Applications of Artificial Intelligence for the Prediction and Diagnosis of Cancer Therapy-Related Cardiac Dysfunction in Oncology Patients

Cardiovascular diseases and cancer are the leading causes of morbidity and mortality in modern society. Expanding cancer therapies that have improved prognosis may also be associated with cardiotoxicity, and extended life span after survivorship is associated with the increasing prevalence of cardiovascular disease. As such, the field of cardio-oncology has been rapidly expanding, with an aim to identify cardiotoxicity and cardiac disease early in a patient who is receiving treatment for cancer or is in survivorship. Artificial intelligence is revolutionizing modern medicine with its ability to identify cardiac disease early. This article comprehensively reviews applications of artificial intelligence specifically applied to electrocardiograms, echocardiography, cardiac magnetic resonance imaging, and nuclear imaging to predict cardiac toxicity in the setting of cancer therapies, with a view to reduce early complications and cardiac side effects from cancer therapies such as chemotherapy, radiation therapy, or immunotherapy.

Dislodgement of balloon expandable stent graft in aortic coarctoplasty, protector or proctor fault?: A case report

INTRODUCTION

Coarctation of the aorta is a congenital narrowing of the thoracic aorta associated with hypertension and significant pressure gradients across the coarctation site. Coarctoplasty by percutaneous approach is the preferred method of treatment. However, complications like stent dislodgement may result and must be immediately managed to prevent adverse outcomes.

CASE PRESENTATION

A 29-year-old male, who had previously undergone a mitral valve replacement, presents with exertional dyspnea and systemic hypertension. Blood pressure measurements revealed a 50 mmHg gradient between the upper and lower extremities. Imaging modalities revealed severe CoA with a 45 mmHg peak systolic gradient. During percutaneous coarctoplasty with a balloon-expandable stent, improper use of the yellow applicator resulted in stent dislodgment. A stent was partially deployed and, after post-dilation, the stenosis was resolved. The patient recovered uneventfully and remained asymptomatic with no evidence of recoarctation at six-month follow-up.

DISCUSSION

Coarctoplasty with stent implantation is a relatively safe yet effective treatment for CoA. However, this technique may be complicated by stent dislodgment due to technical error or device-related issues. The major cause of stent dislodgment in the present case was considered failure to use the yellow applicator. Fortunately, prompt corrective measures allowed uneventful deployment of the stent without major complications.

CONCLUSION

Strict adherence to procedural protocols is critical for minimizing complications and achieving optimal outcomes on CoA interventions.

Causal effects of circulating immune cells on coronary atherosclerosis: Evidence from Mendelian randomization

The role of circulating immune cells in coronary atherosclerosis remains unclear. This study aimed to assess the causal effects of various immune cells on coronary atherosclerosis using Mendelian randomization (MR). Circulating immune cell datasets were obtained from genome-wide association studies, and coronary atherosclerosis datasets were obtained from FinnGen. Single-nucleotide polymorphisms satisfying the assumptions of association, independence, and exclusivity were screened in the datasets and analyzed using MR, with inverse-variance weighted as the main method. Horizontal pleiotropy, heterogeneity, and sensitivity analyses were performed using the MR-Egger, Cochran Q, and leave-one-out analyses, respectively. The MR analysis showed that effector memory double negative (DN) (cluster of differentiation [CD]4-CD8-) %DN (odds ratio [OR]: 1.042, 95% confidence interval [CI]: 1.008-1.077, P = .014), CD4 on CD39+ CD4+ (OR: 1.027, 95% CI: 1.001-1.054, P = .040), C-X3-C motif chemokine receptor 1 on CD14+ CD16- monocytes (OR: 1.035, 95% CI: 1.010-1.060, P = .006), C-C chemokine receptor 7 on naive CD4+ (OR: 1.035, 95% CI: 1.006-1.076, P = .023), and immunoglobulin D- CD38- %lymphocytes (OR: 1.098, 95% CI: 1.016-1.187, P = .019) were associated with an increased genetic susceptibility to coronary atherosclerosis, with no horizontal pleiotropy (P ≥ .05). Cochran Q showed no heterogeneity (P ≥ .05), and the sensitivity analysis indicated that the results were robust. The MR analysis revealed various markers and immune cell subsets, including effector memory DN (CD4-CD8-) %DN, CD4 on CD39+ CD4+, C-X3-C motif chemokine receptor on CD14+ CD16- monocytes, C-C chemokine receptor 7 on naive CD4+, and IgD- CD38- %lymphocytes, associated with increased genetic susceptibility to coronary atherosclerosis. This provides a genetic explanation for the role of specific immune cells in inducing and exacerbating coronary artery disease and offers new ideas for the exploration of immune markers and immune-targeted drugs.

An in silico analysis of heart rate impact on wall shear stress hemodynamic parameters in aortic coarctation

This study examines how heart rate (HR) affects hemodynamics in a South African infant with Coarctation of the Aorta. Computed tomography angiography segments aortic coarctation anatomy; Doppler echocardiography derives inlet flow waveforms. Simulations occur at 100, 120, and 160 beats per minute, representing reduced, resting, and elevated HR levels. Turbulence was analyzed over time and space using turbulence-resolving and pulsatile large-eddy simulations. Specifically, a 60% reduction in HR led to a reduction in maximum velocity by 45%, and a 57% decrease in pressure drop. The reduction in turbulence-related metrics was less significant. The ratio of turbulent kinetic energy to total kinetic energy decreased by 2%, while turbulent wall shear stress decreased by 3%. These results demonstrate that HR significantly affects velocity and pressure drop, while turbulence arising from the coarctation region is relatively unaffected. The balance between turbulent kinetic energy and total kinetic energy shows minimal enhancement due to the complex interplay among HR, turbulence, and geometry. This complexity prompts discussion on how HR-slowing medications, such as beta-blockers or ivabradine, could positively influence hemodynamic stresses. In particular, the results indicate that while HR modulation can influence flow dynamics, it may not significantly reduce turbulence-induced shear stresses within the coarctation zone. Therefore, further investigation is necessary to understand the potential impact of HR modulation in the management of CoA, and whether interventions targeting the anatomical correction of the coarctation may be more effective in improving hemodynamic outcomes.

Revolutionizing Cardiology: The Role of Artificial Intelligence in Echocardiography

Background: Artificial intelligence (AI) in echocardiography represents a transformative advancement in cardiology, addressing longstanding challenges in cardiac diagnostics. Echocardiography has traditionally been limited by operator-dependent variability and subjective interpretation, which impact diagnostic reliability. This study evaluates the role of AI, particularly machine learning (ML), in enhancing the accuracy and consistency of echocardiographic image analysis and its potential to complement clinical expertise. Methods: A comprehensive review of existing literature was conducted to analyze the integration of AI into echocardiography. Key AI functionalities, such as image acquisition, standard view classification, cardiac chamber segmentation, structural quantification, and functional assessment, were assessed. Comparisons with traditional imaging modalities like computed tomography (CT), nuclear imaging, and magnetic resonance imaging (MRI) were also explored. Results: AI algorithms demonstrated expert-level accuracy in diagnosing conditions such as cardiomyopathies while reducing operator variability and enhancing diagnostic consistency. The application of ML was particularly effective in automating image analysis and minimizing human error, addressing the limitations of subjective operator expertise. Conclusions: The integration of AI into echocardiography marks a pivotal shift in cardiovascular diagnostics, offering enhanced accuracy, consistency, and reliability. By addressing operator variability and improving diagnostic performance, AI has the potential to elevate patient care and herald a new era in cardiology.

Surgical revascularisation in an adult with coarctation of the aorta

One of the most common congenital cardiac anomalies is coarctation of the aorta (CoA) It accounts for 4%-6% of all congenital heart defects. A CoA case surviving into adulthood may result in hypertension, weak femoral pulse, limb and bowel ischaemia and heart failure. A man in his early 20s presented with severe lower limb and abdominal pain with long-standing hypertension, refractory to antihypertensives. Difference in upper and lower limb blood pressures, weak peripheral pulses and radiofemoral delay were noted. Angiogram showed adult CoA with total occlusion of the proximal aortic segment. The patient underwent left axillary artery to descending thoracic aorta bypass grafting, had a normal recovery and was put on life-long antihypertensives. An untreated case of CoA surviving into adulthood will result in complications. Any individual with unknown aetiology of hypertension and ischaemic symptoms must be screened for CoA.

New ultrasound techniques. Present and future

The present study highlights the advances in ultrasound, especially regarding its clinical applications to critically ill patients. Artificial intelligence (AI) is crucial in automating image interpretation, improving accuracy and efficiency. Software has been developed to make it easier to perform accurate bedside ultrasound examinations, even by professionals lacking prior experience, with automatic image optimization. In addition, some applications identify cardiac structures, perform planimetry of the Doppler wave, and measure the size of vessels, which is especially useful in hemodynamic monitoring and continuous recording. The "strain" and "strain rate" parameters evaluate ventricular function, while "auto strain" automates its calculation from bedside images. These advances, and the automatic determination of ventricular volume, make ultrasound monitoring more precise and faster. The next step is continuous monitoring using gel devices attached to the skin.

Comparing Patency of Pulmonary Stent Implantation and Balloon Angioplasty in Pulmonary Vein Stenosis: A Systematic Review and Meta-Analysis

Pulmonary vein stenosis (PVS) is an insidious diagnosis associated with morbidity and mortality. Pharmacologic therapy may suffice initially, but advanced stages demand mechanical intervention. Pulmonary stent implantation (PSI) and pulmonary balloon angioplasty (PBA) are common strategies, both carrying restenosis risks. This meta-analysis compares PSI and PBA to determine the superior revascularization strategy. We systematically searched databases until November 2023, identifying 11 studies with 780 patients. Studies, including those involving patients undergoing balloon angioplasty (BA) or stent angioplasty (SA) for PVS, were selected. Case reports, editorials, and cross-sectional studies were omitted. Primary outcomes included restenosis requiring reintervention, 5-year freedom from restenosis, and procedure-related complications. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Meta-regression analysis assessed factors like age and stent size. Study quality was evaluated using the Newcastle-Ottawa scale. This Systematic review and meta-analysis incorporated 11 observational studies. PSI exhibited a lower risk of restenosis requiring reintervention (OR 0.34, 95% CI 0.13, 0.87, p = 0.02) and significantly higher 5-year freedom from restenosis (OR 4.42, 95% CI 1.11, 17.62, p = 0.04) compared to PBA, with no significant difference in procedure-related complications. Meta-regression analysis showed age and stent size insignificantly affecting restenosis risk. Our review supports PSI as the preferred revascularization strategy for PVS due to superior patency benefits, emphasizing its role as the initial treatment choice. Further research is warranted for validation, considering individual patient factors in treatment selection.

Multimodal Fusion Artificial Intelligence Model to Predict Risk for MACE and Myocarditis in Cancer Patients Receiving Immune Checkpoint Inhibitor Therapy

Background

Immune checkpoint inhibitor (ICI) therapy has dramatically improved the prognosis for some cancers but can be associated with myocarditis, adverse cardiovascular events, and mortality.

Objectives

The aim of this study was to develop an artificial intelligence (AI) model to predict the increased likelihood for the development of ICI-related myocarditis and adverse cardiovascular events.

Methods

Cancer patients treated with ICI at a tertiary institution from 2011 to 2022 were reviewed. Baseline characteristics, laboratory values, electrocardiograms, and cardiovascular clinical outcomes were extracted. A composite outcome of ICI-related myocarditis and major adverse cardiovascular events (transient ischemic attack/stroke, new diagnosis of heart failure, myocardial infarction, and cardiac death) was used to develop a multimodal joint fusion AI model by combining baseline tabular data with electrocardiogram (ECG) in a single end-to-end model. ECG data were parsed using 1-D convolution and tubular data using multilayer perceptron.

Results

Of 2,258 cancer patients who had ICI therapy and troponin measurement (mean age 68.5 ± 11.5 years, 59.7% male), the composite of cardiovascular clinical adverse events, including ICI-related myocarditis and major adverse cardiovascular events, occurred in 264 (11.7%) unique patients, with 428 events overall (including 59 [3%] ICI-related myocarditis events and 59 [3%] cardiac deaths). The proposed joint fusion model outperformed individual ECG and baseline electronic medical record data and laboratory value models with an area under the operating characteristics curve of 0.72 (0.64 true positive rate and 0.98 negative predictive value).

Conclusion

A multimodal fusion AI model to predict myocarditis and adverse cardiovascular events in cancer patients starting ICI therapy had good prognostic performance. It may have clinical utility in identifying at-risk patients who may benefit from closer surveillance.

Left Atrial Appendage Occlusion: Expanding Indications and New Developments

Percutaneous left atrial appendage occlusion (LAAO) is recommended in several major international society guidelines as a viable alternative to therapeutic anticoagulation for the prevention of ischemic stroke in patients with nonvalvular atrial fibrillation or flutter. Recent innovations in device development have improved the safety and procedural success of LAAO, further fueling enthusiasm for expanding its indications beyond patients with high-bleeding risk from oral anticoagulation use. It is the aim of this review to provide historical context in addition to recent updates and upcoming developments and provide practical suggestions on how best to care for patients who are candidates for LAAO in contemporary practice. Recent data comparing the safety and efficacy of post-LAAO antiplatelet vs. antithrombotic therapy will be highlighted, with specific recommendations regarding which patients are best suited for each strategy. We will also address the safety and practical considerations provided by emerging trials on concomitant LAAO during other structural heart interventions such as transcatheter aortic valve replacement and mitral valve interventions, as well as electrophysiology procedures including catheter ablation for atrial fibrillation and pacemaker implantation. Practical considerations for the use of transesophageal echocardiography or intracardiac echocardiography for procedural guidance will also be discussed. As the evidence supporting LAAO continues to evolve, this review will serve as a primer on the recent and upcoming advances in device technology and management strategies positioned to further push LAAO forward into the future.

Mitral Regurgitation Evaluation in Modern Echocardiography: Bridging Standard Techniques and Advanced Tools for Enhanced Assessment

Mitral regurgitation (MR) is one of the most common valvular heart diseases worldwide. Echocardiography remains the first line and most effective imaging modality for the diagnosis of mitral valve (MV) pathology and quantitative assessment of MR. The advent of three-dimensional echocardiography has significantly enhanced the evaluation of MV anatomy and function. Furthermore, recent advancements in cardiovascular imaging software have emerged as step-forward tools, providing a powerful support for acquisition, analysis, and interpretation of cardiac ultrasound images in the context of MR. This review aims to provide an overview of the contemporary workflow for echocardiographic assessment of MR, encompassing standard echocardiographic techniques and the integration of semiautomated and automated ultrasound solutions. These novel approaches include advancements in segmentation, phenotyping, morphological quantification, functional grading, and chamber quantification.

The association between lipoprotein(a) levels and the development of cardiac allograft vasculopathy

Lipoprotein(a) [Lp(a)] has been established as an independent risk factor for cardiovascular diseases. However, its role in cardiac allograft vasculopathy (CAV) development remains controversial. In a retrospective cohort study of 385 patients who underwent heart transplant between 2001 and 2023, Lp(a) concentrations were compared between patients with and without clinically significant CAV (grade 0-1 vs 2-3). Preoperative Lp(a) concentrations were not significantly different between patients with and without CAV (14.0 vs 12.0 mg/dL, P = .42). High (≥50 mg/dL) Lp(a) values were not associated with CAV development on univariable or multivariable analysis (hazard ratio [HR] 1.009, 95 % confidence interval [CI]: 0.47-2.14, P = .9). A history of graft rejection was the only independent factor associated with CAV (HR 2.88, 95 % CI: 1.50-5.52, P = .001). Elevated Lp(a) levels were not associated with increased risk of CAV. The lack of a significant association between traditional risk factors and CAV underscores that CAV is not purely an atherosclerotic process and different pathophysiological mechanisms are involved.

The Unique Challenge of Coronary Artery Disease in Adult Patients with Congenital Heart Disease

Advances in medical and surgical interventions have resulted in a steady increase in the number of patients with congenital heart disease (CHD) reaching adult age. Unfortunately, this ever-growing population faces an added challenge: an increased risk of acquiring coronary artery disease. This review provides insight into the complex interactions between coronary artery disease and CHD in adults. We describe the peculiar features of cardiac anatomy in these patients, the possible role cardiac sequelae may play in an increased risk of myocardial ischemia, and the diagnostic challenges in this patient group. Furthermore, this review outlines the risk factors and potential mechanisms of accelerated atherosclerosis in adults with CHD by pointing out areas where current knowledge is incomplete and highlighting areas for further research. The review concludes by examining potential management strategies for this particular population, emphasizing the necessity for a multidisciplinary approach. Understanding the unique coronary risks that adults with CHD experience can enhance patient care and improve long-term results.

Lipoprotein(a) and long-term in-stent restenosis after percutaneous coronary intervention

AIMS

Lipoprotein(a) [Lp(a)] has demonstrated its association with atherosclerosis and myocardial infarction. However, its role in the development of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) is not clearly established. The aim of this study is to investigate the association between Lp(a) and ISR.

METHODS AND RESULTS

A retrospective study of adult patients who underwent successful PCI between January 2006 and December 2017 at the three Mayo Clinic sites and had a preprocedural Lp(a) measurement was conducted. Patients were divided into two groups according to the serum Lp(a) concentration [high Lp(a) ≥ 50 mg/dL and low Lp(a) < 50 mg/dL]. Univariable and multivariable analyses were performed to compare risk of ISR between patients with high Lp(a) vs. those with low Lp(a). A total of 1209 patients were included, with mean age 65.9 ± 11.7 years and 71.8% were male. Median follow-up after baseline PCI was 8.8 [interquartile range (IQR) 7.4] years. Restenosis was observed in 162 (13.4%) patients. Median serum levels of Lp(a) were significantly higher in patients affected by ISR vs. non-affected cases: 27 (IQR 73.8) vs. 20 (IQR 57.5) mg/dL, P = 0.008. The rate of ISR was significantly higher among patients with high Lp(a) vs. patients with low Lp(a) values (17.0% vs. 11.6%, P = 0.010). High Lp(a) values were independently associated with ISR events (hazard ratio 1.67, 95% confidence interval 1.18-2.37, P = 0.004), and this association was more prominent after the first year following the PCI.

CONCLUSION

Lipoprotein(a) is an independent predictor for long-term ISR and should be considered in the evaluation of patients undergoing PCI.

Late Outcomes of Ascending-to-Descending Bypass for Aortic Coarctation

BACKGROUND

Ascending-to-descending aortic bypass is a repair option for patients with complex aortic coarctation. This technique is reported to have minimal early morbidity and mortality; however, the long-term results of the procedure are unknown.

METHODS

This study analyzed the late outcomes of 81 consecutive patients with aortic coarctation who underwent ascending-to-descending aortic bypass through a median sternotomy from January 1985 to December 2012. The study was limited to this interval to allow for a minimum of 10-year follow-up. Fifty-two patients had recurrent coarctation after previous repair, and 44 patients had concomitant cardiac procedures at the time of ascending-to-descending bypass.

RESULTS

There was no perioperative mortality, and overall survival at 5, 10, and 20 years was 94%, 90%, and 85%, respectively, similar to an age- and sex-matched population. There were no interventions for the ascending-to-descending bypass during follow-up, and no deaths were known to be related to the bypass graft. Subsequent cardiac operations were performed through a median sternotomy in 7 patients (9%), and late imaging in 48 patients (59%) demonstrated no hemodynamically significant stenoses or pseudoaneurysms. At late follow-up, median systolic blood pressure was 124 mm Hg, and one-half of the patients were receiving either no or only 1 antihypertensive agent.

CONCLUSIONS

Ascending-to-descending aortic bypass is a safe operation with excellent long-term outcomes for adult patients with complex aortic coarctation. The procedure is durable and appears to improve systemic hypertension. Importantly, ascending-to-descending bypass does not hinder the safe performance of subsequent operations performed through a median sternotomy.

Research priorities for the study of atrial fibrillation during acute and critical illness: recommendations from the Symposium on Atrial Fibrillation in Acute and Critical Care

Atrial fibrillation (AF) is a common arrhythmia encountered in acute and critical illness and is associated with poor short and long-term outcomes. Given the consequences of developing AF, research into prevention, prediction and treatment of this arrhythmia in the critically ill are of great potential benefit, however, study of AF in critically ill patients faces unique challenges, leading to a sparse evidence base to guide management in this population. Major obstacles to the study of AF in acute and critical illness include absence of a common definition, challenges in designing studies that capture complex etiology and assess causality, lack of a clear outcome set, difficulites in recruitment in acute environments with respect to timing, consent, and workflow, and failure to embed studies into clinical care platforms and capitalize on emerging technologies. Collaborative effort by researchers, clinicians, and stakeholders should be undertaken to address these challenges, both through interdisciplinary cooperation for the optimization of research efficiency and advocacy to advance the understanding of this common and complex arrhythmia, resulting in improved patient care and outcomes. The Symposium on Atrial Fibrillation in Acute and Critical Care was convened to address some of these challenges and propose potential solutions.

Iatrogenic atrial septal defects in structural heart interventions: Opening the Pandora's box

In the modern era of structural heart interventions, the total number of transseptal procedures is growing exponentially, thus increasing the rate and need for management of iatrogenic atrial septal defects (iASDs). To date, there are no official guidelines on the assessment and management of iASDs, due to inconclusive evidence on whether patients benefit more from the percutaneous closure of iASD than from conservative management and vigorous follow-up. Despite the abundance of observational studies on iASDs, there is still a lack of randomized studies. Evidence so far show that percutaneous closure is no superior over conservative treatment in patients with iASDs, however, it has been demonstrated that patients with spontaneous closure of iASDs experience less heart failure (HF) hospitalizations. On the other hand, researchers have investigated the beneficial nature of interatrial shunt therapy in patients with HFpEF and, more recently, with HFrEF, due to the presumed hemodynamic benefits. Herein, we provide an updated review of relevant literature, focusing on iASD persistence rates, predicting factors for their persistence, and clinical outcomes of iASD persistence, to summarize available evidence and discuss future directions in the field.

Use of artificial intelligence-guided echocardiography to detect cardiac dysfunction and heart valve disease in rural and remote areas: Rationale and design of the AGILE-echo trial

BACKGROUND

Transthoracic echocardiography (TTE) is essential in the diagnosis of cardiovascular diseases (CVD), including but not limited to heart failure (HF) and heart valve disease (HVD). However, its dependence on expert acquisition means that its accessibility in rural areas may be limited, leading to delayed management decisions and potential missed diagnoses. Artificial intelligence-guided (AI)-TTE offers a solution by permitting non-expert image acquisition. The impact of AI-TTE on the timing of diagnosis and early initiation of cardioprotection is undefined.

METHODS

AGILE-Echo (use of Artificial intelligence-Guided echocardiography to assIst cardiovascuLar patient managEment) is a randomized-controlled trial conducted in 5 rural and remote areas around Australia. Adults with CV risk factors and exercise intolerance, or concerns regarding HVD are randomized into AI-TTE or usual care (UC). AI-TTE participants may have a cardiovascular problem excluded, identified (leading to AI-guided interventions) or unresolved (leading to conventional TTE). UC participants undergo usual management, including referral for standard TTE. The primary endpoint is a composite of HVD or HF diagnosis at 12-months. Subgroup analysis, stratified based on age range and sex, will be conducted. All statistical analyses will be conducted using R.

RESULTS

Of the first 157 participants, 78 have been randomized into AI-TTE (median age 68 [IQR 17]) and 79 to UC (median age 65 [IQR 17], P = .034). HVD was the primary concern in 37 participants (23.6%) while 84.7% (n = 133) experienced exercise intolerance. The overall 10-year HF incidence risk was 13.4% and 20.0% (P = .089) for UC and AI-TTE arm respectively. Atrial remodeling, left ventricular remodeling and valvular regurgitation were the most common findings. Thirty-three patients (42.3%) showed no abnormalities.

CONCLUSIONS

This randomized-controlled trial of AI-TTE will provide proof-of-concept for the role of AI-TTE in identifying pre-symptomatic HF or HVD when access to TTE is limited. Additionally, this could promote the usage of AI-TTE in rural or remote areas, ultimately improving health and quality of life of community dwelling adults with risks, signs or symptoms of cardiac dysfunction.

Discrimination and net-reclassification of cardiovascular disease risk with lipoprotein(a) levels: The ATTICA study (2002-2022)

BACKGROUND

Lipoprotein(a) [Lp(a)] is recognized as a risk factor for atherosclerotic cardiovascular disease (ASCVD). However, its influence on clinical risk evaluations remains unclear.

OBJECTIVE

This study aimed to determine whether Lp(a) improves CVD risk prediction among apparently healthy adults from the general population.

METHODS

In 2002, n = 3,042 adults free of CVD, residing in the Athens metropolitan area, in Greece, were recruited. A 20-year follow-up was conducted in 2022, comprising n = 2,169 participants, of which n = 1,988 had complete data for CVD incidence.

RESULTS

Lp(a) levels were significantly associated with 20-year ASCVD incidence in the crude model (hazard ratio per 1 mg/dL: 1.004, p = 0.048), but not in multi-adjusted models considering demographic, lifestyle, and clinical factors. Adding Lp(a) to the Reynolds Risk Score (RRS) and Framingham Risk Score (FRS) variables resulted in positive net reclassification improvement (NRI) values (0.159 and 0.160 respectively), indicating improved risk classification. Mediation analysis suggested that C-reactive protein, interleukin-6, and fibrinogen mediate the relationship between Lp(a) and ASCVD. No significant interaction was observed between Lp(a) and potential moderators.

CONCLUSION

Lp(a) levels can predict 20-year CVD outcomes and improve CVD risk prediction within the general population, possibly via the intricate relationship between Lp(a), systemic inflammation, atherothrombosis.

Case report of the successful treatment of a rare complication of pulmonary vein stenting: atrial rupture and stent detachment

Pulmonary vein stenosis (PVS) is a relatively rare pulmonary vascular disease in clinical practice, and radiofrequency ablation (RFA) is a common cause of pulmonary vein stenosis. Owing to its nonspecific symptoms and irregular follow-up, PVS is often misdiagnosed. In severe cases, intervention is needed, with the main treatment options being pulmonary vein stenting and/or balloon dilation, both of which carry risks of serious complications. We report a patient with severe pulmonary vein stenosis who experienced right atrial wall rupture and stent detachment during an interventional procedure. Through active intraoperative intervention, we successfully avoided serious complications.

Omics research in atherosclerosis

Atherosclerosis (AS) is a chronic inflammatory disease characterized by lipid deposition within the arterial intima, as well as fibrous tissue proliferation and calcification. AS has long been recognized as one of the primary pathological foundations of cardiovascular diseases in humans. Its pathogenesis is intricate and not yet fully elucidated. Studies have shown that AS is associated with oxidative stress, inflammatory response, lipid deposition, and changes in cell phenotype. Unfortunately, there is currently no effective prevention or targeted treatment for AS. The rapid advancement of omics technologies, including genomics, transcriptomics, proteomics, and metabolomics, has opened up novel avenues to elucidate the fundamental pathophysiology and associated mechanisms of AS. Here, we review articles published over the past decade and focus on the current status, challenges, limitations, and prospects of omics in AS research and clinical practice. Emphasizing potential targets based on omics technologies will improve our understanding of this pathological condition and assist in the development of potential therapeutic approaches for AS-related diseases.

Machine learning for pacemaker implantation prediction after TAVI using multimodal imaging data

Pacemaker implantation (PMI) after transcatheter aortic valve implantation (TAVI) is a common complication. While computed tomography (CT) scan data are known predictors of PMI, no machine learning (ML) model integrating CT with clinical, ECG, and transthoracic echocardiography (TTE) data has been proposed. This study investigates the contribution of ML methods to predict PMI after TAVI, with a focus on the role of CT imaging data. A retrospective analysis was conducted on a cohort of 520 patients who underwent TAVI. Recursive feature elimination with SHAP values was used to select key variables from clinical, ECG, TTE, and CT data. Six ML models, including Support Vector Machines (SVM), were trained using these selected variables. The model's performance was evaluated using AUC-ROC, F1 score, and accuracy metrics. The PMI rate was 18.8%. The best-performing model achieved an AUC-ROC of 92.1% ± 4.7, an F1 score of 71.8% ± 9.9, and an accuracy of 87.9% ± 4.7 using 22 variables, 9 of which were CT-based. Membranous septum measurements and their dynamic variations were critical predictors. Our ML model provides robust PMI predictions, enabling personalized risk assessments. The model is implemented online for broad clinical use.

The Emerging and Important Role of Artificial Intelligence in Cardiac Surgery

Artificial Intelligence (AI) has greatly affected our everyday lives and holds great promise to change the landscape of medicine. AI is particularly positioned to improve care for the increasingly complex patients undergoing cardiac surgery using the immense amount of data generated in the course of their care. When deployed, AI can be used to analyze this information at the patient's bedside more expediently and accurately, all while providing new insights. This review summarizes the current applications of AI in cardiac surgery from the vantage point of a patient's journey. Applications of AI include preoperative risk assessment, intraoperative planning, postoperative patient care, and outpatient telemonitoring, encompassing the spectrum of cardiac surgical care. Offloading of administrative processes and enhanced experience with information gathering also represent a unique and under-represented avenue for future use of AI. As clinicians, understanding the nomenclature and applications of AI is important to contextualize issues, to ensure problem-driven solutions, and for clinical benefit. Precision medicine, and thus clinically relevant AI, remains dependent on data curation and warehousing to gather insights from large multicentre repositories while treating privacy with the utmost importance. AI tasks should not be siloed but rather holistically integrated into clinical workflow to retain context and relevance. As cardiac surgeons, AI allows us to look forward to a bright future of more efficient use of our clinical expertise toward high-level decision making and technical prowess.

The use of echocardiography in the management of shock in critical care: a prospective, multi-centre, observational study

PURPOSE

Echocardiography is recommended as a first-line tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. The aims of this work were to evaluate the utilisation of echocardiography in patients presenting to critical care with shock, its impact on decision making, and adherence to governance guidelines.

METHODS

We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom (UK) and Crown Dependencies, led by the UK's Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 h to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making.

RESULTS

1015 patients with shock were included. An echocardiogram was performed on 545 (54%) patients within 72 h and 436 (43%) within 24 h of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive or cardiogenic shock had their management altered numerically more often by echocardiography (n = 15 [75%] and n = 100 [58%] respectively). Twenty-five percent of echocardiograms performed adhered to current national governance and image storage guidance.

CONCLUSION

Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock.

The Role of Cardiovascular Imaging in the Diagnosis of Athlete's Heart: Navigating the Shades of Grey

Athlete's heart (AH) represents the heart's remarkable ability to adapt structurally and functionally to prolonged and intensive athletic training. Characterized by increased left ventricular (LV) wall thickness, enlarged cardiac chambers, and augmented cardiac mass, AH typically maintains or enhances systolic and diastolic functions. Despite the positive health implications, these adaptations can obscure the difference between benign physiological changes and early manifestations of cardiac pathologies such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), and arrhythmogenic cardiomyopathy (ACM). This article reviews the imaging characteristics of AH across various modalities, emphasizing echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography as primary tools for evaluating cardiac function and distinguishing physiological adaptations from pathological conditions. The findings highlight the need for precise diagnostic criteria and advanced imaging techniques to ensure accurate differentiation, preventing misdiagnosis and its associated risks, such as sudden cardiac death (SCD). Understanding these adaptations and employing the appropriate imaging methods are crucial for athletes' effective management and health optimization.

A multi-task deep learning approach for real-time view classification and quality assessment of echocardiographic images

High-quality standard views in two-dimensional echocardiography are essential for accurate cardiovascular disease diagnosis and treatment decisions. However, the quality of echocardiographic images is highly dependent on the practitioner's experience. Ensuring timely quality control of echocardiographic images in the clinical setting remains a significant challenge. In this study, we aimed to propose new quality assessment criteria and develop a multi-task deep learning model for real-time multi-view classification and image quality assessment (six standard views and "others"). A total of 170,311 echocardiographic images collected between 2015 and 2022 were utilized to develop and evaluate the model. On the test set, the model achieved an overall classification accuracy of 97.8% (95%CI 97.7-98.0) and a mean absolute error of 6.54 (95%CI 6.43-6.66). A single-frame inference time of 2.8 ms was achieved, meeting real-time requirements. We also analyzed pre-stored images from three distinct groups of echocardiographers (junior, senior, and expert) to evaluate the clinical feasibility of the model. Our multi-task model can provide objective, reproducible, and clinically significant view quality assessment results for echocardiographic images, potentially optimizing the clinical image acquisition process and improving AI-assisted diagnosis accuracy.

Application of Echocardiography in Anaesthesia: From Preoperative Risk Assessment to Postoperative Care

Echocardiography has carved out a fundamental niche in anaesthesiology, revolutionizing the monitoring and management of cardiac function during surgery. Clinical practice has changed from simple 2D and 3D echocardiography to more sophisticated applications such as incorporating artificial intelligence. Echocardiography provides detailed real-time information about cardiac anatomy and function, helping anaesthesiologists make better decisions regarding tailoring anesthetic interventions and optimizing patient outcomes. From optimizing hemodynamic management in patients with severe aortic stenosis to fine-tuning fluid and vasopressor therapy in patients with right heart dysfunction, echocardiography has improved the care provided in the perioperative period. These applications permit the demonstration of not only technical advantages that could accrue from echocardiography but are also a part of individualized care to improve the outcomes of patients. The challenges in integrating echocardiography with anaesthesia include operator dependency, a steep learning curve in acquiring echocardiographic skills, and limitations due to patient factors and technological limitations, which lead to poor echocardiographic performance. Additionally, transoesophageal echocardiography (TEE) is an invasive procedure with several potential risks that must be considered cautiously. Continuing education, certification recommendations, and skill development are prerequisites for this echocardiography tool to remain robust and reliable in anaesthesiology. Technological innovation, especially in improving 3D imaging and integration with artificial intelligence, is where a very bright future lies ahead for echocardiography. It would further accelerate the process of echocardiographic evaluation and improve diagnostic accuracy. All these would turn out to be more person-centered for each patient. Anaesthesiologists must, therefore, pace themselves with such developments so these can be appropriately applied in the clinics. In summary, echocardiography became so integrally ingrained into anaesthesia that it propelled the specialty with essential tools anaesthesiologists use to manage patients for optimum outcomes. Its application has difficulties and limitations, but continued professional development and development of echocardiographic technology will make sure that its benefits are maximized. Quickly, echocardiography is becoming central to anaesthesiology's role in optimizing patient care and surgical success as we move into the application of evermore sophisticated echocardiographic techniques.

CT Angiography for Aortic Arch Anomalies: Prevalence, Diagnostic Efficacy, and Illustrative Findings

Aortic arch anomalies encompass a diverse spectrum of conditions. Elucidating the prevalence of these anomalies, their impact on patient wellbeing, and the most effective diagnostic tools are crucial steps in ensuring optimal patient care. This paper aims to explore the various presentations of aortic arch anomalies, emphasizing the remarkable utility of computed tomography (CT) angiography in their definitive diagnosis and characterization. We conducted a retrospective study on patients who were submitted to the CT angiography of the thoracic aorta or supra-aortic trunks, or the contrast-enhanced CT scans of the thorax and/or cervical region between January 2021 and February 2024 in our Hospital. Out of the total of 2350 patients, 18 were diagnosed with aortic arch anomalies, with an average age of approximately 55 years. The aortic arch anomalies identified in the study were as follows: left aortic arch with the aberrant origin of the right subclavian artery, right aortic arch (types I and II), double aortic arch, aortic coarctation, aortic pseudocoarctation, and ductus diverticulum. Although often asymptomatic, aortic arch anomalies require recognition and CT using advanced post-processing techniques is the optimal diagnostic method with the ability to also identify other associated cardiac or vascular malformations.

Assessment of an Artificial Intelligence Tool for Estimating Left Ventricular Ejection Fraction in Echocardiograms from Apical and Parasternal Long-Axis Views

This work aims to evaluate the performance of a new artificial intelligence tool (ExoAI) to compute the left ventricular ejection fraction (LVEF) in echocardiograms of the apical and parasternal long axis (PLAX) views. We retrospectively gathered echocardiograms from 441 individual patients (70% male, age: 67.3 ± 15.3, weight: 87.7 ± 25.4, BMI: 29.5 ± 7.4) and computed the ejection fraction in each echocardiogram using the ExoAI algorithm. We compared its performance against the ejection fraction from the clinical report. ExoAI achieved a root mean squared error of 7.58% in A2C, 7.45% in A4C, and 7.29% in PLAX, and correlations of 0.79, 0.75, and 0.89, respectively. As for the detection of low EF values (EF < 50%), ExoAI achieved an accuracy of 83% in A2C, 80% in A4C, and 91% in PLAX. Our results suggest that ExoAI effectively estimates the LVEF and it is an effective tool for estimating abnormal ejection fraction values (EF < 50%). Importantly, the PLAX view allows for the estimation of the ejection fraction when it is not feasible to acquire apical views (e.g., in ICU settings where it is not possible to move the patient to obtain an apical scan).

Revolutionizing Cardiac Imaging: A Scoping Review of Artificial Intelligence in Echocardiography, CTA, and Cardiac MRI

BACKGROUND AND INTRODUCTION

Cardiac imaging is crucial for diagnosing heart disorders. Methods like X-rays, ultrasounds, CT scans, and MRIs provide detailed anatomical and functional heart images. AI can enhance these imaging techniques with its advanced learning capabilities.

METHOD

In this scoping review, following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) Guidelines, we searched PubMed, Scopus, Web of Science, and Google Scholar using related keywords on 16 April 2024. From 3679 articles, we first screened titles and abstracts based on the initial inclusion criteria and then screened the full texts. The authors made the final selections collaboratively.

RESULT

The PRISMA chart shows that 3516 articles were initially selected for evaluation after removing duplicates. Upon reviewing titles, abstracts, and quality, 24 articles were deemed eligible for the review. The findings indicate that AI enhances image quality, speeds up imaging processes, and reduces radiation exposure with sensitivity and specificity comparable to or exceeding those of qualified radiologists or cardiologists. Further research is needed to assess AI's applicability in various types of cardiac imaging, especially in rural hospitals where access to medical doctors is limited.

CONCLUSIONS

AI improves image quality, reduces human errors and radiation exposure, and can predict cardiac events with acceptable sensitivity and specificity.

Obicetrapib on top of maximally tolerated lipid-modifying therapies in participants with or at high risk for atherosclerotic cardiovascular disease: rationale and designs of BROADWAY and BROOKLYN

BACKGROUND

Obicetrapib, a novel, selective cholesteryl ester transfer protein (CETP) inhibitor, reduces low-density lipoprotein cholesterol (LDL-C), LDL particles, apolipoprotein (Apo) B, and lipoprotein(a) [Lp(a)] and increases high-density lipoprotein cholesterol (HDL-C) when added to statins with or without ezetimibe. By substantially reducing LDL-C, obicetrapib has the potential to lower atherogenic lipoproteins in patients with atherosclerotic cardiovascular disease (ASCVD) or heterozygous familial hypercholesterolemia (HeFH) whose LDL-C levels remain high despite treatment with available maximally tolerated lipid-modifying therapies, addressing an unmet medical need in a patient population at high risk for cardiovascular events.

METHODS AND RESULTS

BROADWAY (NCT05142722) and BROOKLYN (NCT05425745) are ongoing placebo-controlled, double-blind, randomized Phase III trials designed to examine the efficacy, safety, and tolerability of obicetrapib as an adjunct to dietary intervention and maximally tolerated lipid-modifying therapies in participants with a history of ASCVD and/or underlying HeFH whose LDL-C is not adequately controlled. The primary efficacy endpoint was the percent change in LDL-C from baseline to day 84. Other endpoints included changes in Apo B, non-HDL-C, HDL-C, Apo A1, Lp(a), and triglycerides in addition to parameters evaluating safety, tolerability, and pharmacokinetics. BROADWAY also included an adjudicated assessment of major adverse cardiovascular events, measurements of glucose homeostasis, and an ambulatory blood pressure monitoring substudy. A total of 2,532 participants were randomized in BROADWAY and 354 in BROOKLYN to receive obicetrapib 10 mg or placebo (2:1) for 365 days with follow-up through 35 days after the last dose. Results from both trials are anticipated in 2024.

CONCLUSION

These trials will provide safety and efficacy data to support the potential use of obicetrapib among patients with ASCVD or HeFH with elevated LDL-C for whom existing therapies are not sufficiently effective or well-tolerated.

Diagnostic Modalities in Heart Failure: A Narrative Review

Heart failure (HF) can present acutely or progress over time. It can lead to morbidity and mortality affecting 6.5 million Americans over the age of 20. The HF type is described according to the ejection fraction classification, defined as the percentage of blood volume that exits the left ventricle after myocardial contraction, undergoing ejection into the circulation, also called stroke volume, and is proportional to the ejection fraction. Cardiac catheterization is an invasive procedure to evaluate coronary artery disease leading to HF. Several biomarkers are being studied that could lead to early detection of HF and better symptom management. Testing for various biomarkers in the patient's blood is instrumental in confirming the diagnosis and elucidating the etiology of HF. There are various biomarkers elevated in response to increased myocardial stress and volume overload, including B-type natriuretic peptide (BNP) and its N-terminal prohormone BNP. We explored online libraries such as PubMed, Google Scholar, and Cochrane to find relevant articles. Our narrative review aims to extensively shed light on diagnostic modalities and novel techniques for diagnosing HF.

Iatrogenic Atrial Septal Defect After MitraClip Transcatheter Edge-to-Edge Repair: To Close or Not to Close?

The evolution of percutaneous procedures that use transseptal puncture to treat left-sided structural heart disease has led to the emergence of iatrogenic atrial septal defects as a potential complication. These defects can result in hemodynamic decompensation and worsening clinical outcomes. Some iatrogenic atrial septal defects require immediate closure, others do not. This case report presents 2 patients who underwent transcatheter edge-to-edge mitral valve repair with transseptal puncture and required iatrogenic atrial septal defect closure (1 immediate and 1 delayed). The goal of this report is to highlight iatrogenic atrial septal defect assessment and the possible need for closure after transseptal puncture.

A Novel Diastolic Doppler Index Less Affected by Aortic Arch Anomalies Co-existing with Coarctation

Severity assessment for coarctation of the aorta (CoA) is challenging due to concomitant morphological anomalies (complex CoA) and inaccurate Doppler-based indices. Promising diagnostic performance has been reported for the continuous flow pressure gradient (CFPG), but it has not been studied in complex CoA. Our objective was to characterize the effect of complex CoA and associated hemodynamics on CFPG in a clinical cohort. Retrospective analysis identified discrete juxtaductal (n = 25) and complex CoA (n = 43; transverse arch and/or isthmus hypoplasia) patients with arm-leg systolic blood pressure gradients (BPG) within 24 h of echocardiography for comparison to BPG by conventional Doppler indices (simplified Bernoulli equation and modified forms correcting for proximal kinetic energy and/or recovered pressure). Results were interpreted using the current CoA guideline (BPG ≥ 20 mmHg) to compare diagnostic performance indicators including receiver operating characteristic curves, sensitivity, specificity, and diagnostic accuracy, among others. Echocardiography Z-scored aortic diameters were applied with computational simulations from a preclinical CoA model to understand aspects of the CFPG driving performance differences. Diagnostic performance was substantially reduced from discrete to complex CoA for conventional Doppler indices calculated from patient data, and by hypoplasia and/or long segment stenosis in simulations. In contrast, diagnostic indicators for the CFPG only modestly dropped for complex vs discrete CoA. Simulations revealed differences in performance due to inclusion of the Doppler velocity index and diastolic pressure half-time in the CFPG calculation. CFPG is less affected by aortic arch anomalies co-existing with CoA when compared to conventional Doppler indices.

Lipoprotein (a) and cerebrovascular disease

The role of lipoprotein (a) [Lp(a)] in cerebrovascular disease is a topic of importance. In this narrative review, pertinent studies have been leveraged to comprehensively examine this relationship from diverse perspectives.Lp(a) shares structural traits with low-density lipoprotein cholesterol. Lp(a) is synthesized by hepatocytes, and its plasma levels are genetically determined by the LPA gene, which produces apolipoprotein (a).Numerous epidemiological studies have confirmed the positive correlation between elevated serum Lp(a) levels and the occurrence or recurrence of cerebrovascular events, especially ischemic strokes, in adults. It should be noted that the correlation strength varies among studies and is marginal in Mendelian randomization studies.Regarding pediatric patients, screening is currently limited to those with a relevant medical history. Lp(a) seems to play a significant role in the pathogenesis of arterial ischemic stroke in children because environmental thrombotic and atherogenic factors are generally not present.Phase 3 trials of novel Lp(a) targeting agents, such as pelacarsen and olpasiran, are anticipated to demonstrate their efficacy in reducing the incidence of stroke. Given the richness of the literature, new guidelines regarding Lp(a) screening and management in targeted populations are warranted to provide more effective primary and secondary prevention.

The Role of Multimodality Imaging in Cardiomyopathy

PURPOSE OF REVIEW

There has been increasing use of multimodality imaging in the evaluation of cardiomyopathies.

RECENT FINDINGS

Echocardiography, cardiac magnetic resonance (CMR), cardiac nuclear imaging, and cardiac computed tomography (CCT) play an important role in the diagnosis, risk stratification, and management of patients with cardiomyopathies. Echocardiography is essential in the initial assessment of suspected cardiomyopathy, but a multimodality approach can improve diagnostics and management. CMR allows for accurate measurement of volumes and function, and can easily detect unique pathologic structures. In addition, contrast imaging and parametric mapping enable the characterization of tissue features such as scar, edema, infiltration, and deposition. In non-ischemic cardiomyopathies, metabolic and molecular nuclear imaging is used to diagnose rare but life-threatening conditions such amyloidosis and sarcoidosis. There is an expanding use of CCT for planning electrophysiology procedures such as cardioversion, ablations, and device placement. Furthermore, CCT can evaluate for complications associated with advanced heart failure therapies such as cardiac transplant and mechanical support devices. Innovations in multimodality cardiac imaging should lead to increased volumes and better outcomes.

Correlation Between Lipoprotein(a) and Prognosis for Coronary Artery Disease in Patients Undergoing Percutaneous Coronary Intervention

Background

Elevated lipoprotein(a) (Lp[a]) is a risk factor for first atherosclerotic thrombosis events, but the role of elevated Lp(a) in secondary prevention is controversial. This study aimed to retrospectively investigate the influence of elevated Lp(a) levels on the prognosis of patients with coronary artery disease.

Methods

The team collected and compared clinical information of patients hospitalized during percutaneous coronary intervention (PCI). This study used a multivariate logistic regression model to evaluate the relationships between Lp(a) levels, cardiovascular risk factors, and the prognosis of coronary artery disease in patients undergoing PCI.

Results

There were no statistically significant differences between patients grouped according to Lp(a) level in terms of sex; age; body mass index and obesity; hyperuricemia; smoking; cardiac insufficiency; acute myocardial infarction; multivessel lesion; in-stent restenosis; secondary PCI; apolipoprotein AI level; incidence of high total cholesterol or high low-density lipoprotein cholesterol; or family history of hypertension, diabetes, or coronary artery disease. The average Lp(a) concentration did not statistically significantly decrease after 1 year of statin treatment after PCI. One year after patients began statins, there were no significant differences between Lp(a) groups in the incidence of high triglycerides (P = .13), high total cholesterol (P = .52), or high low-density lipoprotein cholesterol (P = .051). Multivariate logistic regression analysis indicated that diabetes (P = .02) was associated with in-stent restenosis, whereas diabetes (P = .02) and multivessel lesions (P < .001) were associated with secondary PCI in patients who underwent coronary angiography 1 year after PCI. Compared with normal Lp(a) levels, high Lp(a) levels did not significantly increase the incidence of in-stent restenosis or secondary PCI in patients who underwent coronary angiography 1 year after PCI.

Conclusion

Sustained high concentrations of Lp(a) did not significantly increase the incidence of in-stent restenosis or secondary PCI in patients who underwent coronary angiography 1 year after PCI.

Real-time Elastography and Contrast-Enhanced Ultrasound for Evaluating Adventitia in the Early Diagnosis of Vulnerable Plaques: an Exploratory Study Based on Histopathology

Vulnerable plaque is closely related to the occurrence of ischemic stroke. Therefore, early accurate identification of plaque vulnerability is crucial in risk stratification. In the development of vulnerable plaques, the change of the adventitia is earlier than that of the intima. Currently, researchers focused on the ultrasound detection of intraplaque and intima, but adventitia was often ignored in the examination. Real-time elastography technology (RTE) provides an estimation of adventitia stiffness, and contrast-enhanced ultrasound (CEUS) provides the quantification of adventitial VV. Therefore, we aimed to evaluate the value of adventitia in the early diagnosis of plaque vulnerability by combining CEUS and RTE based on histopathology. Rabbit carotid atherosclerosis models were established, and CEUS and RTE were performed. Normalized maximal video-intensity enhancement (MVE) was calculated to quantify adventitial VV density, and strain values were acquired to evaluate the adventitial elasticity. After removal of the lesion lumen, histological analysis of each excised plaque and adventitia was performed, and vulnerable plaques (n = 32) and stable group (n = 13) were distinguished. Normalized MVE of the adventitial VV and adventitial strain values in the vulnerable group was significantly higher than those in the stable group. Normalized MVE and strain values had a positive linear correlation with histological findings. Normalized MVE of the adventitial VV combined with adventitial strain values could identify plaque vulnerability with the area under the curve of 0.913 (sensitivity 90% and specificity 97%). Accordingly, the multimodal ultrasound detection strategy of adventitia has a high diagnostic value for early plaque vulnerability.

Machine-learning approaches for risk prediction in transcatheter aortic valve implantation: Systematic review and meta-analysis

OBJECTIVES

With the expanding integration of artificial intelligence (AI) and machine learning (ML) into the structural heart domain, numerous ML models have emerged for the prediction of adverse outcomes after transcatheter aortic valve implantation (TAVI). We aim to identify, describe, and critically appraise ML prediction models for adverse outcomes after TAVI. Key objectives consisted in summarizing model performance, evaluating adherence to reporting guidelines, and transparency.

METHODS

We searched PubMed, SCOPUS, and Embase through August 2023. We selected published machine learning models predicting TAVI outcomes. Two reviewers independently screened articles, extracted data, and assessed the study quality according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcomes included summary C-statistics and model risk of bias assessed with the Prediction Model Risk of Bias Assessment Tool. C-statistics were pooled using a random-effects model.

RESULTS

Twenty-one studies (118,153 patients) employing various ML algorithms (76 models) were included in the systematic review. Predictive ability of models varied: 11.8% inadequate (C-statistic <0.60), 26.3% adequate (C-statistic 0.60-0.70), 31.6% acceptable (C-statistic 0.70-0.80), and 30.3% demonstrated excellent (C-statistic >0.80) performance. Meta-analyses revealed excellent predictive performance for early mortality (C-statistic: 0.81; 95% confidence interval [CI], 0.65-0.91), acceptable performance for 1-year mortality (C-statistic: 0.76; 95% CI, 0.67-0.84), and acceptable performance for predicting permanent pacemaker implantation (C-statistic: 0.75; 95% CI, 0.51-0.90).

CONCLUSIONS

ML models for TAVI outcomes exhibit adequate-to-excellent performance, suggesting potential clinical utility. We identified concerns in methodology and transparency, emphasizing the need for improved scientific reporting standards.

Revolutionizing Cardiology through Artificial Intelligence-Big Data from Proactive Prevention to Precise Diagnostics and Cutting-Edge Treatment-A Comprehensive Review of the Past 5 Years

BACKGROUND

Artificial intelligence (AI) can radically change almost every aspect of the human experience. In the medical field, there are numerous applications of AI and subsequently, in a relatively short time, significant progress has been made. Cardiology is not immune to this trend, this fact being supported by the exponential increase in the number of publications in which the algorithms play an important role in data analysis, pattern discovery, identification of anomalies, and therapeutic decision making. Furthermore, with technological development, there have appeared new models of machine learning (ML) and deep learning (DP) that are capable of exploring various applications of AI in cardiology, including areas such as prevention, cardiovascular imaging, electrophysiology, interventional cardiology, and many others. In this sense, the present article aims to provide a general vision of the current state of AI use in cardiology.

RESULTS

We identified and included a subset of 200 papers directly relevant to the current research covering a wide range of applications. Thus, this paper presents AI applications in cardiovascular imaging, arithmology, clinical or emergency cardiology, cardiovascular prevention, and interventional procedures in a summarized manner. Recent studies from the highly scientific literature demonstrate the feasibility and advantages of using AI in different branches of cardiology.

CONCLUSIONS

The integration of AI in cardiology offers promising perspectives for increasing accuracy by decreasing the error rate and increasing efficiency in cardiovascular practice. From predicting the risk of sudden death or the ability to respond to cardiac resynchronization therapy to the diagnosis of pulmonary embolism or the early detection of valvular diseases, AI algorithms have shown their potential to mitigate human error and provide feasible solutions. At the same time, limits imposed by the small samples studied are highlighted alongside the challenges presented by ethical implementation; these relate to legal implications regarding responsibility and decision making processes, ensuring patient confidentiality and data security. All these constitute future research directions that will allow the integration of AI in the progress of cardiology.

Fiberscope-Based Measurement of Coaptation Height for Intraoperative Assessment of Mitral Valve Repair

BACKGROUND

Restoring adequate coaptation height is a key principle of mitral valve (MV) repair. This study aimed to evaluate the utility of fiberscope (FS) technology to assess MV coaptation height for intraoperative use.

METHODS

Ex-vivo testing was performed on five adult porcine hearts. The left atrium (LA) was resected, and the left ventricle (LV) was pressurized retrograde to 27 ± 1mm Hg. An endoscope was inserted into the LV apex, centered under the MV orifice. An FS system (Milliscope II camera, LED light source, and 0.7 mm diameter × 15 cm long) 90° semirigid scope with 1.2 mm focal length) was mounted above the MV annulus in a custom alignment and measuring fixture. Three blinded measurements were taken at two locations on each MV, A2 and P2 segment, from the top of coaptation to the leaflet edge identified by the FS. Accurate positioning was verified using the LV endoscope. A control (metal rod of similar thickness) was used for comparison, with coaptation height recorded when the control was seen via the endoscope.

RESULTS

Coaptation heights were similar for the control and FS methods across all hearts at A2 (11.6 ± 2.6 mm control vs 11.8 ± 2.2 mm FS) and P2 (13.3 ± 2.6 mm control vs 13.4 ± 2.9 mm FS) segments, with similar measurement variability (control SD 0.1-1.0 mm; FS SD 0.1-0.9 mm). One outlier was excluded from analysis (n = 19/20). The maximum absolute difference and percent error between measurement methods were less than 1.1 mm (median [IQR], 0.6 [0.3-0.9] mm) and less than 14% (4.1 [2.2-7.6]%).

CONCLUSIONS

Utilization of a miniaturized FS enabled precise and accurate quantification of MV coaptation. This technique is promising for evaluating post-repair valve competence and coaptation height.

The usefulness of staged extra-anatomic bypass for coarctation of the aorta with arch hypoplasia, from premature neonate to adult

Various surgical techniques have been developed for coarctation of the aorta. However, coarctation repair in neonates with arch hypoplasia remains challenging. We herein report a case in which a premature neonate under 1500 g with coarctation of the aorta and arch hypoplasia underwent an extra-anatomical bypass at 18 days old. A second extra-anatomical bypass was performed at 3 years of age, and a third extra-anatomic bypass for recurrent coarctation was performed in adulthood. By increasing the size of the graft as the patient grows, extra-anatomic bypass can be a useful surgical option for premature neonates with coarctation and arch hypoplasia.

Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement

INTRODUCTION

Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation.

METHODS

A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes.

RESULTS

The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US.

CONCLUSION

Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.

Echocardiography in the neonatal unit: current status and future prospects

INTRODUCTION

Traditionally echocardiography was used by pediatric cardiologists to diagnose congenital heart defects in neonates. Formalized neonatal hemodynamic fellowships have been established where neonatologists acquire advanced echocardiographic skills to gain anatomical, physiological, and hemodynamic information in real time and utilize this information in making a timely and accurate physiology-based clinical decision.

AREA COVERED

Differences between a comprehensive formal structural echocardiography, neonatologist performed targeted echocardiography and limited assessment on point-of-care-ultrasonography for specific indications have been covered. This article is focused at providing a comprehensive review of the status of echocardiography in the neonatal units, recent advancements and its future prospects in the neonatal intensive care units.

EXPERT OPINION

Comprehensive guidelines providing the scope of practice, a framework for training, and robust clinical governance process for the neonatologist performed targeted echocardiography have been established. In the last decade, echocardiography has emerged as essential vital bedside diagnostic tool in providing high-quality care to the sick infants in the neonatal units, and it has proved to improve the outcomes in neonates. It is now being considered as a modern hemodynamic monitoring tool. Advances in technology, machine learning, and application of artificial intelligence in applications of echocardiography seem promising adjunct tools for rapid assessment in emergency situations.

Mini-access ascending aorto-bifemoral bypass surgery for the treatment of aortic steno-occlusive disease

Objectives

Mid-aortic syndrome is a rare condition characterized by severe aortic narrowing, leading to high upper body blood pressure and organ hypoperfusion, necessitating surgical intervention. Although central bypassing is considered ideal, it involves extensive incisions. To overcome these limitations, less-invasive approaches have been developed. This study aims to introduce a mini-access approach using video-endoscopy and to evaluate the feasibility and outcomes of mini-access ascending aorto-bifemoral bypass surgery.

Methods

From November 2020 to May 2022, we performed ascending aorta to bifemoral artery bypass operations on 7 patients to treat steno-occlusive diseases in the downstream aorta. A Y-graft was created, and procedures were conducted under general anesthesia using video-endoscopy with limited skin incisions.

Results

Intraoperatively, there were no major complications, and none of the patients required cardiopulmonary bypass support. Furthermore, there were no postoperative mortalities or major complications. Postoperatively, the mean ankle-brachial index significantly improved from 0.59/0.59 to 0.96/0.92 (P = .004), and the mean glomerular filtration rate increased from 61.1 to 85.3 mL/min/1.73 mm2 (P = .012). Additionally, symptoms of claudication resolved in all patients.

Conclusions

Videoscope-assisted mini-access aortic bypass surgery not only provides favorable early postoperative outcomes but also represents a technically feasible alternative to traditional surgical approaches for the treatment of steno-occlusive aortic diseases.

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.