Diagnosis and Management of Aortic Valve Stenosis: The Role of Non-Invasive Imaging

Aortic stenosis is the most common heart valve disease necessitating surgical or percutaneous intervention. Imaging has a central role for the initial diagnostic work-up, the follow-up and the selection of the optimal timing and type of intervention. Referral for aortic valve replacement is currently driven by the severity and by the presence of aortic stenosis-related symptoms or signs of left ventricular systolic dysfunction. This review aims to provide an update of the imaging techniques and seeks to highlight a practical approach to help clinical decision making.

Dark blood ischemic LGE segmentation using a deep learning approach

Funding Acknowledgements

Type of funding sources: None.

Introduction

The extent of ischemic scar detected by Cardiac Magnetic Resonance (CMR) with late gadolinium enhancement (LGE) is linked with long-term prognosis, but scar quantification is time-consuming. Deep Learning (DL) approaches appear promising in CMR segmentation.  Purpose: To train and apply a deep learning approach to dark blood (DB) CMR-LGE for ischemic scar segmentation, comparing results to 4-Standard Deviation (4-SD) semi-automated method. Methods: We trained and validated a dual neural network infrastructure on a dataset of DB-LGE short-axis stacks, acquired at 1.5T from 33 patients with ischemic scar. The DL architectures were an evolution of the U-Net Convolutional Neural Network (CNN), using data augmentation to increase generalization. The CNNs worked together to identify and segment 1) the myocardium and 2) areas of LGE. The first CNN simultaneously cropped the region of interest (RoI) according to the bounding box of the heart and calculated the area of myocardium. The cropped RoI was then processed by the second CNN, which identified the overall LGE area. The extent of scar was calculated as the ratio of the two areas. For comparison, endo- and epi-cardial borders were manually contoured and scars segmented by a 4-SD technique with a validated software. Results: The two U-Net networks were implemented with two free and open-source software library for machine learning. We performed 5-fold cross-validation over a dataset of 108 and 385 labelled CMR images of the myocardium and scar, respectively. We obtained high performance (> ∼0.85) as measured by the Intersection over Union metric (IoU) on the training sets, in the case of scar segmentation. With regards to heart recognition, the performance was lower (> ∼0.7), although improved (∼ 0.75) by detecting the cardiac area instead of heart boundaries. On the validation set, performances oscillated between 0.8 and 0.85 for scar tissue recognition, and dropped to ∼0.7 for myocardium segmentation. We believe that underrepresented samples and noise might be affecting the overall performances, so that additional data might be beneficial. Figure1: examples of heart segmentation (upper left panel: training; upper right panel: validation) and of scar segmentation (lower left panel: training; lower right panel: validation). Conclusion: Our CNNs show promising results in automatically segmenting LV and quantify ischemic scars on DB-LGE-CMR images. The performances of our method can further improve by expanding the data set used for the training. If implemented in a clinical routine, this process can speed up the CMR analysis process and aid in the clinical decision-making. Abstract Figure.

Novel transcatheter mitral prosthesis designed to preserve physiological ventricular flow dynamics

BACKGROUND

Current mitral bioprostheses are akin to the aortic valve and therefore abolish the left ventricular (LV) physiological vortex. We evaluated the hemodynamic performance and the effects on intraventricular flow dynamics (IFD) of a novel mitral bioprosthesis that presents an innovative design, mimicking the native valve.

METHODS

A D-shaped self-expandable stent-bovine pericardium monoleaflet valve was designed to provide physiological asymmetric intraventricular flow. Twelve juvenile sheep were consecutively implanted transapically. Post-implant studies were obtained immediately after the implantation and at 3 months to assess the hemodynamic performance of the prostheses, using Doppler echocardiography and IFD using echo particle imaging velocimetry.

RESULTS

Three deaths occurred during follow-up, one due to valve misplacement because of poor imaging visualization and 2 not valve related. Mean transvalvular gradient and effective orifice area after implantation and at 3 months were 2.2 ± 1.2 mmHg and 4.0 ± 1.1 cm², and 3.3 ± 1.5 mmHg and 3.5 ± 0.5 cm², respectively. LV vortex dimension, orientation and physiologic anti-clockwise rotation were preserved compared with pre-operative normal LV flow pattern. One animal showed a moderate paravalvular leak, others mild or none. LV outflow tract obstruction, valve thrombosis or hemolysis were not observed.

CONCLUSIONS

Our preclinical in vivo results, confirm the good hemodynamic performance of this new transcatheter bioprosthesis with preservation of the physiological IFD. Clinical studies are needed to document whether these characteristics will foster LV recovery and improve the clinical outcome of patients with mitral regurgitation.

3-D Echocardiography Is Feasible and More Reproducible than 2-D Echocardiography for In-Training Echocardiographers in Follow-up of Patients with Heart Failure with Reduced Ejection Fraction

Left ventricular volumes (LVVs) and ejection fraction (LVEF) are key elements in the evaluation and follow-up of patients with heart failure with reduced ejection fraction (HFrEF). Therefore, a feasible and reproducible imaging method to be used by both experienced and in-training echocardiographers is mandatory. Our aim was to establish if, in a large echo lab, echocardiographers in-training provide feasible and more reproducible results for the evaluation of patients with HFrEF when using 3-dimensional echocardiography (3-DE) versus 2-dimensional echocardiography (2-DE). Sixty patients with HFrEF (46 males, age: 58 ± 17 y) underwent standard transthoracic 2-D acquisitions and 3-D multibeat full volumes of the left ventricle. One expert user in echocardiography (expert) and three echocardiographers with different levels of training in 2-DE (beginner, medium and advanced) measured the 2-D LVVs and LVEFs on the same consecutive images of patients with HFrEF. Afterward, the expert performed a 1-mo training in 3-DE analysis of the users, and both the expert and trainees measured the 3-D LVVs and LVEF of the same patients. Measurements provided by the expert and all trainees in echo were compared. Six patients were excluded from the study because of poor image quality. The mean end-diastolic LVV of the remaining 54 patients was 214 ± 75 mL with 2-DE and 233 ± 77 mL with 3-DE. Mean LVEF was 35 ± 10% with 2-DE and 33 ± 10% with 3-DE. Our analysis revealed that, compared with the expert user, the trainees had acceptable reproducibility for the 2-DE measurements, according to their level of expertise in 2-DE (intra-class coefficients [ICCs] ranging from 0.75 to 0.94). However, after the short training in 3-DE, they provided feasible and more reproducible measurements of the 3-D LVVs and LVEF (ICCs ranging from 0.89-0.97) than they had with 2-DE. 3-DE is a feasible, rapidly learned and more reproducible method for the assessment of LVVs and LVEF than 2-DE, regardless of the basic level of expertise in 2-DE of the trainees in echocardiography. In echo labs with a wide range of staff experience, 3-DE might be a more accurate method for the follow-up of patients with HFrEF.

Prognostic value of right ventricular mechanical pattern assessed with 3D echocardiography in patients with left-sided heart disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the New National Excellence Programme (ÚNKP-19-3-I) of the Ministry for Innovation and Technology in Hungary, and the Artificial Intelligence Research Field Excellence Programme of the National Research, Development and Innovation Office of the Ministry of Innovation and Technology in Hungary.

Background

Right ventricular (RV) ejection fraction (EF) has established prognostic significance, which is independent of left ventricular (LV) EF in various cardiac diseases. However, RV EF is a cumulative result of the complex interplay between distinct mechanical components (i.e., shortening along the longitudinal, radial, and anteroposterior directions), and the prognostic value of RV motion decomposition remains to be quantified.

Objective

Our aim was to explore whether the assessment of longitudinal, radial, and anteroposterior motion components of the RV with 3D transthoracic echocardiography offers prognostic value in patients with left-sided heart disease.

Methods

Two hundred and ninety-two consecutive patients (age 59 ± 17 years, 70% male) with left-sided heart disease underwent standard clinical investigations and 3D echocardiographic examination. They were followed-up for 6.7 ± 2.2 years, and cardiac death served as the primary endpoint. LV and RV volumes and ejection fractions were quantified by the offline analysis of 3D datasets. The ReVISION method was applied to the 3D models of the RV to decompose the motion along the three orthogonal axes and to calculate longitudinal, radial, and anteroposterior EF (LEF, REF, AEF, respectively). Conventional parameters of RV systolic function (tricuspid annular plane systolic excursion [TAPSE], fractional area change [FAC]) were also assessed.

Results

Cardiac death occurred in 60 (21%) patients. Patients who died had lower LV EF (39 ± 16 vs. 52 ± 12%, p < 0.001), RV EF (40 ± 11 vs. 48 ± 8%, p < 0.001), and each mechanical component showed significantly lower values compared to patients alive (LEF: 13 ± 6 vs. 19 ± 6%; REF: 22 ± 7 vs. 25 ± 7%; AEF: 14 ± 6 vs. 18 ± 5%, all p < 0.001). LEF was decreased to a greater degree compared to RV EF (relative %: -30 vs. -18). In univariate Cox regression models, RV EF (Hazard Ratio [HR]: 0.928, 95% Confidence Interval [CI] 0.909 – 0.948, p < 0.001), LEF (0.855 [0.816 – 0.896], p < 0.001), REF (0.932 [0.898 – 0.967], p < 0.001), AEF (0.879 [0.841 – 0.919], p < 0.001), TAPSE (0.881 [0.841-0.923], p < 0.001), and FAC (0.955 [0.933-0.977], p < 0.001) were all found to be significant predictors of cardiac death. From all parameters that were predictive, the optimal combination of variables was identified with an automated stepwise selection algorithm. The final multivariate model included serum creatinine (1.015 [1.010 – 1.020], p < 0.001), haemoglobin concentration (0.965 [0.948 – 0.982], p < 0.001), LV EF (0.977 [0.955 – 0.999], p < 0.05), and LEF (0.899 [0.843 – 0.959], p < 0.01) as independent predictors of cardiac death. Notably, the algorithm rather selected LEF and not RV EF.

Conclusions

3D echocardiography-derived measurements of RV systolic function are able to predict outcomes in patients with left-sided heart disease independently of LV function. The separate quantification of RV mechanical components can hold additional prognostic value compared to conventional echocardiographic parameters.

Vendor-independent software shows limited variability in speckle tracking strain measurements on images of different vendors

Funding Acknowledgements

Type of funding sources: None.

Background

Vendors use proprietary speckle tracking software algorithms for echocardiographic strain measurements, which results in high inter-vendor variability. Little is known about potential advantages or disadvantages of using vendor-independent software in clinical practice.

Purpose

We therefore investigated the reproducibility, accuracy, and ability to identify scar of strain measurements on images from different vendors by using a vendor-independent software.

Methods

A vendor-independent software (TomTec Image Arena) was used to analyze datasets of 63 patients which were obtained on four ultrasound machines from different vendors (GE, Philips, Siemens, Toshiba). We measured the tracking feasibility, inter-vendor bias, the relative and absolute test-re-test variability of strain measurements and their ability to detect scar. Cardiac magnetic resonance delayed enhancement images were used as the reference standard of scar definition.

Results

Tracking feasibility differed depending on the image source (p < 0.05). Variability of global longitudinal strain (GLS) (Figure 1A) was similar (ANOVA p = 0.124) among the images of different vendors whereas variability of segmental longitudinal strain (SLS) (Figure 1B) showed modest difference (ANOVA- peak systolic strain (PS); p = 0.077, end-systolic strain (ES); p = 0.171, post-systolic strain (PSS); p = 0.020). Relative test-re-test variability of GLS showed no differences (ANOVA p = 0.360). Absolute test-re-test errors of SLS measurements showed modest differences among images of different vendors (ANOVA- PS; p = 0.018, ES; p = 0.001, PSS; p = 0.090). No relevant difference in scar detection capability was observed (Figure 1C).

Conclusions

Vendor independent software leads to low bias among strain measurements on images from different vendors. Likewise, measurement variability and the ability to identify scar becomes similar. Our findings suggest that a vendor independent speckle tracking software could help to overcome inter-vendor bias. To which extend such measurements would be more accurate compared to vendor specific software remains to be determined.

Abstract Figure 1

Functional adaptation of the right ventricle to different degrees of the left ventricular systolic dysfunction in patients with left-sided heart disease: a three-dimensional echocardiography study

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular (RV) systolic dysfunction in patients with left-sided heart disease is known adverse factor. However, the RV adaptation at the different degrees of left ventricular (LV) dysfunction remains to be clarified.

Purpose

 to assess the change in RV contraction pattern in relation to LV ejection fraction (EF) in patients with left-sided heart disease.

Methods. LV and RV volumes and EF were measured by 3D-echocardiography in 295 patients with left-sided heart disease (59 ± 17years, 69% male). The 3D meshmodel of the RV was postprocessed by the ReVISION software and its contraction pattern was decomposed along the longitudinal, radial and anteroposterior directions (Fig. A) providing longitudinal, radial and anteroposterior EF (LEF, REF, AEF). Relative contribution of each component to the RV systolic function was measured as the ratio between LEF, REF and AEF and global RVEF (LEFi, REFi, AEFi).

Results. Patients with LV systolic dysfunction also had reduced RVEF. Relative contribution of the longitudinal and anteroposterior components decreased, while radial component increased in patients with reduced LVEF (Table).

RV LEF and AEF significantly correlated with the LVEF (Rho 0.50 and 0.51, p < 0.0001), while the correlation between REF and LVEF was weak (Rho 0.22, p = 0.0002).

There was a significant drop in LEF and AEF (Fig. B) and their relative contribution to the total RVEF (Fig. C) starting from the earlier stages of LV dysfunction. However, it was effectively compensated by significant increase in the radial RV component resulting in preservation of total RVEF in those with normal, mildly and moderately reduced LVEF (50 [46;54] vs 47 [44;52] vs 46 [42;49]%), whereas total RVEF dropped significantly only in severe LV dysfunction (30 [25;39]%; p < 0.0001) (Fig. D).

Conclusions. The longitudinal and anteroposterior RV contraction was related to the LVEF and decreased from early stages of the LV systolic dysfunction. Increase in the radial component compensated for the loss of longitudinal and anteroposterior RV components in mild and moderate LV dysfunction to maintain total RVEF. Drop in all three components resulted in significant reduction of total RVEF in severe LV dysfunction.

Characteristics of study population Overall (N = 295) LVEF≥50% (N = 166) LVEF < 50% (N = 129) LV EF, % 49.6 ± 14.3 59.9 ± 5.6 36.4 ± 10.9* RV EF, % 46.5 ± 9.2 49.8 ± 6.9 42.3 ± 10.0* RV LEFi 0.42 ± 0.09 0.45 ± 0.09 0.38 ± 0.09* RV REFi 0.47 ± 0.1 0.45 ± 0.1 0.50 ± 0.09* RV AEFi 0.39 ± 0.08 0.41 ± 0.08 0.37 ± 0.07* *p < 0.0001 Abstract Figure.

Relation of Mitral Annulus and Left Atrial Dysfunction to the Severity of Functional Mitral Regurgitation in Patients with Dilated Cardiomyopathy

METHODS

56 patients (58 ± 17 years, 42 men) with DCM and FMR and 52 controls, prospectively enrolled, underwent 3DTTE dedicated for mitral valve (MV), LA, and left ventricle (LV) quantitative analysis.

RESULTS

Patients with FMR vs. controls presented increased MA size and sphericity during the entire systole, whereas MA fractional area change (MAFAC) and MA displacement were decreased (15 ± 5 vs. 28 ± 5%; and 5 ± 3 vs. 10 ± 2 mm, p < 0.001). In patients with moderate/severe FMR, MA diameters correlated with PISA radius, EROA, and regurgitant volume (Rvol), as also did the MA area (with PISA radius, EROA, and Rvol: r = 0.48, r = 0.58, and r = 0.47, p < 0.05). MAFAC correlated inversely with EROA and Rvol (r = -0.32 and r = -0.35, p < 0.05), with both active and total LA emptying fractions and with LV ejection fraction as well. In a stepwise multivariate regression model, decreased MAFAC and increased LA volume independently predicted patients with severe FMR.

CONCLUSIONS

Patients with DCM and FMR have MA geometry remodeling and contractile dysfunction, correlated with the severity of FMR. MA contractile dysfunction correlated with both LA and left LV pumps dysfunctions and predicted patients with severe FMR. Our results provide new insights that might help with better selection of patients for MV transcatheter procedures.

P167 The burden of post-actinic heart disease: a case of severe valvular and coronary artery disease in a cancer survivor

Background

A 47-year old female complaining of exertional dyspnoea (NYHA class III) was admitted at our Cardiology department. She had a history of nodular sclerosis Hodgkin lymphoma (HL), treated with chemo- and radiotherapy, and complicated by post-actinic pneumopathy and cardiopathy. At the age of 39, she had undergone coronary artery bypass grafting with left internal mammal artery (LIMA) to left anterior descendent artery and saphenous vein to obtuse marginal branch, and aortic valve replacement with a mechanical prosthesis due to severe aortic stenosis. Some years later, she had undergone percutaneous stenting of the left main (LM) due to occlusion of the LIMA bypass graft.

At admission, the patient was hemodynamically stable, with signs of right-sided congestive heart failure. Both 2D and 3D transthoracic echocardiogram (TTE) showed preserved biventricular function, normal function of the aortic prosthesis, and diffuse calcification of the whole mitral valve apparatus, involving the leaflets, the annulus, the tendinous chords and the anterolateral papillary muscle (Figure Panels A-B), causing severe mitral stenosis (mean gradient 10 mmHg, 3D planimetric area 0.9 cm2, Wilkins score 12) and moderate organic insufficiency (Panel C). The tricuspid valve was also affected, with thickened, hypomobile leaflets, causing mild stenosis (mean gradient 4 mmHg, 3D planimetric area 3.8 cm2) and severe insufficiency (Panel D). Transesophageal echocardiogram (TOE) couldn"t be performed because of actinic oesophagitis. Percutaneous valvuloplasty was contraindicated due to moderate mitral insufficiency, high Wilkins score and a huge amount of calcium affecting the whole valve apparatus but sparing the commissures.

The patient was scheduled to PCI on the LM due to intrastent restenosis, but died during the procedure as a consequence of an intrastent massive thrombosis leading to cardiac arrest.

Learning points

Hodgkin lymphoma survivors are at increased cardiovascular and intraoperative risk. Old radiotherapy protocols for HL may cause severe post-actinic valvular and coronary disease. Post-actinic valvular heart disease often affects aortic and mitral valve more than a decade after irradiation, and may manifest as stenosis, insufficiency or both. Organic regurgitation and stenosis of tricuspid valve are uncommon, but may also occur and lead to worse patient outcome. Despite TOE may bring additional valuable informations in challenging cases, the coexistence of oesophageal sequelae from post-actinic oesophagitis may limit its applicability. TTE is the first line and often the only diagnostic tool available for identifying the characteristic valvular lesions in cancer survivors exposed to radiotherapy. 3D TTE may be particularly useful to identify subtle signs of primary involvement of tricuspid apparatus and quantify the anatomical area of a stenotic tricuspid valve, when severe regurgitation coexists and transvalvular gradients may be unreliable.

Abstract P167 Figure

P181 An uncommon mechanism of severe mitral regurgitation due to infective endocarditis mimicking acute myocardial infarction

Learning points

coronary artery embolization and papillary muscle abscess are very rare and often fatal consequences of infective endocarditis (IE). High (otherwise unexplained) fever and signs of embolism are minor Duke modified criteria for IE that should lead the physician to look for major criteria, such as positive blood cultures or echocardiography suggestive for IE. Emboli seen in the very distal part of the coronary arteries might have caused the ALPM abscess.

Abstract P181 Figure

102 Different mechanics of septal and lateral walls and their effects on left ventricular ejection fraction in patients with left bundle-branch block

Funding Acknowledgements

Karolina Kupczynska was supported by research grant awarded by the Club 30 of the Polish Cardiac Society

Background

Left bundle branch block (LBBB) impairs left ventricular (LV) mechanics and can lead to systolic dysfunction. However, LV mechanical changes that differentiate LBBB patients with preserved and reduced LV ejection fraction (LVEF) remain to be clarified.

Purpose

To measure myocardial work (MWI) and myocardial work efficiency (MWE) of the septal and LV lateral wall in patients with LBBB and various degrees of LV dysfunction using non-invasive strain-derived method.

Methods

Fifty-eight LBBB patients without coronary artery disease (mean age 65 ± 13 years, 60% male) were divided into 4 groups based on their LVEF according to current recommendations for cardiac chamber quantification (figure A): normal (n= 25), mildly (n= 16), moderately (n= 11), and severely (n= 6) reduced LVEF. Septal and lateral wall MWI and MWE were estimated by LV pressure-strain loop obtained by echocardiography.

Results

Both MWI (787 mmHg%, 95% CI 651-924 vs 1956 mmHg%, 95% CI 1758-2154; p &lt; 0.0001) and MWE (71%, 95% CI 66-76 vs 85%, 95% CI 82-87; p = 0.0001) were lower in the septum than in the lateral wall. There was a progressive decrease in septal MWI and MWE with the worsening of LVEF (figure B). Conversely, MWI and MWE of the lateral wall were preserved in patients with normal, mildly and moderately reduced LVEF groups. A significant reduction of MWI and MWE in the lateral wall was detected only in patients with severely reduced LVEF (figure C).

Conclusion

In patients with LBBB, impairment in septal myocardial work escalates according to LVEF loss. Septal dysfunction was compensated by the effective myocardial work of the lateral wall in patients with normal, mildly and moderately reduced LVEF. Mechanical dysfunction of the lateral wall was associated with severe reduction of LVEF.

Abstract 102 Figure.

P798 Right atrial phasic function and correlation with right ventricular function in patients with reduced left ventricular ejection fraction and no pulmonary hypertension:insights from 3D echocardiography

Background

The right atrium (RA) is a highly dynamic chamber with 3 mechanical functions (reservoir, conduit, booster pump) and prognostic implications in heart failure (HF) and pulmonary hypertension (PH). However, RA function and its interplay with the right ventricular (RV) performance in patients (pts) with reduced left ventricular ejection fraction (LVEF) and without PH remain to be clarified.

Methods

We used three-dimensional echocardiography to study 55 pts (61 ± 14 years, 43 men) with LVEF &lt; 40% no more than mild tricuspid regurgitation (TR), and maximum velocity of the TR jet &lt; 3 m/s. We measured the three-dimensional RA total, passive, active ejection volumes (EV) and the respective emptying fractions (EF). In addition, we compared RV volumes and ejection fraction (RVEF) between patients with normal and abnormal RA function.

Results

Mean LVEF was 30 ± 7%. Mean echo-derived pulmonary vascular resistance was 1.64 ± 0.54 Wood units. 28 pts (51%) had reduced RA reservoir function (total EF = 34 ± 9%), 34 pts (62%) had reduced RA conduit function (passive EF = 15 ± 4%), and 10 pts (18%) had reduced RA pump function (active EF = 11 ± 3%). Pts with reduced RA reservoir function showed larger RV end-systolic volume (RVESV 124 ± 48ml vs. 90 ± 32ml; p = 0.004) and lower RVEF (38 ± 8% vs. 46 ± 6%; p &lt; 0.001) than pts with normal RA function. Pts with reduced RA conduit function showed smaller RV stroke volume (RVSV 65 ± 19 ml vs. 80 ± 22ml; p = 0.009). Pts with impaired RA pump function showed larger RVESV (142 ± 45ml vs. 99 ± 41ml; p = 0.02) and lower RVEF (36 ± 6% vs. 43 ± 8%; p = 0.006).

RVESV was positively correlated with total (r2 = 0.47, p &lt; 0.001), passive (r2 = 0.29, p = 0.03) and active (r2 = 0.39, p = 0.003) RAEV, while it was negatively correlated with total (r2=-0.41, p = 0.002), passive (r2=-0.34, p = 0.01) and active (r2=-0.31, p = 0.02) RAEF. RVSV showed a positive correlation with both total (r2 = 0.4, p = 0.002) and passive (r2 = 0.41, p = 0.002) RAEV. Finally, RVEF was positively correlated with total (r2 = 0.51, p &lt; 0.001), passive (r2 = 0.47, p &lt; 0.001), and active (r2 = 0.36, p = 0.007) RAEF.

Conclusions

RA dysfunction is not uncommon in pts with reduced LVEF, even in the absence of PH. In these pts, RA function is associated with significant changes in RV function. The RA acts as a dynamic modulator of RV pump function by redistributing RV filling and ejection force among reservoir, conduit and pump functions in the setting of altered hemodynamics. The clinical and prognostic significance of RA function in pts with reduced LVEF warrant further studies.

47 Identification of threshold values to define right chamber enlargement consistent with severe tricuspid regurgitation

Background

Right ventricle (RV), tricuspid anulus (TA) and right atrium (RA) dilatation, are listed among the supportive signs to grade severe tricuspid regurgitation (TR) according to current EACVI and ESC guidelines. However, at present, there is no cut-off value to define RV, RA and TA dilatation associated to severe TR.

Purpose

Accordingly, we sought to identify the threshold values of RV, RA and TA size associated to severe TR.

Methods

302 patients (59 ± 13 years, 54 % women) with functional TR underwent three- (3D) and two-dimensional (2D) echocardiography to obtain: 3D RV end diastolic volume (RVEDVi) indexed for body surface area (BSA), 3D RV end systolic volume indexed for BSA (RVESVi), 3D RA max volume indexed for BSA (3DRAi), 2D RA systolic volume indexed for BSA (3DRAi), 2D RV basal diameter (2DRVd), 2D RV basal diameter indexed for BSA (2DRVdi), 2D TA measured in the apical 4-chamber view and 2D TA measured in the apical 4-chamber view indexed for BSA. To identify the threshold values of the parameters that discriminate patients with right chamber enlargement associated to severe TR, we selected the probability which returns the best sum of sensitivity and specificity on the ROC curve of the model.

Results

According to EACVI multiparametric approach, 50/302 pts (17%) were found to have severe TR. As shown in Figure, 3DRAi &gt; 45 ml/m2 and 2DRAi &gt; 45 ml/m2 identified patients with RA enlargement associated to severe TR. RVEDVi and RVESVi did not show any predictive value for severe TR. Conversely, 2DRVd &gt; 52 mm (or &gt;30 mm/m2) was associated to severe TR. 2DTA &gt; 42 mm ( or &gt;24 mm/m2) was the selected threshold value for TA dilatation.

Conclusions

Our study provided the threshold values to define the right chamber and TA dilatation associated to severe TR. Implementation of those values in current guidelines can help clinicians to improve their accuracy to identify patients with severe TR.

Abstract 47 Figure.

P190 Chest pain and syncope in Turner"s syndrome: going beyond the obvious to not miss the critical diagnosis. Role of multimodality imaging approach

Learning points

Chest pain and syncope are challenging symptoms in pts presenting in ED. AV pathology and aortic dissection should be always suspected and ruled out. TS is associated with multiple congenital cardiovascular abnormalities and is the most common established cause of aortic dissection in young women. 30% of Turner’s pts have congenitally AV abnormalities, and dilation of the ascending aorta is frequently associated. However, unicuspid AV is a very rare anomaly, usually stenotic at birth and requiring replacement. The presence of pericardial effusion in a pt with chest pain and syncope should raise the suspicion of aortic dissection, even if those symptoms usually accompany severe aortic stenosis. Even if CT is the gold standard imaging technique to rule out aortic dissection, the accuracy of a test is critically related to the image quality. When the suspicion of dissection is high and the reliability of the reference test is low, it’s reasonable to perform a different test to rule out the pathology. Aortography and TOE were pivotal to identify the limited dissection of the ascending aorta.

Abstract P190 Figure.

P173 When the heart doesn"t want to grow up

Background

Blood cysts of heart valves are uncommon and, usually, incidental findings in pediatric population. Rarely seen in adults, blood cysts are normally asymptomatic, even though several cases of embolization, valvular disfunction and left ventricle outflow tract (LVOT) obstruction have been described. Clinical Presentation. We report the case of a 23 year-old woman, with history of a small nodular mass of the mitral valve, found on a previous cardiac magnetic resonance (CMR) at the age of thirteen, who was admitted to our emergency department complaining atypical chest pain. She denied shortness of breath, syncope, tachycardia and fever. She was hemodynamically stable and a fast regression of symptoms was observed. The physical examination was unremarkable. Both the electrocardiogram (ECG) and blood tests were normal. A chest radiography showed normal heart size, without other abnormalities. After having ruled out an acute coronary syndrome, the patient was discharged with the indication to undergo further cardiological assessments. Diagnostic techniques and their most important findings. Therefore, a trans-thoracic echocardiogram was performed revealing normal biventricular function, no aortic root dilation, no pericardial effusion, no valvular regurgitation or stenosis. A round (7x11 mm) mass with hyperechogenic borders and hypoechogenic content was detected on the ventricular side of the anterior mitral valve leaflet consistent with a valvular blood cyst (figure 1: a,b,c). Only trivial mitral valve regurgitation without LVOT obstruction was present. The 3D echo reconstruction allowed to confirm the suspicion of blood cyst and detect a cleft of the posterior mitral valve leaflet, located in the P2 scallop (figure 1: d,e). A repeated CMR showed no contrast enhancement of the mass. Due to the clinical stability and the absence of complications, the patient was suggested to continue an echocardiographic follow-up. Discussion. Cardiac blood cysts are a rare condition with uncertain origin, usually found in infants in the first six months of life. A natural regression after that age has been described, making this condition very unusual in adults. Despite its benign features, when persistent beyond the childhood, the blood cyst can grow and reach even huge dimensions, potentially impairing the valvular function and/or causing LVOT obstruction. Another potential complication of blood cysts may be the arterial embolization. In all these situations surgical resection must be considered. In our patient, the contribution of trans-thoracic echocardiogram and in particular the 3D reconstruction, were pivotal to address the correct diagnosis.

Abstract P173 Figure 1

P275 Feasibility and accuracy of the automated quantification of two- and three-dimensional left ventricular ejection fraction and its role in the arrhythmic risk stratification of organic heart disease

BACKGROUND

New automated approaches for left heart chamber quantification based on adaptive analytics algorithms have been introduced for both two- (2DE) and three-dimensional (3DE) echocardiography. These algorithms measure a left ventricular ejection fraction (LVEF) and reduce the intra- and inter-observer variability associated with the conventional manual tracing of LV endocardial borders. However, the clinical utility of these algorithms in the sudden cardiac death (SCD) risk stratification of patients with organic heart disease remains to be clarified.

PURPOSE

We sought to test the feasibility and the accuracy of two automated algorithms that measure 2DE and 3DE LVEF in patients with impaired LV systolic function and to define the cut-off values for fully automated 2DE and 3DE LVEF that could predict major arrhythmic events (MAE). We wanted also to assess the feasibility of replacing manual 2DE and semi-automated (SA) 3DE LVEF with fully-automated (FA) 2DE and 3DE LVEF respectively, in the stratification of high arrhythmic risk patients.

METHODS

We prospectively enrolled 240 patients (63 ± 13 years, 81% men) with both ischemic and non-ischemic cardiomyopathy with 2DE LVEF &lt; 50%, no previous MAE or coronary artery revascularization &lt; 90 days, after at least 3 months of optimal medical therapy for heart failure. MAE were defined as SCD, resuscitated cardiac arrest (CA), ventricular fibrillation, sustained ventricular tachycardia and appropriate ICD shocks. The risk detection cut-off values for 2DE and 3DE FA LVEF were computed using the maximally selected rank statistics method. In order to predict the risk of MAE we created four different risk models, including both clinical characteristics (age, NYHA class, aetiology of the LV dysfunction) and imaging-derived data (2DE manual LVEF, 2DE FA LVEF, 3DE SA LVEF and 3DE FA LVEF), analyzed by a ROC curve.

RESULTS

During a 27 ± 25months follow-up period, 31 patients (13%) presented MAE including SCD (n= 22; 9%), resuscitated CA (n = 3; 1%) and appropriate ICD shocks (n = 6; 2%). Both 2DE and 3DE FA LVEF showed high feasibility (92% and 95%, respectively), and good agreement with conventional LVEF (2DE mean difference 4 ± 7%, and 3DE mean difference 4 ± 7%). We identified two FA LVEF cut-offs for the MAE detection: 2DE &lt;39% (p = 0.006) and 3DE &lt;37% (p = 0.005). The model including the 2DE FA LVEF showed an area under the curve (AUC) larger than the one including conventional 2DE LVEF (0.83 vs 0.80). Conversely, the AUC obtained with FA 3DE LVEF model was slightly lower than the one obtained using SA 3DE LVEF model (0.80 vs 0.84).

CONCLUSIONS

Both 2DE and 3DE FA LVEF are feasible and accurate alternative to the conventional (manual) or SA endocardial border tracing. The use of specific FA 2DE LVEF cut-off values showed a comparable predictive power in the MAE risk stratification compared to the conventional one with the advantage of very low intra- and inter-observer variability.

P764 Right ventricular basal diameter, but not volume, can predict severe tricuspid regurgitation

Background

According to current EACVI guidelines, right ventricle (RV), tricuspid anulus (TA) and right atrium (RA) dilatation are supportive signs to identify severe functional tricuspid regurgitation (TR) by echocardiography. However, the ranking by which those parameters should be considered to identify severe TR remains to be clarified.

Purpose

Accordingly, the aim of this study is to compare RV, RA and TA association with severe TR and to rank them in order of importance to predict severe TR.

Methods

302 patients (59 ± 13 years, 54 % women) with functional TR underwent two- and three-dimensional echocardiography. Using the nonparameteric Variable Importance (VIMP) software package, we assessed the relative importance of 6 differerent parameters (indexed by body surface area) to identify severe TR: 3D RV end diastolic volume (RVEDVi), 3D RV end systolic volume (RVESVi), 3D RA max volume (3DRAi), 2D RA systolic volume (3DRAi), 2D RV basal diameter (2DRVdi) and 2D TAi measured in the apical 4-chamber view.

Results

According to EACVI multiparametric approach, 50/302 pts (17%) were found to have severe TR. 3DRAi (VIMP = 0.075) was the most important predictor of severe TR. 2DRVdi (VIMP= 0.005) was the second most important parameter and was the only parameter of RV dilation (RVEDVi= -0.0011 and RVESVi= -0.0012) associated to severe TR. Also, 2DRAi (VIMP= 0.023), and 2D TAi (VIMP= 0.004) showed good predictive ability.

Conclusions

Among the various right heart structures undergoing remodeling in patients with functional TR, RA dilation was the most important predictor of severe TR. Also the RV basal diameter, but not the volumes, was a predictor of severe TR. This underlines the importance of the shape, more than the volume of the RV as a predictor of severe TR.

P1581 The global myocardial work index is a powerful predictor of major arrhythmic events in patients with organic heart disease and reduced left ventricular ejection fraction

Background

Current guidelines recommend implantable cardioverter defibrillator (ICD) for primary prevention of sudden cardiac death in patients with left ventricular ejection fraction (2DE LVEF) by two-dimensional echocardiography≤ 35%. However, new echocardiography parameters of LV function such as the mechanical dispersion (MD), the LVEF by three-dimensional echocardiography (3DE) and the global myocardial work index (GWI) have been reported to provide a more accurate stratification of the arrhythmic risk, and potentially improve ICD patient selection.

Purpose

We wanted to compare the arrhythmic risk predictive power of the new parameters of LV function with the conventional 2DLVEF.

Material and Methods

we prospectively enrolled 216 patients (63 ± 12 years, 88% men) with organic heart diseases and 2DE LVEF &lt;50%, in whom we re-measured LVEF using 3DE, and obtained MD and GWI using 2DE speckle tracking. Major arrhythmic events were defined as sudden cardiac death, sustained ventricular tachycardia, ventricular fibrillation and appropriate ICD shocks. We assessed the predictive power of 4 different parameters: 2DE LVEF&lt; 35%; 3DE LVEF&lt; 35%; MD &gt; 80 ms; and GWI&lt; 672 mmHg% to identify patients at risk of major arrhythmic events.

Results

During a mean follow-up of 27 ± 24 months, 24 patients (10%) experienced sudden cardiac death, whereas 28 patients (13%) presented major arrhythmic events. The predictive power in terms of major arrhythmic events prediction (Harrel C statistics) improved from 0.67 (95%CI 0.57-0.76) for 2DE LVEF&lt; 35%, to 0.73 (95%CI 0.64-0.82) for 3DE LVEF&lt; 35%, and 0.77 (95%CI 0.68-0.86) for GWI &lt; 672 mm Hg%. Whereas, MD &gt; 80 ms showed a limited predictive power (HCS= 0.53, 95%CI 0.41-0.76)).

Conclusions

GWI&lt; 672 mm Hg% was the most accurate predictor of major arrhythmic events among echocardiography parameters in patients with organic heart disease and LVEF &lt; 50%.

P669 Functional remodeling of the left atrium after first acute ST-elevation myocardial infarction: a 3D echocardiography study

Background

Left atrium (LA) is a dynamic structure which is functionally coupled with the left ventricle and modulates its function in many cardiac conditions. The geometric and functional remodeling of the LA occurring early after myocardial infarction are poorly understood.

Purpose

We sought to evaluate the early changes in LA geometry and function occurring in survivors of a first acute ST-elevation myocardial infarction (STEMI), using three-dimensional echocardiography (3DE).

Methods

LA phasic volumes and strain (both longitudinal and circumferential) were measured using a dedicated automated software package in 54 patients at pre-discharge after STEMI, and in 54 age- and sex-matched healthy volunteers (controls), (figure 1).

Results

In STEMI patients, both maximal (LAV max) and minimal (LAV min) LA volumes were significantly larger than in controls 63 ± 15 vs. 53 ±11 ml; p = 0,002 and 38 ± 15 ml vs. 25 ± 6; p &lt;0.0001 (respectively). Moreover, when compared to controls (Table 1). Both longitudinal (LASr) and circumferential strain reservoirs showed a significant negative correlation with peak cardiac troponin I values (r=-0.344; p = 0.007 and r=-0.357; p = 0.005, respectively) as an estimate of the extent of myocardial damage.

Conclusion

STEMI was associated to significant geometrical and functional remodeling of the LA which was correlated with the extent of myocardial damage.

Table 1 Controls STEMI patients P-value Longitudinal% LASr 21.8 ± 8.4 13.72 ± 8.27 &lt;0.0001 LAScd -12.8 ± 8.48 -6.43 ± 4.74 &lt;0.0001 LASct -9.73 ± 6.04 -7.26 ± 5.87 0.05 Circumferential % LASr-c 27.31 ± 8.07 18.92 ± 9.16 &lt;0.0001 LAScd-c -11.2 ± 5.93 -6.46 ± 5.68 0.0002 LASct-c -16.22 ± 6.33 -12.41 ± 5.94 0.004 LASr longitudinal strain reservoir, LAScd: longitudinal strain conduit, LAScd: longitudinal strain contraction, LASr-c: circumferential strain reservoir, LAScd-c: circumferential strain conduit , LASct-c:circumferential strain contraction

Abstract P669 Figure 1

38 Prognostic validation of partition values obtained with conventional two-dimensional and doppler echocardiography to grade tricuspid regurgitation severity

Background

Morbidity and mortality associated with severe tricuspid regurgitation (TR) have prompted interest in new corrective transcatheter procedures. However, to properly select patients for interventional procedures, and to assess their effectiveness, a reliable and reproducible grading system of TR severity is mandatory. However, the cut-off values used by current guidelines to differentiate among mild, moderate and severe TR lack clinical validation.

Purpose

We aimed to obtain the threshold values of the currently recommended quantitative echocardiographic parameters used to grade TR severity using pts’ outcome as a reference.

Methods

296 pts, with at least mild TR and complete 2D, 3D and Doppler echocardiographic study, were enrolled and assessed for potential confounders: age, NYHA class, left ventricular ejection fraction, coexistent valvular heart disease and right ventricular (RV) systolic pressure. Average diameter of the vena contracta (VCavg), effective regurgitant orifice area (EROA), regurgitant volume (RVol) and regurgitant fraction (RF) were obtained to grade TR severity. Median follow-up was 47 (17-80) months. The primary composite endpoint was the occurrence of death of any cause or hospitalization for right heart failure (RHF). Survival curves for the composite endpoint were divided in quartiles at median follow-up. Cut-off values for the echo parameters were derived to grade mild (below the 1st quartile), moderate (between 1st and 3rd quartiles), and severe (above the 3r quartile) TR.

Results

33 deaths and 72 hospitalizations for RHF occurred. Event-free rate from death or RHF at the end of follow-up was 14%, 46% and 93% in pts with severe, moderate, and mild TR, respectively. Differences reached statistical significance early (at 1 month), and lasted during the whole follow-up period (Figure). The new threshold values for mild, moderate and severe TR are summarized in Table.

Conclusions

Partition values of quantitative echo-Doppler parameters used to grade mild, moderate and severe TR according to pts’ clinical outcome are significantly lower than those currently reported in guidelines. Further studies are needed to test if these new threshold values for severe TR will translate in earlier referral of pts to valve repair and improved prognosis.

Mild Moderate Severe VCavg &lt;3 mm 3-6 mm &gt;6 mm EROA &lt;0.15 cm&sup2; 0.15-0.30 cm&sup2; &gt;0.30 cm&sup2; R Vol &lt;15 ml 15-30 ml &gt;30 ml RF &lt;25% 25-45% &gt;45%

Abstract 38 Figure.

6067Right ventricular global longitudinal strain predicts cardiovascular mortality and heart failure hospitalization in patients with functional tricuspid regurgitation

Background

Functional tricuspid regurgitation (FTR) and its increasing severity are well-known factors associated with increased morbidity and mortality in patients with pulmonary artery hypertension or left heart diseases.

Purpose

To assess the main clinical and echocardiographic determinants of outcome in patients with various causes of FTR.

Methods

A total of 140 patients (pts) (72±14 years, 40% men) with FTR of diverse etiologies underwent complete 2D and additional 3D echocardiography acquisitions and were followed for a median of 5.2 years (interquartile range 2.1 - 6.7 years). Severe FTR was defined by ≥2 parameters: (1) coaptation defect; (2) vena contract ≥7; (3) PISA radius >9 mm; (4) hepatic vein systolic flow reversal. The primary composite outcome was defined as death from cardiovascular causes and hospitalization due to right-sided heart failure (HF).

Results

74 pts (53%) developed the primary composite outcome. Death occurred in 31 pts (22%), while hospitalization due to right-sided HF occurred in 66 pts (47%). At baseline, patients who developed the primary composite outcome, compared to those who did not, had more symptoms, more severe FTR, higher pulmonary systolic pressure (60±27 vs 43±16 mmHg), larger right atrium (69±34 vs 51±22 mL/mm2), right ventricular (RV) basal diameter (29±6 vs 24±4 mm/m2), larger RV end-diastolic (102±45 vs 76±25 mL/m2) and end-systolic (62±37 vs 43±17 mL/m2) volumes, larger tricuspid annulus area (7.7±1.8 vs 6.8±1.8 cm2/m2), lower RV systolic function (RVEF [42±11 vs 46±8%], TAPSE [18±4 vs 21±4], S' [11±3 vs 12±2], RV global longitudinal strain (RVGLS) [16±5 vs 19±4], RV free wall longitudinal strain [19±7 vs 23.5]); all p-values <0.03. There were no significant differences in age, body size or comorbidities. After multivariable Cox regression analysis, FTR grade severity (hazard ratio [HR]=2.95, 95% confidence interval [CI] 2.14–4.06, p<0.001) and RVGLS (HR= 0.91, 95% CI 0.86–0.95) were the only independent predictors of mortality. A cutoff of −17.5 for RVGLS had 57% sensitivity, 73% specificity and a HR of 2.34 (95% CI of 1.42–3.88, p-value=0.001). The Kaplan Meier survival curve showed that patients with an RVGLS ≥ −17.5 had a higher probability of developing the primary composite outcome, especially at an earlier phase of the follow up when compared to those with higher LS (log rank test chi-square = 13.0, p<0.001) (Figure). At the end of follow up, 60% of patients with a RVGLS ≥-17.5 did not developed the primary composite outcome vs 29% in the group with a LS lower than −17.5.

Kaplan-Meier curve of outcome by RVGLS

Conclusions

In patients with FTR, a decreased RVGLS, with a cutoff of −17.5, proved to be an independent prognostic factor for the development of HF hospitalizations and death from cardiovascular causes.

An atypical case of pulmonary embolism from a jugular vein

Neck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.