Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography

Post-Capillary Pulmonary Hypertension: Clinical Review

Pulmonary hypertension (PH) caused by left heart disease, also known as post-capillary PH, is the most common etiology of PH. Left heart disease due to systolic dysfunction or heart failure with preserved ejection fraction, valvular heart disease, and left atrial myopathy due to atrial fibrillation are causes of post-capillary PH. Elevated left-sided filling pressures cause pulmonary venous congestion due to backward transmission of pressures and post-capillary PH. In advanced left-sided heart disease or valvular heart disease, chronic uncontrolled venous congestion may lead to remodeling of the pulmonary arterial system, causing combined pre-capillary and post-capillary PH. The hemodynamic definition of post-capillary PH includes a mean pulmonary arterial pressure > 20 mmHg, pulmonary vascular resistance < 3 Wood units, and pulmonary capillary wedge pressure > 15 mmHg. Echocardiography is important in the identification and management of the underlying cause of post-capillary PH. Management of post-capillary PH is focused on the treatment of the underlying condition. Strategies are geared towards pharmacotherapy and guideline-directed medical therapy for heart failure, surgical or percutaneous management of valvular disorders, and control of modifiable risk factors and comorbid conditions. Referral to centers with advanced heart and pulmonary teams has shown to improve morbidity and mortality. There is emerging interest in the use of targeted agents classically used in pulmonary arterial hypertension, but current data remain limited and conflicting. This review aims to serve as a comprehensive summary of postcapillary PH and its etiologies, pathophysiology, diagnosis, and management, particularly as it pertains to advanced heart failure.

The value of ultrasound enhancing agents in the echocardiographic acquisition of pulmonary artery systolic pressure: An invasive to non-invasive correlation study

PURPOSE

Right heart catheterization (RHC) is the gold standard for the assessment of pulmonary artery systolic pressures (PASP). Despite high utilization of echocardiography for the non-invasive assessment of PASP, the data comparing real-time non-invasive echocardiographic PASP with invasive PASP is limited. Furthermore, evidence regarding the utility and diagnostic accuracy of ultrasound enhancing agents (UEA) for non-invasive PASP assessment is lacking. To evaluate the accuracy of non-invasive PASP assessment with real-time invasive measures and the incremental benefit of UEA in this setting.

METHODS

This was a prospective cohort study of 90 patients, undergoing clinically indicated RHC for hemodynamic assessment. All patients underwent a limited echocardiogram during RHC. Tricuspid regurgitant velocity (TRV) was measured on unenhanced echo, in the setting of centrally administrated agitated saline, then as either centrally administered or peripherally administered UEA.

RESULTS

Of the 90 patients enrolled in our study, 41% had pulmonary hypertension. The overall mean PASP measured by RHC was 32.8 mmHg (+/- 11.3 mmHg). Unenhanced echocardiograms had a moderate correlation with invasive PASP (r = 0.57; p = < 0.001) which improved to a strong correlation with administration of agitated saline (r = 0.75; p = < 0.001) or centrally administered UEA (r = 0.77; p = < 0.001), with the best correlation noted with peripherally administered UEA (r = 0.83; p = < 0.001). Against invasive PASP, agitated saline enhanced PASP had the lowest bias (0.12mmHg; -15.6 to 15.8mmHg) when compared with all other non-invasive measures of PASP.

CONCLUSIONS

Unenhanced echocardiographic estimation of TRV was found to have a poorer correlation with invasively measured PASP when compared to agitated saline and centrally administered UEA. Agitated saline enhanced PASP demonstrated the lowest bias with invasive PASP when compared to other non-invasive measures of PASP.

Cross-sectional study investigating the relationship between pit recovery time and serum albumin levels in bilateral lower extremity pitting oedema

OBJECTIVES

In this study, we re-evaluated the relationship between pit recovery time (PRT) and serum albumin levels and elucidated the factors influencing PRT.

DESIGN

Cross-sectional study.

SETTING

Patients who visited the outpatient department or were admitted to a small urban hospital in Japan.

PARTICIPANTS

135 adult Japanese patients with bilateral lower extremity pitting oedema.

INTERVENTIONS

Primary and secondary outcome measures: this study assessed the correlation between PRT and serum albumin levels, calculated the predictive accuracy for identifying a group with low albumin levels when the PRT of the lower leg was <40 s, and identified variables that influence PRT.

RESULTS

We found no significant correlation between lower leg PRT and serum albumin levels. Furthermore, a PRT of <40 s was largely ineffective in predicting low albumin levels. Factors influencing PRT included the diagnosis of malnutrition oedema, examinations conducted during hospitalisation, diagnosis of cardiac oedema, use of diuretics, thickness of the lower limb soft tissue, serum creatinine level, estimated right ventricular systolic pressure (RVSP), age, serum albumin level, potassium level and blood urea nitrogen to serum creatinine ratio. Notable correlations with PRT were observed in relation to lower limb soft tissue thickness, age and estimated RVSP.

CONCLUSIONS

Given that the PRT is influenced by multiple factors, its correlation with serum albumin levels is weak. Thus, predicting hypoalbuminaemia based solely on PRT is inaccurate.

Cardiac dimensions and hemodynamics in healthy juvenile Landrace swine

BACKGROUND

Swine are frequently used as animal model for cardiovascular research, especially in terms of representativity of human anatomy and physiology. Reference values for the most common species used in research are important for planning and execution of animal testing. Transesophageal echocardiography is the gold standard for intraoperative imaging, but can be technically challenging in swine. Its predecessor, epicardial echocardiography (EE), is a simple and fast intraoperative imaging technique, which allows comprehensive and goal-directed assessment. However, there are few echocardiographic studies describing echocardiographic parameters in juvenile swine, none of them using EE. Therefore, in this study, we provide a comprehensive dataset on multiple geometric and functional echocardiographic parameters, as well as basic hemodynamic parameters in swine using EE.

METHODS

The data collection was performed during animal testing in ten female swine (German Landrace, 104.4 ± 13.0 kg) before left ventricular assist device implantation. Hemodynamic data was recorded continuously, before and during EE. The herein described echocardiographic measurements were acquired according to a standardized protocol, encompassing apical, left ventricular short axis and long axis as well as epiaortic windows. In total, 50 echocardiographic parameters and 10 hemodynamic parameters were assessed.

RESULTS

Epicardial echocardiography was successfully performed in all animals, with a median screening time of 14 min (interquartile range 11-18 min). Referring to left ventricular function, ejection fraction was 51.6 ± 5.9% and 51.2 ± 6.2% using the Teichholz and Simpson methods, respectively. Calculated ventricular mass was 301.1 ± 64.0 g, as the left ventricular end-systolic and end-diastolic diameters were 35.3 ± 2.5 mm and 48.2 ± 3.5 mm, respectively. The mean heart rate was 103 ± 28 bpm, mean arterial pressure was 101 ± 20 mmHg and mean flow at the common carotid artery was 627 ± 203 mL/min.

CONCLUSION

Epicardial echocardiography allows comprehensive assessment of most common echocardiographic parameters. Compared to humans, there are important differences in swine with respect to ventricular mass, size and wall thickness, especially in the right heart. Most hemodynamic parameters were comparable between swine and humans. This data supports study planning, animal and device selection, reinforcing the three R principles in animal research.

Impact of chronic obstructive pulmonary disease on right ventricular function and remodeling after aortic valve replacement

BACKGROUND

Both chronic obstructive pulmonary disease (COPD) and right ventricular (RV) dysfunction are common factors that have been associated with poor prognosis after aortic valve replacement (AVR). Since there is still uncertainty about the impact of COPD on RV function and dilatation in patients undergoing AVR, we sought to explore RV function and remodeling in the presence and absence of COPD as well as their prognostic implications.

METHODS

Patients who received surgical or transcatheter AVR due to severe AS were screened for COPD. Demographic and clinical data were collected at baseline while echocardiographic measurements were performed at baseline and 1 year after AVR. The study end-point was all-cause mortality.

RESULTS

In total 275 patients were included, with 90 (33%) patients having COPD. At 1-year follow-up, mild worsening of tricuspid annular planar systolic excursion and RV dilatation were observed in patients without COPD, while there were significant improvements in RV longitudinal strain, RV wall thickness but dilatation of RV outflow tract distal dimension in the COPD group compared to the baseline. On multivariable analysis, the presence of COPD provided significant incremental prognostic value over RV dysfunction and remodeling.

CONCLUSIONS

At 1-year after AVR, RV function and dimensions mildly deteriorated in non-COPD group whereas COPD group received significant benefit of AVR in terms of RV function and hypertrophy. COPD was independently associated with >2-fold all-cause mortality and had incremental prognostic value over RV dysfunction and remodeling.

Prognostic Value of Right Ventricular Longitudinal Shortening Fraction in Patients With ST-Elevation Myocardial Infarction: A Prospective Echocardiography Study

Right ventricular systolic dysfunction (RVsD) frequently occurs in patients with ST-elevation myocardial infarction (STEMI). However, the diagnosis depends on the echocardiographic parameters to define RVsD. The right ventricle longitudinal shortening fraction (RV-LSF) is an accurate and reproducible 2-dimensional speckle-tracking parameter associated with clinical events in various pathologies. This study aimed to evaluate the association between RVsD and major adverse cardiovascular event (MACE) occurrence in a cohort of patients with STEMI. Adult patients with STEMI admitted to Amiens University Hospital's cardiovascular intensive care unit between May 2021 and November 2022 who underwent coronary angiography and transthoracic echocardiography within 48 hours of admission were included. RVsD was defined as RV-LSF <20%. The primary outcome was MACE occurrence, including heart failure, myocardial infarction, stroke, and death within 6 months of admission. A multivariable Cox regression analysis with proportional hazard ratio models assessed the association between RVsD and MACEs. In the 164 included patients, 72 (44%) had RVsD and 92 (56%) did not. The RVsD group had a significantly higher proportion of MACEs during the 6-month follow-up (n = 23 of 72, 33%) than the group without RVsD (n = 8 of 92, 9%, p = 0.001). RVsD showed an independent association with MACEs at 6 months (hazard ratio 3.1, 95% confidence interval [CI] 1.35 to 7.30, p = 0.008). Left ventricular ejection fraction <40% and Thrombolysis in Myocardial Infarction score >4 were independently associated with RVsD (odds ratio 2.80, 95% CI 1.34 to 5.98 and odds ratio 2.15, 95% CI 1.18 to 4.39, respectively, p = 0.015). The cumulative risk of MACEs at 6 months was 33% for RV-LSF <20% and 9% for RV-LSF ≥20% (log-rank test p <0.001). RVsD, defined by RV-LSF <20%, is associated with an increased risk of MACEs after STEMI.

The impact of concomitant infective endocarditis in patients with spondylodiscitis and isolated spinal epidural empyema and the diagnostic accuracy of the modified duke criteria

Background

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population.

Methods

We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences.

Results

Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003).

Conclusions

We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

Atrial Functional Tricuspid Regurgitation in Patients Undergoing Transcatheter Aortic Valve Replacement

BACKGROUND

Knowledge about atrial functional tricuspid regurgitation (afTR) in transcatheter aortic valve replacement (TAVR) patients is scarce.

OBJECTIVES

The aim of the study was to analyze the association between the entity and the development of tricuspid regurgitation (TR) in patients undergoing TAVR for aortic stenosis and concomitant TR.

METHODS

We analyzed patients undergoing TAVR for severe aortic stenosis from January 2013 to December 2020 and concomitant at least moderate TR at baseline. afTR was defined as enlargement of the right atrium in relation to the right ventricle. TR development after TAVR and 3-year all-cause mortality were evaluated.

RESULTS

Out of 3,474 TAVR patients, we identified 420 patients with concomitant at least moderate TR. A total of 363 patients were included in the study, with 178 patients stratified in the afTR and 185 in the non-afTR group based on a receiver-operating characteristic curve cutoff of 1.132 of the right atrial/right ventricular area ratio. TR improvement after TAVR was observed in significantly less patients with afTR compared with non-afTR (31.1% vs 60.6%; P < 0.001). Multivariate regression analysis confirmed afTR as independent predictor for TR persistence (adjusted OR: 2.80; 95% CI: 1.66-4.76; P < 0.001). Moreover, afTR was associated with aggravation of TR after TAVR (17.0% vs 6.8%; P = 0.013). Three-year all-cause mortality was significantly higher in patients with persistence compared with patients with improvement of TR (P < 0.001).

CONCLUSIONS

In TAVR patients, afTR is an independent predictor for TR persistence. Moreover, TR persistence is associated with increased 3-year all-cause mortality.

Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure

OBJECTIVES

The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings.

BACKGROUND

Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment.

METHODS

Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE.

RESULTS

A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001).

CONCLUSIONS

Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.

Evaluation of extravascular lung water and cardiac function in normal vaginal delivery by intrapartum bedside ultrasound

BACKGROUND

Healthy parturients may experience pulmonary edema and disturbed cardiac function during labor. We aimed to evaluate the extravascular lung water (EVLW), intravascular volume, and cardiac function of normal parturients during spontaneous vaginal delivery by bedside ultrasound. And to explore the correlation between EVLW and intravascular volume, cardiac function.

METHODS

This was a prospective observational study including 30 singleton-term pregnant women undergoing spontaneous vaginal delivery. Bedside ultrasound was performed at the early labor, the end of the second stage of labor, 2 and 24 h postpartum, and 120 scanning results were recorded. EVLW was evaluated by the echo comet score (ECS) obtained by the 28-rib interspaces technique. Inferior vena cava collapsibility index (IVC-CI), left ventricle ejection fraction, right ventricle fractional area change, left and right ventricular E/A ratio, and left and right ventricular index of myocardial performance (LIMP and RIMP) were measured. Measurements among different time points were compared, and the correlations between ECS and other measurements were analyzed.

RESULTS

During the spontaneous vaginal delivery of healthy pregnant women, 2 had a mild EVLW increase at the early labor, 8 at the end of the second stage of labor, 13 at 2 h postpartum, and 4 at 24 h postpartum (P < 0.001). From the early labor to 24 h postpartum, ECS first increased and then decreased, reaching its peak at 2 h postpartum (P < 0.001). IVC-CI first decreased and then increased, reaching its minimum at the end of the second stage of labor (P < 0.001). RIMP exceeded the cut-off value of 0.43 at the end of the second stage of labor. ECS was weakly correlated with IVC-CI (r=-0.373, P < 0.001), LIMP (r = 0.298, P = 0.022) and RIMP (r = 0.211, P = 0.021).

CONCLUSIONS

During spontaneous vaginal delivery, the most vital period of perinatal care is between the end of the second stage of labor and 2 h postpartum, because the risk of pulmonary edema is higher and the right ventricle function may decline. IVC-CI can be used to evaluate maternal intravascular volume. The increase in EVLW may be related to the increase in intravascular volume and the decrease in ventricular function.

Right Ventricular-Vascular Uncoupling Predicts Pulmonary Hypertension in Clinically Diagnosed Heart Failure With Preserved Ejection Fraction

BACKGROUND

Pulmonary hypertension (PH) is highly prevalent in patients with heart failure with preserved ejection fraction (HFpEF), and it is a strong predictor of adverse outcomes. We aimed to determine possible echocardiographic parameters to predict the presence of PH in patients with HFpEF.

METHODS AND RESULTS

A total of 113 patients with HFpEF were prospectively enrolled from November 2017 to July 2022. The patients underwent invasive cardiac catheterization and simultaneous echocardiography at rest and during exercise. The parameters indicating right ventricle-pulmonary artery uncoupling, including tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) and tricuspid annular systolic velocity (TAS')/PASP were calculated. Receiver operating characteristic curve analysis was used to determine the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH. Sixty-eight patients with HFpEF with PH and 45 without PH were included. Those with PH had lower TAPSE/PASP and TAS'/PASP at rest and during exercise compared with those without PH. Both resting/stress TAPSE/PASP and TAS'/PASP were correlated with rest/exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In multivariable regression analysis, TAPSE/PASP remained a significant predictor of exercise pulmonary capillary wedge pressure and mean pulmonary artery pressure. In receiver operating characteristic curve analysis, the optimal cut-off points of TAPSE/PASP and TAS'/PASP to differentiate patients with HFpEF with PH from those without PH were ≤0.62 and ≤0.47, respectively.

CONCLUSIONS

Right ventricle-pulmonary artery uncoupling is closely correlated with abnormal rest/exercise hemodynamics (pulmonary capillary wedge pressure and mean pulmonary artery pressure) in patients with HFpEF. TAPSE/PASP and TAS'/PASP can be useful parameters to detect PH in patients with HFpEF.

Transcatheter Closure or Surgery for Symptomatic Paravalvular Leaks: The Multicenter KISS Registry

BACKGROUND

The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs.

METHODS AND RESULTS

A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P=0.549) and procedural success (73.7 versus 65.2%; P=0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P=0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P<0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P=0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P=0.679).

CONCLUSIONS

The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Prognostic significance of right ventricular dysfunction in patients presenting with acute left-sided heart failure

BACKGROUND

The prognostic value of right ventricular (RV) function in chronic heart failure (HF) has lately been well established. However, research on its role in acute heart failure (AHF) is sparse.

RESULTS

This study comprised 195 patients, aged between 18 and 80 years, with acute left-sided heart failure (HF) and a left ventricular ejection fraction (LVEF) < 50%. Patients with LVEF ≥ 50%, mechanical ventilatory or circulatory support, poor echocardiographic windows, prosthetic valves, congenital heart diseases, infective endocarditis, and/or life expectancy < 1 year due to non-cardiac causes were excluded. The study participants' mean age was 57.7 ± 10.9 years, and 74.9% were males. Coronary artery disease was present in 80.5% of patients. The mean LVEF was 31% ± 8.7. RV dysfunction (RVD), defined as tricuspid annular plane systolic excursion (TAPSE) < 17 mm, RV S' < 9.5 cm/s and/or RV fractional area change (FAC) < 35%, was identified in 48.7% of patients. The RV was dilated in 67.7% of the patients. RVD was significantly associated with a longer HF duration, atrial fibrillation, and idiopathic dilated cardiomyopathy. The primary outcome, a 6-month composite of cardiovascular death or hospitalization for worsening HF (HHF), occurred in 42% of the participants. Cardiovascular mortality and HHF occurred in 30.5% and 23.9% of the patients, respectively. The primary endpoint and longer CCU stays were significantly more common in patients with RVD than in those with normal RV function. RV dilatation was significantly associated with the primary outcome, whether alone or in combination with RVD. Multivariate regression analysis showed that only RV global longitudinal strain (GLS) independently predicted poor outcomes.

CONCLUSIONS

RVD and RV dilatation strongly predict CV death and HHF in patients with AHF and LVEF < 50%. Multivariate analysis showed that RV GLS was the only predictor of a composite of CV death and HHF.

Elevated systolic pulmonary artery pressure is a substantial predictor of increased mortality after transcatheter aortic valve replacement in males, not in females

BACKGROUND

While pulmonary hypertension (PH) in patients with severe aortic valve stenosis (AS) is associated with increased mortality after transcatheter aortic valve replacement (TAVR), there is limited data on gender differences in the effects on long-term survival.

OBJECTIVE

The aim of this retrospective, multicenter study was to investigate the prognostic impact of pre-interventional PH on survival of TAVR patients with respect to gender.

METHODS

303 patients undergoing TAVR underwent echocardiography to detect PH prior to TAVR via measurement of systolic pulmonary artery pressure (sPAP). Different cut-off values were set for the presence of PH. The primary endpoint was all-cause mortality at 1, 3 and 5 years.

RESULTS

Kaplan-Meier analysis by gender showed that only males exhibited significant increased mortality at elevated sPAP values during the entire follow-up period of 5 years (sPAP ≥ 40 mmHg: p ≤ 0.001 and sPAP ≥ 50 mmHg: p ≤ 0.001 in 1- to 5-year survival), whereas high sPAP values had no effect on survival in females. In Cox regression analysis based on the selected sPAP thresholds, male gender was an independent risk factor for long-term mortality after TAVR in all time courses.

CONCLUSION

Male gender was an isolated risk factor for premature death after TAVR in patients with echocardiographic evidence of PH and severe AS. This could mean that, the indication for TAVR should be discussed more critically in men with severe AS and an elevated sPAP, while in females, PH should not be an exclusion criterion for TAVR.

Cardiac Reverse Remodeling and Changes in Heart Failure Indices After Transcatheter Tricuspid Valve Replacement in Adults With Congenital Heart Disease

BACKGROUND

There are limited data about changes in cardiac function (cardiac reverse remodeling) and heart failure indices after transcatheter tricuspid valve-in-valve replacement (TT-VIVR). The purpose of this study was to evaluate cardiac reverse remodeling and temporal changes in heart failure indices after TT-VIVR in adults with congenital heart disease.

METHODS

Retrospective cohort study of adults with congenital heart disease that underwent TT-VIVR and had >6 months of follow-up (January 1, 2011, to April 30, 2023). Echocardiographic indices of cardiac remodeling and heart failure indices (New York Heart Association class, NT-proBNP (N-terminal pro-brain natriuretic peptide), glomerular filtration rate, and model for end-stage liver disease excluding international normalized ratio score) were assessed preintervention and at 1-, 3-, and 5-year postintervention.

RESULTS

Of 39 patients (age 39 [32-46] years), 14 (36%) and 25 (64%) received Melody valve and Sapien valve prosthesis, respectively. At 1-year post-TT-VIVR, there was a temporal improvement in right atrial reservoir strain (17±8% versus 22±8%, P<0.001), right atrial volume (81 [59-108] versus 63 [48-82] mL/m2, P<0.001), right atrial pressure (12±4% versus 6±4%, P<0.001), and right ventricular global longitudinal strain (-15±7% versus -20±7%, P<0.001). Similarly, there was a temporal improvement in NT-proBNP, glomerular filtration rate, model for end-stage liver disease excluding international normalized ratio score, and New York Heart Association class. The temporal improvements in heart failure indices and valve function were maintained at 3- and 5-year post-TT-VIVR.

CONCLUSIONS

Considering the significant mortality risk associated with reoperations for tricuspid valve replacement, these data suggest favorable outcomes after TT-VIVR, and support TT-VIVR as a viable alternative to surgical tricuspid valve replacement, especially in high-risk patients.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Signal intensity coefficient as a detector of aortic stenosis-induced myocardial fibrosis and its correlation to the long term outcome

OBJECTIVE

Despite advanced aortic valve replacement techniques, aortic stenosis (AS)-induced irreversible myocardial fibrosis contributes to poorer outcomes. Therefore, in addition to early diagnosis of AS, detecting myocardial fibrosis is crucial for physicians to determine the timing of surgery. The Signal Intensity Coefficient (SIC) was used to detect subtle myocardial deformation. Hence, we aimed to investigate whether SIC correlated with myocardial dysfunction and fibrosis from both clinical and preclinical perspectives.

METHODS

We collected medical records and echocardiography images, including the SIC of patients who underwent surgical aortic valve replacement (AVR) for AS from 2010 to 2015. The endpoint of the study was mortality. Median follow-up period was 80 months.

RESULTS

Among 109 patients, 15 died due to cardiovascular causes. Although SIC decreased in all patients post-AVR, patients with an SIC ≥0.34 before surgeries presented with a higher probability of cardiovascular death. In contrast, changes in the left ventricular (LV) ejection fraction, LV mass index, and LV volume failed to predict outcomes. Similarly, SIC was obtained in mice undergoing aortic banding and debanding surgery for comparison with the degree of myocardial fibrosis. SIC was continuously elevated after aortic banding and declined gradually after debanding surgery in mice. Debanding surgery indicated the regression of aortic banding-induced myocardial fibrosis.

CONCLUSION

Pre-AVR SIC was associated with the risk of cardiovascular death and reflected the degree of myocardial fibrosis. Further investigations are required to study the clinical application of SIC in patients with AS.

An attention-based deep learning method for right ventricular quantification using 2D echocardiography: Feasibility and accuracy

AIM

To test the feasibility and accuracy of a new attention-based deep learning (DL) method for right ventricular (RV) quantification using 2D echocardiography (2DE) with cardiac magnetic resonance imaging (CMR) as reference.

METHODS AND RESULTS

We retrospectively analyzed images from 50 adult patients (median age 51, interquartile range 32-62 42% women) who had undergone CMR within 1 month of 2DE. RV planimetry of the myocardial border was performed in end-diastole (ED) and end-systole (ES) for eight standardized 2DE RV views with calculation of areas. The DL model comprised a Feature Tokenizer module and a stack of Transformer layers. Age, gender and calculated areas were used as inputs, and the output was RV volume in ED/ES. The dataset was randomly split into training, validation and testing subsets (35, 5 and 10 patients respectively). Mean RVEDV, RVESV and RV ejection fraction (EF) were 163 ± 70 mL, 82 ± 42 mL and 51% ± 8% respectively without differences among the subsets. The proposed method achieved good prediction of RV volumes (R2  = .953, absolute percentage error [APE] = 9.75% ± 6.23%) and RVEF (APE = 7.24% ± 4.55%). Per CMR, there was one patient with RV dilatation and three with RV dysfunction in the testing dataset. The DL model detected RV dilatation in 1/1 case and RV dysfunction in 4/3 cases.

CONCLUSIONS

An attention-based DL method for 2DE RV quantification showed feasibility and promising accuracy. The method requires validation in larger cohorts with wider range of RV size and function. Further research will focus on the reduction of the number of required 2DE to make the method clinically applicable.

Left atrial volume index as a predictor for left atrial appendage thrombus in patients with non-valvular atrial fibrillation receiving appropriate oral anticoagulation therapy: A prospective multi-center study

OBJECTIVES

We previously reported a higher left atrial volume index (LAVI) was independently associated with left atrial (LA) appendage (LAA) thrombus formation in 737 patients with non-valvular atrial fibrillation (NVAF) receiving appropriate oral anticoagulation therapy. Since our previous study was a retrospective single-center study, we designed and conducted a prospective multi-center study to verify our findings for LAVI as a predictor of LAA thrombus in patients with NVAF receiving appropriate oral anticoagulation therapy.

METHODS

This prospective multi-center study comprised 746 consecutive patients with NVAF recruited between December 2021 and March 2023 from eight institutions in Japan, who were receiving appropriate oral anticoagulation therapy, had undergone transthoracic echocardiography and transesophageal echocardiography (TEE).

RESULTS

LAA thrombi were observed in 21 patients (2.8%). The prevalence of LAA thrombus formation in patients with paroxysmal AF (PAF) was significantly lower than that in patients with non-PAF (0.7% vs. 4.1%, p = .006). LAA thrombus formation was detected in none (0/171) of the patients with normal size LA (LAVI ≤ 34 mL/m2 ). The prevalence of LAA thrombus formation in patients with mildly dilated LA (LAVI: 34-49.9 mL/m2 ) was 2.1% (6/283), but that in PAF patients was low at 1.0% (1/104). Furthermore, this prevalence in patients with severely dilated LA (LAVI ≥ 50 mL/m2 ) was high at 5.1% (15/292).

CONCLUSIONS

The findings of this prospective multi-center study are consistent with those of our previous study. Thus, the need for TEE prior to catheter ablation or electrical cardioversion can be determined by the level of LAVI.

The impact of vascular access location on pulmonary arterial pressure in chronic kidney disease patients undergoing hemodialysis

BACKGROUND AND AIM

It is feared that among chronic kidney disease patients undergoing hemodialysis, arteriovenous fistula (AVF) itself could contribute to pulmonary hypertension (PH). The impact of AVF location on PH is yet to be assessed. We hypothesize that patients with proximal AVF have higher access blood flow and hence higher pulmonary arterial systolic pressure (PASP) than those with distal AVF. We aimed to compare the PASP between patients with proximal and distal AVF.

METHODS

In this cross-sectional study, PASP was estimated using Doppler echocardiography and blood flow in the AVF was assessed by Doppler ultrasound. PASP was modeled by multivariate linear regression. AVF location was the primary exposure of interest.

RESULTS

Out of 89 patients undergoing hemodialysis, 72 (81%) had PH defined as PASP >35 mmHg. The mean blood flow in proximal and distal AVF was, respectively, 1240 and 783 mL/min (mean difference 457 mL/min, p < 0.001). Mean PASP in patients with proximal AVF was 16.6 mmHg higher than those with distal AVF (p < 0.001, 95% CI 8.3-24.9). There was a positive correlation between access blood flow and PASP (r = 0.28, p = 0.007). If access blood flow was included as a covariate in the multivariate model, the association between AVF location and PASP ceased to exist.

CONCLUSION

Patients with proximal AVF have a significantly higher PASP than those with distal AVF, and this could be attributed to the higher blood flow in proximal AVF compared to distal AVF.

Changes in exercise stress echocardiographic parameters before and after transcatheter mitral valve edge-to-edge repair

The safety and feasibility are still not well known for exercise-induced mitral regurgitation (MR). This study is aimed to assess and compare the hemodynamic and symptomatic changes in patients with significant secondary MR during exercise stress echocardiography (ESE) before and after transcatheter edge-to-edge repair (TEER). The study included a total of 15 patients with secondary MR who underwent ESE before and after TEER using the MitraClip system (Abbott, Abbott Park, IL, USA). Echocardiographic data of ESE were collected both before the procedure and during the follow-up visit at 3 months. During the one-year postoperative observation period, the rate of readmission due to heart failure was 13% (n = 2), with no recorded fatalities. Although no significant differences of ESE data were observed in exercise-induced pulmonary hypertension or cardiac output before and after the repair, the severity of MR was significantly improved after the procedure, both at rest (2 [2-3] vs. 1 [1-2], p = 0.0125) and during ESE (3 [3-3] vs. 1 [1-1], p < 0.0001). Furthermore, the New York Heart Association Functional Classification was improved (3 [3-3] vs. 1 [1-1], p < 0.0001) after treatment. For a supplemental analysis, MR during ESE was significantly improved not only in cases with atrial secondary MR but also in ventricular secondary MR. Transcatheter edge-to-edge repair for exercise-induced MR resulted in a significant improvement in postoperative MR severity and subjective symptoms. These results are novel, as they have not been extensively reported previously, particularly among Japanese patients.

Tricuspid Regurgitation and Right Heart Failure: The Role of Imaging in Defining Pathophysiology, Presentation, and Novel Management Strategies

During the last few years, there has been a substantial shift in efforts to understand and manage secondary or functional tricuspid regurgitation (TR) given its prevalence, adverse prognostic impact, and symptom burden associated with progressive right heart failure. Understanding the pathophysiology of TR and right heart failure is crucial for determining the best treatment strategy and improving outcomes. In this article, we review the complex relationship between right heart structural and hemodynamic changes that drive the pathophysiology of secondary TR and discuss the role of multimodality imaging in the diagnosis, management, and determination of outcomes.

Prognostic role of inferior vena collapsibility index in congenital heart disease: A validation study

BACKGROUND

A recent study showed that inferior vena cava collapsibility index (IVCCI) <60% had better prognostic performance as compared to the American Society of Echocardiogram (ASE) criteria for estimating right atrial pressure (RAP). However, this study was based on a selected cohort of adults with congenital heart disease (CHD) that underwent right heart catheterization and limiting the generalizability of the results. The purpose of this study was, therefore, to validate the prognostic performance of IVCCI in a more representative sample of adults with CHD, which would in turn, improve generalizability of the results.

METHODS

Retrospective cohort study of adults with CHD that underwent echocardiogram at Mayo Clinic (2003-2021). Elevated RAP was defined as RAP >10 mmHg, and was estimated using IVCCI <60% or the ASE criteria (maximum IVC diameter < 2.1 cm and IVCCI <50%). Cardiovascular event was defined as heart failure hospitalization, heart transplant or cardiovascular death.

RESULTS

Of the 4029 patients, 754 (19%) and 601 (15%) had elevated RAP (RAP >10 mmHg) based on IVCCI <60%, and the ASE criteria, respectively. Of the 4029 patients, 374 (9%) had cardiovascular events during 7.6 (4.4-10.5) years of follow-up. IVCCI <60% was independently associated with cardiovascular events (adjusted HR 2.08, 95% CI 1.75-2.42; C-statistic 0.708, 95%CI 0.688-0.728), and provided improved prognostic performance as compared to the ASE criteria (C-statistic difference 0.036, 95%CI 0.017-0.055, P = 0.008).

CONCLUSIONS

IVCCI had superior prognostic performance as compared to the ASE criteria.

Urinary N-terminal Pro-Brain Natriuretic Peptide in Newborn Infants with Cardiac and Pulmonary Diseases

OBJECTIVES

 The aim of this study was to assess the feasibility of urinary N-terminal pro-brain natriuretic peptide (NT-proBNP) as noninvasive screening tool for congenital heart diseases in full-term neonates with respiratory distress.

STUDY DESIGN

 A prospective cohort study was conducted on 90 full-term infants. Newborn were assigned into three groups: pulmonary, cardiac, and control groups. Urinary NT-proBNP were measured in all studied groups at day 1 (NT-proBNP1) and day 5 (NT-proBNP5).

RESULTS

 Urinary NT-proBNP1 was higher in cardiac group compared with pulmonary and control groups (488 ± 91, 321 ± 80, and 218 ± 41 ng/L, respectively; p ≤ 0.001). NT-proBNP5 was lower in pulmonary and control group than cardiac group (245 ± 84, 137 ± 39, and 546 ± 284 ng/L, respectively, with p ≤ 0.001). Receiver operating characteristic (ROC) analysis was performed to assess predictive value of NT-proBNP1 in cardiac and pulmonary populations. ROC showed area under curve of 0.97 and cutoff point of ≥386.5 ng/L referring to a cardiac etiology with sensitivity of 93.3%, specificity of 86.7%, negative predictive value of 93%, and positive predictive value of 88%.

CONCLUSION

 Urinary NT-proBNP is feasible to be a noninvasive screening tool to predict congenital heart diseases in full-term neonates. Further studies are needed to assess the correlation between plasma and urinary levels of NT-proBNP in congenital heart diseases in full-term and preterm infants.

Impact on Kidney Function and Medium-Term Outcomes of Transcatheter Aortic Valve Replacement in Patients With Chronic Kidney Disease

Transcatheter aortic valve replacement (TAVR) is now widely approved for the treatment of aortic stenosis, regardless of the patients' surgical risk. However, the outcomes of TAVR and their determinants in patients with chronic kidney disease (CKD) beyond 1 year of follow-up are unknown. We aimed to assess the medium-term outcomes of TAVR in CKD, develop a risk score to estimate the 2-year mortality in patients with CKD, and evaluate the changes in kidney function at discharge after TAVR. Adults who underwent TAVR were retrospectively identified. The CKD stage was determined using the Chronic Kidney Disease Epidemiology 2021 creatinine formula. Improved kidney function was defined as post-TAVR creatinine ≤50% of pre-TAVR creatinine or decrease in creatinine of ≥0.3 mg/100 ml compared with pre-TAVR creatinine. Overall, 1,523 patients (median age 82 years; 59% men; 735 with CKD stage II or less, 661 with CKD III, 83 with CKD IV, and 44 with CKD V [of whom 40 were on dialysis]) were included. The all-cause mortality was higher in CKD stages IV and V on the multivariable analysis (p <0.001) at median follow-up of 2.9 (interquartile range 2.0 to 4.2) years. Moderate or severe tricuspid regurgitation, anemia, right ventricular systolic pressure >40 mm Hg and CKD stages IV and V were independent predictors of 2-year mortality and were used to develop a risk score. At hospital discharge, persisting acute kidney injury after TAVR occurred in 88 of 1,466 patients (6%), whereas improved kidney function occurred in 170 of 1,466 patients (12%). In conclusion, CKD stage was an independent determinant of mortality beyond 2 years after TAVR. Kidney function was more likely to improve than worsen at the time of hospital discharge after TAVR.

Validation of Echocardiographic Measurements in Patients with Pulmonary Embolism in the RIETE Registry

Background  In acute pulmonary embolism (PE), echocardiographic identification of right ventricular (RV) dysfunction will inform prognostication and clinical decision-making. Registro Informatizado Enfermedad TromboEmbolica (RIETE) is the world's largest registry of patients with objectively confirmed PE. The reliability of site-reported RV echocardiographic measurements is unknown. We aimed to validate site-reported key RV echocardiographic measurements in the RIETE registry. Methods  Fifty-one randomly chosen patients in RIETE who had transthoracic echocardiogram (TTE) performed for acute PE were included. TTEs were de-identified and analyzed by a core laboratory of two independent observers blinded to site-reported data. To investigate reliability, intraclass correlation coefficients (ICCs) and Bland-Altman plots between the two observers, and between an average of the two observers and the RIETE site-reported data were obtained. Results  Core laboratory interobserver variations were very limited with correlation coefficients >0.8 for all TTE parameters. Agreement was substantial between core laboratory observers and site-reported data for key parameters including tricuspid annular plane systolic excursion (ICC 0.728; 95% confidence interval [CI], 0.594-0.862) and pulmonary arterial systolic pressure (ICC 0.726; 95% CI, 0.601-0.852). Agreement on right-to-left ventricular diameter ratio (ICC 0.739; 95% CI, 0.443-1.000) was validated, although missing data limited the precision of the estimates. Bland-Altman plots showed differences close to zero. Conclusion  We showed substantial reliability of key RV site-reported measurements in the RIETE registry. Ascertaining the validity of such data adds confidence and reliability for subsequent investigations.

Performance of handheld ultrasound devices in diagnosis of pulmonary hypertension and right heart dysfunction in ICU patients

AIM

The use of handheld ultrasonography devices (HHUD) has increased recently but there are limited data about their performance in the evaluation of right heart dysfunction (RHD) and pulmonary hypertension (PHT). The aim of the study is to compare the performance of a HHUD with a conventional ultrasound device (CUD) in assessing PHT and RHD.

METHODS

This single-center prospective study was performed in a seven-bed teaching hospital intensive care unit (ICU). PHT and RHD criteria were compared by HHUD and CUD. Additional PHT criteria and right ventricle (RV) systolic and diastolic dysfunction criteria were also measured.

RESULTS

Forty-six patients were included in the study. There was no significant difference between the imaging rates and mean values of the parameters measured by both devices. When the positivity rates for additional PHT parameters and RHD criteria were compared, there were no significant differences between the devices. In Bland-Altman's analysis, there was good agreement and there was no bias between the measurements of the two devices but left ventricular end-systolic eccentricity index (LVSEI), right atrium area (RAA), and pulmonary artery diameter (PAD). Ninety percent of the patients had PHT probability, of whom 43% had a low, 37% had intermediate and 10% had a high probability of PHT. Ninety-two percent of the patients had RHD and there was no significant difference between the devices in the diagnosis of RHD (p = .212). When RV systolic and diastolic dysfunction evaluations of the devices were compared according to the British Society of Echocardiography (BSE) criteria there was no significant difference between the devices' measurements in the evaluation of systolic and diastolic function.

CONCLUSION

The imaging and measurement capabilities of the HHUDs for PHT and RHD parameters were similar to CUDs, and considering the inconsistent parameters, the HHUD can be useful in diagnosing these problems.

Tricuspid Annular Plane Systolic Excursion (TAPSE) for the Assessment of Right Ventricular Function in Adult and Pediatric Cardiac Surgery: Modified Two-dimensional and M-mode TAPSE by Transesophageal Echocardiography Compared to M-mode TAPSE by Transthoracic Echocardiography

OBJECTIVES

To compare transesophageal echocardiography-guided 2-dimensional and M-mode tricuspid annular plane systolic excursion (TAPSE) to transthoracic echocardiography (TTE)-guided M-mode TAPSE in terms of accuracy, interobserver, and intra-observer variability.

DESIGN

A prospective, observational study.

SETTING

Adult and pediatric operating rooms.

PARTICIPANTS

Adult and pediatric patients (42 each) undergoing cardiac surgeries.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Modified midesophageal (Mod-ME), deep transgastric, and transgastric TAPSEs were analyzed for reliability and were compared to TTE TAPSE in both adult and pediatric groups. Modified ME TAPSE showed good method agreement with TTE TAPSE (bias = -0.97, p = 0.08 (adult); bias = 0.17, p = 0.71 [pediatric]), and showed a moderate correlation with right ventricular (RV) fractional area change (FAC) (r = 0.41, p = 0.006, [adult]; r = 0.57, p < 0.001, [pediatric]), with acceptable interobserver variability (percentage error =10.56 [adult]; 4.42 [pediatric]) and intraobserver variability (percentage error = 13.1 [adults]; 12.24 [pediatric]). Transgastric TAPSE poorly agreed with TTE TAPSE and had higher interobserver and intraobserver variability. Deep transgastric TAPSE had good method agreement with TTE TAPSE and had acceptable interobserver and intra-observer variability.

CONCLUSIONS

Modified ME TAPSE is a reliable and reproducible measure of RV function before pericardiotomy in both adult and pediatric cardiac surgery. Right ventricular FAC values reflected the RV systolic function better than TAPSE after pericardiotomy. Deep transgastric TAPSE is reliable and reproducible but is less accurate than Mod-ME TAPSE.

Evaluation of Right-Side Filling Pressure in Patients With Obesity With Heart Failure Using Handheld Ultrasound Score

The goal of this investigation is to evaluate the accuracy of handheld ultrasound score in assessing right atrial (RA) pressure in patients with obesity with heart failure. We prospectively studied 123 patients with heart failure referred for right-sided cardiac catheterization. Handheld ultrasound was performed before catheterization to evaluate volume status by estimating RA pressure using end-expiratory inferior vena cava (IVC) dimension, IVC respiratory collapsibility, and right internal jugular (RIJ) vein respiratory collapsibility. A 3-point simple score was created using multiple logistic regression. The patients were divided into 2 groups based on body mass index. The performance of this score was assessed using the receiver operating characteristics curve in each subgroup and was compared with the performance of the 2-point score (expiratory IVC dimension, IVC respiratory collapsibility). Median age was 58 years (interquartile range 48 to 65), and 37% were women. The 3-point score including RIJ performed better than did the 2-point score in patients with obesity (area under the curve 0.84 [0.74 to 0.95] vs 0.69 [0.58 to 0.81], p = 0.001). The performance of the scores did not differ in patients without obesity (area under the curve 0.85 [0.74 to 0.95] vs 0.82 [0.71 to 0.93], p = 0.49). In patients with obesity, the 3-point score had a specificity of 100% and sensitivity of 21% (11% to 31%) for elevated RA pressure ≥10 mm Hg. In conclusion, a 3-point score including both RIJ and IVC assessment performed better in patients with obesity with heart failure and highlights the importance of comprehensive evaluation in patients with obesity to achieve an accurate, noninvasive assessment of volume status.

Technical recommendations for computed tomography guidance of intervention in the right ventricular outflow tract: Native RVOT, conduits and bioprosthetic valves:: A white paper of the Society of Cardiovascular Computed Tomography (SCCT), Congenital Heart Surgeons' Society (CHSS), and Society for Cardiovascular Angiography & Interventions (SCAI)

This consensus document for the performance of Cardiovascular Computed Tomography (CCT) to guide intervention in the right ventricular outflow tract (RVOT) in patients with congenital disease (CHD) was developed collaboratively by pediatric and adult interventionalists, surgeons and cardiac imagers with expertise specific to this patient subset. The document summarizes definitions of RVOT dysfunction as assessed by multi-modality imaging techniques and reviews existing consensus statements and guideline documents pertaining to indications for intervention. In the context of this background information, recommendations for CCT scan acquisition and a standardized approach for reporting prior to surgical or transcatheter pulmonary valve replacement are proposed and presented. It is the first Imaging for Intervention collaboration for CHD patients and encompasses imaging and reporting recommendations prior to both surgical and percutaneous pulmonary valve replacement.

Point-of-Care Echocardiography in the Difficult-to-Image Patient in the ICU: A Narrative Review

OBJECTIVES

The objective of this narrative review was to address common obstacles encountered in the ICU to acquiring quality and interpretable images using point-of-care echocardiography.

DATA SOURCES

Detailed searches were performed using PubMed and Ovid Medline using medical subject headings and keywords on topics related to patient positioning, IV echo contrast, alternative subcostal views, right ventricular outflow tract (RVOT) hemodynamics, and point-of-care transesophageal echocardiography. Articles known to the authors were also selected based on expert opinion.

STUDY SELECTION

Articles specific to patient positioning, IV echo contrast, alternative subcostal views, RVOT hemodynamics, and point-of-care transesophageal echocardiography were considered.

DATA EXTRACTION

One author screened titles and extracted relevant data while two separate authors independently reviewed selected articles.

DATA SYNTHESIS

Impediments to acquiring quality and interpretable images in critically ill patients are common. Notably, body habitus, intra-abdominal hypertension, dressings or drainage tubes, postoperative sternotomies, invasive mechanical ventilation, and the presence of subcutaneous emphysema or lung hyperinflation are commonly encountered obstacles in transthoracic image acquisition in the ICU. Despite these obstacles, the bedside clinician may use obstacle-specific maneuvers to enhance image acquisition. These may include altering patient positioning, respiratory cycle timing, expanding the subcostal window to include multilevel short-axis views for use in the assessment of RV systolic function and hemodynamics, coronal transhepatic view of the inferior vena cava, and finally point-of-care transesophageal echocardiography.

CONCLUSIONS

Despite common obstacles to point-of-care echocardiography in critically ill patients, the beside sonographer may take an obstacle-specific stepwise approach to enhance image acquisition in difficult-to-image patients.

Influence of isometric versus isotonic exercise training on right ventricular morpho-functional parameters in Olympic athletes

BACKGROUND

Cardiovascular adaptations in elite athletes involve both ventricular and atrial changes. Nowadays, limited research exists on right ventricular (RV) remodeling, particularly in female athletes and across different types of exercise training.

METHODS

Our study evaluated 370 athletes (61% males) participated at 2020 Tokyo and 2022 Beijing Olympic Games. Athletes were categorized according to main type of exercise into isometric and isotonic. Comprehensive echocardiographic assessments were conducted to analyze RV morpho-functional parameters, comparing genders and different sporting exercise.

RESULTS

Significant differences in RV parameters were observed based on exercise type and gender. Isotonic athletes showed greater RV remodeling with larger RV outflow tract (15.1 ± 2.1 vs. 14.5 ± 1.7 mm, p < .0001) end-diastolic and end-systolic area (respectively, 24.6 ± 5.5 vs. 21.7 ± 5 mm, p < .000 and 11.7 ± 3.2 vs. 10.1 ± 2.8 mm, p < .0001) and right atrium size (11.7 ± 3.2 vs. 10.2 ± 2.3 mm2 , p = .0001). Functional parameters, such as TDI velocities, were similar between groups. Males showed larger RV area and right atrium size (p < .0001) and lower RV TDI velocities with reduced E' (15.4 ± 2.9 vs. 16.1 ± 3.2 m/s in females, p = .031), resulting in lower E'/A' ratio (1.69 ± .6 vs. 1.84 ± .6 m/s, p = .021), while S' was lower females (14.6 ± 2.3 vs. 14.1 ± 2.4 m/s, p = .041). RV TDI velocities were similar in isotonic and isometric both in male and females.

CONCLUSIONS

In elite athletes, RV morphological changes are influenced by exercise modality but do not translate into functional differences. Female athletes present distinct RV functional profiles, with lower S' velocities and a higher E'/A' ratio. Functional RV TDI parameters are not affected by the typology of exercise practiced.

Establishment of a canine model of pulmonary arterial hypertension induced by dehydromonocrotaline and ultrasonographic study of right ventricular remodeling

OBJECTIVE

Pulmonary arterial hypertension (PAH) means high blood pressure in the lungs. We aimed to observe the right ventricular size, wall thickness and characteristic functional changes and their associations with PAH in an established model of beagle dogs, and to explore convenient, reliable and sensitive ultrasound indicators for assessing right ventricular remodeling.

METHODS

Twenty healthy beagle dogs (8-10 kg) were randomly divided into control group (N-dimethylformamide, n = 10) and dehydromonocrotaline (DHMCT) group (DHMCT, n = 10). N-dimethylformamide or DHMCT was injected through a catheter into the right atrium, and then right heart catheterization, routine echocardiography and two-dimensional speckle tracking imaging (2D-STI) were performed before modeling (0 weeks) and 8, 14 weeks after modeling. Hemodynamic parameters and right ventricular function-related ultrasound data were acquired. At the end of the experiment, the animals were killed and the lung tissues were taken for HE staining. Left and right ventricular walls were separated and weighed respectively, and right ventricular hypertrophy index (RVHI) was measured. The associations of the routine ultrasound data and 2D-STI data at each time point with hemodynamic parameters and RVHI were analyzed.

RESULTS

At 0, 8 and 14 weeks, gradual decreases in the right ventricular global longitudinal strain (RVLS) were found in DHMCT group. RVH occurred in DHMCT group, and DHMCT group had a significantly higher RVHI than that of control group (49.83 ± 4.83% vs. 39.80 ± 1.40%, P < .001) and larger pulmonary artery media thickness. RVLS had significant positive correlations with RVSP (r = 0.74, P < .001), mRVP (r = 0.72, P < .001), PASP (r = 0.75, P < .001), mPAP (r = 0.72, P < .001) and PVR (r = 0.68, P < .001). There was a significant positive correlation between RVLS and RVHI (r = 0.74, P < .001).

CONCLUSION

The right ventricular function in PAH can be effectively assessed by echocardiography, and RVLS measured by 2D-STI sensitively reflects right ventricular remodeling following PAH.

Isolated unilateral pulmonary artery atresia in an adult presenting with cor pulmonale

Unilateral pulmonary artery atresia (UPAA) is a rare embryonic vascular malformation, leading to general presentations of exertional dyspnoea, pneumonia and haemoptysis. Our patient, a man in his early 30s, presented with a history of progressive breathlessness over a period of 2 years. History showed multiple admissions for pneumonia over his childhood and adolescence. Physical examination revealed a loud P2, an ejection systolic murmur and coarse crepitations in multiple lung fields. Severe pulmonary artery hypertension was noted on two-dimensional echocardiography. CT studies confirmed right pulmonary artery atresia with aspergilloma and bronchiectasis. With this diagnosis of UPAA, this case report intends to raise awareness among clinicians to consider this as a rare cause of cor pulmonale in an adult.

Comparing preoperative fasting and ultrasound-measured intravascular volume status in elective surgery, enhanced recovery patients versus inpatient, urgent surgery patients and the ability of IVC collapsibility to predict post-induction hypotension

Hypotension following induction of general anaesthesia has been shown to result in increased complications and mortality postoperatively. Patients admitted to the hospital undergoing urgent surgery are often fasted from fluids for significant periods compared to elective patients subject to Enhanced Recovery After Surgery protocols despite guidelines stating that a two-hour fast is sufficient. The aim of this prospective, observational study was to compare fasting times and intravascular volume status between elective surgery patients subject to enhanced recovery protocols and inpatient, urgent surgery patients and to assess differences in the incidence of post-induction hypotension. Fasting data was obtained by questionnaire in the preoperative area in addition to inferior vena cava collapsibility index, a non-invasive measure of intravascular volume. Blood pressure readings and drug administration for the ten minutes following induction were obtained from patients' charts. Inpatients undergoing urgent surgery were fasted significantly longer than enhanced recovery patients and had lower intravascular volume. However, no difference was found in the incidence of post-induction hypotension.

Digital Ulcers and Ventricular Arrhythmias as Red Flags to Predict Replacement Myocardial Fibrosis in Systemic Sclerosis

BACKGROUND

Cardiac involvement in systemic sclerosis (SSc) affects the prognosis of the disease. Echocardiography is the first line imaging tool to detect cardiac involvement, but it is not able to routinely detect myocardial fibrosis. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is the gold standard for replacement myocardial fibrosis assessment, but its availability is currently limited.

AIM

We aimed to assess the clinical and instrumental parameters that would be useful for predicting the presence of LGE-CMR, to achieve a better selection of patients with SSc that could benefit from third-level CMR imaging.

METHODS

344 SSc patients underwent a comprehensive echocardiogram and LGE-CMR on the same day; for 189 patients, a 24 h ECG Holter monitoring was available.

RESULTS

CMR showed non-junctional replacement myocardial fibrosis via LGE in 25.1% patients. A history of digital ulcers (OR 2.188; 95% C.I. 1.069-4.481) and ventricular arrhythmias at ECG Holter monitoring (OR 3.086; 95% C.I. 1.191-7.998) were independent predictors of replacement myocardial fibrosis.

CONCLUSIONS

CMR can detect patterns of clinical and subclinical cardiac involvement, which are frequent in SSc. A history of digital ulcers and evidence of ventricular arrhythmias at ECG Holter monitoring are red flags for the presence of replacement myocardial fibrosis in CMR. The association between digital ulcers and myocardial fibrosis suggests that a similar pathological substrate of abnormal vascular function may underlie peripheral vascular and cardiac complications.

Myocardial Mechanics and Associated Valvular and Vascular Abnormalities in Left Ventricular Noncompaction Cardiomyopathy

Left ventricular (LV) non-compaction (LVNC) is a rare genetic cardiomyopathy due to abnormal intra-uterine arrest of compaction of the myocardial fibers during endomyocardial embryogenesis. Due to the partial or complete absence of LV compaction, the structure of the LV wall shows characteristic abnormalities, including a thin compacted epicardium and a thick non-compacted endocardium with prominent trabeculations and deep intertrabecular recesses. LVNC is frequently associated with chronic heart failure, life-threatening ventricular arrhythmias, and systemic embolic events. According to recent findings, in the presence of LVNC, dysfunctional LV proved to be associated with left atrial volumetric and functional abnormalities and consequential dilated and functionally impaired mitral annulus, partly explaining the higher prevalence of regurgitation. Although the non-compaction process morphologically affects only the LV, signs of remodeling of the right heart were also detected. Moreover, dilation and stiffening of the aorta were present. The aim of the present detailed review was to summarize findings regarding changes in cardiac mechanics, valvular abnormalities, and vascular remodeling detected in patients with LVNC.

Right ventricular myocardial work for the prediction of early right heart failure and long-term mortality after left ventricular assist device implant

AIMS

Right heart failure (RHF) after left ventricular assist device (LVAD) implant is burdened by high morbidity and mortality rates and should be prevented by appropriate patient selection. Adequate right ventricular function is of paramount importance but its assessment is complex and cannot disregard afterload. Myocardial work (MW) is a non-invasive Speckle Tracking Echocardiography-derived method to estimate pressure-volume loops. The aim of this study was to evaluate the performance of right ventricular myocardial work to predict RHF and long-term mortality after LVAD implant.

METHODS AND RESULTS

Consecutive patients from May 2017 to February 2022 undergoing LVAD implant were retrospectively reviewed. Patients without a useful echocardiographic exam prior to LVAD implant were excluded. MW analysis was performed. The primary endpoints were early RHF (<30 days from LVAD implant) and death at latest available follow-up. We included 23 patients (mean age 64 ± 8 years, 91% men). Median follow-up was 339 days (IQR: 30-1143). Early RHF occurred in six patients (26%). A lower right ventricular global work efficiency [RVGWE, OR 0.86, 95% confidence intervals (CI) 0.76-0.97, P = 0.014] was associated with the occurrence of early RHF. Among MW indices, the performance for early RHF prediction was greatest for RVGWE [area under the curve (AUC) 0.92] and a cut-off of 77% had a 100% sensitivity and 82% specificity. At long-term follow-up, death occurred in 4 of 14 patients (28.6%) in the RVGWE > 77% group and in 6 of 9 patients (66.7%) in the RVGWE < 77% group (HR 0.25, 95% CI 0.07-0.90, P = 0.033).

CONCLUSION

RVGWE was a predictor of early RHF after LVAD implant and brought prognostic value in terms of long-term mortality.

Added value of 3D echocardiography in the diagnosis and prognostication of patients with right ventricular dysfunction

Recent inroads into percutaneous-based options for the treatment of tricuspid valve disease has brought to light how little we know about the behavior of the right ventricle in both health and disease and how incomplete our assessment of right ventricular (RV) physiology and function is using current non-invasive technology, in particular echocardiography. The purpose of this review is to provide an overview of what three-dimensional echocardiography (3DE) can offer currently to enhance RV evaluation and what the future may hold if we continue to improve the 3D evaluation of the right heart.

Association between reduced left ventricular ejection fraction and peritoneal dialysis related peritonitis: a single center retrospective cohort study in Japan

We present a single-center retrospective analysis of 228 Japanese patients with peritoneal dialysis, in which we examined whether reduced left ventricular ejection fraction (LVEF) is a risk factor for peritonitis development. Time-dependent multivariable-adjusted Cox proportional hazards models revealed that reduced LVEF (LVEF < 50% vs. preserved LVEF ≥ 50%, hazard ratio (HR) 2.10; 95% confidence interval (CI) 1.16-3.82) was associated with peritonitis. Qualitatively, similar associations with reduced LVEF (< 50%) were observed for enteric peritonitis (adjusted HR 7.68; 95% CI 2.51-23.5) but not for non-enteric peritonitis (adjusted HR 1.15; 95% CI 0.54-2.44). Reduced LVEF is associated with a significantly higher risk of subsequent peritonitis, particularly enteric peritonitis. These results indicate that patients with reduced LVEF may be at risk of enteric peritonitis from bowel sources caused by intestinal involvement due to cardiac dysfunction.

Management and outcomes of carcinoid heart disease with liver metastases of midgut neuroendocrine tumours

OBJECTIVE

Despite recent advances in surgical and interventional techniques, knowledge on the management of carcinoid heart disease (CHD) remains limited. In a cohort of patients with liver metastases of midgut neuroendocrine tumours (NETs), we aimed to describe the perioperative management and short-term outcomes of CHD.

METHODS

From January 2003 to June 2022, consecutive patients with liver metastases of midgut NETs and severe CHD (severe valve disease with symptoms and/or right ventricular enlargement) were included at Beaujon and Bichat hospitals. All patients underwent clinical evaluation and echocardiography.

RESULTS

Out of 43 (16%) consecutive patients with severe CHD and liver metastases of midgut NETs, 79% presented with right-sided heart failure. Tricuspid valve replacement was performed in 26 (53%) patients including 19 (73%) cases of combined pulmonary valve replacement. The 30-day postoperative mortality rate was high (19%), and preoperative heart failure was associated with worse survival (p=0.02). Epicardial pacemakers were systematically implanted in operated patients and 25% were permanently paced. A postoperative positive right ventricular remodelling was observed (p<0.001). A greater myofibroblastic infiltration was observed in pulmonary versus tricuspid valves (p<0.001), suggesting that they may have been explanted at an earlier stage of the disease than the tricuspid valve, with therefore potential for evolution.

CONCLUSIONS

We observed a high postoperative mortality rate and baseline right-sided heart failure was associated with worse outcome. In surviving patients, a positive right ventricular remodelling was observed. Prospective, multicentre studies are warranted to better define the management strategy and to identify biomarkers associated with outcome in CHD.

Congestion in Heart Failure: From the Secret of a Mummy to Today's Novel Diagnostic and Therapeutic Approaches: A Comprehensive Review

This review paper presents a review of the evolution of this disease throughout the centuries, describes and summarizes the pathophysiologic mechanisms, briefly discusses the mechanism of action of diuretics, presents their role in decongesting heart failure in patients, and reveals the data behind ultrafiltration in the management of acutely or chronically decompensated heart failure (ADHF), focusing on all the available data and advancements in this field. Acutely decompensated heart failure (ADHF) presents a critical clinical condition characterized by worsening symptoms and signs of heart failure, necessitating prompt intervention to alleviate congestion and improve cardiac function. Diuretics have traditionally been the mainstay for managing fluid overload in ADHF. Mounting evidence suggests that due to numerous causes, such as coexisting renal failure or chronic use of loop diuretics, an increasing rate of diuretic resistance is noticed and needs to be addressed. There has been a series of trials that combined diuretics of different categories without the expected results. Emerging evidence suggests that ultrafiltration may offer an alternative or adjunctive approach.

Inferior vena cava collapsibility index as a predictor of hypotension after induction of general anesthesia in hypertensive patients

BACKGROUND

Hypertensive patients are more susceptible to develop hypotension after the induction of general anesthesia (GA), most likely due to hypovolemia. An inferior vena cava collapsibility index (IVCCI) > 40-50% can predict hypotension after the induction of GA in the general population by variable accuracies. The current study aimed to investigate IVCCI% as a predictor of postinduction hypotension in hypertensive patients undergoing noncardiac surgery.

METHODS

Ultrasound IVCCI % was assessed for all controlled hypertensive patients immediately before induction of GA. After induction of GA, patients were diagnosed with postinduction hypotension if their systolic arterial pressure (SAP) dropped by ≥ 30% of the baseline value and/or mean arterial pressure (MAP) dropped to < 65 mmHg up to 15 min after intubation. The receiver operating characteristic (ROC) curve of IVCCI% was compared to patients' classification either developing hypotension after induction of GA or not as a gold standard.

RESULTS

Of the 153 patients who completed the study, 62 (40.5%) developed hypotension after the induction of GA, and 91 (59.5%) did not. An IVCCI > 39% predicted the occurrence of postinduction hypotension with high accuracy (84%) (AUC 0.908, P < 0.001). The area of uncertainty (by gray zone analysis) of IVCCI lies at values from 39 to 45%. This gray zone included 21 patients (13.7% of all patients).

CONCLUSION

An inferior vena cava collapsibility index > 39% before anesthetic induction can be a simple noninvasive reliable predictor of hypotension after the induction of GA for hypertensive patients not treated with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and undergoing noncardiac surgery.

TRIAL REGISTRATION

This clinical trial was approved by the Institutional Review Board (IRB) at Zagazig University (ZUIRB #9424 dated 03/04/2022), and patients' informed consent for participation in the study was obtained during the period from May 2022 to May 2023. All study procedures were carried out in accordance with the ethical standards of the Helsinki Declaration of 2013.

Impact of extra-mitral valve cardiac involvement in patients with primary mitral regurgitation undergoing transcatheter edge-to-edge repair

BACKGROUND

In the context of primary mitral regurgitation (PMR), the selection of patients for transcatheter edge-to-edge repair (TEER) does not include a systematic assessment of PMR-associated cardiac remodelling.

AIMS

We aimed to investigate the epidemiology and prognostic significance of different phenotypes of extra-mitral valve (MV) cardiac involvement in a large series of patients with PMR referred for TEER.

METHODS

The study included 654 patients from the multicentre Italian GIOTTO registry, stratified into groups according to extra-mitral valve (MV) cardiac involvement. The primary endpoint was all-cause death at 2-year follow-up.

RESULTS

Patients with no cardiac involvement (NI; n=58), left heart involvement (LHI; n=343) and right heart involvement (RHI; n=253) were analysed. Acute technical success was achieved in 98% of patients. Kaplan-Meier curve analysis revealed significantly worse survival in patients with LHI and RHI (p=0.041). On multivariate Cox regression analysis, extra-MV cardiac involvement, haemoglobin level and technical success were independent predictors of the primary endpoint occurrence.

CONCLUSIONS

Grading cardiac involvement may help refine risk stratification, since at least 1 group of extra-MV cardiac involvement represents in itself a negative predictor of midterm outcome.

Updated definition of pulmonary hypertension and outcome after transcatheter aortic valve implantation

OBJECTIVE

The European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown.

METHODS

579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH.

RESULTS

Out of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group.

CONCLUSIONS

New ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.

Normative Values of Echocardiographic Chamber Size and Function in Older Healthy Adults: The Multi-Ethnic Study of Atherosclerosis

Background

Echocardiographic (2DE) thresholds indicating disease or impaired functional status compared to normal physiologic aging in individuals ≥ 65 years are not clearly defined. In the present study, we sought to establish standard values for 2DE parameters related to chamber size and function in older adults without cardiopulmonary or cardiometabolic conditions.

Methods

In this cross-sectional study of 3032 individuals who underwent 2DE at Exam 6 in the Multi-Ethnic Study of Atherosclerosis (MESA), 608 participants fulfilled our inclusion criteria, with normative values defined as the mean value ± 1.96 standard deviations and compared across sex and race/ethnicity. Functional status measures included NT-proBNP, 6-minute walk distance [6MWD], and Kansas City Cardiomyopathy Questionnaire [KCCQ]. Prognostic performance using MESA cutoffs was compared to established guideline cutoffs using time-to-event analysis.

Results

Participants meeting our inclusion criteria (69.5 ± 7.0 years, 46.2% male, 47.5% White) had lower NT-proBNP, higher 6MWD, and higher (better) KCCQ summary values. Women had significantly smaller chamber sizes and better biventricular systolic function. White participants had the largest chamber dimensions, while Chinese participants had the smallest, even after adjustment for body size. Current guidelines identified 81.6% of healthy older adults in MESA as having cardiac abnormalities.

Conclusions

Among a large, diverse group of healthy older adults, we found significant differences in cardiac structure and function across sexes and races/ethnicities, which may signal sex-specific cardiac remodeling with advancing age. It is crucial for existing guidelines to consider the observed and clinically significant differences in cardiac structure and function associated with healthy aging. Our study highlights that existing guidelines, which grade abnormalities in echocardiographic cardiac chamber size and function based on younger individuals, may not adequately address the anticipated changes associated with normal aging.

Echocardiographic reference intervals of the dimensions of the main pulmonary artery and the right pulmonary artery: a prospective study in 269 healthy dogs

INTRODUCTION

No data are available on the echocardiographic reference intervals (RIs) for the main pulmonary artery (MPA) and right pulmonary artery (RPA) dimensions in a large sample of dogs. Therefore, we aimed to describe the echocardiographic RIs of the MPA and RPA dimensions in normal dogs.

ANIMALS, MATERIALS, AND METHODS

Two hundred and sixty nine healthy dogs of different breeds, age and body weight (BW) were prospectively enrolled in this multicenter, observational study. The MPA diameter, RPA maximum diameter (RPAmax), and RPA minimum diameter (RPAmin) were measured from the right parasternal short axis view. Prediction intervals (PIs) for MPA, RPAmax and RPAmin were generated using allometric scales. Reference intervals (RI) of MPA indexed to the ascending aorta (MPA/AO), and RPAmax and RPAmin indexed to the aortic annulus (RPAmax/Aod and RPAmin/Aod), were defined.

RESULTS

A positive linear relationship between MPA, RPAmax, RPAmin and BW was evident after logarithmic transformation (R2 = 0.859, R2 = 0.787 and R2 = 0.725, respectively; P<0.0001). According to allometric scales, the PI for the MPA normalized for BW (MPA_N) was between 5.50 and 8.07, the PI for the RPAmax normalized for BW (RPAmax_N) was between 3.23 and 5.62, while the PI for the RPAmin normalized for BW (RPAmin_N) was between 1.62 and 3.30. The median MPA/AO was 0.92 (RI, 0.78-1.01), the median RPAmax/Aod was 0.70 (RI, 0.53-0.98) and the median RPAmin/Aod was 0.40 (RI, 0.29-0.61).

DISCUSSION AND CONCLUSIONS

The reported RIs of the MPA and RPA dimensions in normal dogs could increase the diagnostic accuracy of transthoracic echocardiography in the identification of pulmonary artery enlargement in dogs.

Clinical implications of endotoxin activity and Polymyxin-B hemoperfusion in critically ill patients with septic cardiomyopathy: A single-center, retrospective, observational study

BACKGROUND

To explore the association between endotoxin activity (EA) and septic cardiomyopathy (SCM), the relationship between endotoxin removal by Polymyxin-B hemoperfusion (PMX-HP) and recovery from SCM (R-SCM), and the correlation between R-SCM and the 28-day mortality in septic patients admitted to the intensive care unit (ICU).

METHODS

Observational study that included patients admitted to two ICUs of a tertiary university hospital between April 2011 and December 2019, who received PMX-HP for sepsis/septic shock. The SCM and R-SCM were assessed by transthoracic echocardiography.

RESULTS

Among 148 patients, SCM was diagnosed in 60 (46%) of them and had no relationship with median EA (SCM group: 0.73; no-SCM group: 0.66, p = 0.48). Recovery from SCM was observed in 24 patients (49%) and was independently associated with the PMX-HP (OR 4.19, 95%CI [1.22, 14.3]; p = 0.02) and the SAPS2 II score (OR 0.94, 95%CI [0.9, 0.98]; p = 0.006). In the SCM group, the 28-day mortality was 60% and was independently predicted by R-SCM (OR 0.02, 95%CI [0.001, 0.3] p = 0.005) and SAPS II score (OR 1.11, 95%CI [1.01, 1.23] p = 0.037).

CONCLUSIONS

In septic patients, EA was not associated with SCM. However, endotoxin removal by Polymyxin-B hemoperfusion was associated with recovery from cardiomyopathy, which was a predictor of lower 28-day mortality.