Characteristics, outcomes and the necessity of continued guideline-directed medical therapy in patients with heart failure with improved ejection fraction

BACKGROUND

Much remains to be learned about patients with heart failure with improved ejection fraction (HFimpEF).

OBJECTIVE

This study sheds light on the characteristics and clinical outcomes of HFimpEF patients, including the consequences of halting guideline-directed medical therapy (GDMT).

METHODS

This retrospective study was conducted on patients diagnosed with heart failure with reduced ejection fraction (HFrEF) who underwent a second echocardiogram at least 6 months apart between January 2009 and February 2023. The primary outcomes were major adverse cardiovascular events (MACEs), including all-cause mortality and heart failure hospitalization. The second outcome was recurrent HFrEF.

RESULTS

Of 4,560 HFrEF patients were included, 3,289 (72.1%) achieved HFimpEF within a median follow-up period of 3.4 years (IQR: 1.8 - 5.9 years). Among these HFimpEF patients, recurrent HFrEF was observed in 941 (28.6%) patients during a median follow-up period of 2.3 years (IQR: 0.8-4.6 years). The proportion of patients who halted GDMT was 70.4%, 53.2%, 59.8% and 63.8% for MRA, beta-blockers, ACEI/ARB/ARNI and SGLT-2 inhibitors. Multivariable Cox analysis revealed ischemic heart disease, chronic kidney disease, coronary heart disease, lower left ventricular ejection fraction, larger left ventricular diastolic dimension and non-use GDMT are associated with recurrent HFrEF. Individuals without GDMT use exhibited lower chances of persistently recovering ejection fraction and high risks of MACEs compared to those who continue use.

CONCLUSIONS

HFimpEF is a common condition across all clinical follow-ups. Prevalent discontinuation of GDMT medications may contribute significantly to recurrent HFrEF, placing patients at a higher risk for poor prognosis.

Tissue-tracking mitral annular displacement predicts impaired left ventricular mechanics and adverse outcomes in aortic stenosis with preserved left ventricular ejection fraction

AIMS

Tissue-tracking mitral annular displacement (TMAD) is a simple marker for left ventricular (LV) systolic function. However, its clinical impact in aortic stenosis (AS) remains unclear. We aimed to investigate the significance of TMAD on LV mechanics in comparison with global longitudinal strain (GLS) and its prognostic value in AS.

METHODS

We retrospectively reviewed 91 patients with moderate or severe AS and preserved LV ejection fraction (≥ 50 %). TMAD was measured from an apical four-chamber view and indexed to the LV long-axis length (%TMAD). The associations between TMAD and LV ejection fraction (LVEF) and GLS, including the regional distribution (apical, mid, and basal) of longitudinal strain (LS), were evaluated. We also assessed the impact of %TMAD on clinical outcomes, including cardiovascular death, heart failure hospitalization, and unplanned aortic valve replacement.

RESULTS

%TMAD showed a moderate correlation with LVEF (r = 0.45, P < 0.001) and a strong correlation with |GLS| (r = 0.81, P < 0.001). In the regional LS analysis, %TMAD correlated strongly with mid and basal LS, but modestly with apical. The cutoff value of %TMAD for predicting impaired GLS (|GLS| < 14.7 %, as previously reviewed) was 9.8 %, which also predicted event-free survival (Log-rank P = 0.001). In a Cox proportional hazards model, lower %TMAD was significantly associated with worse clinical outcomes, independent of AS severity and LVEF.

CONCLUSIONS

%TMAD is a marker of LV longitudinal systolic function, particularly reflecting mid-basal longitudinal systolic function, and can be a useful prognosticator in AS patients.

A 2D-STI echocardiographic diagnostic model established for cardiac amyloidosis complicated with multiple myeloma

OBJECTIVE

This study aimed to investigate the clinical characteristics of multiple myeloma(MM) with amyloidosis(AL) and evaluate the diagnostic utility of two-dimensional speckle tracking imaging(2D-STI) echocardiography in MM with cardiac amyloidosis(CA), with the goal of providing guidance for early screening and differentiation.

METHODS

Among 616 newly diagnosed multiple myeloma (NDMM) patients, 359 met the inclusion and exclusion criteria, and divided into MM-AL and MM without AL according to the histopathological results. MM-AL patients were subdivided into MM-CA and MM without CA subgroups according to cardiac involvement criteria. Baseline characteristics and 2D-STI echocardiographic parameters were comparatively analyzed. Variables potentially predictive of MM-CA were identified through univariate analysis, with accuracy assessed by area under the curve (AUC). Variables were dichotomized using optimal cut-off values to construct a multivariate logistic regression model.

RESULTS

The initial symptoms of MM-AL were mainly bone pain and anemia, but the incidence of ostealgia was lower (45.7 %) and the prevalence of congestive heart failure (CHF) was higher (12.8 %) compared with MM without AL patients. No significant differences were observed in myocardial injury biomarkers, tumor burden, or t(11,14) translocation. MM-CA patients presented with 40.0 % severe heart failure (HF) NYHA class III-IV at diagnosis and experienced 33.3 % adverse cardiovascular events. An echocardiographic model incorporating left ventricular ejection fraction(LVEF), pulmonary artery systolic pressure(PASP), hydropericardium, and global longitudinal strain (GLS) demonstrated the highest diagnostic accuracy for MM-CA, with an AUC of 0.90 (95 % CI, 0.81-1.00) (sensitivity: 95.6 %, specificity: 80.0 %, accuracy: 90.8 %).

CONCLUSION

There was no specific difference between the clinical manifestations and routine examinations of MM with or without AL patients. This study introduces a novel multi-parameter echocardiographic model for MM-CA diagnosis, providing a clinically valuable tool for early screening and differentiation.

Right Atrial Strain in Pediatric Pulmonary Hypertension-A Prospective Observational Study

Right ventricular (RV) afterload due to elevated pulmonary arterial (PA) pressure in pulmonary hypertension (PH) causes long-term right atrial (RA) remodeling and dysfunction. RA function has been shown to correlate with PA pressures and outcome in both adult and pediatric patients with PH. We studied the role of RA strain in estimating PA pressures in congenital heart disease (CHD)-associated PH. Children below 12 years undergoing elective repair of CHD with left-to-right shunts and echocardiographic evidence of PH were included. RA reservoir, conduit and contractile strain along with conventional measures of RV function and PA pressure were measured using transthoracic echocardiography after induction of anaesthesia. Pre-and post-repair invasive PA pressures were measured after surgical exposure. 51 children with a median age of 24 months (range 4-144 months) were included, most of whom were undergoing VSD closure. Contractile RA strain showed good correlation with pre-repair systolic PA pressure in mmHg (r = 0.59, 95%CI 0.37-0.75) or expressed as a percentage of SBP (r = 0.67, 95%CI 0.49-0.80). It also predicted persistent postoperative PH as well as pre-repair pulmonary artery acceleration time and right ventricular systolic pressure measured from tricuspid regurgitation jet. The trends of correlation observed suggest a possible prognostic role of RA strain in ACHD with PH and potential utility in its echocardiographic assessment. The observed findings merit deeper evaluation in larger cohorts.

Machine learning prediction of right ventricular volume and ejection fraction from two-dimensional echocardiography in patients with pulmonary regurgitation

Right ventricular (RV) end-diastolic volume (RVEDV) and ejection fraction (RVEF) by cardiac MRI (cMRI) guide management in chronic pulmonary regurgitation (PR). Two-dimensional echocardiography suboptimally correlate with RV volumes. This study tested whether combination of guideline-directed RV measures in a machine learning (ML) framework improves quantitative assessment of RVEDV and RVEF. RV measurements were obtained on subjects with > mild PR who had cMRI and echocardiogram within 90 days. A gradient-boosted trees algorithm predicted cMRI RV dilation (RVEDV > 160 ml/m2) and RV dysfunction (RVEF<47%), first with "guideline-only" measures, and then with "expanded-features" to include 44 total echocardiographic, clinical, and demographic variables. Model performance was compared to clinician visual assessment. Of 232 studies (56% tetralogy of Fallot, 20% pulmonary stenosis), the median age was 21.5 years, 21 (9%) had RV dilation, and 42 (18%) had RV dysfunction. For RV dilation prediction, the guideline-only model area under the receiver operating characteristic (AUROC)=0.68, and expanded-features model AUROC=0.85. At 90% sensitivity, the expanded-features model had 73% specificity, 25% positive predictive value (PPV), and 99% negative predictive value (NPV) This was similar to clinician performance (sensitivity 81%, specificity 81%, PPV 29%, NPV 98%). For prediction of RV dysfunction, the guideline-only AUROC= 0.71, additional features did not improve the model, and clinicians outperformed the model. In patients with PR, a ML model combining guidelines for RV assessment with demographic and additional echocardiographic parameters may effectively rule-out those with significant RV dilation at clinical thresholds for intervention, and performs similarly to expert clinicians.

Artificial intelligence and digital tools for design and execution of cardiovascular clinical trials

Recent advances have given rise to a spectrum of digital health technologies that have the potential to revolutionize the design and conduct of cardiovascular clinical trials. Advances in domain tasks such as automated diagnosis and classification, synthesis of high-volume data and latent data from adjacent modalities, patient discovery, telemedicine, remote monitoring, augmented reality, and in silico modelling have the potential to enhance the efficiency, accuracy, and cost-effectiveness of cardiovascular clinical trials. However, early experience with these tools has also exposed important issues, including regulatory barriers, clinical validation and acceptance, technological literacy, integration with care models, and health equity concerns. This narrative review summarizes the landscape of digital tools at each stage of clinical trial planning and execution and outlines roadblocks and opportunities for successful implementation of digital tools in cardiovascular clinical trials.

Association of aortic valve size with the degree of aortic valve calcification in severe high-gradient aortic stenosis

AIMS

Less pronounced calcification of the aortic valve (AVC) was observed in women with aortic stenosis (AS) when compared with men. Since women have smaller aortic valves (AVs), this could explain a lower calcium load. We aimed to analyse the association of AV size with AVC independent from sex.

METHODS AND RESULTS

Consecutive patients with high-gradient AS, who underwent cardiac computed tomography (CT), were assessed. AV annulus area and AVC with the Agatston score were measured on CT. In total, 601 patients (mean age 80 ± 7 years, 45% female) were included. Women had smaller AV annulus areas (4.12 ± 0.67 vs. 5.15 ± 0.78 cm2, P < 0.001) and lower Agatston scores [2018 (1456-3017) vs. 3394 (2562-4530), P < 0.001] than men. We found a significant correlation (r = 0.594, P < 0.001) and independent association (β = 926.20, P < 0.001) of AV annulus area with AVC. On separate regression analyses for men and women, AVC was independently associated with AV annulus area in both sexes (βmen = 887.77; βwomen = 863.48, both P < 0.001). When patients were stratified into AV size quartiles, patients in the lower quartiles were more likely to have AVC values below recommended sex-specific AVC thresholds. In the lowest quartile, 28% of female and 27% of male patients had Agatston scores below 1200 Agatston units (AU) (women) and 2000 AU (men), while this proportion decreased to 6 and 2%, respectively, in the quartiles with the largest annulus areas.

CONCLUSION

In high-gradient AS, AVC strongly depends on AV annulus area. This association is not dependent on sex. Thus, AVC should be indexed to AV size in addition to sex.

Concentric remodeling and the metabolic-associated steatotic liver disease in patients with type 1 diabetes: an exploratory study

INTRODUCTION

Diabetic cardiomyopathy in young patients with type 1 diabetes (T1D) usually presents as asymptomatic diastolic heart dysfunction with left ventricle (LV) remodeling. Its prevalence seems to be underestimated. One of the factors seemingly influencing LV remodeling is a metabolic-associated steatotic liver disease (MASLD), which was extensively investigated in patients with type 2 diabetes but not with T1D. This study aimed to describe the correlation between MASLD risk and relative wall thickness (RWT) in young patients with T1D without heart failure symptoms or treatment.

MATERIALS AND METHODS

Study participants were recruited at the inpatient diabetology department, in admission order. Patients underwent a set of laboratory tests and echocardiographic examinations. The risk of MASLD was estimated using fatty liver index (FLI). Acquired data was then statistically analyzed.

RESULTS

The study group consisted of 55 patients. 25 participants had RWT > 0.42, suggesting LV remodeling. Study participants did not differ in HbA1c, NT-proBNP, HDL, LDL, non-HDL, and uric acid concentrations. However, patients with RWT > 0.42 had higher FLI (40.97 vs. 13.82, p < 0.01) and BMI (27.3 vs. 22.5, p < 0.01) and differed in transaminase concentrations. Moreover, patients with RWT > 0.42 had significantly higher LV mass index (85.6 vs. 68.2 g/m2) and altered mitral ring velocities. In univariable logistic regression, FLI correlated with LV remodeling risk (OR 1.028, p = 0.05). The optimal cutoff point for FLI predicting the RWT > 0.42 was 26.38 (OR 10.6, p = 0.04, sensitivity 0.857, specificity 0.657).

CONCLUSIONS

FLI correlates with RWT in patients with T1D independently of diabetes metabolic control and hypothetically may support recognizing T1D patients with a higher risk of LV remodeling.

The preferable position for quantifying left ventricular diameter by transthoracic echocardiography

BACKGROUND

In quantifying left ventricular (LV) diameter, which position for echocardiographic measurements, mitral valve tip level (MV-tip) or LV mid level (LV-mid), more accurately represents the LV volume is unclear. Furthermore, which factor affects the measurement error also has not been elucidated.

METHODS

We enrolled 150 patients without myocardial infarction and local asynergy who underwent echocardiography and cardiac magnetic resonance imaging (CMRI). Echocardiographic LV diastolic diameter (LVDD) and LV systolic diameter (LVDS) were measured at both MV-tip and LV-mid, and the LV end-diastolic volume (LVEDV) and end-systolic volume (LVESV) were quantified using CMRI. We quantified the degree of aortic wedging as the angle between the anterior wall of the aorta and the ventricular septal surface (ASA).

RESULTS

The average LVDD was smaller and average LVDS larger when measured at the MV-tip than at the LV-mid. In regression analyses, the correlation coefficient between LVDD and LVEDV was larger at LV-mid (R = 0.89) than at MV-tip (R = 0.82), and the correlation coefficient between LVDS and LVESV also larger at LV-mid (R = 0.93) than MV-tip (R = 0.87). ASA, Valsalva diameter, left atrial diameter, patient height, and LV mass significantly affected the echocardiographic measurement error, but no factor affected the measurement error when quantifying LVDD at the LV-mid level.

CONCLUSIONS

The echocardiographic LV diameter measured at LV-mid has a stronger correlation with LV chamber size derived from CMRI than measurements at MV-tip. The LVDD measured at the LV-mid level is not affected by other factors.

Mitral Annular Disjunction: A Scoping Review

Mitral annular disjunction (MAD) is the atrial displacement of the mitral valve (MV) hinge point, especially along the posterior mitral leaflet, which leads to inhomogeneous blood flow into the left ventricle, causing chronic fibrotic changes, malignant arrhythmias, and even sudden cardiac arrest. Some studies suggest that MAD is a part of normal heart morphology; however, the origin is still controversial. MAD commonly occurs with MV prolapse and myxomatous degenerative MV disease. In almost 20% of cases, MAD can occur independently as well. The prevalence of MAD in normal hearts varies from 8.6% to 96%, depending on the imaging modality and the cutoff used to define MAD. Transthoracic echocardiography is often the initial screening test, but the low sensitivity of transthoracic echocardiography to identify MAD makes it easy to miss the diagnosis altogether. More advanced imaging, especially cardiac MRI, is the gold standard for diagnosing MAD and risk stratification. MAD is an independent predictor of malignant arrhythmia. Among patients with MAD, risk stratification is based on the age at diagnosis, previous syncopal attacks, premature ventricular contractions, papillary muscle fibrosis, and longitudinal disjunction distance. Most asymptomatic patients are managed conservatively; however, radiofrequency ablation should be considered in patients with high-risk or symptomatic MAD due to the risk of ventricular arrhythmias and sudden cardiac death.

Prognostic significance of diastolic wall strain as a predictor of remodeling and poor outcomes in heart failure and pulmonary embolism: A systematic review

BACKGROUND

Diastolic wall strain (DWS), also referred to as right ventricular (RV) dysfunction, is a significant predictor of pulmonary embolism (PE) and heart failure (HF). Rooted in linear elastic theory, DWS reflects decreased wall thinning during diastole, indicating reduced left ventricular (LV) compliance and increased diastolic stiffness. Elevated diastolic stiffness is associated with worse outcomes, particularly in PE and HF with preserved ejection fraction (HFpEF). This study systematically reviews the prognostic significance of DWS and its impact on PE and HF.

METHODS

A systematic search of scientific literature published between 2014 and 2024 was conducted using PubMed and Cochrane Reviews. Keywords such as "diastolic wall strain," "right ventricular dysfunction," and "pulmonary embolism" were employed to identify relevant studies. Seven articles meeting the inclusion criteria were selected and analyzed to synthesize insights into DWS and its role in risk stratification and prognosis for PE and HF patients.

RESULTS

The findings suggest that elevated DWS values are correlated with increased short- and long-term mortality in PE patients and a higher likelihood of early complications in both PE and HF. In cases where HF is present alongside elevated DWS, the risk of significant bleeding is heightened. DWS emerged as a reliable tool for PE risk stratification and predicting adverse outcomes in HF patients.

CONCLUSION

DWS is an essential prognostic marker for PE and HF, independently predicting major adverse cardiac events (MACE). Its straightforward assessment can improve risk stratification and guide clinical management in individuals at risk for cardiac failure.

Mitral Annulus Disjunction: A Comprehensive Cardiovascular Magnetic Resonance Phenotype and Clinical Outcomes Study

BACKGROUND

Clinical importance of mitral annulus disjunction (MAD) is not well established.

PURPOSE

Characterize a population of MAD all-comers diagnosed by cardiac magnetic resonance imaging (MRI).

STUDY TYPE

Retrospective.

POPULATION

MAD confirmed in 222 patients, age of 49.2 ± 19.3 years, 126 (56.8%) males.

FIELD STRENGTH/SEQUENCE

1.5 T and 3 T/steady-state free precession and inversion recovery.

ASSESSMENT

Clinical history, outcomes, imaging, and arrhythmia data. MAD defined as a separation ≥2 mm between left ventricular myocardium and mitral annulus. Presence and pattern of late gadolinium enhancement (LGE) were analyzed. LGE in the papillary muscles and adjacent to MAD were identified as MAD related. Ventricular arrhythmias (VA) were grouped into non-sustained ventricular arrhythmias (NSVA) or sustained. Cardiovascular death assessed.

STATISTICAL TESTS

Differences between baseline characteristics were compared. Univariate regression was used to investigate possible associations between ventricular arrhythmia and cardiovascular death with characteristics associated with the severity of MAD. A multivariable logistic regression included significant variables from the univariate analysis and was performed for MAD-related and global LGE.

RESULTS

MAD extent 5.0 ± 2.6 mm. MV annulus expanded during systole for MAD ≥6 mm. Systolic expansion associated with prolapse, billowing, and curling. LGE present in 82 patients (36.9%). Twenty-three patients (10.4%) showed MAD-related LGE by three different observers. No association of LGE with MAD extent (P = 0.545) noted. Follow-up 4.1 ± 2.4 years. No sustained VA observed. In univariable analysis, NSVA was more prevalent in patients with MAD ≥6 mm (33.3% vs. 9.9%), but this was attenuated on multivariate analysis (P = 0.054). The presence of NSVA was associated with global LGE but not MAD-related LGE in isolation (P = 0.750). Three patients died of cardiovascular causes (1.4%) and none had MAD-related LGE. None died of sudden cardiac arrest.

CONCLUSION

In patients referred for cardiac MRI, mitral valve dysfunction was associated with MAD severity. Scar was not related to the extent of MAD, but associated with NSVA. The risk of sustained arrhythmias and cardiovascular death was low in this population.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: Stage 2.

The Multicenter STudy On a Precise algorithm for diagnosis of heart failure with preserved ejection fraction, STOP-HFPEF study: study protocol and design

This study aims to develop a new heart failure with preserved ejection fraction (HFpEF) diagnostic algorithm tailored to Asian populations, addressing limitations of current diagnostic models. Existing HFpEF diagnostic algorithms primarily target patients with dyspnea and metabolic comorbidities, such as obesity, which are more prevalent in Western populations. However, in Asian countries, HFpEF cases are less frequently associated with obesity, leading to less prominent dyspnea and more noticeable symptoms such as fatigue. By incorporating exercise stress echocardiography and focusing on early-stage HFpEF, particularly in patients with symptoms beyond dyspnea, we seek to enable early diagnosis and intervention, ultimately extending healthy life expectancy and improving quality of life. The STOP-HFPEF (The Multicenter STudy On a Precise algorithm for diagnosis of Heart Failure with Preserved Ejection Fraction) study is a multicenter prospective observational investigation in Japan. Certified by the Japanese Society of Echocardiography, the study includes participants aged 20 and older who undergo exercise stress echocardiography. The primary goal is to develop a scoring model for diagnosing HFpEF in heart-failure stages A, B, and C. Secondary outcomes will assess the clinical utility of the new diagnostic score by comparing heart-failure incidence, cardiovascular events, and mortality rates.Study registration: Registered at the UMIN registry (UMIN000054565) on 1 July 2024.

Echocardiographic findings of patients with transthyretin amyloid cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is becoming increasingly recognized with the aging population, advancements in understanding of disease pathobiology and the potential benefits of emerging therapies. Bone scintigraphy, including 99mTc-labeled pyrophosphate scintigraphy, is currently considered the first-line modality for identifying ATTR-CM. Therefore, it is important to increase the preset probability using inexpensive and simple tests including echocardiography. Although there were a lot of typical echocardiographic findings of amyloid cardiomyopathy, unexplained left ventricular (LV) wall thickness, LV apical sparing, and a discrepancy between LV wall thickness and QRS voltage were selected as red flags/clues for ATTR-CM in various current diagnostic algorithms. Although echocardiography is useful for ATTR-CM screening, there are several limitations. Therefore, it is important to perform echocardiography and combine it with physical examination, laboratory findings, and other imaging data.

Successful Use of Intraoperative Modified Valsalva Maneuver for Atrial Flutter Reversal in Pediatric Cardiac Surgery: Case Report and Review of Literature

This case report describes the successful use of an intraoperative modified Valsalva maneuver to reverse atrial flutter in a pediatric patient with complex congenital heart disease undergoing systemic-to-pulmonary shunt surgery. The technique involved manipulating the Adjustable Pressure Limiting (APL) valve on the anesthesia machine to simulate the hemodynamic effects of the modified Valsalva maneuver, allowing for non-invasive management of supraventricular tachycardia without pharmacological intervention or electrical cardioversion. This intervention stabilized the patient's arrhythmia, maintaining hemodynamic stability throughout the procedure. The case highlights the potential of the maneuver as a safe, effective, and non-invasive alternative for arrhythmia management in pediatric cardiac surgeries, advocating for further research to validate this approach and possibly integrate it into standard practice for similar clinical scenarios.

A reproducible step-by-step approach to the surgical repair of the Rheumatic mitral valve

The rheumatic mitral disease represents a complex progressive disorder that affects young adults and causes severe morbidity and mortality. Valve replacement with a mechanical valve has been the traditional treatment for these patients. Valve replacement increases longevity but necessitates several lifestyle changes. Improved understanding of the pathophysiology of the disease and standardization of mitral repair techniques, renewed interest is now generated in repairing these complex valves. We review the existing evidence for the repairing rheumatic mitral valve and propose a practical and systematic approach to repair the valve to ensure higher success rates.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01857-9.

Prognostic Implications of Guideline-Directed Medical Therapy for Heart Failure in Functional Mitral Regurgitation: A Systematic Review and Meta-Analysis

Objectives: Randomized evidence on the role of heart failure guideline-directed medical therapy for patients with functional mitral regurgitation (FMR) is lacking. The present meta-analysis sought to investigate the prognostic impact of different pharmacotherapy categories recommended in heart failure on subjects with FMR. Methods: A systematic literature review was conducted to identify studies reporting the association of renin angiotensin system inhibitors (RASi), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA) with outcomes in FMR. A random-effects meta-analysis was conducted to quantify the unadjusted and adjusted hazard ratios [(a)HRs] for all-cause death and the composite outcome in each medical category. Results: Twelve studies with 6,715 FMR patients were included. The use of RASi and BB was associated with a significantly lower risk of all-cause mortality (HR 0.52 [0.39-0.68]; p < 0.00001, I2 = 62% and HR 0.62 [0.49-0.77]; p < 0.0001, I2 = 44%, respectively) and the composite outcome (HR 0.54 [0.44-0.67]; p < 0.00001, I2 = 33% and HR 0.62 [0.52-0.75], p < 0.00001, I2 = 35%, respectively) in unadjusted models. Both RASi (aHR 0.73 [0.56-0.95], p = 0.02, I2 = 52%) and BB (aHR 0.60 [0.41-0.88], p = 0.009, I2 = 55%) retained their association with the composite outcome in pooled adjusted models. The prognostic benefit of using RASi or BB was retained in subgroup analyses including only (1) patients with moderate or severe FMR and (2) patients with reduced or mildly reduced left ventricular ejection fraction. MRA did not demonstrate a significant association with improved outcomes. Conclusions: RASi and BB administration appear to have a favorable prognostic impact on patients with FMR, regardless of the severity of regurgitation.

Mechanistic study of electroacupuncture preconditioning in alleviating myocardial ischemia-reperfusion injury in rats: involvement of mTOR/ROS signaling pathway to inhibit ferroptosis

PURPOSE

The objective of this study was to investigate the mechanism of electroacupuncture pretreatment in reducing myocardial ischemia-reperfusion injury in rats.

MATERIALS AND METHODS

The comparison of HR among the different groups did not yield statistically significant differences (p > 0.05). Additionally, the trend of HR change at different time points within each group was not statistically significant (p > 0.05). In contrast, the comparison of SBP among the different groups showed statistically significant differences (p < 0.05). Furthermore, the trend of SBP change at different time points within each group exhibited significant differences (p < 0.05).

RESULTS

Compared to the Sham group, rats in the I/R group and EA control group showed a significant decrease in EF, FS, SOD, p-mTOR/mTOR, GPX4, and FTH1, and an increase in CK-MB, cTnI, LDH, iron, ROS, MDA, ACSL4, and NCOA4 (p < 0.05). Compared to EA control group, rats in the EA group exhibited a significant increase in EF, FS, SOD, p-mTOR/mTOR, GPX4, and FTH1, and a decrease in CK-MB, cTnI, LDH, iron, ROS, MDA, ACSL4, and NCOA4 (p < 0.05). Compared to the EA group, rats in the EA + RAP group showed a significant decrease in EF, FS, SOD, p-mTOR/mTOR, GPX4, and FTH1, and an increase in CK-MB, cTnI, LDH, iron, ROS, MDA, ACSL4, and NCOA4 (p < 0.05).

CONCLUSIONS

Electroacupuncture preconditioning confers protective effects against myocardial ischemia-reperfusion injury in rats. Its mechanism may involve the activation of the mTOR/ROS signaling pathway by electroacupuncture to inhibit ferroptosis.

To Each Imaging Modality, Their Own MAD

PURPOSE

The clinical significance of mitral annular disjunction (MAD) is uncertain. Imaging modality might impact the prevalence of MAD. We aimed to assess MAD prevalence at transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) as well as their inter-modality agreement.

METHODS

This observational retrospective study included patients undergoing TTE and CMR within 6 months. MAD was defined as ≥1 mm systolic separation between the left atrial wall-mitral leaflet and the left ventricular (LV) wall. The maximum MAD longitudinal extent was measured. The inter-modality agreement for MAD diagnosis was evaluated.

RESULTS

One hundred twenty four patients (59 ± 17 years; 62% male) were included. MAD was detected in 60 (48%) using CMR and in 10 (8%) using TTE. All patients with MAD on TTE had MAD on CMR. The inter-modality agreement was low (Cohen's kappa = 0.17) but improved when the diagnostic cut-off was increased from 1 to 5 mm (Cohen's kappa = 0.66). The median longitudinal length of MAD was 2.0 mm (25th-75th percentiles: 1.5-3.0) by CMR and 4.0 mm (25th-75th percentiles: 2.7-4.5) by TTE with moderate agreement (intraclass correlation coefficient = 0.66).

CONCLUSION

MAD of limited extent is common on CMR and more than two thirds of patients showing MAD on CMR did not have MAD on TTE. The inter-modality agreement between TTE and CMR increased when the diagnostic threshold for MAD was increased from 1 to 5 mm. Methodological discrepancies impact MAD assessment and contribute to the discordant prevalence and clinical significance reported in the literature.

Echocardiography and Heart Failure: An Echocardiographic Decision Aid for the Diagnosis and Management of Cardiomyopathies

PURPOSE OF REVIEW

The purpose of this review is to highlight the utility of echocardiography in the diagnosis and management of cardiomyopathies.

RECENT FINDINGS

Echocardiographic parameters function synergistically to guide decision-making ranging from early detection of disease and screening to risk stratification of complex disease. The collective wealth of information available from 2D/3D assessment, Doppler, diastology and strain makes echocardiography an invaluable decision aid.

Optimal follow-up duration of cardiac function tests in patients treated with trastuzumab: an analysis using the Japanese Adverse Drug Event Report (JADER) database

BACKGROUND

One of the most serious adverse events associated with trastuzumab treatment is cardiac dysfunction, including congestive heart failure. Therefore, regular cardiac screening with echocardiography is commonly performed during trastuzumab treatment, although it is unclear for how long the patient will continue to be evaluated. We investigated the time to the occurrence of trastuzumab-induced cardiac dysfunction using the Japanese Adverse Drug Event Report (JADER) database. We examined the optimal duration of cardiac function evaluation in patients treated with trastuzumab.

METHODS

This study used data registered between April 2004 and September 2023 in the JADER database. We investigated the time to onset of cardiotoxicity in patients treated with trastuzumab, trastuzumab emtansine, or trastuzumab deruxtecan. We considered the time to exclude outliers detected using the Smirnov-Grubbs test as the optimal follow-up duration for cardiac function tests.

RESULTS

Of 868,478 patients who reported adverse drug events, 977 experienced cardiac dysfunctions among those treated with trastuzumab. A total of 375 patients were included in the analysis after excluding patients for whom the time to onset of cardiotoxicity was unknown or those who experienced cardiac dysfunction after receiving trastuzumab followed by anthracycline. The median time to cardiotoxicity was 4.5 months (range 0-100 months). However, ≥ 19 months after the start of trastuzumab administration was detected as an outlier in the target population (P = 0.036).

CONCLUSION

The duration of regular follow-up of cardiac function using echocardiography during anti-HER2 therapy can be 18 months from the start of treatment.

Advances and challenges in echocardiographic diagnosis and management of cardiac amyloidosis

Cardiac amyloidosis is an infiltrative cardiomyopathy characterized by the abnormal accumulation of amyloid proteins within the heart muscle. It is recognized as a rare yet significant cardiac disease that is often overlooked as a potential cause of heart failure and cardiac arrhythmias, particularly in older individuals with rates escalating from 8 to 17 cases per 100,000 individuals. Cardiac amyloidosis primarily manifests as two predominant subtypes: light-chain and transthyretin amyloidosis, collectively accounting for over 95% of clinical cases. Early diagnosis of these conditions is often hindered by overlapping symptoms with other cardiac pathologies, resulting in diagnostic delays and suboptimal patient outcomes. Echocardiography, a non-invasive imaging technique, has become indispensable for diagnosing cardiac amyloidosis, uncovering crucial echocardiographic signs such as thickening of the left ventricular wall, diastolic dysfunction, and a granular appearance of the myocardium. Recent advancements in echocardiography have significantly enhanced the diagnostic accuracy of cardiac amyloidosis and improved patient management. Advanced echocardiographic techniques, including strain imaging, 3D echocardiography, and contrast echocardiography, have significantly enhanced diagnostic accuracy and prognostication. Future directions in echocardiography encompass the integration of artificial intelligence, the development of novel contrast agents, and the refinement of 4D echocardiography to further optimize patient care. This study explores the pivotal role of echocardiography in both diagnosing and managing cardiac amyloidosis, delving into the disease's underlying mechanisms, distinctive imaging characteristics, the significance of regular echocardiographic assessments, and discusses the challenges associated with differentiating between various types of amyloidosis without supplemental imaging or biopsy methods.

Quantification of Pulmonary Regurgitation After Surgical Repair of Tetralogy of Fallot Using Vector Flow Mapping

BACKGROUND

Pulmonary valvular regurgitation in postoperative patients with repaired tetralogy of Fallot (rTOF) significantly impairs exercise capacity and causes right heart failure. Quantitative evaluation of the pulmonary valvular regurgitation fraction (PRF) by cardiac magnetic resonance (CMR) is commonly used to determine the indication for surgical or catheter interventions, but less commonly using echocardiography.

METHODS AND RESULTS

We retrospectively investigated the feasibility and validation of vector flow mapping (VFM) for the quantification of PRF (VFM-PRF) in 34 pediatric patients with rTOF, comparing it to CMR-derived PRF (CMR-PRF) and other qualitative or semiquantitative echocardiographic indices. Each predictive value for CMR-PRF ≥40% was assessed using receiver operating characteristic curves. VFM-PRF and CMR-PRF showed good agreement, with a correlation coefficient of 0.90 and the highest predictive value for CMR-PRF ≥40%, resulting in an area under the curve of 0.93. Other conventional echocardiographic parameters demonstrated poor predictive accuracy.

CONCLUSIONS

This is the first report to demonstrate the accurate quantification of PRF by echocardiography using VFM in pediatric patients with rTOF, showing good agreement with CMR results. Particularly in children, VFM may be clinically useful in determining the indication for reintervention for pulmonary valve replacement, offering a possible alternative to CMR, which often requires deep sedation and general anesthesia.

AI-echocardiography: Current status and future direction

Echocardiography, which provides detailed evaluations of cardiac structure and pathology, is central to cardiac imaging. Traditionally, the assessment of disease severity, treatment effectiveness, and prognosis prediction relied on detailed parameters obtained by trained sonographers and the expertise of specialists, which can limit access and availability. Recent advancements in deep learning and large-scale computing have enabled the automatic acquisition of parameters in a short time using vast amounts of historical training data. These technologies have been shown to predict the presence of diseases and future cardiovascular events with or without relying on quantitative parameters. Additionally, with the advent of large-scale language models, zero-shot prediction that does not require human labeling and automatic echocardiography report generation are also expected. The field of AI-enhanced echocardiography is poised for further development, with the potential for more widespread use in routine clinical practice. This review discusses the capabilities of deep learning models developed using echocardiography, their limitations, current applications, and research utilizing generative artificial intelligence technologies.

The value of contrast-enhanced ultrasound in assessing carotid plaque vulnerability and predicting stroke risk

The presence of vulnerable carotid plaques plays a critical role in ischemic stroke pathogenesis, with intraplaque neovascularization (IPN) serving as a key indicator of plaque instability. Contrast-enhanced ultrasound (CEUS) provides a comprehensive evaluation of both plaque surface morphology and microvascular features. This study assesses the utility of CEUS in identifying vulnerable carotid plaques, quantifying IPN, and predicting stroke risk. The study involved 91 patients with carotid stenosis who underwent carotid endarterectomy (CEA). Preoperative assessments included CEUS and high-resolution magnetic resonance imaging (HR-MRI). Following surgery, plaque samples were collected and subjected to pathological analysis. CEUS offered comprehensive morphological insights, categorizing plaques by the direction of diffusion into inside-out and non-inside-out types. Neovascularization was semi-quantitatively evaluated using CEUS. HR-MRI and pathological assessments identified the composition and vulnerability of plaques. Microvessel density (MVD), microvessel area (MVA), and microvessel ratio (MVR) in plaque sections were quantified using high-power microscopy. Among the 91 subjects, 53 had a history of symptomatic stroke, while 38 had experienced asymptomatic stroke events. The analysis identified a significant association between symptomatic stroke events and fibrous cap rupture (FCR), as indicated by CEUS (P = 0.032), contrast agent diffusion within the plaque (P = 0.002), and a semi-quantitative grade 3 neovascularization (P = 0.007). Regression analysis further established CEUS grade 3 as an independent predictor of symptomatic stroke events (OR = 3.39, 95% CI: 1.25-9.19). CEUS showed comparable sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in identifying vulnerable plaques when compared to HR-MRI, with slightly superior values for CEUS; however, the differences did not reach statistical significance (P = 0.503). Plaques demonstrating inside-out contrast agent diffusion had a markedly higher incidence of FCR and intraplaque hemorrhage (IPH) than those without such diffusion (P < 0.001). A positive correlation existed between the CEUS grade and both MVD and MVR (P < 0.001), but no significant relationship was observed with MVA (P = 0.221). Additionally, a significant association was found between the CEUS grade and IPH (P = 0.008). In summary, this study emphasizes the utility of CEUS in identifying vulnerable carotid plaques and evaluating neovascularization, both of which correlate with stroke risk. Notably, a CEUS grade 3 score may serve as an independent predictor of symptomatic stroke. This evidence supports the potential of CEUS as an effective, non-invasive method for assessing carotid plaque instability and identifying individuals at elevated risk for stroke.

Recurrent atrial fibrillation markers post radiofrequency catheter ablation

Atrial fibrillation (AF), the most common type of heart arrhythmia, is recognized as an independent risk factor for stroke. Fortunately, catheter ablation (CA) offers an effective treatment option for AF patients. However, numerous studies have reported suboptimal outcomes, as AF recurrence rates often remain elevated even after CA. Consequently, there exists a need for early identification of patients prone to recurrence, necessitating anti-inflammatory and/or antiarrhythmic treatment post-CA. The discovery and application of markers associated with AF recurrence could significantly aid in this early identification process. In this review, we present an overview of AF recurrence markers from three distinct perspectives (biochemical, imaging, and electrocardiographic markers).

Editorial for the Special Issue "Novel Echocardiographic Techniques for the Assessment of Cardiovascular Disease"

The global burden of cardiovascular disease (CVD) continues to pose a significant challenge to healthcare systems worldwide [...].

Exploring the impact of angiotensin-converting enzyme (ACE) gene polymorphism on early diastolic function in hypertension using four-dimensional echocardiography

BACKGROUND

This study explores the relationship between angiotensin-converting enzyme (ACE) gene polymorphisms and early diastolic dysfunction in patients with hypertension utilizing four-dimensional echocardiography and assesses the prognosis.

METHODS

This study consecutively selected 470 patients with hypertension who visited the Fourth Affiliated Hospital of Soochow University between September 2021 and August 2022, with 274 meeting the inclusion criteria. Hypertension gene testing was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques, and the Hardy-Weinberg equilibrium test was used to confirm genetic equilibrium. Patients were categorized into the D allele group (n = 163) and the non-D allele group (n = 111). Diastolic function was assessed using four-dimensional echocardiography, which included averaging the E/e' ratio over three cardiac cycles, measuring the left atrial (LA) maximum volume index (LA volume), tricuspid regurgitation velocity (TR velocity), LA strain, and left ventricular isovolumic relaxation time (IVRT). Patients were subsequently classified into the diastolic dysfunction group (n = 133) and the normal diastolic function group (n = 141). Chi-square tests were used to analyze differences in diastolic function indicators between the groups, Logistic regression was applied to control for potential confounding factors, and receiver operating characteristic (ROC) curves were plotted to assess the predictive value of different ACE alleles for diastolic dysfunction in patients with hypertension.

RESULTS

The genotype distribution in both the D allele group and the non-D allele group was consistent with Hardy-Weinberg equilibrium (P > 0.05). Compared to the non-D allele group, echocardiographic indicators in the D allele group showed a decline in diastolic function: the average E/e' ratio over three cardiac cycles (14.67 [13.82, 15.80] vs. 9.30 [8.12, 12.00]), LA volume (32.76 [29.34, 34.61] vs. 25.61 [22.63, 29.64] ml/m2), TR velocity (2.90 [2.40, 2.90] vs. 1.40 [1.10, 2.40] cm/s), LA strain (18.00 [14.00, 25.00] vs. 37.00 [24.00, 40.00] %), and IVRT (104.25 [95.87, 106.25] vs. 88.09 [80.99, 96.56] ms). Differences between each group were statistically significant (all P < 0.05). The number of patients with diastolic dysfunction was higher in the D allele group (n = 102; 62.6%) compared to the non-D allele group (n = 31; 27.9%). In the logistic regression model, the D allele was associated with an increased risk of early diastolic dysfunction in hypertension (OR = 4.32, 95% CI = 2.56-7.27, P < 0.01). In the adjusted model, the D allele remained associated with an elevated risk of early diastolic dysfunction in hypertension (OR = 3.83, 95% CI = 2.24-6.54, P < 0.01). ROC curve analysis indicated that the D allele has predictive value for early diastolic dysfunction in patients with hypertension (area under the curve [AUC], 0.667; 95% confidence interval [CI], 0.608-0.723; sensitivity, 76.7%; and specificity, 56.7%; P < 0.05).

CONCLUSIONS

The ACE-D allele is associated with early diastolic dysfunction in hypertension. ACE gene testing can enhance the predictive value for diastolic dysfunction in patients with hypertension.

Predictors and Prognostic Effects of Perioperative Myocardial Injury After Transcatheter Aortic Valve Replacement According to VARC-3 Criteria

Purpose

The impact of periprocedural myocardial injury (PPMI) according to VARC-3 criteria in patients undergoing transcatheter aortic valve replacement (TAVR) remains unclear. This study aimed to investigate the incidence, risk factors, and prognosis of PPMI in patients with severe aortic who underwent TAVR in China.

Materials and Methods

Between September 2012 and November 2021, 516 patients with severe aortic stenosis who underwent TAVR at the Fuwai Hospital were consecutively enrolled. PPMI was defined according to the VARC-3 criteria as a 70-fold increase of upper reference limit in cardiac troponin I (cTnI) levels. We compared the baseline characteristics, perioperative conditions, and in-hospital and long-term endpoints between the PPMI and non-PPMI groups. Logistic regression analysis was used to determine the predictors of PPMI. Survival probabilities for outcomes between the PPMI and non-PPMI groups were estimated using the Kaplan-Meier method.

Results

Of the enrolled patients (mean age: 75.5±7.2 years, 57.5% male), the incidence of PPMI was 20.5%. The median cTnI was 24.9 (interquartile range: 11.4-60.2) times the upper reference limit. After multivariable adjustment, female sex (odds ratio [OR]: 3.01, 95% confidence interval [CI]: 1.88-4.82, P < 0.001), anticoagulant use (OR: 0.27, 95% CI: 0.08-0.96, P = 0.043), balloon-expandable valve (OR: 0.27, 95% CI: 0.09-0.79, P = 0.017), and secondary valve implantation (OR: 2.66, 95% CI: 1.40-5.03, P = 0.003) were significantly associated with PPMI. Patients with PPMI had short- and long-term outcomes similar to those without PPMI.

Conclusion

Female sex and secondary valve implantation are predictors of an increased risk of PPMI, whereas baseline anticoagulant use and the use of balloon-expandable valves are protective factors. The presence of PPMI does not seem to indicate poor short- or long-term prognosis in patients undergoing TAVR.

Role of [99mTc]Tc-DPD gated-SPECT-CT in the assessment of myocardial uptake patterns in transthyretin amyloidosis (TTR-CA)

PURPOSE

To evaluate the feasibility of identifying various distribution patterns of [99mTc]Tc-DPD in patients with cardiac transthyretin amyloidosis using gated SPECT-CT.

MATERIALS AND METHODS

Gated SPECT-CT was performed in patients with a positive scintigraphy result for cardiac amyloidosis due to transthyretin (TTR-CA). Patients were categorized into several groups based on sex, degree of radiopharmaceutical uptake according to the Perugini's visual scale and ventricular ejection fraction (LVEF). Cardiac polar maps were obtained using Emory Cardiac Toolbox™ software and scored by segments according to radiopharmaceutical uptake on a scale from 0 (no uptake) to 4 (very high uptake intensity). The Mann-Whitney U and Pearson's Chi-square statistical tests were employed to identify significant differences in distribution patterns according to the different variables under study.

RESULTS

65 patients were evaluated. The gender variable determined the main statistically significant differences, highlighting distinct distribution patterns of the radiopharmaceutical at the cardiac level: while women showed lower accumulation of [99mTc]Tc-DPD in the middle anterior (p=0.035) and basal anterior (p=0.001) segments, whereas men demonstrated higher accumulation in the basal anteroseptal (p=0.009) and basal inferoseptal (p=0.009) segments, and lower scores in the lateroapical segment (p=0.039).

CONCLUSIONS

Gated SPECT-CT is an essential tool for assessing the distribution pattern of [99mTc]Tc-DPD of patients with TTR-CA, offering valuable insights into the pathophysiology of the disease.

Long-Term Prognostic Power of Three-Dimensional Speckle-Tracking Echocardiography-Derived Peak Left Atrial Reservoir Global Longitudinal Strain in Healthy Adults-An Analysis from the MAGYAR-Healthy Study

Introduction: The contraction-relaxation pattern of the left atrial (LA) walls is opposite to that detected in the left ventricle, which includes thinning in radial, lengthening in longitudinal, and widening in circumferential directions in the systolic reservoir phase of LA function as measured by three-dimensional speckle-tracking echocardiography (3DSTE). Global longitudinal strain (GLS) is a quantitative feature of longitudinal wall contraction referring to the whole LA. The present study aims to clarify the expected prognostic impact of peak LA-GLS as assessed by 3DSTE in healthy participants during a long-term follow-up period. Methods: The study consisted of 142 healthy adults (with an average age of 32.1 ± 12.7 years; 72 of the participants were men), in whom complete two-dimensional Doppler echocardiography and 3DSTE were performed on a voluntary basis. Results: Thirteen adults suffered from a cardiovascular event, including two cardiac deaths during a mean follow-up of 8.35 ± 4.20 years. Peak LA-GLS ≥ 20.9%, as assessed by 3DSTE, was found to be a significant predictor for cardiovascular event-free survival by using ROC analysis (specificity 74%, sensitivity 62%, area under the curve 0.69, p = 0.025). Healthy individuals with peak LA-GLS < 20.9% had a lower LV-EF and a significantly higher ratio of cardiovascular events compared to cases with peak LA-GLS ≥ 20.9%. Subjects who experienced cardiovascular events had lower peak LA-GLS and the ratio of subjects with peak LA-GLS < 20.9% proved to be significantly increased compared to that of cases without cardiovascular events. Conclusions: 3DSTE-derived peak LA-GLS representing LA lengthening in the end-systolic reservoir phase of LA function predicts future cardiovascular events in healthy adults.

Left atrial strain predicts paroxysmal atrial fibrillation recurrence after catheter ablation: a 1-year study using three-dimensional speckle-tracking echocardiography

BACKGROUND

Radiofrequency catheter ablation (RFCA) is a widely employed method for restoring sinus rhythm(SR) in patients with drug-refractory paroxysmal atrial fibrillation (PAF). Three-dimensional speckle tracking echocardiography (3DSTE) is a precise and practical imaging technique for clinically assessing myocardial function in the left atrium. The objective of this study was to assess alterations in three-dimensional strains and predict recurrence in patients with PAF following RFCA.

METHODS

A total of 109 patients diagnosed with drug-refractory PAF and scheduled for RFCA were included in this study between September 2019 and June 2022. Conventional echocardiography and 3DSTE were performed prior to and one year(median period of 12.2 months) after RFCA. Global three-dimensional left atrial (LA) strain parameters, along with those of the left ventricle, were measured and analyzed statistically. The primary study endpoint was the recurrence of atrial fibrillation (AF).

RESULTS

Among the 109 patients, 78 maintained a stable SR during the one-year follow-up after RFCA, while 31 experienced a recurrence of AF. Notably, patients who sustained SR demonstrated significant improvements in various LA strain parameters, including reservoir, pump, and conduit functions, compared to both their preoperative levels and those of patients who experienced recurrence(p < 0.05). Additionally, patients with sustained SR exhibited a significant reduction in LA volume compared to those with recurrence(p = 0.003). Furthermore, left ventricular global longitudinal strain (LVGLS) and left ventricular global area strain (LVGAS) of the left ventricle showed improvement while maintaining a preserved left ventricular ejection fraction (LVEF) after RFCA(p < 0.05). Our multivariate regression analysis revealed that left atrial reservoir strain (LASr) independently predicted the recurrence of AF [odds ratio (OR), 1.19, 95% confidence interval (CI), 1.05-1.35, p = 0.005]. Receiver operating characteristic(ROC) curve showed that the area under the curve(AUC) for LASr in assessing the risk of recurrence after RFCA in patients with PAF was 0.70 ( 95% CI, 0.60-0.81, P = 0.001). The calculated cutoff value was 16.5%.

CONCLUSIONS

RFCA plays a pivotal role in preserving SR and restoring LA function in patients with PAF. 3D-STE is highly effective for post-RFCA prognostic assessment. LASr, a predictive marker for the recurrence of PAF assists in the stratification of risk and contributes to informed treatment decisions, offering valuable points of reference.

Evaluation of the prognostic value of lateral MAPSE in patients with suspected coronary artery disease

Objectives

To evaluate the prognostic value of lateral mitral annular plane systolic excursion (MAPSE) in the prediction of major adverse cardiology events (MACE) in patients with suspected coronary artery disease (CAD).

Methods

233 consecutive patients were enrolled with suspected CAD from October 2012 to September 2013 and performed contrast-enhanced cardiac magnetic resonance (CMR) and two-dimensional echocardiogram studies no later than 72 h after admission. CMR imaging protocol included 4-chamber cine(cine-CMR), cardiovascular magnetic resonance angiography (CMRA) and late gadolinium enhancement (LGE). The primary endpoint is the time of first occurrence of a MACE The independent association between lateral MAPSE and MACE was evaluated by Kaplan-Meier analysis and multivariable Cox regression analysis. C statistic and net reclassification improvement (NRI) were used to evaluate the prognostic value of lateral MAPSE in MACE.

Results

Forty-five MACE occurred during an average follow-up of 9.2 years. Patients with lateral MAPSE＜9.885 mm experienced a significantly higher incidence of MACE than patients with lateral MAPSE ≥ 9.885 mm (P＜0.001). After adjustment for established univariate predictors (age, diabetes, hypertension, hypercholesterolemia, transmural myocardial infarction), lateral MAPSE remained a significant independent predictor of MACE (HR = 1.373; P = 0.020). The incorporation of lateral MAPSE into the risk model resulted in significant improvement in C statistic (increasing from 0.668 to 0.844; P = 0.005). NRI improvement was 0.33 (P＜0.001).

Conclusions

lateral MAPSE derived from cine-CMR is an independent predictor of MACE, and improve risk reclassification beyond traditional clinical and CMR risk factors in patients with suspected coronary disease.

Elevated Lp(a) and its association with cardiac fibrosis in group II pulmonary hypertension patients

BACKGROUND

Group II Pulmonary Hypertension (PH) secondary to Heart Failure with preserved Ejection Fraction (HFpEF) is associated with significant morbidity and mortality. Lipoprotein(a) [Lp(a)] is a novel biomarker implicated in cardiovascular pathology, yet its role in myocardial fibrosis within this population remains underexplored. This study investigates the association between elevated Lp(a) levels and cardiac fibrosis to improve understanding of its prognostic and diagnostic utility.

METHODS

This retrospective cohort study included 100 patients with Group II PH secondary to HFpEF. Serum Lp(a) levels were quantified using enzymatic assays, and myocardial fibrosis was assessed using Cardiac Magnetic Resonance Imaging (CMR) techniques, including T1 mapping and late gadolinium enhancement (LGE). Statistical models adjusted for confounding factors.

RESULTS

Elevated Lp(a) levels were significantly associated with increased myocardial extracellular volume (31% vs. 27%, p < 0.01), prolonged native T1 times, and increased odds of myocardial scar formation. Structural cardiac changes correlated with Lp(a) concentrations.

CONCLUSION

Elevated Lp(a) is a key marker of myocardial fibrosis and structural remodeling in Group II PH secondary to HFpEF. Routine Lp(a) measurement may enhance risk stratification and inform therapeutic strategies.

Predictive Value of Lung Ultrasound Combined With ACEF Score for the Prognosis of Acute Myocardial Infarction

BACKGROUND

Lung ultrasound (LUS) and the ACEF score (age, creatinine, and ejection fraction) have been shown to be pivotal in predicting an unfavorable prognosis in acute myocardial infarction (AMI).

HYPOTHESIS

The aim of this study is to investigate the prognostic value of LUS combined with ACEF score in AMI.

METHODS

The ACEF score and the total number of B-lines in eight thoracic regions of LUS were calculated. Adverse events were recorded during hospitalization and follow-up, defined as all-cause death and other cardiovascular events. Multivariate logistic regression identified predictors of adverse events during hospitalization. Multivariate Cox regression identified predictors of adverse events during follow-up.

RESULTS

We enrolled 204 patients. The B-lines (adjusted OR 1.08, [95% CI: 1.03-1.13], p < 0.01) and the ACEF score (adjusted OR 2.71 [95% CI: 1.07-6.81], p < 0.05) independently predicted adverse events during hospitalization. The C-index values were 0.81 (p < 0.01) for the ACEF score, 0.81 (p < 0.01) for LUS, and 0.86 (p < 0.01) for their combination. One hundred seventy-one patients were followed up for 12 months (IQR, 8.13-15.93). Both the B-lines (adjusted HR 1.06 [95% CI: 1.03-1.09], p < 0.05) and the ACEF score (adjusted HR 1.95 [95% CI: 1.10-3.43], p < 0.05) remained associated with an increased risk of adverse events during follow-up. The C-index values were 0.74 (p < 0.01) for the ACEF score, 0.73 (p < 0.01) for LUS, and 0.80 (p < 0.01) for their combined predictive ability.

CONCLUSIONS

The B-lines and ACEF score are associated with adverse events in AMI patients. When combined, they provide increasing value in assessing the risk of adverse events, which has significant implications for risk stratification.

Association of Left Ventricular Function With Cerebral Small Vessel Disease in a Community-Based Population

BACKGROUND AND OBJECTIVES

The relationship of cardiac function with cerebral small vessel disease (CSVD) remains unknown. The study aimed to investigate the association between left ventricular (LV) function and CSVD in a community-based population.

METHODS

Community-dwelling residents in China from the cross sectional survey of the PRECISE (PolyvasculaR Evaluation for Cognitive Impairment and vaScular Events) cohort were included. LV ejection fraction (LVEF) and LV fractional shortening (LVFS) were measured for LV systolic function, and mitral E/A ratio (the ratio of the peak trans-mitral filling velocity during early diastole and late diastole) was evaluated for LV diastolic function by transthoracic echocardiogram (TTE). Total CSVD score and CSVD imaging makers including white matter hyperintensity (WMH), lacunes, cerebral microbleeds (CMB), and enlarged perivascular spaces (EPVS) were assessed. The associations of cardiac function with CSVD were analyzed using ordinal or binary logistic regression models. Restricted cubic spline models fitted for logistic regression models were used.

RESULTS

A total of 3063 participants with available TTE and brain MRI data were included in the study. In the multivariable logistic regression analysis, LVEF and LVFS were not associated with total CSVD score or markers of CSVD. E/A ratio showed a negative correlation with total CSVD score (cOR, 0.89, 95% CI: 0.80-0.98, p = 0.01). Participants with E/A ≤ 0.8 or ≥ 2 had a higher total CSVD score than those with 0.8 < E/A < 2 (cOR 1.20, 95% CI: 1.00-1.43, p = 0.046). E/A ratio was also correlated with lacunes, moderate to severe EPVS, and periventricular WMH. Logistic regression analyses with restricted cubic spline further demonstrated that a lower E/A ratio were associated with a higher total CSVD score.

CONCLUSION

Our study showed that mitral E/A ratio was associated with nonhemorrhagic CSVD. LV diastolic dysfunction assessed by TTE provides clues for the early warning of high CSVD burden.

Usefulness of Cardiac Resynchronization Therapy Optimization Using Combined Electrocardiography and Echocardiography

Introduction Optimization of cardiac resynchronization therapy (CRT) using a 12-lead electrocardiogram (ECG) alone may not sufficiently improve left ventricular (LV) function in all cases. Therefore, we aimed to investigate whether additional optimization using transthoracic echocardiography (TTE) could further enhance CRT efficacy. Methods Sixty-five patients who underwent CRT implantation between March 2018 and July 2022 at Sakakibara Heart Institute, Japan, were included in this study. Data were collected at three points: before optimization (point A), after ECG-based optimization (point B), and after TTE-based adjustments (point C). Results The mean age was 74±11 years (male: 78.4%). The PR interval was significantly prolonged at points B and C compared with that at point A. The QRS width narrowed significantly at point B (119±20 ms vs. 137±20 ms, p<0.01) but increased at point C (124±20 ms), approaching point A levels. Thirty-six patients achieved LV dyssynchrony improvement with ECG optimization alone, whereas 29 required TTE adjustments for further improvement. Patients needing TTE optimization had higher QRS width at point C than at point B. TTE adjustments significantly improved LV ejection fraction (28.1±6.8% to 31.5±8.0%, p=0.01) and reduced septal flash (46.2% to 15.4%, p=0.04). The need for TTE adjustments was similar to the usage of CRT devices with and without auto-adjustment functions. Conclusion TTE-based optimization enhances LV function and synchrony in cases where ECG-based adjustments alone are insufficient, highlighting the importance of TTE evaluation in CRT optimization.

Reference intervals of two-dimensional speckle tracking-derived endocardial global longitudinal strain analysis in 132 healthy cats

INTRODUCTION

The assessment of left ventricular myocardial deformation and function by two-dimensional speckle tracking-derived strain analysis is an established method in human cardiology. It also progressively gains recognition in veterinary cardiology in both dogs and cats.

OBJECTIVES

The objectives of this study were to create reference intervals for two-dimensional speckle tracking echocardiography (STE)-derived endocardial global longitudinal strain (GLS) in a population of healthy adult cats of different breeds. Influences of heart rate, body weight, and age were investigated.

ANIMALS

A total of 132 healthy, adult cats were included in this study.

MATERIALS AND METHODS

Left apical two-, three-, and four-chamber views were obtained prospectively for GLS measurements using two-dimensional speckle tracking performed with cardiac performance analysis. Potential influence of body weight, heart rate, and age was analyzed, and the interobserver and intra-observer variability of the measurements was determined.

RESULTS

Endocardial GLS values were not significantly influenced by body weight (P=0.102), heart rate (P=0.144), or age (P=0.075). A reference interval for GLS of -21.18% to -37.50% (±4.12) was determined. The interobserver and intra-observer variability showed excellent agreement.

DISCUSSION AND CONCLUSIONS

Two-dimensional STE is a feasible technique for the evaluation of cardiac myocardial deformation and systolic function in cats. Showing an excellent interobserver and intra-observer agreement, two-dimensional STE is a promising method for clinical analysis of cardiac deformation in cats.

Unraveling aortic hemodynamics using fluid structure interaction: biomechanical insights into bicuspid aortic valve dynamics with multiple aortic lesions

Aortic lesions, exemplified by bicuspid aortic valves (BAVs), can complicate congenital heart defects, particularly in Turner syndrome patients. The combination of BAV, dilated ascending aorta, and an elongated aortic arch presents complex hemodynamics, requiring detailed analysis for tailored treatment strategies. While current clinical decision-making relies on imaging modalities offering limited biomechanical insights, integrating high-performance computing and fluid-structure interaction algorithms with patient data enables comprehensive evaluation of diseased anatomy and planned intervention. In this study, a patient-specific workflow was utilized to biomechanically assess a Turner syndrome patient's BAV, dilated ascending aorta, and elongated arch. Results showed significant improvements in valve function (effective orifice area, EOA increased approximately twofold) and reduction in valve stress (~ 1.8-fold) following virtual commissurotomy, leading to enhanced flow dynamics and decreased viscous dissipation (~ twofold) particularly in the ascending aorta. However, increased viscous dissipation in the distal transverse aortic arch offset its local reduction in the AAo post-intervention, emphasizing the elongated arch's role in aortic hemodynamics. Our findings highlight the importance of comprehensive biomechanical evaluation and integrating patient-specific modeling with conventional imaging techniques for improved disease assessment, risk stratification, and treatment planning, ultimately enhancing patient outcomes.

Right Ventricular Dysfunction in Cardiac Anesthesia: Perioperative Assessment and Underlying Mechanisms

The importance of right ventricular (RV) function has often been overlooked until recently; however, RV function is now recognized as a significant prognostic predictor in medically managing cardiovascular diseases and cardiac anesthesia. During cardiac surgery, the RV is often exposed to stressful conditions that could promote perioperative RV dysfunction, such as insufficient cardioplegia, volume overload, pressure overload, or pericardiotomy. Recent studies have shown that RV dysfunction during cardiac anesthesia could cause difficulty in weaning from cardiopulmonary bypass or even poor postoperative outcomes. Severe perioperative RV failure may be rare, with an incidence rate ranging from 0.1% to 3% in the surgical population; however, in patients who are hemodynamically unstable after cardiac surgery, almost half reportedly present with RV dysfunction. Notably, details of RV function, particularly during cardiac anesthesia, remain largely unclear since long-standing research has focused predominantly on the left ventricle (LV). Thus, this review aims to provide an overview of the current perspective on the perioperative assessment of RV dysfunction and its underlying mechanisms in adult cardiac surgery. This review provides an overview of the basic RV anatomy, physiology, and pathophysiology, facilitating an understanding of perioperative RV dysfunction; the most challenging aspect of studying perioperative RV is assessing its function accurately using the limited modalities available in cardiac surgery. We then summarize the currently available methods for evaluating perioperative RV function, focusing on echocardiography, which presently represents the most practical tool in perioperative management. Finally, we explain several perioperative factors affecting RV function and discuss the possible mechanisms underlying RV failure in cardiac surgery.

Prognosis of pulmonary hypertension in patients with hypertrophic cardiomyopathy: A multicenter propensity score matching study

Objectives

Pulmonary hypertension (PH) is known to be associated with increased mortality in patients suffering from left ventricular disease. The aim of this study was to assess the incidence of PH among patients diagnosed with hypertrophic cardiomyopath (HCM) and to evaluate its prognostic significance.

Methods

The study cohort consisted of 2781 patients with HCM. Among them, 226 patients had PH (8.1%), and 2555 patients did not have PH (91.8%). The fourteen demographic and clinical variables were matched between the two groups using a 1:3 propensity score matching (PSM) method. Kaplan-Meier survival curves and Cox proportional hazard regression models were used to evaluate the correlation between PH and mortality. Moreover, a competing risk regression analysis was conducted to assess the competing risk.

Results

Before matching, there were 519 (18.7 %) patients with all-cause mortality, including 292 (10.5 %) patients who experienced cardiovascular mortality and 128 (4.6 %) patients who experienced SCD. There was a significant difference in the Kaplan-Meier survival curves for all-cause mortality (log-rank P < 0.0001), cardiovascular mortality (log-rank P < 0.0001) and SCD (log-rank P = 0.0005). After matching, there were also significant differences in cardiovascular mortality (log-rank P = 0.011) and SCD (log-rank P = 0.042), but only a similar trend was observed for all-cause mortality (log-rank P = 0.052). Cox regression analyses suggested that PH was an independent risk predictor for cardiovascular mortality [HR: 1.666; 95 % CI: 1.145-2.424; P = 0.008].

Conclusion

HCM patients with PH characterized by increased cardiovascular mortality and SCD, as well as a similar trend in all-cause mortality. Moreover, PH is an independent risk factor for cardiovascular mortality.

Transforming Echocardiography: The Role of Artificial Intelligence in Enhancing Diagnostic Accuracy and Accessibility

Artificial intelligence (AI) has shown transformative potential in various medical fields, including diagnostic imaging. Recent advances in AI-driven technologies have opened new avenues for improving echocardiographic practices. AI algorithms enhance the image quality, automate measurements, and assist in the diagnosis of cardiovascular diseases. These technologies reduce manual errors, increase consistency, and match the diagnostic performances of experienced echocardiographers. AI in tele-echocardiography offers significant benefits, particularly in rural and remote regions in Japan, where healthcare provider shortages and geographic isolation hinder access to advanced medical care. AI enhances accessibility, provides real-time remote analyses, supports continuous monitoring, and improves the quality and efficiency of remotely delivered cardiac care. However, addressing challenges related to data security, transparency, integration into clinical workflows, and ethical considerations is essential for the successful implementation of AI in echocardiography. On overcoming these challenges, AI will be able to revolutionize echocardiography and ensure timely and effective cardiac care for all patients in the future.

Myxomatous degeneration of aortic valve causing severe aortic regurgitation. A rare case report

Myxomatous degeneration of a valve is a non-inflammatory degenerative process due to the disruption of the fibrous layer of the valve with mucopolysaccharide accumulation. It is mostly seen in the mitral valve but involvement in only aortic valve is rare. Here we present a case report of a 37-year-old man who came with shortness of breath for the past three months and was diagnosed with severe aortic regurgitation due to myxomatous aortic valve causing rupture of the non-coronary and right coronary cusp. After preoperative workup, he was taken for aortic valve replacement surgery. Intraoperative findings confirmed the rupture of right and non-coronary cusps from their annular attachment and the myxomatous nature of the aortic valve. Histopathological examination confirmed the myxomatous changes in the valve. The patient underwent aortic valve replacement with a 23 mm TTK Chitra valve and on follow-up, he is doing well. Although aortic valve regurgitation is a common disease, myxomatous degeneration of isolated aortic valve leading to aortic regurgitation is rare. This patient did not have any signs of connective tissue disorders like Marfan's syndrome, Ehlers-Danlos, etc., but presented with myxomatous aortic valve throwing an insight into further research into this rare disease.

Comparative phenotyping of C57BL/6J substrains reveals distinctive patterns of cardiac aging

Research in aging often refers to animal models, particularly C57BL/6J (B6J) mice, considered gold standard. However, B6J mice are distributed by different suppliers, which results in divers substrains exhibiting notable phenotypic differences. To ensure a suitable phenotype of cardiac aging, we performed heart analyses of young (5 months) and old B6J mice (24 months) from two substrains: B6JRj (Janvier) and B6JCrl mice (Charles River). In hearts of both substrains, myocardial fibrosis increased with age; however, only in old B6JRj mice cardiac hypertrophy associated with a decreased ejection fraction was observed. Gene set enrichment analysis in heart tissue using proteomic data revealed different age-associated pathway changes between the substrains, especially in oxidative phosphorylation. Functional assessment of isolated cardiomyocytes verified cardiac impairment during aging in B6JRj mice. Overall, results demonstrate that cardiac aging manifests as a moderate systolic dysfunction in B6JRj mice, while B6JCrl mice display no functional changes with age.

Left atrial myopathy in rheumatic mitral stenosis; three-dimensional and speckle tracking echocardiography study

BACKGROUND

In developing countries, rheumatic mitral valve stenosis (MS) is still a problem and its progression leads to left atrial (LA) damage. Due to the complexity of the LA geometry, currently used techniques like antero-posterior dimension (LAD) and 2D echo derived LA volume (LAV) have several limitations that are corrected by 3D derived LA volumes in addition to functional evaluation.

PURPOSE

To assess the LA functions using 2D speckle tracking echocardiography and 3D transthoracic echocardiography in patients with clinically significant MS in comparison to normal healthy subjects.

RESULTS

Fifty patients and 50 healthy controls were studied. Patients' mean age was 40.2 ± 8.8 years, the majority were female 45(81.8%). 3D indexed LA maximum (LAVmaxI) and minimum (LAVminI) volumes were significantly higher in MS than in the control group, whereas 3D LA EF was significantly lower in MS than in the control group (p 0.001). LA strain reservoir, conduit, and contraction parameters were significantly lower in the MS group than in the control group (p = 0.001). However, only 3D LAEF, 2D LASr, 2D LAScd, and 2D LASct showed a correlation with the mitral valve area with a p < 0.05, but 3D LAVmaxI and 3D LAVminI did not. Additionally, in the comparison of severe and very severe mitral stenosis subgroups, 3D LAVmaxI and 3D LAVminI did not show any statistically significant differences between the two groups, although 3D LAEF, 2D LASr, 2D LAScd, and 3D LASct showed significant difference between the two groups (p < 0.05).

CONCLUSIONS

Left atrial functional and structural remodelling has been highlighted in patients with significant rheumatic MS. However, left atrial functional assessment by 3D echocardiography and 2D speckle tracking echocardiography correlate better with mitral valve area than conventional LA size measurements. Whether the functional assessment of the LA has an additive predictive value with regards to patient outcome needs to be interrogated.

Correlation between CT-derived fractional flow reserve and myocardial strain in ischemic heart disease patients with single coronary artery stenosis assessed based on CCTA

Purpose

We aimed to investigate the correlation between CT-derived fractional flow reserve (CTFFR) and myocardial strain in patients with single coronary artery stenosis and to investigate the diagnostic value of CTFFR in identifying impaired myocardial strain.

Methods

We selected 89 patients, categorized into three groups based on the affected coronary artery: 36 with left anterior descending (LAD), 23 with left circumflex (LCX), and 30 with right coronary artery (RCA) stenosis, along with 25 healthy controls. We investigated correlations between CTFFR and both global and regional myocardial strain parameters. Additionally, we assessed the ability of the CTFFR to detect impaired myocardial strain in these patients.

Results

In this study, no significant difference was found in overall myocardial strain between the patient and control groups. However, regional longitudinal strain (LS) and circumferential strain (CS) in the myocardial areas supplied by stenotic coronary arteries was significantly lower in each patient group compared to the others (P < 0.001). The CTFFR exhibited a strong negative correlation with both regional and global myocardial strain, with a stronger association for regional strain. Particularly in group LAD, CTFFR in optimal diastole phase (CTFFR-D) was negatively correlated with Endo-LS (r = -0.66, P < 0.001). Receiver operator characteristic curve (ROC) analysis indicated that CTFFR were effective in diagnosing impaired myocardial strain, particularly LS.

Conclusion

There is a strong correlation between CTFFR, which is a functional measure for assessing coronary artery stenosis, and myocardial strain. CTFFR can identify impaired myocardial strain and can be used as an indirect indicator of myocardial ischemia.

Dizziness in Fabry Disease

Background/Objectives: Fabry disease is an X-linked lysosomal storage disease. Earlier studies have mentioned dizziness/balance issues and vestibular involvement as a symptom of Fabry disease. Research on the matter remains scarce. This pilot study aims to show the prevalence of dizziness/balance issues and whether it is due to peripheral, central, or other factors. Methods: A Dizziness Handicap Inventory, with added questions, was sent out to 91 Fabry patients to estimate the prevalence of dizziness/balance issues. Additionally, this study reports analyses from eight Fabry patients with self-reported dizziness/balance issues who were offered referrals for in-depth investigations of their condition. All eight underwent a comprehensive oto-neurological examination, Videonystagmography, a Video Head impulse test, vestibular myogenic evoked potential, and audiometry. Results: A total of 55 of the 91 patients with Fabry disease answered the survey. Of these, 78.2% felt symptoms of dizziness/balance issues. The most common form of dizziness/balance issues was short-lasting attacks. All eight ENT-examined patients had normal outer and middle ear conditions. Five of eight Fabry patients had abnormal results in the optokinetic test and audiometry. Conclusions: The survey showed a high prevalence of dizziness/balance issues in Fabry patients. The abnormal optokinetic test suggested a central cause and was the only objective measurement we found that could lead to an explanation for dizziness/balance issues. Polypharmacy was present in all eight examined patients and could also explain the dizziness/balance issues in Fabry patients. There is no other clear pattern regarding the characteristics of dizziness/balance issues in Fabry patients in this exploratory study.