Transthoracic Echocardiographic Study Research Articles

Abstract 4138386: Deep Learning-Enabled Assessment of Right Ventricular Function Using 2D Echocardiograms Improves 1-Year Mortality Prediction in Patients with Severe Mitral Regurgitation Undergoing Transcatheter Edge-to-Edge Repair

Background: Right ventricular (RV) function has a well-established prognostic role in patients with severe mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (TEER) and is typically assessed using echocardiography-measured tricuspid annular plane systolic excursion (TAPSE). Recently, a deep learning model has been proposed that accurately predicts RV ejection fraction (RVEF) from 2D echocardiographic videos, with similar diagnostic accuracy as 3D imaging. Aims: This study aimed to evaluate the prognostic utility of the deep learning-predicted RVEF values in patients with severe MR undergoing TEER. Methods: This multicenter registry study analyzed the associations between the predicted RVEF values and 1-year mortality in patients with severe MR undergoing TEER. To predict RVEF, 2D apical four-chamber view videos from preprocedural transthoracic echocardiographic studies were exported and processed by a rigorously validated deep learning model. Results: From 1,366 patients undergoing TEER between 2017 and 2023, good-quality 2D apical four-chamber view videos could be retrieved for 1,154 patients (84.5%). Survival at one year after TEER was 84.7%. The predicted RVEF values ranged from 26.6% to 64.0% and correlated only modestly with TAPSE (Pearson correlation coefficient R: 0.33; p -value: <0.001). Importantly, predicted RVEF levels were superior to TAPSE levels in predicting 1-year mortality after TEER (area under the curve: 0.687 vs. 0.625; p -value: 0.029). Furthermore, Kaplan-Meier survival analysis revealed that patients with preserved RV function (defined as a predicted RVEF of ≥45%) had significantly better 1-year survival rates than patients with reduced RV function (92.1% [95% CI: 89.5-94.7%] vs. 80.3% [95% CI: 77.4-83.3%], respectively, hazard ratio for 1-year mortality: 2.67, p -value: <0.001). Conclusion: Deep learning-enabled assessment of RV function using standard 2D echocardiographic videos can refine the prognostication of patients with severe MR undergoing TEER. Thus, it can be used to screen for patients with RV dysfunction who might benefit from intensified follow-up care.

New left ventricular thrombus and embolic events in left ventricular dysfunction postmyocardial infarction

Background: We aimed to assess the incidence and evolution of new left ventricular thrombus (LVT), and the incidence of manifest systemic embolism, in patients with severe left ventricular (LV) systolic dysfunction postacute anterior myocardial infarction (MI) who had been discharged on dual antiplatelet therapy. Methods: We prospectively included consecutive patients with postacute anterior MI and LV ejection fraction (LVEF) ≤35% or apical aneurysms or large infarctions with LVEF ≤40%. Transthoracic echocardiography (TTE) confirmed no LVT before hospital discharge, and a second TTE was performed at 30 days and a third one at 3 months. All TTE studies were prespecified to assess LVT, and the patients were screened for the development of clinically manifest systemic embolisms. Results: Two hundred and two consecutive patients (males 93%; mean age 55.2±6.4 years; mean LVEF 29.5±5.0%) were included. At 30 days (interquartile range: 2837 days), a new LVT was detected in 12 (5.9%) patients. Oral anticoagulant was added to all patients with LVT, and aspirin was continued in 5 (42.7%) patients for a month. The 3month TTE showed favorable evolution of LV size, LVEF and apical wall motion score index compared to the baseline. At 3 months, the LVT disappeared in 7 (58.3%) patients and 5 patients still had a mural LVT of smaller size, and none got new LVT. Among the group without LVT, one patient had a stroke, and another had a myocardial infarction and died. Conclusions: In contemporary practice, and using routine TTE, the incidence of new LVT in patients with severe LV dysfunction postacute anterior MI is low. They have a favorable LVT evolution with minor risk for clinically manifest systemic embolism.

The impact of spinal anesthesia on cardiac function in euvolemic vascular surgery patients: insights from echocardiography and biomarkers.

Existing evidence of the effect of spinal anesthesia (SA) on cardiac systolic function is scarce and inconclusive. This study aimed to evaluate the effects induced by a single injection of SA for elective vascular surgery on left (LV) and right (RV) ventricular systolic performance using transthoracic echocardiography (TTE). A prospective study. Single-center study, university hospital. Adult patients undergoing elective vascular surgery with SA. During patients' evaluations fluid administration was targeted using arterial waveform monitoring. All patients underwent TTE studies before and after SA induction for the assessment of indices reflective of LV and RV systolic function. Blood samples were drawn to measure troponin and brain natriuretic peptide (BNP) levels. A total of 62 patients (88.7% males, 71.00 ± 9.42 years) were included in the study. The primary outcome was the difference before and after SA in LV ejection fraction (LVEF) and tricuspid annular plane systolic excursion (TAPSE). In total population, LVEF significantly increased after SA 53.07% [16.51]vs 53.86% [13.28]; p < 0.001). End-systolic volume (ESV, 69.50 [51.50] vs. 65.00 [29.50] ml; p < 0.001) decreased while stroke volume (SV) insignificantly increased (70.51 ± 16.70 vs. 73.00 ± 18.76ml; p = 0.131) during SA. TAPSE remained unchanged (2.23 [0.56] vs. 2.25 [0.69] mm; p = 0.558). In patients with impaired compared to those with preserved LV systolic function, the changes evidenced in LVEF (7.49 ± 4.15 vs. 0.59 ± 2.79; p < 0.001), ESV (-18.13 ± 18.20 vs-1.53 ± 9.09; p < 0.001) and SV (8.71 ± 11.96 vs-1.43 ± 11.89; p = 0.002) were greater. This study provides evidence that SA in patients undergoing elective vascular surgery improved LV systolic function, while changes in RV systolic function are minimal.

Yield of Echocardiography with Bubble Studies Among Acute Ischemic Stroke Patients.

Background: Transthoracic (TTE) and transesophageal (TEE) echocardiographic studies with agitated saline, also known as "bubble studies" (BSs), are used to diagnose patent foramen ovales (PFOs) in cryptogenic strokes (CSs). Guidelines limit PFO closure recommendations to CS patients ≤ 60 but BSs are often performed as part of standard order sets, leading to inappropriate studies in older patients with already-established stroke etiologies. Methods: This retrospective single-center study included acute ischemic stroke patients between January 2021 and June 2022 and assessed the stroke etiology and number of the echocardiographic studies performed. Results: A total of 663 patients were admitted during this period with 413 (62.3%) classified as non-CS. Overall, 390 (58.8%) TTE and 40 (6.0%) TEE with BSs were conducted. Of that, non-CS patients received 252 TTE and 17 TEE with BSs. PFOs were diagnosed in 36 CS and 18 non-CS patients and 14 of the 15 PFO closures were performed in the CS patients for primary stroke prevention. The one closure in the non-CS patient was performed in conjunction with the open excision of a mitral valve mass. Conclusions: Therefore, the majority of the BSs performed in non-CS patients yielded no change in management. Our study identifies a large volume of diagnostic studies that are not supported by current clinical guidelines and instead, may contribute to healthcare waste. A new institutional protocol should be established to improve operational efficiency and reduce the downstream implications of diagnostic overuse in ischemic stroke care.

LV reverse remodeling after SAVR in patients with severe symptomatic aortic stenosis: impact on the clinical outcome

Abstract Introduction Surgical aortic valve replacement (SAVR) is the treatment of choice for young patients with severe aortic stenosis (AS) and low surgical risk. Left ventricular (LV) reverse remodeling (RR) after surgery is expected to occur. However, this is not always the case following afterload relief, and this may impact the prognosis. We aimed to assess the prognostic effect of distinct definitions of LV RR after SAVR in the long-term outcome of patients with severe AS. Methods Single-centre prospective study including patients referred for SAVR due to severe symptomatic AS, with no previous history of ischemic cardiomyopathy. Both pre- and post-operative transthoracic echocardiographic (TTE) and cardiac magnetic resonance (CMR) study (at the 3rd to 6th month after SAVR) were performed. LV RR was defined when in presence of at least one of the imaging criteria: &amp;gt;15% decrease in end-diastolic volume (EDV) by CMR; &amp;gt;15% decrease in LV indexed mass (LVM) by CMR; &amp;gt;10% decrease in geometric remodeling (LV mass/EDV ratio) by CMR; &amp;gt;10% increase in LV ejection fraction (LVEF) by CMR; &amp;gt;50% increase on global longitudinal strain (GLS) by TTE. We assess the prognostic value of RR definitions for the outcome after SAVR using Cox regression and Kaplan-Meier analysis. The primary endpoint was defined as all-cause mortality, heart failure (HF) hospitalization or worsening HF. Results We enrolled 140 patients – mean age 71±9 years-old, 49% male, predominantly high-gradient-normal flow AS (mean gradient 65±18mmHg, aortic valve area 0.7±0.2cm2, index stroke volume 47±11mL/m2) submitted to SAVR. At a mean follow-up (FUP) of 34±12 months, 23 (16%) patients met the primary endpoint: 4% (5 patients) died immediately after surgery; three patients died at the FUP (overall mortality rate of 6%). 12 patients (9%) were admitted for HF and 7 (5%) had at least one episode of worsening HF. 118 patients had complete pre and post-surgery imaging study (mean FUP: 36±10 months): 103 patients (87%) had at least one RR parameter (Table 1). Post-operative RR was not independently associated with the clinical outcome (Figure 1A). LVM was the sole independent predictor of the outcome at univariate analysis (Figure 1B–F). Conclusions LV RR after SAVR is highly prevalent in a cohort of patients with classical severe symptomatic AS. However, only LVM regression independently predicts the clinical outcome after surgery. This may stand the greater importance of structural reverse remodeling, rather than LV functional improvement, after pressure overload relief.

Echo triaging works. How to use international guidelines

Abstract Introduction Transthoracic echocardiography (TTE) is the first-choice non-invasive imaging modality for the assessment of cardiac structure and function due to its wide availability, speed, cost-effectiveness and reproducibility. Therefore, there is exponential increase in demand in TTE across all specialties in medicine and surgery. Hence, it is important to carefully triage patients according to current international guidelines. Purpose To reduce inappropriate TTE scans by using guideline driven indications in triaging echo scans in the UK tertiary hospital. Methods Strict list of guidelines driven indications adapted to local practice was used for triaging echo requests which included both inpatient and outpatient TTEs. The 4 objectives: appropriateness, completeness of requests as well as impact of performed studies on the follow-up and patient management plan were assessed before and after implementation of new triaging tool. To ensure similar working and staff environment was sustained we studied the pattern of referrals in the same month of the year- September. The triage process was conducted by accredited physiologists. The same month was chosen to reflect true change of practice. Change in patient management and follow up were evaluated for a minimum duration of 6-months. Results Overall there were 1112 TTEs performed in September 2022 and 1081 - in September 2023. Prospective TTE referral triaging began in March 2023. We have studied and analyzed above criteria retrospectively. In 2022 there were 18% inappropriate requests; 37% of requests lacked sufficient clinical information and 10% of studies did not lead to change in management plan according to clinical letters. There was also high proportion of inappropriate requests for inpatients (9%). Within 6 months of implementation there was a significant improvement in the appropriateness (82% vs. 99%, p&amp;lt;0.001), with increase in supply of adequate clinical information (63.4% vs. 86.1%, p&amp;lt;0.001). However, there was no significant change using TTE study results in changing patient management (10%). All inpatients had 100% appropriate requests. Conclusion The implementation of triage criteria resulted in a significant improvement in TTE referrals: both in appropriateness and completeness of requests. However, some clinicians did not use echo in patient management plan. Future research on lack of use of TTE results in clinical practice might help to utilize the limited echo capacity to full.

Predictors of adverse cardiac events in a large cohort of patients with antiphospholipid syndrome

Abstract Background Non-valvular cardiac disease in antiphospholipid syndrome (APS) has been modestly evaluated. Aim We wanted to assess the prevalence and evolution of major adverse cardiovascular events(MACE) in a cohort of APS patients. Material and Methods From a large cohort of 181 APS patients included in a study from 2011-2012.year data for the occurrence of MACE in 10 years of follow-up were evaluated in 82 patients (86.6% females, 62.2% with primary (PAPS), and 37.8% patients with APS associated with systemic lupus erythematosus (SLE) (sAPS)). At the inclusion in all patients, a transthoracic echocardiography study for the assessment of dimensions and functionality of the left and right heart along with valvular functions and morphology. Standard atherosclerotic risk factors prevalence was analyzed. Antiphospholipid antibodies(aPL) analysis included the detection of aCL (IgG/IgM), ß2GPI (IgG/IgM), and LA, and all patients were treated according to the valid guidelines by the rheumatologist. Data regarding the occurrence of new myocardial infarction (MI), cerebrovascular events (CVI), arterial and/or venous thrombosis, heart failure (HF), and cardiovascular death (considered as MACE) have been collected 10 years after inclusion. Results The prevalence of standard atherosclerotic risk factors was less than 40% in both study groups. Left ventricle ejection fraction(LVEF) was over 45% in more than 90% of patients in both groups (p=0.246) with valvular dysfunction present in 49% of PAPS and 58.1% of sAPS patients (p=0.426). 9.8% PAPS and 12.9% sAPS had coronary artery disease(CAD) (p=0.724) and HF was present in 7.8% PAPS and 3.2% sAPS (p=0.645). MACE occurred in 17.6% of PAPS and 22.6% of sAPS (p=0.585). The new MI occurred in 9.8% of PAPS and 9.7% of sAPS (p=1.000), CVI in 5.9% of PAPS and 3.2% of sAPS (p=1.000), HF in 5.9% of PAPS and 3.2% of sAPS (p=1.000) and cardiovascular death in 9.8% of PAPS and 12.9% of sAPS (p=0.724). New thrombotic events (arterial and/or venous) occurred in 15.7% of PAPS and 17.2% of sAPS (p=1.000). During the follow-up period, 66.7% of PAPS and 55.2% of SAPS (p=0.313) were treated with aspirin, 25.5% of PAPS and 25.0% of sAPS with warfarin, and chloroquine was administered in 46.8% of PAPS and 53.6% of sAPS (p=0.571). Age (p=0.008), gender (p=0.034), thrombotic APS (p=0.033), hypertension (p=0.003), diabetes mellitus (p=0.043), and cardiovascular manifestations present at the time of APS diagnosis (p=0.035), namely CAD (p=0.001) and HF (p=0.005) were significantly associated with 10y MACE. aPL type and category were not associated with 10y MACE. In a multivariate logistic model, age. hypertension, and HF were independent predictors for 10y MACE. Conclusions APS patients develop new cardiovascular events despite optimal medical therapy. Cardiovascular evaluation at the time of diagnosis and proper cardiologist follow-up with the rigorous treatment of standard atherosclerotic risk factors is of utmost importance.

Left ventricular global longitudinal strain is associated with filling pressure and cardiac output in an outpatient setting: Insights from CardioMEMS™

Introduction and objectivesLeft ventricular global longitudinal strain (LVGLS) is an indicator of myocardial function in patients with heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Nevertheless, it is not clear whether LVGLS correlates with filling pressures and cardiac output (CO) in an ambulatory setting. We aimed to assess whether LVGLS is associated with invasive pulmonary artery pressures (PAP) and CO in outpatients using the invasive remote monitoring CardioMEMS™ system. MethodsThis single-center, prospective observational study included patients with HFrEF undergoing remote monitoring using the CardioMEMS™ system, between January 2020 and December 2022. Repeated transthoracic echocardiography (TTE) studies were performed in each patient and invasive hemodynamic data were obtained during the TTE studies using the CardioMEMS™ system. Univariate and multivariate models were used to assess the potential association between LVGLS and invasive PAP and CO. ResultsTwelve patients were included and 46 TTE studies were analyzed. LVGLS was correlated with diastolic (d) PAP (r=0.403, p=0.041) and CO (r=−0.426, p=0.039) in the univariate analysis. In multivariate models, LVGLS was an independent predictor of dPAP and CO, but not mean PAP or systolic PAP. The variation of LVGLS between TTE studies was correlated with the variation of dPAP during follow-up (r=0.60, p=0.017). ConclusionsIn a cohort of HFrEF patients under invasive hemodynamic remote monitoring, LVGLS was independently associated with invasive filling pressures and CO, in an outpatient setting. These findings reinforce the value of LVGLS for the management of outpatients with HFrEF.

High-Throughput Deep Learning Detection of Mitral Regurgitation.

Diagnosis of mitral regurgitation (MR) requires careful evaluation by echocardiography with Doppler imaging. This study presents the development and validation of a fully automated deep learning pipeline for identifying apical 4-chamber view videos with color Doppler echocardiography and detecting clinically significant (moderate or severe) MR from transthoracic echocardiograms. A total of 58 614 transthoracic echocardiograms (2 587 538 videos) from Cedars-Sinai Medical Center were used to develop and test an automated pipeline to identify apical 4-chamber view videos with color Doppler across the mitral valve and then assess MR severity. The model was tested internally on a test set of 1800 studies (80 833 videos) from Cedars-Sinai Medical Center and externally evaluated in a geographically distinct cohort of 915 studies (46 890 videos) from Stanford Healthcare. In the held-out Cedars-Sinai Medical Center test set, the view classifier demonstrated an area under the curve (AUC) of 0.998 (0.998-0.999) and correctly identified 3452 of 3539 echocardiography videos as having color Doppler information across the mitral valve (sensitivity of 0.975 [0.968-0.982] and specificity of 0.999 [0.999-0.999] compared with manually curated videos). In the external test cohort from Stanford Healthcare, the view classifier correctly identified 1051 of 1055 manually curated videos with color Doppler information across the mitral valve (sensitivity of 0.996 [0.990-1.000] and specificity of 0.999 [0.999-0.999]). In the Cedars-Sinai Medical Center test cohort, MR moderate or greater in severity was detected with an AUC of 0.916 (0.899-0.932) and severe MR was detected with an AUC of 0.934 (0.913-0.953). In the Stanford Healthcare test cohort, the model detected MR moderate or greater in severity with an AUC of 0.951 (0.924-0.973) and severe MR with an AUC of 0.969 (0.946-0.987). In this study, a novel automated pipeline for identifying clinically significant MR from full transthoracic echocardiography studies demonstrated excellent performance across large numbers of studies and across multiple institutions. Such an approach has the potential for automated screening and surveillance of MR.

Effects of SGLT2 Inhibitors on Cardiac Mechanics in Hispanic and Black Diabetic Patients.

Background: Clinical trials demonstrating improved cardiovascular outcomes with SGLT2 inhibitors have often had limited representation from Black and Hispanic populations. While the mechanisms of action are not well known, ethnicity- or gender-based receptor physiology may render SGLT2 inhibitors a better agent in certain populations over others. Methods: A medical records query yielded diabetic patients initiated on SGLT2 inhibitors between 2013 and 2020. Patients with coronary artery disease, cardiac arrhythmias, and heart failure were excluded. Transthoracic echocardiographic studies (TTE) before and after starting SGLT2 inhibitors were analyzed, and post-processing left ventricular global longitudinal strain (LV GLS) analysis was also performed on each echocardiographic study. Univariate outliers and patients with missing data were excluded. Results: Among 94 patients with TTE (mean age 60.7 years; 68% Hispanics, 22.3% Blacks; median follow up of 7 months), there were significant improvements in the mean LV GLS (-15.3 vs. -16.5; p = 0.01), LV mass (LVM) (198.4 ± 59.6 g vs. 187.05 ± 50.6 g; p = 0.04), and LV mass index (LVMI) (100.6 ± 26.6 g/m2 vs. 94.3 ± 25.4 g/m2; p = 0.03) before and after initiating SGLT2 inhibitors but no significant change in the ratio (MV E/E') of peak early diastolic mitral flow velocity (E) and spectral pulsed-wave Doppler-derived early diastolic velocity from the septal mitral annulus (E') (12.5 ± 5.7 vs. 12.7 ± 4.8; p = 0.38). Changes in HbA1c (r2 = 0.82; p = 0.026), LVM (r2 = 0.20; p = 0.04), and LVMI (r2 = 0.20; p = 0.04) were found to be independently associated with changes in values of LV GLS on follow-up echocardiograms, when compared to the pre-medication LV GLS number. Conclusion: Non-White diabetic patients receiving SGLT2 inhibitors against a backdrop of other cardioprotective medications demonstrate significant improvements in LV remodeling and LV GLS, driven in part by an improvement in glycemic control. Large, prospective studies are needed to explore the differences in the therapeutic actions of SGLT2 inhibitors among different populations.

Therapeutic impact of basic critical care echocardiography performed by residents after limited training

BackgroundThe objective was to assess the agreement between therapeutic proposals derived from basic critical care echocardiography performed by novice operators in ultrasonography after a limited training (residents) and by experts considered as reference. Secondary objectives were to assess the agreement between operators’ answers to simple clinical questions and the concordance between basic two-dimensional measurements.MethodsThis observational, prospective, single-center study was conducted over a 3-year period in a medical-surgical intensive care unit. Adult patients with acute circulatory and/or respiratory failure requiring a transthoracic echocardiography (TTE) examination were studied. In each patient, a TTE was performed by a resident novice in ultrasonography after a short training program and by an expert, independently but within 1 h and in random order. Each operator addressed standardized simple clinical questions and subsequently proposed a therapeutic strategy based on a predefined algorithm.ResultsResidents performed an average of 33 TTE studies in 244 patients (156 men; age: 63 years [52–74]; SAPS2: 45 [34–59]; 182 (75%) mechanically ventilated). Agreement between the therapeutic proposals of residents and experienced operators was good-to-excellent. The concordance was excellent for suggesting fluid loading, inotrope or vasopressor support (all Kappa values > 0.80). Inter-observer agreement was only moderate when considering the indication of negative fluid balance (Kappa: 0.65; 95% CI 0.50–0.80), since residents proposed diuretics in 23 patients (9.5%) while their counterparts had the same suggestion in 35 patients (14.4%). Overall agreement of responses to simple clinical questions was also good-to-excellent. Intraclass correlation coefficient exceeded 0.75 for measurement of ventricular and inferior vena cava size.ConclusionsA limited training program aiming at acquiring the basic level in critical care echocardiography enables ICU residents novice in ultrasonography to propose therapeutic interventions with a good-to-excellent agreement with experienced operators.

Impairment in Right Ventricular-Pulmonary Arterial Coupling in Overweight and Obesity.

Background: The association of obesity with right ventricular function and the interplay between right heart and pulmonary circulation is incompletely understood. We evaluate the role of obesity as a determinant of right ventricular-pulmonary artery coupling (RVAC). Methods: We retrospectively studied consecutive subjects without overt cardiovascular or pulmonary disease. Subjects were stratified according to body mass index (BMI) as normal weight, overweight, or obese. A transthoracic echocardiographic study was used to assess left and right heart functional and structural parameters. RVAC was assessed using the ratio of peak systolic velocity of the tricuspid annulus to pulmonary artery systolic pressure (PASP). Results: A total of 145 subjects were enrolled with diabetes mellitus incidence higher in obese. There was no difference in left ventricular global longitudinal strain and in PASP or markers of right ventricular systolic function based on BMI. RVAC was significantly lower in the presence of obesity (normal weight: 0.52 (0.19) cm·(sec·mmHg)-1 vs. overweight: 0.47 (0.16) cm·(sec·mmHg)-1 vs. obese: 0.43 (0.14) cm·(sec·mmHg)-1, p = 0.03), even after adjustment for confounders (β: -0.085, 95% confidence interval: -0.163, -0.009, p = 0.029). Conclusions: Our findings highlight the relationship between metabolic impairment and RVAC, suggesting additional mechanisms for heart failure development observed in obese subjects.

Multielectrode catheter-based pulsed field ablation of persistent and long-standing persistent atrial fibrillation

Abstract Background Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. Purpose We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via the multielectrode FarawaveTM pulsed field ablation (PFA) catheter in patients with persistent AF sustained beyond 6 months (PerAF&amp;gt;6m) and long-standing persistent AF (LSPAF). Methods The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia (AT) regionalization and ablation (Stage 3). Results Seventy-two [age:68±10y, 61.1%males; AF history: 25 (18-45) months] patients with PerAF&amp;gt;6m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF termination occurred while ablating the mitral edge of the postero-lateral ridge (40.3%), the inferior left atrium above the proximal coronary sinus (27.4%), the interatrial septum (22.6%), the superior aspect of the postero-lateral ridge (6.5%), the base of the appendage (3.2%). AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The FarawaveTM catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit (Figure 1). Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112±25min and 59±22 min, respectively. Major complications occurred in 2 (2.8%) patients with pre-existing left ventricular systolic dysfunction (EF&amp;lt;35%) who required inotropic therapy due to acute heart failure. Hemodynamics normalized within 24h and both patients were discharged after 2 and 3 additional hospital days. Transient ST-segment elevation was documented in 4 patients after peri-mitral PFA; timely nitrate administration led to ECG normalization within 10 minutes. Single-procedure success rate was 81.8% after 13.3±1.9 months of follow-up; AF-free survival was 93.1% (Figure 2). A subgroup of 36 patients completed a follow-up transthoracic echocardiography study to assess left atrial mechanical contraction changes after ablation. Median A-wave velocity was 30 (IQR: 20-35) cm/s post-ablation and 50 (IQR: 41-70) cm/s after a mean of 7.3±1.8 months post-ablation. Conclusions In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favorable clinical outcomes were observed at one year of follow-up.Entrainment from the PFA Catheter.Kaplan-Meier Analysis.

CASE REPORT: SELF–EXPANDING TRANSCATHETER VALVE IMPLANTATION (ACURATE NEO 2) IN A VERY SMALL NATIVE AORTIC ANNULUS

Abstract We present the case of a 74–year–old female, symptomatic for dyspnea on exertion, evaluated by our Cardiac Team for severe aortic valve (AV) stenosis. The transesophageal echocardiography showed a stenotic tricuspid AV (valve area of 0.51 cm2, peak and mean gradients of 75 mmHg and 43 mmHg respectively), normal left ventricle (LV) ejection fraction without significant intraventricular gradient. Pre–operative thoraco–abdominal computed tomography angiography showed an AV without significant calcifications, an aortic annulus perimeter of 51.7 mm (area of 207,8 mm2) and a left ventricular outflow tract (LVOT) perimeter of 45.3 mm with elliptical shape (area of 149,9 mm2). The TAVR procedure was performed with an ‘off–label’ implantation of a SE THV with supra–annular location of leaflets (Acurate Neo 2 23 mm), without any predilation. The post–procedural transthoracic echocardiographic study highlighted the correct positioning of the bioprosthesis without significant protrusion in the LVOT and without any interference with the mitral valve apparatus. The main clinical, technical and procedural considerations have been: According to recommendations, the minimum perimeter of 56.5 mm and the minimum area of 254 mm2 represent the lower limits of the sizing guidelines for THV currently available. We used a SE valve with supra–annular location of the leaflets that offers a potential advantage over BE valves and intra annular SE valves, ensuring a larger effective orifice area. We avoided pre– and post–dilatation to reduce the risk of annular damage and/or rupture The precision of THV implantation (with minimal protrusion in LVOT) was maximized when the rapid pacing during phase 2 of the valve deployment was utilized. A short period of DAPT can be considered in order to prevent a potential increase of thromboembolic events secondary to small aortic valve area. In our opinion the main goal is to prevent high implantation and commissural misalignment in order to facilitate the subsequent coronary percutaneous interventions if needed. Even prophylactic coronary stenting (‘chimney fashion‘) should be avoided unless absolutely necessary. These technical considerations applies also to allow a subsequent valve–in–valve (VIV) procedure, if indicated. To our knowledge, this is among the smallest native aortic annulus so far described and treated percutaneously in a tricuspid stenotic aortic valve with a self–expanding (SE) THV Acurate Neo 2.

The impact of severe obesity on image quality and ventricular function assessment in echocardiography and cardiac MRI

This study sought to evaluate the impact of severe obesity on image quality and ventricular function assessment in cardiovascular magnetic resonance (MRI) and trans-thoracic echocardiography (TTE). We studied 100 consecutive patients who underwent clinically indicated cardiac MRI and TTE studies within 12 months between July 2017 and December 2020; 50 (28 females and 22 males; 54.5 ± 18.7 years) with normal body mass index (BMI) (18.5–25 kg/m2) and 50 (21 females and 29 males; 47.2 ± 13.3 years) with severe obesity (BMI ≥ 40 kg/m2). MRI and TTE image quality scores were compared within and across cohorts using a linear mixed model. Categorical left (LVF) and right (RVF) ventricular function were compared using Cohens Kappa statistic. Mean BMI for normal weight and obese cohorts were 22.2 ± 1.7 kg/m2 and 50.3 ± 5.9 kg/m2, respectively. Out of a possible 93 points, mean MRI image quality score was 91.5 ± 2.5 for patients with normal BMI, and 88.4 ± 5.5 for patients with severe obesity; least square (LS) mean difference 3.1, p = 0.460. TTE scores were 64.2 ± 13.6 for patients with normal BMI and 46.0 ± 12.9 for patients with severe obesity, LS mean difference 18.2, p < 0.001. Ventricular function agreement between modalities was worse in the obese cohort for both LVF (72% vs 80% agreement; kappa 0.53 vs 0.70, obese vs. normal BMI), and RVF (58% vs 72% agreement, kappa 0.18 vs 0.34, obese vs. normal BMI). Severe obesity had limited impact on cardiac MRI image quality, while obesity significantly degraded TTE image quality and ventricular function agreement with MRI.

Correlation of Tricuspid Annular Plane Systolic Excursion (TAPSE), as a predictor of Right Ventricular Systolic Function with Left Ventricular Systolic Function

Introduction: Right Ventricular (RV) function is a strong predictor of outcome in many Cardiovascular Diseases, but its significance is often neglected. Right Ventricle (RV) dysfunction may be secondary to Left Ventricle (LV) dysfunction as a consequence of “Ventricular Interdependence. Tricuspid Annular Plane Systolic Excursion (TAPSE) is an Echocardiographic measure that allows us to assess Right Ventricular systolic function and it correlates well with reference techniques like Cardiac Magnetic Resonance Imaging. Echocardiographic recording of the Tricuspid Annular Plane Systolic Excursion (TAPSE) has been recommended for assessing Right Ventricular function in cardiac patients. As RV dysfunction is associated with high in-hospital morbidity and mortality, early reorganization of RV dysfunction is warranted in patients with or without LV dysfunction. Objective: Our objective was to demonstrate the relationship of TAPSE, as a predictor of RV Systolic Function with Left Ventricular Systolic Function. Method: This was a cross –sectional study in patients undergoing comprehensive Transthoracic Echocardiography for any indication. From April 2022 to March 2023 we prospectively enrolled 100 adult (from 30 to age 103years) of both sexes who presented to the Cardiology Clinic of LABAID Cardiac Hospital. We performed a complete Transthoracic Echocardiography study. Assessed LV systolic function by conventional method. We additionally measured TAPSE in 2-dimensional M-mode Echocardiograms from the apical 4- chamber view, positioning the cursor on the lateral Tricuspid Annulus near the free RV wall and aligning it as close as possible to the apex of the heart. The mean values were taken by at least 2 measurements for reducing inter-observer and intra-observer variability’s. Values of TAPSE as a predictor of RV Systolic Function were correlated with Left Ventricular Systolic Function. Patients with confirmed congenital &amp; Valvular heart disease were excluded. Results: Mean TAPSE values were (19.15±3.87mm) irrespective of LVEF, with no significant differences between sexes, (18.45±3.801 mm) in male , (19.94±3.853 mm) in female (P=.056). TAPSE value was (22.00±1.581 mm) in person with normal LVEF &amp; (16.77±2.455 mm) in person with reduced LVEF (P&lt;.001). A statistically significant positive correlation of LVEF (r=.813) and significant negative correlation of EPSS (r=-.639) were observed with TAPSE (p&lt;0.001). But no significant correlation of TAPSE was found between age (r=-.185), gender (r=.192) &amp; RVIDd (r= -.063) (p &gt;0.05). Multivariate analysis confirmed these correlations and the interactions between variables. Graph of estimated population-based TAPSE values adjusted by LV function was provided. Conclusion: We determined the values of TAPSE in patients with or without LV systolic dysfunction and assessed relationship of these values with LVEF. TAPSE is predictive of RV Systolic function &amp; correlated significantly with LV systolic function. The TAPSE measurement is simple &amp; reproducible. This observation could guide decision making in daily clinical practice. Bangladesh Crit Care J March 2024; 12 (1): 11-17

Artificial intelligence-based classification of echocardiographic views

Abstract Aims Augmenting echocardiography with artificial intelligence would allow for automated assessment of routine parameters and identification of disease patterns not easily recognized otherwise. View classification is an essential first step before deep learning can be applied to the echocardiogram. Methods and results We trained two- and three-dimensional convolutional neural networks (CNNs) using transthoracic echocardiographic (TTE) studies obtained from 909 patients to classify nine view categories (10 269 videos). Transthoracic echocardiographic studies from 229 patients were used in internal validation (2582 videos). Convolutional neural networks were tested on 100 patients with comprehensive TTE studies (where the two examples chosen by CNNs as most likely to represent a view were evaluated) and 408 patients with five view categories obtained via point-of-care ultrasound (POCUS). The overall accuracy of the two-dimensional CNN was 96.8%, and the averaged area under the curve (AUC) was 0.997 on the comprehensive TTE testing set; these numbers were 98.4% and 0.998, respectively, on the POCUS set. For the three-dimensional CNN, the accuracy and AUC were 96.3% and 0.998 for full TTE studies and 95.0% and 0.996 on POCUS videos, respectively. The positive predictive value, which defined correctly identified predicted views, was higher with two-dimensional rather than three-dimensional networks, exceeding 93% in apical, short-axis aortic valve, and parasternal long-axis left ventricle views. Conclusion An automated view classifier utilizing CNNs was able to classify cardiac views obtained using TTE and POCUS with high accuracy. The view classifier will facilitate the application of deep learning to echocardiography.

Automated Atrial Fibrillation Diagnosis by Echocardiography without ECG: Accuracy and Applications of a New Deep Learning Approach.

Automated rhythm detection on echocardiography through artificial intelligence (AI) has yet to be fully realized. We propose an AI model trained to identify atrial fibrillation (AF) using apical 4-chamber (AP4) cines without requiring electrocardiogram (ECG) data. Transthoracic echocardiography studies of consecutive patients ≥ 18 years old at our tertiary care centre were retrospectively reviewed for AF and sinus rhythm. The study was first interpreted by level III-trained echocardiography cardiologists as the gold standard for rhythm diagnosis based on ECG rhythm strip and imaging assessment, which was also verified with a 12-lead ECG around the time of the study. AP4 cines with three cardiac cycles were then extracted from these studies with the rhythm strip and Doppler information removed and introduced to the deep learning model ResNet(2+1)D with an 80:10:10 training-validation-test split ratio. 634 patient studies (1205 cines) were included. After training, the AI model achieved high accuracy on validation for detection of both AF and sinus rhythm (mean F1-score = 0.92; AUROC = 0.95). Performance was consistent on the test dataset (mean F1-score = 0.94, AUROC = 0.98) when using the cardiologist's assessment of the ECG rhythm strip as the gold standard, who had access to the full study and external ECG data, while the AI model did not. AF detection by AI on echocardiography without ECG appears accurate when compared to an echocardiography cardiologist's assessment of the ECG rhythm strip as the gold standard. This has potential clinical implications in point-of-care ultrasound and stroke risk stratification.

Explainable machine learning using echocardiography to improve risk prediction in patients with chronic coronary syndrome.

The European Society of Cardiology guidelines recommend risk stratification with limited clinical parameters such as left ventricular (LV) function in patients with chronic coronary syndrome (CCS). Machine learning (ML) methods enable an analysis of complex datasets including transthoracic echocardiography (TTE) studies. We aimed to evaluate the accuracy of ML using clinical and TTE data to predict all-cause 5-year mortality in patients with CCS and to compare its performance with traditional risk stratification scores. Data of consecutive patients with CCS were retrospectively collected if they attended the outpatient clinic of Amsterdam UMC location AMC between 2015 and 2017 and had a TTE assessment of the LV function. An eXtreme Gradient Boosting (XGBoost) model was trained to predict all-cause 5-year mortality. The performance of this ML model was evaluated using data from the Amsterdam UMC location VUmc and compared with the reference standard of traditional risk scores. A total of 1253 patients (775 training set and 478 testing set) were included, of which 176 patients (105 training set and 71 testing set) died during the 5-year follow-up period. The ML model demonstrated a superior performance [area under the receiver operating characteristic curve (AUC) 0.79] compared with traditional risk stratification tools (AUC 0.62-0.76) and showed good external performance. The most important TTE risk predictors included in the ML model were LV dysfunction and significant tricuspid regurgitation. This study demonstrates that an explainable ML model using TTE and clinical data can accurately identify high-risk CCS patients, with a prognostic value superior to traditional risk scores.

The Prognostic Significance of Atrial Fibrillation and Left Atrium Size in Patients with Aortic Stenosis.

Aim Aortic stenosis increases left atrial (LA) pressure and may lead to its remodeling. This can cause supraventricular arrhythmia. The aim of this study was to determine if the size of the LA and the presence of atrial fibrillation are related to the prognosis of patients with aortic stenosis.Material and methods Clinical evaluation and standard transthoracic echocardiographic studies were performed in 397 patients with moderate to severe aortic stenosis.Results In all patients, LA dimension above the median (≥43 mm) was associated with a significantly higher risk of death [HR 1.79 (CL 1.06-3.03)] and a LA volume above the median of 80 ml was associated with a significantly higher risk of death [HR 2.44 (CI 1.12-5.33)]. The presence of atrial fibrillation was significantly associated with a higher risk of death (p &lt;0.0001). The presence of atrial fibrillation [HR 1.69 (CI 1.02-2.86)], lower left ventricular ejection fraction [HR 1.23 (CI 1.04-1.45)], higher NYHA heart failure class [HR 4.15 (CI 1.40-13.20)] and renal failure [HR 2.10 (CI 1.31-3.56)] were independent risk factors of death in patients in aortic stenosis.Conclusion The size and volume of the LA and the occurrence of atrial fibrillation are important risk factors for death in patients with aortic stenosis. The presence of renal dysfunction, low left ventricular ejection fraction, high NYHA functional class and atrial fibrillation are independent risk factors of poor prognosis in patients with aortic stenosis.