Two-dimensional Echocardiograms Research Articles

Deep learning to assess right ventricular ejection fraction from two-dimensional echocardiograms in precapillary pulmonary hypertension.

Precapillary pulmonary hypertension (PH) is characterized by a sustained increase in right ventricular (RV) afterload, impairing systolic function. Two-dimensional (2D) echocardiography is the most performed cardiac imaging tool to assess RV systolic function; however, an accurate evaluation requires expertise. We aimed to develop a fully automated deep learning (DL)-based tool to estimate the RV ejection fraction (RVEF) from 2D echocardiographic videos of apical four-chamber views in patients with precapillary PH. We identified 85 patients with suspected precapillary PH who underwent cardiac magnetic resonance imaging (MRI) and echocardiography. The data was divided into training (80%) and testing (20%) datasets, and a regression model was constructed using 3D-ResNet50. Accuracy was assessed using five-fold cross validation. The DL model predicted the cardiac MRI-derived RVEF with a mean absolute error of 7.67%. The DL model identified severe RV systolic dysfunction (defined as cardiac MRI-derived RVEF<37%) with an area under the curve (AUC) of.84, which was comparable to the AUC of RV fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE) measured by experienced sonographers (.87 and.72, respectively). To detect mild RV systolic dysfunction (defined as RVEF ≤ 45%), the AUC from the DL-predicted RVEF also demonstrated a high discriminatory power of.87, comparable to that of FAC (.90), and significantly higher than that of TAPSE (.67). The fully automated DL-based tool using 2D echocardiography could accurately estimate RVEF and exhibited a diagnostic performance for RV systolic dysfunction comparable to that of human readers.

Echocardiogram-based ventricular isogeometric cardiac analysis using multi-patch fitted NURBS

Monitoring the cardiac function often relies on non-invasive vital measurements, electrocardiograms, and low-resolution echocardiograms. The monitoring data can be augmented with numerical modeling results to support treatment-risk assessment. Often, medical images are not suitable for high-fidelity modeling due to their spatial sparsity and low resolution. In this work, we present a workflow that converts a limited number of two-dimensional (2D) echocardiogram images into analysis-suitable left-ventricle geometries for isogeometric analysis (IGA). The image data is fitted by reshaping a multi-patch NURBS template. This fitting procedure results in a smooth interpolation with a limited number of degrees of freedom. In addition, a coupled 3D-0D cardiac model is extended with a pre-stressing method to perform ventricular-cardiac-mechanic analyses based on in vivo images. The workflow is benchmarked using population-averaged imaging data, which demonstrates that both the shape of the left ventricle and its mechanical response are well predicted in sparse-data scenarios. The case of a clinical patient is considered to demonstrate the suitability of the workflow in a real-data setting.

Permissive Cardiotoxicity As a Guiding Principle to CAR-T Therapy with Reduced Ejection Fraction Heart Failure

Introduction: Pivotal CAR-T registrational trials for the six CAR-T therapies currently FDA approved have excluded those with heart failure (HF), defined either by low ejection fraction (EF) or clinical symptoms of HF (NYHA functional classification). This has created a real-world dilemma for clinicians desiring to treat this patient population. There is concern that those with HF may not tolerate the physiologic and hemodynamic stressors associated with cytokine release syndrome (CRS) and immune effector cell associated neurotoxicity syndrome (ICANS) and thus have increased risk of severe morbidity or death. The emerging concept of permissive cardiotoxicity seeks to allow for an acceptable level of cardiac toxicity to allow for treatment with highly efficacious but potentially cardiac toxic treatments like CAR-T therapy. To that end, in this study, we provide our real-world, single-institution experience with CAR-T therapy in patients with medically optimized HF with reduced EF (HFrEF) prior to date of apheresis. Methods: This was a retrospective review of 168 (100 B-cell lymphoma and 68 multiple myeloma) CAR-T therapy patients, with 20 (12%) identified with HFrEF of ≤50% prior to apheresis by two-dimensional transthoracic echocardiogram as part of the standard CAR-T screening process and without clinical symptoms of HF at time of apheresis. 19/20 patients received standard of care CAR-T products. This study was conducted following IRB approval. Statistical analysis was done using R version 4.2.3. Kaplan-Meier curves were used to calculate progression free survival(PFS) and overall survival(OS). Results: Twenty patients with HFrEF prior to CAR-T infusion were identified with median EF of 44.1% (range 25-50%) (see Table 1, Baseline Characteristics). The median age was 63.5 (37-82) years-old, predominately male gender (80%), Caucasian (70%), with ECOG of 1 (95%), and 10 patients (50%) received axicabtagene ciloleucel (axi-cel). Most patients received CAR-T for B-cell lymphoma (80%). Cardiac history included 5 (25%) with previous CAD, 1 (5%) with previous PAD, and 4 (20%) with history of atrial fibrillation/flutter. Cardio-Oncology was consulted prior to CAR-T therapy in 10 (50%) and 12 (60%) were optimized on goal-directed therapy (GDT). CKD was pre-existing in 4 (20%) patients. Where measured, all patients had a pre-CAR-T troponin within normal institutional limits (&amp;lt;0.05ng/mL). NT-BNP at baseline was only measured in 6 (30%) patients with a median value of 110pg/mL (49-3200, upper limit of normal 125pg/mL). Longitudinal strain prior to CAR-T was measured in 5 (25%) patients with median value of -16% (-19 to -10%, &amp;lt;-17% normal). There were no cases of grade ≥3 CRS with 3 (15%) grade 1 and 12 (60%) grade 2 CRS (see Table 1, Safety Outcomes). There were 4 (20%) with grade 3 ICANS, although most patients 12 (60%) did not experience ICANS. Compared to ZUMA-1, the 10 patients receiving axi-cel did not have significantly higher rates of CRS or ICANS. Tocilizumab was administered in 15 (75%) of patients and steroids given in 10 (50%) of patients. Following CAR-T infusion, 11 (55%) of patients required ICU admission, no patients required vasopressors, 6 (30%) experienced an AKI, 2 (10%) had LFT abnormalities, 4 (20%) had an arrhythmia, and 5 (25%) had further decline in EF with recovery occurring in most cases where measured. Only 2 (10%) of patients had an HF exacerbation within 30 days of CAR-T infusion. PFS and OS were 11.3 and 26 months, respectively. Conclusion: Given that all registrational CAR-T trials excluded HF, notable reservation exists among clinicians in the use of CAR-T therapy in patients with a history of HF and particularly HFrEF. In our institutional experience of 20 patients with good performance status and medically optimized on GDT, we demonstrate that CAR-T therapy can be given safely with rates of CRS and ICANS similar to that expected in the non-HF population. Additionally, while ICU utilization was high, the incidence of arrhythmias, renal or hepatic toxicity as indicators of end organ dysfunction, non-recovering EF decline, and heart failure exacerbation following CAR-T infusion were quite low. It is thus our practice to consider CAR-T therapy on a case by case basis in those with a history of HFrEF. The key to success being maximal cardiac optimization achieved through early engagement of our Cardio-Oncology colleagues based upon the concept of permissive cardiotoxicity.

Abstract 18826: Atrial Fibrillation, Atrial Myopathy, and the Risk of Recurrent Stroke or Transient Ischemic Attack After Cryptogenic Stroke

Background: The annual risk of recurrent stroke after cryptogenic stroke (CS) is estimated at 3-6%. Atrial myopathy, characterized by left atrial structural and electrophysiological remodeling, is associated with atrial fibrillation (AF) and stroke. Hypothesis: Atrial myopathy is associated with an increased risk of recurrent stroke or transient ischemic attack (rCVA) within one year. Methods: Patients with interpretable echocardiograms who received an implantable loop recorder for CS at a tertiary care medical center (2015-22) were included and followed for at least 1 year. Left atrial emptying fraction (LAEF) and reservoir strain (LARS) were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, vascular disease, carotid artery stenosis, and rCVA were ascertained by review of hospital medical records. Incident AF post CS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. Results: 159 patients (mean age 74.4 years, 52.1% female) were followed for at least one-year post CS. Patients with rCVA had significantly lower LAEF (p=0.012) and near-significantly lower LARS (p=0.088) compared to those who did not. The odds of rCVA were 4.82 (2.22, 7.11)-fold greater in those found to have new AF independent of LAEF, LARS, and remaining covariates including carotid artery stenosis. Patients on anticoagulation at time of rCVA had trends towards reduced stroke severity (p=0.184). Conclusions: Atrial myopathy characterized by AF or reduced LA function is associated with rCVA post CS.

Diagnosis of the venous duct in fetuses of the early period of human ontogeny

To carry out an analysis of data from the world literature regarding the role of Doppler assessment of blood flow in the venous duct of the fetus in chromosomal abnormalities in the first trimester of pregnancy, as a marker – the spectral form of wave blood flow and its pulsation, which is generated by changes in the pressure and volume of blood to the heart of the fetus. Prenatal diagnosis of venous blood flow makes it possible to assess the state of the fetal cardiovascular system. Blood flow in the ductus venosus is an integrative indicator that reflects the formation of blood circulation of both the uteroplacental and placental-fetal components of gestational hemodynamics during physiological and complicated pregnancy. The performance of this test is 63%, and in combination with the assessment of the thickness of the clavicle – 89.1%. When reverse values of blood flow in the ductus venosus are detected in the phase of contraction of the atrium and dilated cervical space, it is necessary to carry out karyotyping to rule out chromosomal abnormalities. Dopplerography allows us to objectively assess the functioning state of the fetus during physiological and complicated pregnancy based on the study of the state of blood flow in the vessels of the placenta, in the middle cerebral artery, thoracic aorta, renal arteries, inferior vena cava and venous duct. The spectrum of venous blood flow reflects changes in volume and pressure in the atria during the cardiac cycle. With normal fetal development, blood flow in the venous duct has a pulsating character in the form of a unidirectional three-phase curve that corresponds to different periods of the cardiac cycle. The spectrum of normal blood flow in the venous duct in a healthy newborn has a biphasic curve, with the direction from the portal sinus to the inferior vena cava. During three weeks of regular examinations in most babies, obliteration of the venous duct occurs, and the ductus turns into a venous connection. Two-dimensional echocardiogram, color and pulsed dopplerography allow recording the waveforms of blood flow in several structures of the heart. Doppler analysis of blood flow in the venous duct is important to perform in fetuses of the first trimester, as it increases the sensitivity of the combined test in assessing the risk of chromosomal disorders. Assessment of blood flow in the ductus venosus provides an understanding of physiological and pathological processes in the fetal body and identifies fetuses that are prone to or at risk of disease.

Estimation of Risk and Proportion of Coronary Artery Disease in People Living with HIV/AIDS in Indian Setting: A Pilot Study

Objective: The objective of this study was to assess the Framingham Risk Score as well as the prevalence of coronary artery disease (CAD) in people living with HIV/AIDS (PLHA) male patients, in an Indian setting. Design: This descriptive pilot study was conducted in a multispecialty hospital which is a reference center for HIV/AIDS. Materials and Methods: The study included 50 HIV-positive male patients who underwent basic biochemical analysis, namely lipid profile, blood sugar (fasting), electrocardiogram, CD4 count along with basic personal history (including smoking habits and lifestyle), course of disease progression, and drug history. All were subjected to a two-dimensional echocardiogram and treadmill test (TMT). Subjects with a positive TMT underwent a confirmatory stress thallium/coronary angiography. Framingham Risk Scores were calculated, using standard scoring charts. Standard protocol forms were made for each patient. Results: The median diagnosed duration of HIV disease was 2.8 years (range: 0.5–7 years). The median 10-year risk of CAD (as calculated from the Framingham scores) was 1%. Major contributing risk factors were dyslipidemia, diabetes, and hypertension and were found to be greater as compared to published literature. Four patients had positive TMT, but all four had a negative, coronary angiogram. Conclusions: Biological plausibility suggests that CAD may be more common in PLHA due to the chronic inflammatory nature of the disease and the effects of the dyslipidemia effect of ART; however, our pilot study with the limitations could not substantiate this.

Study of Correlation between Right Ventricular Ejection Fraction with Left Ventricular Ejection Fraction in Patients of Chronic Heart Failure with Diabetes, using Two-dimensional Echocardiography

Abstract Introduction: Diabetes is one of the most significant health issues. Patients with type 2 diabetes mellitus (DM) are more susceptible to an elevated cardiovascular risk, including heart failure. Echocardiography should help in the early identification of these myocardial abnormalities that would help properly treat these individuals. Materials and Methods: The study was conducted over 18 months and focused on patients with diabetes and chronic heart failure who met inclusion and exclusion criteria. Ethical approval was obtained, and all patients provided their consent to participate in the study. The participants underwent a two-dimensional echocardiogram to assess their heart function, and relevant laboratory tests, imaging results, and information about medications received during their hospitalization were recorded. Results: As per The New British Society of Echocardiography criteria, 64 patients had impaired left ventricular ejection fraction (LVEF), and 31 had severely impaired LVEF. The majority of the patients with impaired LVEF, 53%, also had impaired right ventricular ejection fraction (RVEF). Of 31 patients with severely impaired LVEF, 58% also had severely impaired RVEF. The association between LVEF and RVEF is statistically significant (P &lt; 0.05). There is a positive correlation between LVEF (%) and RVEF (%), which was statistically significant (P &lt; 0.05). Severe dysfunction in LVEF is also present in patients with severe dysfunction of RVEF. Conclusion: The majority of patients who had reduced LVEF also had reduced RVEF, and this association was significant. While there was a correlation between glycosylated hemoglobin levels and both LVEF and RVEF, it was not statistically significant. Hence, patients who are identified to have lower LVEF should also be evaluated for RVEF.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

RIGHT VENTRICULAR FUNCTION IN ARTERIAL HYPERTENSION (M-MODE ECHOCG STUDY)

Objective: Until recently Researchers underestimated right ventricular (RV) physiological and described it as passive conduit with a little pumping capability which just connects right atrium (RA) with pulmonary artery. Over the last decades, numerous studies have demonstrated the physiological and clinical importance of RV function. Contrary to the LV, the RV has much complex geometry. It consists of an inlet, outlet, and apical trabecular portion which are different structurally and functionally. There is no information about Right ventricular outflow structure and function in patients with Arterial Hypertension (AH). The aim of the research was to study the changes of RV Outflow and Inflow functional parameters in patients with Arterial Hypertension. Design and method: We studied 214 patients AH (male-115, fem-99, mean age 55.6±12.2, mean arterial pressure – systolic 174.1±15.2, diastolic 96.8±11.2). Control group consist from 180 normal persons (male-88, fem-92, mean age 49.7±12.2, mean arterial pressure – systolic 122.1±12.2, diastolic 71.8±10.2). All participants undergone standard EchoCG examination. Two-dimensional echocardiograms of the parasternal short axis view at the level of the aortic root were obtained for the RVOT sizes and fractional shortening (RVOT-FS) values. M-mode recordings of the RVOT were obtained and dimensions were measured at end -diastole and end systole. RV outflow Fractional Shortening (RVoutFS%, calculated with formula (RVoutDiastD-RVoutSystD)/RVoutDiastD%). Results: 12 patients had stage-1 AH, 138- stage 2 and 64 stage 3 AH. In AH group RV wall thickness (4.2±0.9 mm versus 3.5±0.7mm), RV outflow tract systolic and diastolic diameters (32.8±4.8mm and 14.7±3.2mm versus 30.8±4.7 and 13.2±2.8mm) where greater and RVoutFS% (55.1±4.8% versus 58.8±4.3%) Pulmonary flow acceleration time (121.6±17.1versus 132.6±12.2 msec) lesser then in control. On the other hand, there was no difference in TAPSE between the groups. Conclusions: Despite any differences in RV inflow function There are prominent changes in RV outflow tract function and structure in patients with AH. RVoutFS% is a marker of early functional changes of RV in patients with AH

CE-452778-1 LEFT ATRIAL MECHANICAL DYSFUNCTION AND THE INCIDENCE OF ATRIAL FIBRILLATION WITHIN 1 YEAR OF EMBOLIC STROKE OF UNKNOWN SOURCE

Atrial fibrillation (AF) is detected in a significant proportion of patients with embolic stroke of unkown source (ESUS) on subsequent cardiac monitoring and represents an indication for anticoagulation to prevent future stroke in these patients. Left atrial mechanical dysfunction often precedes development of atrial fibrillation and may represent an upstream marker which can readily be assessed at the point of care to inform decisions about future stroke prevention in people with ESUS. To evaluate the association between left atrial mechanical dysfunction, measured by left atrial emptying fraction (LAEF) and reservoir strain (LARS), and incident atrial fibrillation in patients with ESUS. Patients with interpretable echocardiograms who received an implantable loop recorder for ESUS at a tertiary care medical center between 2015 and 2022 were included and followed for 1 year. LAEF and LARS were calculated from two-dimensional transthoracic echocardiograms. Covariates including congestive heart failure, hypertension, age, diabetes, sex, stroke/transient ischemic attack, and vascular disease were ascertained by review of hospital medical records. Incident AF post ESUS was obtained from review of loop recorder data. Odds ratios were calculated using logistic regression models. Two-sided student's T-test was used to compare means of continuous variables. 167 patients (mean age 74.4 years, 52.1% female) were followed for 1 year after ESUS. AF was detected in 49 (20.3%) patients. Patients who developed AF had lower LAEF (46.78% vs 57.50%, P<0.01) and LARS (24.33% vs 31.60%, P<0.01) compared to those who did not develop AF. LAEF and LARS were independently associated with AF within 1 year of ESUS (Table). Left atrial mechanical dysfunction, detected by meeasurement of left atrial reseervoir strain and emptying fraction, is independently associated with the incidence of atrial fibrillation within 1 year of ESUS.

Right Ventricular Function Indices at Rest and During Exercise in Hyperthyroid Patients: A Cross-sectional Study.

Since hyperthyroidism could be associated with right ventricular dysfunction, this study intended to investigate right ventricular (RV) function using strain echocardiography in hyperthyroid patients both at rest and in maximum-stress conditions. This cross-sectional study was conducted at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, from January 2019 to January 2020. All study participants completed a maximum treadmill exercise test, as well as a complete two-dimensional echocardiogram at rest and the peak of stress test. The data were analyzed using SPSS statistical software. The independent samples t test and Mann-Whitney U test were used for numerical, and the Chi square test was used for nominal variables. P<0.05 was considered statistically significant. The final analysis included 52 participants (26 subjects in each group). In a maximal stress situation, we found that among the RV function indices, RV global longitudinal strain (P=0.0001), systolic strain rate (P=0.0001), diastolic strain rate (P=0.0002), and tricuspid annular plane systolic excursion (P=0.019) werereduced significantly in the hyperthyroid patients compared to the control group. There was also a linear correlation between RV size and thyroid stimulating hormone (TSH) level (P=0.009, r=0.36). Moreover, we found a negative linear correlation between TSH level with maximum stress RV strain and diastolic strain rate (P<0.001). The findings of the present study revealed a significant change in RV function indices among hyperthyroid patients. Therefore, it highlights the necessity of early diagnosis and treatment of hyperthyroidism, as well as RV function evaluation in these patients.

Dexrazoxane and Long-Term Heart Function in Survivors of Childhood Cancer.

For survivors of childhood cancer treated with doxorubicin, dexrazoxane is cardioprotective for at least 5 years. However, longer-term data are lacking. Within the Children's Oncology Group and the Dana Farber Cancer Institute's Childhood Acute Lymphoblastic Leukemia Consortium, we evaluated four randomized trials of children with acute lymphoblastic leukemia or Hodgkin lymphoma, who received doxorubicin with or without dexrazoxane, and a nonrandomized trial of patients with osteosarcoma who all received doxorubicin with dexrazoxane. Cumulative doxorubicin doses ranged from 100 to 600 mg/m2 across these five trials, and dexrazoxane was administered uniformly (10:1 mg/m2 ratio) as an intravenous bolus before doxorubicin. Cardiac function was prospectively assessed in survivors from these trials, plus a matched group of survivors of osteosarcoma treated with doxorubicin without dexrazoxane. Two-dimensional echocardiograms and blood biomarkers were analyzed centrally in blinded fashion. Multivariate analyses adjusted for demographic characteristics, cumulative doxorubicin dose, and chest radiotherapy determined the differences and associations by dexrazoxane status. From 49 participating institutions, 195 participants were assessed at 18.1 ± 2.7 years since cancer diagnosis (51% dexrazoxane-exposed; cumulative doxorubicin dose 297 ± 91 mg/m2). Dexrazoxane administration was associated with superior left ventricular fractional shortening (absolute difference, +1.4% [95% CI, 0.3 to 2.5]) and ejection fraction (absolute difference, +1.6% [95% CI, 0.0 to 3.2]), and lower myocardial stress per B-type natriuretic peptide (-6.7 pg/mL [95% CI, -10.6 to -2.8]). Dexrazoxane was associated with a reduced risk of having lower left ventricular function (fractional shortening < 30% or ejection fraction < 50%; odds ratio, 0.24 [95% CI, 0.07 to 0.81]). This protective association was primarily seen in those treated with cumulative doxorubicin doses ≥ 250 mg/m2. Among young adult-aged survivors of childhood cancer, dexrazoxane was associated with a cardioprotective effect nearly 20 years after initial anthracycline exposure.

Correlates of atherosclerotic vascular disease in stable postrenal transplant patients from South India

Introduction: Renal transplant recipients (RTRs) show increased mortality after 1st year of undergoing renal transplantation. Cardiovascular disease (CVD) is the major cause of mortality in these patients. Oxidative stress (OS), inflammation, and endothelial dysfunction (ED) represent a key triad for the onset and progression of atherosclerosis. The present study was undertaken to assess OS, inflammatory biomarkers, and ED as a surrogate marker of atherosclerosis in stable RTRs. Materials and Methods: Thirty stable post-RTRs along with 30 healthy individuals as controls were included in the study conducted at a tertiary care teaching hospital in south India. Lipid profile; OS markers; malondialdehyde (MDA), ischemia-modified albumin (IMA), and ferric reducing ability of plasma (FRAP); inflammatory marker high-sensitivity C-reactive protein and interleukin 6 (IL-6); ED markers nitric oxide (NO) and P-selectin were estimated using standard methods. Lipid indices were calculated. Carotid intima-media thickness, two-dimensional echocardiogram, and renal Doppler scans were done. Results: No difference in lipid profile was observed between the RTRs and the control groups. RTRs had significantly higher oxidant markers (MDA and IMA), inflammatory marker (IL-6), marker of ED (NO), and lower antioxidant marker (FRAP) (P < 0.05) compared to the control group. RTRs had significantly more number of carotid plaques compared to the control group. A positive correlation was observed between number of carotid plaque and OS, ED, and inflammatory markers. Conclusion: RTRs have increased CVD risk despite undergoing renal replacement therapy. This can be attributed to the increased OS and inflammation which is seen in these patients.

Double-arterial cannulation strategy in patients presenting with Type A aortic dissection

Background: Cannulation strategies in ascending aorta and arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the preferred strategy, but it does come with its set of demerits. Double-arterial cannulation (DAC) may decrease DHCA time and avoid its related morbidity and mortality. Aim: The aim was to compare patients undergoing surgery in acute Type A dissection by DAC with antegrade cerebral perfusion under moderate hypothermia and single-arterial cannulation (SAC) technique under DHCA with respect to the primary outcome of stroke, seizure, and psychosis and the secondary outcome as malperfusion, hospital stay, and mortality. Materials and Methods: This study was a retrospective analysis of 64 patients operated for acute ascending aortic dissection (AAD) extending into arch and major vessels in the Department of CTVS, UN Mehta Institute of Cardiology and Research between July 2015 and July 2020. After screening through the hospital data, 30 patients operated by SAC and 34 patients operated by DAC technique were selected and their files were studied and analyzed. All patients were diagnosed using two-dimensional echocardiogram and computerized tomography aortogram to confirm the diagnosis. Forty-four patients who presented to emergency were stabilized before taking up for emergency surgery and 20 were operated semi-electively. Out of 64 patients, 40 patients underwent Bentall's procedure using composite mechanical valve, 10 patients underwent ascending aorta replacement, 7 patients underwent ascending aorta replacement with hemiarch, 2 patients underwent Bentall's with coronary artery bypass grafting, 2 patients underwent David's procedure, 2 patients underwent Yacoub's procedure, and 1 patient underwent Bentall's procedure using biological valve. Out of 30 patients operated by SAC, 25 patients had femoral cannulation and 5 patients had only right axillary cannulation. In the DAC group, all had right axillary artery and femoral cannulation. All patients were analyzed for primary and secondary outcomes. Results: A total of 64 patients diagnosed with Type A AAD with dissection flap extending into major vessels were included in the study. Those patients operated with DAC technique had a significantly lower incidence of stroke, malperfusion, and hospital mortality as compared to the patients with SACs. Conclusion: In AAD involving major arch vessel and femoral arteries, the idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost iimportance. The idea is to provide rapid and safe blood inflow to arterial system in order to maintain cardiopulmonary bypass (CPB) and organ perfusion, which is of utmost importance. The right axillary artery is least involved in acute aortic dissection and when cannulated can provide uninterrupted flow to brain and also provide sufficient inflow to maintain CPB. Along with this, if femoral artery cannulation provides flow to abdominal organs and lower limb, it will prevent malperfusion syndrome. DAC is safe in complex Type A aortic dissection and aortic arch surgery and has better perioperative outcomes compared to SAC.

Biventricular longitudinal strain as a predictor of functional improvement after D-shant device implantation in patients with heart failure.

The creation of an atrial shunt is a novel approach for the management of heart failure (HF), and there is a need for advanced methods for detection of cardiac function response to an interatrial shunt device. Ventricular longitudinal strain is a more sensitive marker of cardiac function than conventional echocardiographic parameters, but data on the value of longitudinal strain as a predictor of improvement in cardiac function after implantation of an interatrial shunt device are scarce. We aimed to investigate the exploratory efficacy of the D-Shant device for interatrial shunting in treating heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), and to explore the predictive value of biventricular longitudinal strain for functional improvement in such patients. A total of 34 patients were enrolled (25 with HFrEF and 9 with HFpEF). All patients underwent conventional echocardiography and two-dimensional speckle tracking echocardiogram (2D-STE) at baseline and 6 months after implantation of a D-Shant device (WeiKe Medical Inc., WuHan, CN). Left ventricular global longitudinal strain (LVGLS) and right ventricular free wall longitudinal strain (RVFWLS) were evaluated by 2D-STE. The D-Shant device was successfully implanted in all cases without periprocedural mortality. At 6-month follow-up, an improvement in New York Heart Association (NYHA) functional class was observed in 20 of 28 patients with HF. Compared with baseline, patients with HFrEF showed significant reduced left atrial volume index (LAVI) and increased right atrial (RA) dimensions, as well as improved LVGLS and RVFWLS, at 6-month follow-up. Despite reduction in LAVI and increase in RA dimensions, improvements in biventricular longitudinal strain did not occur in HFpEF patients. Multivariate logistic regression demonstrated that LVGLS [odds ratio (OR): 5.930; 95% CI: 1.463-24.038; P = 0.013] and RVFWLS (OR: 4.852; 95% CI: 1.372-17.159; P = 0.014) were predictive of improvement in NYHA functional class after D-Shant device implantation. Improvements in clinical and functional status are observed in patients with HF 6 months after implantation of a D-Shant device. Preoperative biventricular longitudinal strain is predictive of improvement in NYHA functional class and may be helpful to identify patients who will experience better outcomes following implantation of an interatrial shunt device.

DEEP LEARNING MODELS FOR AUTOMATING ASSESSMENT OF LEFT VENTRICULAR WALL THICKNESS AND DIMENSIONS

Left ventricular (LV) geometric patterns aid clinicians in the diagnosis and prognostication of various cardiomyopathies. Two-dimensional transthoracic echocardiogram is the clinical standard for the assessment of LV dimensions. Assessment of LV dimensions and wall thickness is known to be associated with significant interobserver and intraobserver variability. Automation of echocardiographic interpretation using machine learning may allow non-experts to assess LV dimensions while improving reliability.

Echocardiographic Characterization of Left Heart Morphology and Function in Highly Trained Male Judo Athletes.

The long-term practice of judo can lead to various changes in the heart including increased dimensions of the left ventricle in diastole and thickening of the interventricular septum and the posterior wall of the left ventricle. This study aimed to assess left ventricular morphology and function in elite male judokas. A comparative cross-sectional study was conducted that included a total of 20 subjects, 10 judokas, and 10 healthy non-athletes aged 24 ± 2.85 years. Demographic and anthropometric data were analyzed. All subjects underwent a medical examination and a two-dimensional transthoracic echocardiogram. Different parameters of left ventricular morphology and function were measured and compared between athletes and non-athletes. Left ventricle mass and LV mass index were higher in judokas than in non-athletes (p < 0.05), as well as PW thickness (9.78 ± 0.89 mm vs. 8.95 ± 0.76 mm). A total of six (n = 6) of athletes had eccentric hypertrophy, while others had normal heart geometry. LVEDd, LVEDs, LVEDd/BSA, and LVEDs/BSA were significantly higher in judokas (p < 0.05). LVEDd in athletes ranged from 48 to 62 mm. These values, combined with normal diastolic function, ejection fraction, and shortening fraction, indicate that the judokas’ cardiac adaptation was physiological rather than pathological.

Low-Dose Thrombolysis in an Intermediate High-Risk Submassive Pulmonary Embolism With Right Atrial Thrombus: A Case Report

BACKGROUND: Venous thromboembolism, encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is the third most common acute cardiovascular syndrome. It requires prompt diagnosis and risk-based treatment strategies. CASE: A 47-year-old male, 30-pack-year smoker who recently underwent open reduction and internal fixation of the right femur presented with dyspnea. There was no hemodynamic instability. Twelve-lead electrocardiogram showed sinus rhythm with incomplete right bundle-branch block, and troponin was elevated. Chest x-ray showed dilated right descending pulmonary artery. Two-dimensional echocardiogram revealed right atrial thrombus with right ventricular dysfunction. Computed tomography of the pulmonary artery confirmed massive PE with infarct on the posterobasal segment of the right lower lobe. Venous duplex scan of the lower extremities showed an acute DVT of the right femoral vein, popliteal vein, and peroneal vein. Anticoagulation was started. With a dilemma of a recent surgery in an intermediate high-risk submassive PE, options other than guideline-recommended systemic thrombolysis were considered. A multidisciplinary consensus recommended the administration of low-dose thrombolysis, which later resulted to clinical improvement. CONCLUSION: This is the first documented local case of successful resolution of a right atrial thrombus with pulmonary thrombus and DVT using low-dose thrombolysis, without complications of bleeding, in a patient with contraindications to thrombolysis. With more clinical experience and studies of low-dose recombinant tissue plasminogen activator in this special population, it can offer a promising treatment option. KEYWORDS: pulmonary embolism, submassive, low-dose systemic thrombolysis, contraindication for thrombolysis, alteplase, tPA, right atrial thrombus

Signs of Cardiac Injury in Critically Ill Paediatric Patients with COVID-19: a Single-Center Experience in Brazil.

ResumoFundamento Alguns pacientes com COVID-19 apresentam injúria miocárdica.Objetivo Detectar a injúria miocárdica em pacientes criticamente doentes, e comparar o envolvimento cardíaco entre crianças com síndrome respiratória aguda grave (SARS) e crianças com síndrome inflamatória multissistêmica (MIS-C).Métodos Todas as crianças acometidas da COVID-19 admitidas em uma unidade de terapia intensiva de referência foram cadastradas de forma prospectiva e fizeram uma ecografia transtorácica bidimensional (ETT-2D) e um teste de troponina I cardíaca (cTnI) nas primeiras 72 horas. Para a análise estatística, um p <0,05 bilateral foi considerado significativo.Resultados 33 pacientes foram incluídos, dos quais 51,5% apresentaram cTnI elevada e/ou ETT-2D anormal e 36,4% precisaram de suporte cardiovascular, que foi mais frequente em pacientes com cTnI elevada e anormalidades em ETT-2D do que em pacientes com exames normais (83,3% e 33,3%, respectivamente; p 0,006, 95% IC = 0,15-0,73). Os achados de ETT-2D mais comuns foram efusão pericárdica (15,2%) e regurgitação tricúspide/mitral (15,2%). Sinais de envolvimento cardíaco foram mais comuns na MIS-C que na SARS. Pacientes com MIS-C também apresentaram um índice mais alto de necessidade de suporte cardiovascular (66,7% X 25%, p 0,03, 95% IC = -0,7 a -0,04) e um índice mais frequente de cTnI elevada (77,8% X 20,8%; p 0,002, 95% IC = 0,19 a 0,79). Os valores preditivos negativos de cTnI para detecção de anormalidades de ETT-2D foram 100% para pacientes com MIS-C, e 73,7% para pacientes com SARS.Conclusão Sinais de injúria cardíaca foram comuns, especialmente em pacientes com MIS-C. As anormalidades na ETT-2D foram sutis. A realização de um teste de cTnI na admissão pode ajudar os prestadores de assistência de saúde a discriminar os pacientes com uma necessidade mais urgente de uma ETT-2D.

Cardiac Segmentation Method Based on Domain Knowledge.

Echocardiography plays an important role in the clinical diagnosis of cardiovascular diseases. Cardiac function assessment by echocardiography is a crucial process in daily cardiology. However, cardiac segmentation in echocardiography is a challenging task due to shadows and speckle noise. The traditional manual segmentation method is a time-consuming process and limited by inter-observer variability. In this paper, we present a fast and accurate echocardiographic automatic segmentation framework based on Convolutional neural networks (CNN). We propose FAUet, a segmentation method serially integrated U-Net with coordinate attention mechanism and domain feature loss from VGG19 pre-trained on the ImageNet dataset. The coordinate attention mechanism can capture long-range dependencies along one spatial direction and meanwhile preserve precise positional information along the other spatial direction. And the domain feature loss is more concerned with the topology of cardiac structures by exploiting their higher-level features. In this research, we use a two-dimensional echocardiogram (2DE) of 88 patients from two devices, Philips Epiq 7C and Mindray Resona 7T, to segment the left ventricle (LV), interventricular septal (IVS), and posterior left ventricular wall (PLVW). We also draw the gradient weighted class activation mapping (Grad-CAM) to improve the interpretability of the segmentation results. Compared with the traditional U-Net, the proposed segmentation method shows better performance. The mean Dice Score Coefficient (Dice) of LV, IVS, and PLVW of FAUet can achieve 0.932, 0.848, and 0.868, and the average Dice of the three objects can achieve 0.883. Statistical analysis showed that there is no significant difference between the segmentation results of the two devices. The proposed method can realize fast and accurate segmentation of 2DE with a low time cost. Combining coordinate attention module and feature loss with the original U-Net framework can significantly increase the performance of the algorithm.