Transthoracic Echocardiographic Parameters Research Articles

Heart failure with preserved ejection fraction management: a systematic review of clinical practice guidelines and recommendations.

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the ten guidelines and recommendations retrieved, seven showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced disease. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.

Heterogeneity of right ventricular echocardiographic parameters in systemic lupus erythematosus among four clinical subgroups, as stratified by clinical organ involvement in observational cohort

BackgroundSystemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease. Cardiac involvement in SLE is rare but plays an important prognostic role. The degree of cardiac involvement according to SLE subsets...

How to use echocardiography to manage patients with shock?

Echocardiography enables the intensivist to assess the patient with circulatory failure. It allows the clinician to identify rapidly the type and the cause of shock in order to develop an effective management strategy. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied. Early and repeated echocardiography is a valuable tool for the management of shock in the intensive care unit. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography.The four core types of shock (cardiogenic, hypovolemic, obstructive, and septic) can readily be identified by echocardiography. Echocardiography can differentiate the different pathologies that may be the cause of each type of shock. More importantly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock, which emphasises on the added value of transthoracic echocardiography (TTE) in such population of patients.In this review we aimed to provide to clinicians a bedside strategy of the use of TTE parameters to manage patients with shock. In the first part of this overview, we detailed the different TTE parameters and how to use them to identify the type of shock. And in the second part, we focused on the use of these parameters to evaluate the effect of treatments, in different types of shock.

Accuracy and Efficacy of Artificial Intelligence-Derived Automatic Measurements of Transthoracic Echocardiography in Routine Clinical Practice.

Background: Transthoracic echocardiography (TTE) is the gold standard modality for evaluating cardiac morphology, function, and hemodynamics in clinical practice. While artificial intelligence (AI) is expected to contribute to improved accuracy and is being applied clinically, its impact on daily clinical practice has not been fully evaluated. Methods: We retrospectively examined 30 consecutive patients who underwent AI-equipped TTE at a single institution. All patients underwent manual and automatic measurements of TTE parameters using the AI-equipped TTE. Measurements were performed by three sonographers with varying experience levels: beginner, intermediate, and expert. Results: A comparison between the manual and automatic measurements assessed by the experts showed extremely high agreement in the left ventricular (LV) filling velocities (E wave: r = 0.998, A wave: r = 0.996; both p < 0.001). The automated measurements of LV end-diastolic and end-systolic diameters were slightly smaller (-2.41 mm and -1.19 mm) than the manual measurements, although without significant differences, and both methods showing high agreement (r = 0.942 and 0.977, both p < 0.001). However, LV wall thickness showed low agreement between the automated and manual measurements (septum: r = 0.670, posterior: r = 0.561; both p < 0.01), with automated measurements tending to be larger. Regarding interobserver variabilities, statistically significant agreement was observed among the measurements of expert, intermediate, and beginner sonographers for all the measurements. In terms of measurement time, automatic measurement significantly reduced measurement time compared to manual measurement (p < 0.001). Conclusions: This preliminary study confirms the accuracy and efficacy of AI-equipped TTE in routine clinical practice. A multicenter study with a larger sample size is warranted.

Use of artificial intelligence and I-Score for prediction of recurrence before catheter ablation of atrial fibrillation

BackgroundBased solely on pre-ablation characteristics, previous risk scores have demonstrated variable predictive performance. This study aimed to predict the recurrence of AF after catheter ablation by using artificial intelligence (AI)-enabled pre-ablation computed tomography (PVCT) images and pre-ablation clinical data. MethodsA total of 638 drug-refractory paroxysmal atrial fibrillation (AF) patients undergone ablation were recruited. For model training, we used left atria (LA) acquired from pre-ablation PVCT slices (126,288 images). A total of 29 clinical variables were collected before ablation, including baseline characteristics, medical histories, laboratory results, transthoracic echocardiographic parameters, and 3D reconstructed LA volumes. The I-Score was applied to select variables for model training. For the prediction of one-year AF recurrence, PVCT deep-learning and clinical variable machine-learning models were developed. We then applied machine learning to ensemble the PVCT and clinical variable models. ResultsThe PVCT model achieved an AUC of 0.63 in the test set. Various combinations of clinical variables selected by I-Score can yield an AUC of 0.72, which is significantly better than all variables or features selected by nonparametric statistics (AUCs of 0.66 to 0.69). The ensemble model (PVCT images and clinical variables) significantly improved predictive performance up to an AUC of 0.76 (sensitivity of 86.7% and specificity of 51.0%). ConclusionsBefore ablation, AI-enabled PVCT combined with I-Score features was applicable in predicting recurrence in paroxysmal AF patients. Based on all possible predictors, the I-Score is capable of identifying the most influential combination.

Improvement in left ventricle geometry and function after kidney transplantation

Chronic kidney disease (CKD) is associated with remodeling of the left ventricle (LV), affecting both its geometry and function. Kidney transplantation in patients with stage 5 CKD may lead to improvements in LV remodeling and result in better cardiac function. The aim of the study was to determine changes and improvements in LV geometry and function after kidney transplantation in patients with stage 5 CKD. This was an observational study conducted by collecting secondary data from the Hospital's Kidney Transplantation Registry, Dr. Sardjito General Hospital spanning the years 2017 to 2020. The study employed a comparative design, contrasting the results before and after treatment (kidney transplantation). We compared transthoracic echocardiographic parameters for LV geometry and function before and after kidney transplantation. The evaluation timeframe after kidney transplantation was divided into &lt;12 and ³12 mo. A total of 27 patients qualified for inclusion in this study. In the &lt;12 mon (n=20) evaluation group, there was a reduction in proportion of LV hypertrophy from 70% to 45%. There was an increase in global LV systolic function (ejection fraction) from 60.1±10.95% to 67.85±6.48% (p=0.014), and a decrease in LV diastolic dysfunction from 45% to 15% (p=0.07). In the ³12 mon (n=11) evaluation group, there was a decrease in the proportion of LV hypertrophy from 81.8 to 54.5%, an increase in global LV systolic function (ejection fraction) from 57.73±13.07% to 69.36±6.12% (p=0.011), and a decreased LV diastolic dysfunction from 63.6% to 0% (p=0.016). In conclusion, significant changes in LV geometry and function are observed following kidney transplantation, indicating improvements in these parameters. There are improvements in LV systolic function started at &lt;12 mo and in LV diastolic function at ³12 mo after kidney transplantation.

Can transesophageal echocardiography be safely omitted in patients scheduled for elective ablation of atrial arrhythmias? Data based on the LATTEE registry.

According to the present guidelines, transesophageal echocardiography (TEE) before scheduled catheter ablation (CA) for atrial arrhythmias (atrial fibrillation [AF] or atrial flutter [AFL]) is not deemed obligatory for optimally anticoagulated patients. However, daily clinical practice significantly differs from the recommendations. We aimed to identify transthoracic echocardiographic parameters that could be useful in identifying patients without left atrial thrombus (LAT), which makes it possible to avoid unnecessary TEE before scheduled CA. This is a sub-analysis of a multicenter, prospective, observational study - the LATTEE registry. A total of 1346 patients referred for TEE before scheduled CA of AF/AFL were included. LAT was present in 44 patients (3.3%) and absent in the remaining 1302, who were younger, more likely to have paroxysmal AF, and displayed sinus rhythm during TEE. Additionally, they exhibited a lower incidence of heart failure, diabetes, systemic connective tissue disease, and chronic obstructive pulmonary disease. Furthermore, they had a lower CHA2DS2-VASc score and a higher prevalence of direct oral anticoagulants. Echocardiographic parameters, including left ventricular ejection fraction (LVEF) >65%, left atrial diameter (LAD) <40 mm, left atrial area (LAA) <20 cm2, left atrial volume (LAV) <113 ml, and left atrial volume index (LAVI) <51 ml/m2, demonstrated 100% sensitivity and 100% negative predictive value for the absence of LAT and were met by 417 patients. Additional echocardiographic indices: LVEF/LAD ≥1.4, LVEF/LAVI ≥1.6, and LVEF/LAA ≥2.7 identified 57 additional patients, bringing the total of predicted LAT-free patients to 474 (35%). Simple echocardiographic parameters could help identify individuals for whom TEE could be safely omitted before elective CA due to atrial arrhythmias.

Features of Hemodynamics in Elderly Patients Undergoing CABG Surgery at the Stage of Induction Anesthesia

Due to the global trend of the population ageing, an important task of modern medicine is to improve the provision of medical care for elderly patients. These people have reduced compensatory reserves of the body and numerous chronic pathologies, necessitating a more meticulous approach to anesthesia induction and maintenance by anesthesiologists. According to the authors, the use of propofol and fentanyl leads to decreased myocardial contractility and reduction in overall peripheral vascular resistance. However, the resulting decrease in perfusion pressure in vital organs and tissues, as a consequence of the aforementioned effects, is unacceptable in elderly patients with coronary heart disease (CHD).&#x0D; The aim&#x0D; . To analyze changes in hemodynamics in elderly patients undergoing coronary artery bypass grafting (CABG) during the induction of anesthesia.&#x0D; &#x0D; Materials and methods. A prospective study was conducted which included the results of examination of 20 patients with CHD over 60 years old who underwent CABG without the use of cardiopulmonary bypass at the National Amosov Institute of Cardiovascular Surgery (Kyiv, Ukraine). The mean age of the patients was 67.5±6.8 years. There were 16 (80%) men and 4 (20%) women. Typical manifestations of heart failure were noted (there were 1 [5%], 10 [50%] and 9 [45%] NYHA functional class I, II and III patients, respectively). Also, the patients were classified according to the Canadian classification of angina: 1 (5%), 9 (45%) and 10 (50%) patients fell within class I, II and III, respectively. Stage 2-3 hypertension was reported in 18 patients (90%).&#x0D; For induction of anesthesia, the following medications were used: propofol 1.5 mg/kg, fentanyl 2.0 μg/kg, and rocuronium bromide 0.1 mg/kg. Anesthesia maintenance included: propofol 4 mg/kg/hour, fentanyl 2.0 μg/kg/hour. Hemodynamic parameters saturation indices (SpO2), and transthoracic echocardiography parameters were recorded at the following stages: 1) upon the patient’s arrival in the operating room; 2) prior to tracheal intubation; 3) immediately after tracheal intubation; 4) 25 minutes after intubation.&#x0D; Results. Upon arrival in the operating room, the hemodynamic parameters reflected stable general condition of the examined patients. After administration of induction agents according to the study design, it was recorded that mean blood pressure (BP) was 72.7±4.76% (p&lt;0.001), heart rate was 89.8±5.95% (p=0.0004), cardiac index was 81.47±6.6% (p&lt;0.001), and systemic vascular resistance index (SVRI) was 89.9±7.02% of the baseline values (p=0.063). After intubation, an increase in most hemodynamic indicators was observed, although only mean BP, which constituted 86.7±8.8% of the baseline data (p&lt;0.001), and SVRI (89.8±11.04% of the baseline data, p=0.0315), significantly differed from the baseline values. Within 25 minutes after the intubation, the parameters decreased again: with mean BP 74.9±7.9% (p&lt;0.001), heart rate 91.3±9.5% (p=0.008), cardiac index 79.6±10.1% (p&lt;0.001), and SVRI 91.1±9.34% (p=0.062) of the baseline values.&#x0D; Conclusions. The main changes in hemodynamics were reported during induction of anesthesia, where a significant decrease in most indicators compared to the baseline state was recorded. After intubation, the parameters slightly increased but did not return to the baseline values. During further anesthesia maintenance, a significant decrease in most indicators relative to the baseline data were observed. The instability of hemodynamic parameters during the induction stage of anesthesia in elderly patients with CHD can be an obstacle to the normal course of the perioperative period, necessitating the search for methods to stabilize them.

How to use echocardiography to manage patients with shock?

Echocardiography enables the intensivist to assess the patient with circulatory failure. It allows the clinician to identify rapidly the type and the cause of shock in order to develop an effective management strategy. Important characteristics in the setting of shock are that it is non-invasive and can be rapidly applied. Early and repeated echocardiography is a valuable tool for the management of shock in the intensive care unit. Competency in basic critical care echocardiography is now regarded as a mandatory part of critical care training with clear guidelines available. The majority of pathologies found in shocked patients are readily identified using basic level 2D and M-mode echocardiography.The four core types of shock (cardiogenic, hypovolemic, obstructive, and septic) can readily be identified by echocardiography. Echocardiography can differentiate the different pathologies that may be the cause of each type of shock. More importantly, as a result of more complex and elderly patients, the shock may be multifactorial, such as a combination of cardiogenic and septic shock, which emphasises on the added value of transthoracic echocardiography (TTE) in such population of patients.In this review we aimed to provide to clinicians a bedside strategy of the use of TTE parameters to manage patients with shock. In the first part of this overview, we detailed the different TTE parameters and how to use them to identify the type of shock. And in the second part, we focused on the use of these parameters to evaluate the effect of treatments, in different types of shock.

Feasibility and prognostic significance of ventricular-arterial coupling after myocardial infarction: the RIGID-MI cohort.

The clinical significance and feasibility of the recently described non-invasive parameters exploring ventricular-arterial coupling (VAC) remain uncertain. This study aimed to assess VAC parameters for prognostic stratification in stable patients with left ventricular ejection fraction (LVEF) ≥40% following myocardial infarction (MI). Between 2018 and 2021, patients with LVEF ≥40% were evaluated 1 month following MI using transthoracic echocardiography (TTE) and arterial tonometry at rest and after a handgrip test. VAC was studied via the ratio between arterial elastance (Ea) and end-systolic LV elastance (Ees) and between pulse wave velocity (PWV) and global longitudinal strain (GLS). Patients were followed for major adverse cardiovascular events (MACE): all-cause death, acute heart failure, stroke, AMI, and urgent cardiovascular hospitalization. Among the 374 patients included, Ea/Ees and PWV/GLS were obtained at rest for 354 (95%) and 253 patients (68%), respectively. Isometric exercise was workable in 335 patients (85%). During a median follow-up of 32 months (interquartile range: 16-42), 41 (11%) MACE occurred. Patients presenting MACE were significantly older and had a higher prevalence of peripheral arterial disease, lower GLS, higher Ea, PWV, and PWV/GLS ratio. The Ea/Ees ratio and standard TTE parameters during isometric exercise were not associated with MACE. After adjustment, the PWV/GLS ratio was the only VAC parameter independently associated with outcome. Receiver operating characteristic curve analysis identified a PWV/GLS ratio >0.70 (Youden's index = 0.37) as the best threshold to identify patients developing MACE: hazard ratio (95% confidence interval) = 2.2 (1.14-4.27), P = 0.02. The PWV/GLS ratio, assessed 1 month after MI, identifies a group of patients at higher risk of MACE providing additional value on top of conventional non-invasive parameters.

Impact of arteriovenous fistula on flow states in the evaluation of aortic stenosis among ESKD patients on dialysis.

An arteriovenous fistula (AVF) in patients with end-stage kidney disease (ESKD) can influence flow states. We sought to evaluate if assessment of aortic stenosis (AS) by transthoracic echocardiographic (TTE) differs in the presence of AVF compared to other dialysis accesses in patients on dialysis. We identified consecutive ESKD patients on dialysis and concomitant AS from a single center between January 2000 and March 2021. We analyzed TTE parameters of AS severity (velocities, gradients, aortic valve area [AVA]) and hemodynamics (cardiac output [CO], valvuloarterial impedance [Zva]) and compared AS parameters in patients with AVF versus other dialysis access. The cohort included 94 patients with co-prevalent ESKD and AS; mean age 66years, 71% male; 43% Black, 24% severe AS. Dialysis access: 53% AVF, 47% others. In the overall cohort, no significant differences were noted between AVF versus non-AVF in AVA/CO/Zva, but with notable subgroup differences. In mild AS, CO was significantly higher in AVF versus non-AVF (6.3 vs. 5.2L/min; p=.04). In severe AS, Zva was higher in the AVF versus non-AVF (4.6 vs. 3.6mm Hg/mL/m2 ). With increasing AS severity in the AVF group, CO decreased, coupled with increase in Zva, likely counterbalancing the net hemodynamic impact of the AVF. Among ESKD patients with AS, TTE parameters of flow states and AS severity differed in those with AVF versus other dialysis accesses and varied with progression in severity of AS. Future longitudinal assessment of hemodynamic parameters in a larger cohort of co-prevalent ESRD and AS would be valuable.

Machine learning score focused only on echocardiographic data to predict in-hospital outcomes in ICCU patients. A study from the ADDICT ICCU cohort

Abstract Background While several studies have shown the strong prognostic value of several transthoracic echocardiography (TTE) parameters in patients admitted in intensive cardiac care unit (ICCU), the interest of a severity score integrating these parameters has not been established. Machine learning (ML) represents an innovative and accurate statistical method to embed TTE parameters into a scoring system. Purpose To investigate the feasibility and accuracy of ML integrating TTE parameters measured at admission in ICCU to predict in-hospital major adverse cardiovascular events (MACE) and to compare its performance with existing scores. Methods In April 2021, 1,499 patients admitted to 39 French ICCU were included in the ADDICT-ICCU Cohort (NCT05063097). A comprehensive TTE was performed within the first 24 hours of admission. Twenty TTE parameters were systematically collected. ML involved automated feature selection by Boruta to select variables and prevent model overfitting. Several ML models (LASSO, Random Forest and XGBoost) were then trained on 70% of patients and evaluated on the other 30% as internal validation. Their performances were compared against standard logistic regression model, using receiver operating characteristics (ROC) curves, precision-recall (PR) curves and area-under-the curves (AUC). The primary composite outcome was in-hospital MACEs defined by all-cause mortality, cardiogenic shock (requiring medical or mechanical haemodynamic support) and resuscitated cardiac arrest. The external validation cohort of the ML score was performed in another center on 300 patients. Results Of 1,499 consecutive patients screened (63±15 years, 70% male), MACEs occurred in 67 patients (4.5%) including: 27 (1.8%) deaths, 38 (2.53%) cardiogenic shocks, and 14 (0.9%) resuscitated cardiac arrests. To build the ML models, 5 TTE parameters were selected as being the most important in predicting MACEs: LVOT VTI, E/e’ ratio, sPAP, TAPSE, and LVEF. The XGBoost model showed the best performance compared with the other ML models (AUROC for XGBoost: 0.83, Random-forest: 0.81, LASSO regression 0.79 and to a regression model: 0.76). Using the XGBoost model as our final ML-score, SHAP values for the parameters were: 0.047 for LVOT VTI, 0.041 for E/e’ ratio, 0.028 for SPAP, 0.021 for TAPSE and 0.01 for LVEF. Our ML-score exhibited a higher AUC compared with existing scores (TIMI, GRACE, qSOFA, Acute-HF) (Figure 1), and an incremental prognostic value for predicting in-hospital MACEs over and above clinical or biological data (Chi-square 59.72 p&amp;lt;0.001; C-Index 0.8 [0.71;0.89], p=0.012) (Figure 2). Conclusion The ML score including only TTE parameters exhibited a higher prognostic value to predict in-hospital MACE compared with any other existing traditional methods in patients admitted in ICCU. This ML score could be implemented in clinical practice given its ease of use (only 5 TTE parameters to analyze) and its prognostic implication.Figure 1.PerformanceFigure 2.Prognostic value

Left atrial strain measurement to predict new-onset atrial fibrillation in ST-elevation myocardial infarction patients

Abstract Background/Introduction ST-elevation myocardial infarction (STEMI) remains a healthcare burden not only through increased mortality risk, but also development of chronic cardiac pathologies like atrial fibrillation (AF). Left atrial (LA) reservoir strain is a known predictor of incident AF in the general population. Purpose Our aim was to explore the additional prognostic value of LA reservoir strain measured by transthoracic echocardiography (TTE) in STEMI patients for new-onset atrial fibrillation (NOAF). Methods Data were analyzed retrospectively from an ongoing STEMI registry. Patients with previous myocardial infarction, AF, known history of heart failure, severe valvular pathology, suboptimal image quality, AF during TTE or missing follow-up were excluded. TTE was performed within 48 hours of hospitalization. LA reservoir strain was measured in apical 4-chamber view. LA strain &amp;lt;23% was used as cut-off value for impaired LA function as previously established. The endpoint was NOAF. Follow-up was censored at last patient visit or at 5 years. Results In total 1238 patients (mean age 60±12 years; 930 (75%) men) were included. After median follow-up of 22 months (IQR 12; 60) 106 (8.6%) patients developed NOAF, most events (71 (67%)) taking place within the first year after STEMI. Mean LA reservoir strain was more impaired in patients who developed NOAF as compared to those who did not (19.3 ± 8.1% versus 24.3 ± 8.8% respectively (p&amp;lt;0.001). Clinical and echocardiographical characteristics are shown in the table. Cumulative event-free survival rates at 1, 3 and 5 years in patients with preserved versus decreased LA strain were 97%, 95% and 93% versus 91%, 89% and 83% respectively (Log-rank X2 = 21.1; p&amp;lt;0.001; Figure). Factors significant on univariable Cox regression analysis (age, presence of chronic obstructive pulmonary disease, troponin levels, left ventricular end-diastolic diameter, interventricular septum diameter, left ventricular global longitudinal strain, LA volume index, LA reservoir strain, E/E’ ratio and right ventricular fractional area change) were included in multivariable model, where LA reservoir strain remained significantly associated with NOAF (HR 0.96 (0.93 – 0.99); p=0.015). Addition of LA strain provided incremental prognostic value over baseline clinical risk factors, traditional TTE parameters and left ventricular global longitudinal strain (X2 84.5 vs 88.8; p=0.013). Conclusion LA reservoir strain was associated with new-onset atrial fibrillation in STEMI patients after adjusting for relevant clinical and echocardiographic risk factors.TableFigure

Abstract 17921: Diastolic Dysfunction Might Predict Outcomes in Acute Coronary Syndrome Patients Undergoing Primary Percutaneous Coronary Intervention

Introduction: Acute coronary syndrome (ACS) leads to diastolic dysfunction which might cause unfavorable long-term clinical outcomes. We aim to evaluate the association between diastolic parameters in patients with an ACS and event rates including 30-day mortality and 6-month readmission rates. Methodology: We studied 1579 patients with ACS who underwent primary percutaneous coronary intervention (PCI) from January 1, 2010 through December 31, 2020. Clinical, laboratory, transthoracic echocardiographic (TTE) and coronary angiographic parameters were retrospectively reviewed. Diastolic parameters (E/A ratio, TR velocity, LVEF and LAVI) in patients with left anterior descending artery (LAD) PCI (n=879) were compared with those who underwent PCI to non-LAD artery (n=700). Percentage of 6-month all-cause readmission, cardiogenic shock as well as mortality rates were calculated in both cohorts. Results: The mean age of 1579 ACS patients was 65 + 12 years, BMI 29 + 5 kg/m 2 , peak high sensitivity troponin 624 ng/L, E/A ratio 1.065, TR velocity 3.2 m/s, LAVI 34.26 mL/m 2 and LVEF 50.1%. The percentage of hospital readmission within 6 months was higher in patients with diastolic dysfunction and LAD PCI compared to those with non-LAD PCI (19% versus 16%, p - value=0.004). Although patients with diastolic dysfunction and LAD PCI had higher percentage of cardiogenic shock compared to non-LAD PCI group (6.0% versus 3.7%, p -value&lt;0.001), 1-year mortality did not differ between the 2 groups ( p -value=0.84). Conclusion: Diastolic dysfunction is associated with worse clinical outcomes in patients undergoing LAD PCI which warrants a larger prospective clinical study.

Echocardiography Versus Magnetic Resonance Imaging Quantification and Novel Algorithm for Isolated Severe Tricuspid Regurgitation

Transthoracic echocardiography (TTE) is the first-line tool to evaluate isolated tricuspid regurgitation (TR) but it has limitations and its TR quantification compared with magnetic resonance imaging (MRI) has been studied infrequently. We compared isolated severe TR quantification by TTE against MRI and developed a novel TTE-based algorithm. Isolated TR patients graded severe by TTE and who underwent MRI January 2007 to June 2019 were studied. The TTE and MRI measurements were analyzed by correlation, area under receiver-operative characteristics curve (AUC), and classification and regression tree algorithm of TTE parameters to best identify MRI-derived severe TR (regurgitant volume ≥45ml and/or fraction ≥50%). A total of 108 of 262 (41%) that were graded as severe TR by TTE also had severe TR by MRI. There were moderate correlations between TTE and MRI in the quantification of TR severity and right atrial size (Pearson r=0.428 to 0.645) but none to modest correlations between them in right ventricle quantification. The key TTE parameters to identify MRI-derived severe TR in the decision tree regression algorithm were right atrial volume indexed ≥47ml/m2 and effective regurgitant orifice area ≥0.45cm2 and especially if there is right ventricle free wall strain ≥ -9.5%. This novel algorithm has an AUC of 0.76% and 79% agreement to detect severe TR by MRI, which higher than the American Society of Echocardiography criteria with AUC 0.68% and 66% agreement (p=0.006 and p <0.001, respectively). In conclusion, TTE-derived TR and right atrial quantification had moderate correlation and discrimination of severe TR by MRI, from which a novel TTE algorithm was derived, which had incrementally a higher accuracy than contemporary guidelines' criteria alone.

Association of Shock Index with Echocardiographic Parameters in Cardiac Intensive Care Unit

BackgroundA high shock index (SI), the ratio of heart rate (HR) to systolic blood pressure (SBP), has been associated with unfavorable outcomes. We sought to determine the hemodynamic underpinnings of an elevated SI using 2-D and doppler Transthoracic Echocardiography (TTE) in unselected cardiac intensive care unit (CICU) patients. MethodsWe included Mayo Clinic CICU admissions from 2007 to 2018 who were in sinus rhythm at the time of TTE. The SI was calculated using HR and SBP at the time of TTE. Patients were grouped according to SI: <0.7, 4012 (64%); 0.7–0.99, 1764 (28%); and ≥ 1.0, 513 (8%). Pearson's correlation coefficient was used to assess associations between continuous variables. ResultsWe included 6289 unique CICU patients, 58% of whom had acute coronary syndrome. The median age was 67.9 years old and 37.8% were females. The mean SI was 0.67 BPM/mmHg. As the SI increased, markers of left ventricular (LV) systolic function and forward flow decreased, including left ventricular ejection fraction (LVEF), fractional shortening, left ventricular outflow tract (LVOT) velocity time integral (VTI), stroke volume, LV stroke work index, and cardiac power output. Biventricular filling pressures increased, and markers of right ventricular function worsened with rising SI. Most TTE measurements reflecting LV function and forward flow were inversely correlated with SI, including LV stroke work index (r = −0.59) and LVOT VTI (r = −0.41), as were both systemic vascular resistance index (r = −0.43) and LVEF (r = −0.23). ConclusionCICU patients with elevated SI have worse biventricular function and systemic hemodynamics, particularly decreased stroke volume and related calculated TTE parameters. The SI is an easily available marker that can be used to identify CICU patients with unfavorable hemodynamics who may require further assessment.

Mechanisms and implications of mitral regurgitation in patients with severe aortic stenosis who received transcatheter aortic valve replacement.

This study aimed to investigate the mechanisms and clinical implications of mitral regurgitation (MR) in patients with severe aortic stenosis (AS) who received transcatheter aortic valve replacement (TAVR). We conducted retrospective echocardiographic analyses at baseline and 6 months after TAVR in 140 patients with symptomatic AS (85±5 years) who underwent TAVR. We defined significant MR as ≥ moderate based on evaluation of transthoracic echocardiography (TTE). There were 48 patients (34%) with preexisting MR at the baseline. Among measured TTE parameters, end-systolic wall stress (ESWS), mitral annulus area, and mitral valve thickening index were independent factors associated with preexisting MR (odds ratio [OR]: 1.013, 95% confidence interval [CI]: 1.005-1.021; OR: 1.740, 95% CI: 1.314-2.376; OR: 2.306, 95% CI: 1.426-3.848; respectively). Six months after TAVR, there were 34 patients with post-existing MR, A history of atrial fibrillation and ESWS after TAVR were independent factors (OR: 3.013, 95% CI: 1.208-7.556; OR: 1.013, 95% CI: 1.000-1.023; respectively). The Kaplan-Meier plot indicated that preexisting MR was a risk factor for heart failure-related events within 1 year of discharge after TAVR (p=.012). In patients who underwent TAVR for severe AS, preexisting MR was associated with having a thickened mitral valve and large mitral annulus size induced by high ESWS. These patients may have worse prognosis after TAVR and should be closely monitored in the long term.

Impact of Premature Ventricular Complex (PVC) Burden on the Left Ventricle in the Structurally Normal Heart: Hemodynamic Alterations of Idiopathic PVC on Echocardiography.

Premature ventricular complex (PVC) without structural heart disease is mostly viewed as a benign arrhythmia. However, the high burden of PVC causes cardiomyopathy due to intraventricular dyssynchrony. The effects of ectopic contraction on left ventricular (LV) hemodynamics in the structurally normal heart are unclear. To examine the effect of PVC burden on LV dimension, LV systolic function, and intraventricular blood flow, and to determine whether ectopic ventricular contraction affects LV hemodynamics. Patients aged ≥ 18 years with PVC ≥ 5% on Holter recording were enrolled and divided into groups G1 (5-10%), G2 (10-20%), and G3 (≥ 20%). We excluded patients with structural heart diseases, pacemakers, and LV systolic dysfunction [LV ejection fraction (LVEF) < 50%]. Clinical characteristics and routine transthoracic echocardiography parameters were compared. The end-systolic LV internal dimension increased according to the PVC burden from G1 to G3 (p = 0.001). LVEF was inversely associated with PVC burden from G1 to G3 (p = 0.002). The same pattern was seen for LV outflow tract (LVOT) maximal velocity (p = 0.005) and maximal pressure gradient (PG) (p = 0.005), LVOT velocity time integral (VTI) (p = 0.03) and LV stroke volume index (LVSI) (p = 0.008). Systolic function and LV end-systolic dimension were inversely associated with PVC burden. Decreased LVOT flow velocity and PG were related to increased PVC burden. LVOT VTI and LVSI were smaller when the PVC burden exceeded 20%. These negative hemodynamic manifestations of idiopathic PVC were considerable even in structure normal hearts, hence the early elimination of PVC is strongly advised.

Effects of Systolic Pulmonary Arterial Pressure on Long-Term Mortality in Patients with Chronic Obstructive Pulmonary Disease and TAVI

Objective: Previous studies have shown that the presence of chronic obstructive pulmonary disease (COPD) has an effect on negative mortality and morbidity in transcatheter aortic valve implantation (TAVI) patients, the effect of systolic pulmonary artery pressure (sPAP) on long-term mortality in these patients has not been investigated. In this study, we planned to investigate the effect of sPAP on long-term mortality in patients with known COPD who were scheduled for TAVI. Methods: In this retrospective study, a total of 72 patients diagnosed with COPD and undergoing TAVI were included. Patients were divided into 2 groups based on their baseline sPAP values as for both cut off values of 34 mmhg 46 mmhg respectively [normal (sPAP &lt;34 mmHg) and moderate-to-severe (sPAP ≥34 mmHg); 46 mmhg the cut-off value defined as the predictive value of mortality with the roc curve]. Transthoracic echocardiography parameters were used for sPAP evaluation. The primary endpoint was determined as 5-year mortality. Results: When comparing the groups based on their 5-year mortality, it was observed that sPAP values were significantly higher in the mortality group (p &lt; 0.001). In addition, when patients were classified according to sPAP groups, 5-year mortality was found to be significantly higher in patients with sPAP ≥34 mmHg (&lt;0.001) and sPAP ≥46 mmHg (p&lt;0.001). Conclusion: The most significant outcome derived from our study is that elevated sPAP values measured solely through echocardiography serve as a crucial indicator of in-hospital and 5-year mortality risk among TAVI patients previously diagnosed with COPD.

Causes and prognosis analysis of hyperdynamic left ventricular ejection fraction in intensive care unit patients with sepsis

To analyze the causes of hyperdynamic left ventricular ejection fraction (LVEF) in sepsis patients in the intensive care unit (ICU) and its impact on prognosis. A retrospective cohort study was conducted. The clinical data of 273 sepsis patients admitted to the department of critical care medicine of the Affiliated People's Hospital of Jiangsu University from January 2018 to October 2021 were collected including gender, age, severity score, comorbidities, source of infection, vital signs, transthoracic echocardiographic (TTE) parameters, fluid intake and output, vasoactive drug dose, therapeutic measures and prognostic indicators. The patients were divided into normal LVEF group (LVEF 0.55-0.70), low LVEF group (LVEF < 0.55) and hyperdynamic LVEF group (LVEF > 0.70) according to the TTE examination results within 7 days of ICU admission. The clinical indicators among the three groups were compared and analyzed, and multivariate Logistic regression analysis was used to screen risk factors for the development of hyperdynamic LVEF in patients with sepsis. Spearman correlation analysis was used to determine the correlation between the mortality of different types of LVEF and clinical variables. Among 273 patients, 20 patients with severe valvular or cardiomyopathy at admission and those who did not completed cardiac ultrasound within 7 days of ICU admission were excluded. A total of 253 patients were finally enrolled, including 169 patients in the normal LVEF group, 40 patients in the low LVEF group, and 44 patients in the hyperdynamic LVEF group. There were statistically significant differences in age, sequential organ failure assessment (SOFA) score, central venous pressure (CVP), heart rate (HR), oxygenation index (PaO2/FiO2), blood lactate (Lac), urine output, vasoactive drug dose, ratio of hypertension, ischemic heart disease, chronic liver disease, cancer, invasive mechanical ventilation and renal replacement therapy (RRT), and incidence of septic shock among the different types of LVEF groups. TTE results analysis showed that the hyperdynamic LVEF group had higher stroke volume (SV) and cardiac index (CI) than those in the normal LVEF and low LVEF groups, lower systemic vascular resistance (SVR) than that in the normal LVEF and low LVEF groups, and an increased E/A ratio. The 90-day mortality in the hyperdynamic LVEF group was significantly higher than that in the normal LVEF and low LVEF groups [59.1% (26/44) vs. 24.9% (42/169), 32.5% (13/40), both P < 0.05]. Multivariate Logistic regression analysis showed that chronic liver disease [odds ratio (OR) = 1.712, 95% confidence interval (95%CI) was 0.912-3.234, P < 0.001], cancer (OR = 2.784, 95%CI was 1.296-6.151, P < 0.001), HR (OR = 1.026, 95%CI was 1.014-1.038, P < 0.001), vasoactive drug dose (OR = 1.133, 95%CI was 1.009-1.291, P < 0.001), and invasive mechanical ventilation (OR = 2.141, 95%CI was 1.285-3.651, P < 0.001) were independent factors for hyperdynamic LVEF in ICU sepsis patients. Correlation analysis showed that the mortality of hyperdynamic LVEF, normal LVEF and low LVEF patients was positively correlated with vasoactive drug dose (r value was 0.251, 0.361, 0.289, respectively, all P < 0.001). The mortality of the hyperdynamic LVEF patients was negatively correlated with SVR (r = -0.545, P < 0.001). Chronic liver disease, cancer, HR, vasoactive drugs dose, and invasive mechanical ventilation are independent risk factors for hyperdynamic LVEF in patients with sepsis. Hyperdynamic LVEF is positively associated with mortality in sepsis patients, which may be due to the the decrease of SVR caused by septic vascular paralysis.