinants. GLS and MAPSE were also the strongest predictors, among other factors. LAS, when determined by evaluating the left atrial reservoir function, was significantly associated with left ventricular function, especially the systolic longitudinal function. Left ventricular function should be considered when assessing left atrial function by LAS.

Thoracoscopic Radiofrequency Fragmentation of the Left Atrium as a Bridge to Decision Before Heart Transplant.

Atrial fibrillation and congestive heart failure can provoke and aggravate each other. Often the boundaries between those diseases are ambiguous, and successful diagnosis is initially elusive. However, the last stage of congestive heart failure can lead the patient to heart transplant. We suggested that restoration and stabilization of sinus rhythm could be used as a differential diagnostic criterion to distinguish dilated cardiomyopathy from atrial fibrillation. We investigated the possibility that thoracoscopic radiofrequency fragmentation of the left atrium could be a valid a bridge to decision before heart transplant in patients with the combination of atrial fibrillation and congestive heart failure with reduced left ventricular ejection fraction. The pilot study included 3 men who consecutively received thoracoscopic radiofrequency fragmentation of the left atrium from November 2021 to May 2022. All 3 patients had a combination of atrial fibrillation and congestive heart failure with a reduced ejection fraction and left ventricle dilatation (echocardiography, Simpson method: 31%, 33%, and 30%, respectively) despite receiving as highly as possible drug therapy and normalization of heart rate. The patients were 42, 38, and 55 years old, with rates of N-terminal pro-B-type natriuretic peptide of 3047, 2548, and 2542 pg/mL, respectively. The follow-up examination was performed every month. The total durations of the follow-up were 12, 9, and 7 months, respectively. By month 3 after the surgery, the left ventricular ejection fraction began to increase. By month 6 of follow-up, the left ventricular ejection fraction reached its maximum value and stabilized. All patients reported cessation of congestive heart failure symptoms. Thoracoscopic radiofrequency fragmentation of the left atrium can be considered a bridge to decision before heart transplant in patients with a combination of atrial fibrillation and congestive heart failure with reduced left ventricular ejection fraction.

Research on the measurement method of artillery recoil displacement based on acceleration integration

The measurement of artillery recoil displacement is investigated in this paper. Unlike most existing works in which optical measurements are susceptible to fire, smoke, and obstructions in the light propagation path, a measurement method based on acceleration integration is proposed in this paper. First, the recoil acceleration data is obtained by the acceleration sensor and data acquisition module, and then transmitted to the host computer for subsequent data processing. Then, the pre-processing methods including low-pass filter, effective data segment extraction, and cubic spline interpolation are utilized to handle the original recoil acceleration data. Afterward, the adaptive integration algorithm based on the Simpson method is proposed to integrate the pre-processed acceleration to obtain the recoil displacement, which improves the integration accuracy and reduces the amount of computation compared with other common integration methods. Finally, the performance of the proposed method used to measure the recoil displacement is verified through a simulation example and practical experiments.

P282 PAUCISYMPTOMATIC POST–COVID MYOCARDITIS IN A YOUNG ATHLETE DURING THE DIAGNOSTIC INVESTIGATIONS BEFORE RETURNING TO COMPETITIVE PRACTICE, POSSIBLE USEFULNESS OF THE GLS ANALYSIS

Abstract It is now known that the Covid19 infection can cause myocardial inflammatory damage. Several studies have shown that the echocardiographic parameter of the global longitudinal strain (GLS) was reduced compared to the general population even in paucisymptomatic patients. A young competitive athlete came to our observation for the diagnostic investigations before returning to competitive practice (return to play protocol) after Sars–Cov2 infection. The electrocardiogram did not show significant abnormalities as well as spirometry examination. Negative inflammation indexes and markers of myocardial damage were observed. The cycloergometer test showed no signs of myocardial distress, rapid chronotropic increase and dyspnea at 100W work load. HolterECG was performed showing 830 isolated ventricular ectopic beats. Echocardiographic examination showed preserved left ventricular systolic function (FEVS 59% – Simpson method) with a moderate reduction of GLS parameter –16,9%. The cardiopulmonary exercise test (CPET) showed an early anaerobic threshold and a normal pVO2max but not in line with the presumed range for a top–level athlete. Putting together the symptoms described, the CPET data and GLS parameter, despite the negative first–level investigations he underwent MRI that documented a myocardial edema in the mid–basal region of inferior and inferolateral walls of the left ventricle. Suitability for competitive practice was blocked, a gradual physical readaptation path was started and therapy with low–dose bisoprolol was set. An important clinical improvement is reported at the 6–month follow–up with evidence of normalization of the GLS parameter –23%. The CPET howed a realignment of the HR/VCO2 curve with a late threshold and increment of pVO2max. The 6–month control MRI examination showed almost no signs of myocardial inflammation and so the patient was made suitable for returning to competitive sport. In our case first–level investigations did not support any hypothesis of myocardial inflammation. The presence of stress symptoms confirmed by CPET data but especially the reduction of GLS parameter led to a deepening investigation with MRI that confirmed the presence of myocardial inflammatory lesion. Our case suggests that within a “return to play” protocol for athletes with recent SarsCov2 infection, the analysis of left ventricular systolic function by GLS may represent an additional useful element to be considered in support of standard investigations.

The Role of Myocardial Strain Imaging in the Pre- and Post-Operative Assessment of Patients with Single Ventricle.

The term "single ventricle" refers to a wide range of cardiac structural and functional abnormalities which cause the morphologically right or left ventricle to be hypoplastic or functionally inadequate. Patients with single-ventricle physiology have followed a series of palliative surgeries, resulting in the dominant ventricle supporting only the systemic circulation and the systemic venous return draining directly to the pulmonary arteries. Such patients present a progressive decline in myocardial performance, and their management is associated with high morbidity, mortality and resource usage. At each management step, imaging is critical in eligibility assessment, pre-procedural planning and prompt detection of myocardial dysfunction. However, the complex and asymmetric geometry of the dominant ventricle and its segmental wall motion abnormalities make the echocardiographic evaluation of myocardial performance in these patients rather challenging. Consequently, conventional 2-dimensional echo functional parameters, such as ejection fraction by Simpson's biplane method or shortening fraction by M-mode, is complex and often not feasible to apply. On the other hand, speckle-tracking echocardiography is angle and geometry independent and has better reproducibility. As such, it constitutes an appealing method for assessing myocardial function in patients with single-ventricle hearts. Therefore, this review aims to investigate the role of myocardial strain imaging by speckle-tracking echocardiography in the pre-and post-operative assessment of patients with single-ventricle hearts.

Conduction system pacing improves the outcomes on patients with high percentage of ventricular pacing and heart failure with mildly reduced ejection fraction.

This study aimed to investigate the efficacy and safety of CSP in patients with a high percentage of ventricular pacing and heart failure with HFmrEF. Patients who underwent CSP for HFmrEF and ventricular pacing >40% were consecutively enrolled from January 2018 to May 2021. All participants were followed up at least 12 months. Clinical data including cardiac performance and lead outcomes were compared before and after the procedure. Left ventricular ejection fraction (LVEF) was measured using the biplane Simpson's method. HFmrEF was defined as heart failure with the LVEF ranging from 41%-49%. CSP was successfully performed in 64 cases (96.97%), which included 16 cases of left bundle branch pacing (LBBP) and 48 cases of His bundle pacing (HBP). After a mean of 23.12 ± 8.17 months follow-up, NYHA classification (P < 0.001), LVEF (42.45 ± 1.84% vs. 49.97 ± 3.57%, P < 0.001) and left ventricular end diastolic diameter (LVEDD) (55.59 ± 6.17 mm vs. 51.66 ± 3.48 mm, P < 0.001) improved significantly. During follow-up, more than half (39/64,60.9%) of patients returned to normal LVEF and LVEDD with complete reverse remodeling. The pacing threshold in LBBP was lower (0.90 ± 0.27 V@0.4 ms vs. 1.61 ± 0.71 V@0.4 ms, P < 0.001) than that in HBP. No perforation, electrode dislodging, thrombosis or infection was observed during follow-up. CSP could improve the clinical outcomes in patients with HFmrEF and a high percentage of ventricular pacing. LBBP might be a better choice because of its feasibility and safety, especially in patients with infranodal atrioventricular block.

Abstract #1413268: Prevalence of LV Diastolic Dysfunction in Patients of Type 2 Diabetes Mellitus with a Normal Systolic Function

To determine the incidence of LVDD in T2DM having a normal LV systolic function. The observational study was done to have an idea of the burden of underlying silent myocardial abnormality of heart failure with a preserved ejection fraction in T2DM. The aim of this study was to determine the prevalence of LVDD in a normotensive T2DM population with a preserved LVEF and importance of initiating early therapy with agents like SGLT2is Patients diagnosed with T2DM & disease duration of ≤2 years, on oral agents, underwent TTE and assessment of their LVEF and grading of LV diastolic dysfunction. LVEF was calculated by Simpson's method and LVEF ≥50% was considered as normal. All those having E:e' ≤8, (Grade I LV diastolic dysfunction/impaired relaxation) assessed by TDI were shortlisted. TTE and Doppler imaging, to assess left ventricular systolic and diastolic function was done. Echocardiography was performed by harmonic imaging mode by Acuson-Siemens-X 300 machine's cardiac probe according to the standard protocol. Exclusion criteria was for subjects with hypertension/on antihypertensives, evidence of CAD [excluded by history of angina, chest pain, ECG changes and abnormal TMT results], subjects with evidence of valvular disease, on insulin and HbA1c >9%. A total of 2,150 cases were assessed with the inclusion criteria stated above at the hospital, over a period of 4 years. Of the 2,150 cases included 56% (1204) were males, and 44% (946) were females. 72% (1548), [59% males and 41% females] had Grade I LV diastolic dysfunction. A normal pulse pressure (≤50 mm Hg) was observed in 580 patients (27%). The study concludes that there is a huge prevalence of LV diastolic dysfunction, in T2DM patients, which is an important risk factor increasing cardiac mortality, if not corrected early. As there is a strong evidence of the benefits of SGLT2is in reducing mortality and hospitalisation for heart failure in patients of T2DM with a preserved LVEF all these patients should be treated with them added on to OADs and LSM, unless contraindicated.

Left Ventricular Hypertrophy and Clinical Outcomes in Heart Failure Patients Based on Hypertension Subtypes: Insights from a Tertiary Hospital Heart Failure Registry in Malang, Indonesia

Background Left ventricular hypertrophy (LVH) is a maladaptive response to chronic pressure overload and an important risk factor sudden death in patients with heart failure. Previous studies show that LVH is a risk factor for systolic heart failure. It’s interesting to examine whether Isolated Systolic Hypertension (ISH) in the presence of LVH contribute to clinical outcome. Objective: The aims of this study to examined association of ISH with cardiovascular outcomes and to examined associations of ISH and LVH in Heart failure registry patient Methods: A total of 120 subject’s were collected from Saiful Anwar Heart Failure Registry from January 2019 to December 2019. All participants were individually interviewed with a structured questionnaire for collecting baseline characteristic. Subject were classified into 2 group of hypertension (ISH and Systolic Diastolic Hypertension (SDH)). ISH based on the criteria of SBP ≥ 140 and DBP &lt; 90 mmHg and SDH based on SBP ≥ 140 and DBP ≥ 90 mmHg. The EF and volumes were measured with 2D-biplane Simpson's method by measured as a standart manner Result’s: ISH commonly found among older hypertensive patients than SDH (Mean age 61,23±11,2 yo vs 53,52±11,1 yo, respectively, p&lt;0,04)). LVH was more prevalence among ISH than SDH. No difference in clinical outcome such as in hospital mortality, Rehospitalization, and Lengt of stay were observed in both groups. Complication of hypertension was similar in both groups such as stroke, Myocardial Infarct, and Chronic Kidney Disease. Intrestingly, no difference also observe in compliance to the drug between ISH and SDH. We also examined subgroup analysis of subject’s with ISH. There was no statistically significant difference in clinical outcome between ISH with LVH and ISH without LVH. Conclusion: In this study, we suggest that ISH more common in older patient with HF than SDH but had similar associations with cardiovascular mortality and rehospitalization. ISH was associated with a higher prevalence of left ventricular hypertrophy than SDH.

Comparison of visual estimation and quantitative measurement of left ventricular ejection fraction in untrained perioperative echocardiographers

BackgroundPerioperative evaluation of the left ventricular systolic function is essential information to help diagnose and manage life-threatening perioperative emergencies. Although quantifying the left ventricular ejection fraction (LVEF) is recommended to determine the left ventricular function, it may not always be feasible in emergency perioperative settings. This study compared the visual estimation of LVEF (eyeballing) by noncardiac anesthesiologists with the quantitative LVEF measured using a modified Simpson’s biplane method.MethodsTransesophageal echocardiographic (TEE) studies of 35 patients were selected and 3 different echocardiographic views (the mid-esophageal four chamber view, the mid-esophageal two chamber view, and the transgastric mid-papillary short axis view) were recovered from each study and displayed in random order. Two cardiac anesthesiologists certified in perioperative echocardiography independently measured LVEF using the modified Simpson method and categorized LVEF into five grades: hyperdynamic LVEF, normal, mildly reduced LVEF, moderately reduced LVEF and severely reduced LVEF. Seven noncardiac anesthesiologists with limited experience in echocardiography also reviewed the same TEE studies and estimated the LVEF and graded LV function. The precision of the LV function classification and the correlation between visual estimation of LVEF and quantitative LVEF were calculated. The agreement of measurements between the two methods was also assessed.ResultsPearson’s correlation between the LVEF estimated by the participants and the quantitative LVEF using the modified Simpson method was 0.818 (p < 0.001). Of a total of 245 responses, 120 (49.0%) responses were correct grading of the LV function. Participants were able to classify the LV function more accurately in the LV function grades 1 and 5 (65.3%). The 95% level of agreement of the Bland-Altman method was − 11.3-24.5. -21.9-22.6, − 23.1-26.5, − 20.5-22.0 and − 26.6-11.1 for LV grade 1 to 5, respectively.ConclusionVisual estimation of LVEF in perioperative TEE has acceptable accuracy in untrained echocardiographers and can be used for rescue TEE.

Most Common Risk Factors Associated with Peripartum Cardiomyopathy amongst Kurdish Population

Background: Peripartum cardiomyopathy (PPCM) is idiopathic cardiomyopathy that presents during the last trimester or the first several months after delivery and it is a serious complication of pregnancy. Objectives: The aim was to assess the most common risk factors seen among pregnant women leading to PPCM and factors that are associated with better outcomes after therapy. Materials and Methods: A total of 20 patients who presented to the outpatient cardiology clinic and fulfilled the diagnostic criteria of the European Society of Cardiology were recruited to participate in the study. A detailed history was obtained and left ventricular measurements were evaluated using M-mode, 2-dimentional, and Simpson methods to estimate the ejection fraction. Data were analyzed using the Statistical Package for the Social Sciences. Results: Mean age at diagnosis was 34.7 ± 5.2 years. Multiparous women constituted 60% of the study sample. Gestational age at presentation ranged between 28 and 38 weeks, with a mean of 32.9 ± 2.6. Being overweight was a common feature as 60% of patients had above-normal body mass index. Family history was reported in 50% of patients, followed by passive smoking (35%), hypertension (25%), thyroid disorders (30%), and type II diabetes mellitus (20%). The mean left ventricular ejection fraction at the time of diagnosis was 32.3% ± 6.7% with an increase to 44.2% ± 8.9% at follow-up. Younger patients were more likely to regain normal left ventricular function following diagnosis (P = 0.005). Conclusion: These preliminary results strongly demonstrate that advanced maternal age, anemia, multiparity, and family history were the most common risk factors seen among our population.

Single-Site Experience with an Automated Artificial Intelligence Application for Left Ventricular Ejection Fraction Measurement in Echocardiography

Left ventricular ejection fraction (LVEF) is a key parameter in evaluating left ventricular (LV) function using echocardiography (Echo), but its manual measurement by the modified biplane Simpson (MBS) method is time consuming and operator dependent. We investigated the feasibility of a server-based, commercially available and ready-to use-artificial intelligence (AI) application based on convolutional neural network methods that integrate fully automatic view selection and measurement of LVEF from an entire Echo exam into a single workflow. We prospectively enrolled 1083 consecutive patients who had been referred to Echo for diagnostic or therapeutic purposes. LVEF was measured independently using MBS and AI. Test-retest variability was assessed in 40 patients. The reliability, repeatability, and time efficiency of LVEF measurements were compared between the two methods. Overall, 889 Echos were analyzed by cardiologists with the MBS method and by the AI. Over the study period of 10 weeks, the feasibility of both automatic view classification and seamlessly measured LVEF rose to 81% without user involvement. LVEF, LV end-diastolic and end-systolic volumes correlated strongly between MBS and AI (R = 0.87, 0.89 and 0.93, p < 0.001 for all) with a mean bias of +4.5% EF, -12 mL and -11 mL, respectively, due to impaired image quality and the extent of LV function. Repeatability and reliability of LVEF measurement (n = 40, test-retest) by AI was excellent compared to MBS (coefficient of variation: 3.2% vs. 5.9%), although the median analysis time of the AI was longer than that of the operator-dependent MBS method (258 s vs. 171 s). This AI has succeeded in identifying apical LV views and measuring EF in one workflow with comparable results to the MBS method and shows excellent reproducibility. It offers realistic perspectives for fully automated AI-based measurement of LVEF in routine clinical settings.

A Rare Case of Acute Stanford Type a Aortic Dissection Presenting with Anterior St-Elevation Myocardial Infarction

Abstract Introduction Aortic dissections occur as a result of a tear in the intimal layer, continued longitudinal splitting within the intima and media, and formation of false lumen. This could lead to sudden death or severe aortic regurgitation and cardiogenic shock. The presented case here describes a patient with acute anterior ST-elevation myocardial infarction due to acute Stanford type A ascending aortic dissection. Case presentation A 55-year-old male presented with severe chest pain, radiating into the back, jaw, and left arm, and signs of cardiogenic shock. Electrocardiography showed acute anterior ST-elevation myocardial infarction and echocardiography confirmed that there was a reduced left ventricle ejection fraction (38% calculated using the Simpson method), severe aortic regurgitation, and wall motion abnormalities. Based on these findings, we made a diagnosis of acute myocardial infarction. In accordance with the current guidelines, we opted for an interventional therapeutic approach. Angiography showed left main trunk dissection extending to the left anterior descending coronary artery caused by ascending aorta dissection. This finding altered the diagnosis and treatment plan and the patient was immediately sent to the operating room for emergency surgery. Conclusions Aortic dissection should be suspected in patients presenting with acute anterior ST-elevation myocardial infarction, severe aortic regurgitation, and cardiogenic shock. Involvement of the left main trunk and left anterior descending artery occurs much more rarely than that of the right coronary artery, which causes inferior myocardial infarction.

Order of Convergence, Extensions of Newton–Simpson Method for Solving Nonlinear Equations and Their Dynamics

Local convergence of order three has been established for the Newton–Simpson method (NS), provided that derivatives up to order four exist. However, these derivatives may not exist and the NS can converge. For this reason, we recover the convergence order based only on the first two derivatives. Moreover, the semilocal convergence of NS and some of its extensions not given before is developed. Furthermore, the dynamics are explored for these methods with many illustrations. The study contains examples verifying the theoretical conditions.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.

Left ventricular lead delivery system used to implant right ventricular lead via persistent left superior vena cava.