Optimal Method for Assessing Right Ventricular to Pulmonary Arterial Coupling and Subclinical Right Ventricular Dysfunction in Older Aged Healthy Adults: The Multi-Ethnic Study of Atherosclerosis

Right ventricular (RV) to pulmonary arterial (PA) coupling describes the ability of the RV to augment contractility in response to increased afterload. Several echocardiographic indexes of RV-PA coupling have been defined; however, the optimal numerator in the coupling ratio is unclear. We sought to establish which of these ratios is best for assessing RV-PA coupling based on their relations with 6-minute walk distance (6MWD), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) in aging adults. In this study of 1,611 Multi-Ethnic Study of Atherosclerosis participants who underwent echocardiography at Exam 6, we evaluated the association between different numerators, including tricuspid annular planar systolic excursion (TAPSE), fractional area change (FAC), RV free wall strain, and tissue Doppler imaging S' velocity to pulmonary artery systolic pressure (PASP) with 6MWD, NT-proBNP, and KCCQ score, adjusted for socioeconomic and cardiovascular disease risk factors. Our cohort had a mean age of 73 ± 8 years, 54% female, 17% Chinese American, 22% African American, 22% Hispanic, and 39% White participants. The mean ( ± SD) TAPSE/PASP, FAC/PASP, tissue Doppler imaging S' velocity/PASP, and RV free wall strain:PASP ratios were 0.7 ± 0.2, 1.3 ± 0.3, 0.5 ± 0.1, and 0.8 ± 0.2, respectively. All RV-PA coupling indices decreased with age (p <0.0001 for all). TAPSE:PASP ratio was lower in older (³85 years) female (0.59 ± 0.14) versus male (0.65 ± 0.17) participants (p = 0.01), whereas FAC/PASP ratio was higher in the same female versus male participants (p <0.01). TAPSE/PASP and FAC/PASP ratios were significantly and strongly associated with all NT-proBNP, 6MWD, and KCCQ scores in fully adjusted and receiver operating characteristic analysis. In older community-dwelling adults free of heart failure and pulmonary hypertension, both FAC/PASP and TAPSE:PASP ratios are optimal for assessment of RV-PA coupling based on its association with 6MWD, NT-proBNP, and KCCQ score. FAC/PASP ratio has the additional benefit of reflecting age and gender-related geometric and functional changes.

Reference Values for Indexed Echocardiographic Chamber Sizes in Older Adults: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Normalization of echocardiographic chamber measurements for body surface area may result in misclassification of individuals with obesity or sarcopenia. Normalization for alternative measures of body size may be preferable, but there remains a dearth of information on their normative values and association with cardiovascular function metrics.

METHODS AND RESULTS

A total of 3032 individuals underwent comprehensive 2-dimensional echocardiography at Exam 6 in MESA (Multi-Ethnic Study of Atherosclerosis). In the subgroup of 608 individuals free of cardiopulmonary disease (69.5±7.0 years, 46% male, 48% White, 17% Chinese, 15% Black, 21% Hispanic), normative values were derived for left and right cardiac chamber measurements across a variety of ratiometric (body surface area, body mass index, height) and allometric (height1.6, height2.7) scaling parameters. Normative upper and lower reference values were provided for each scaling parameter stratified across age groups, sex, and race or ethnicity. Among scaling parameters, body surface area and height were associated with the least variability across race and ethnicity categories and height2.7 was associated with the least variability across sex categories.

CONCLUSIONS

In this diverse cohort of community-dwelling older adults, we provide normative values for common echocardiographic parameters across a variety of indexation methods.

Multi-Ethnic Study of Atherosclerosis Early Heart Failure Study: Rationale, Design, and Baseline Characteristics

BACKGROUND

Current prevalence estimates of heart failure (HF) are primarily based on self-report or HF hospitalizations. There is an unmet need to define the prevalence and pathogenesis of early symptomatic HF, which may be undiagnosed and precedes HF hospitalization.

METHODS

The MESA (Multi-Ethnic Study of Atherosclerosis) Early HF study was conducted during MESA exam 6 to determine the prevalence of early HF and investigate the transition from risk factors to early HF in a diverse population-based cohort of older adults. Between 2016 and 2018, 3285 MESA participants from 6 field centers underwent comprehensive speckle-tracking echocardiography with passive leg raise maneuver, Kansas City Cardiomyopathy Questionnaire, 6-minute walk test, arterial stiffness assessment, and proteomics (including NT-proBNP [N-terminal pro-B-type natriuretic peptide]).

RESULTS

Median age was 73 (25th-75th percentile 67-81) years, 53.2% were female, 25.6% were Black, 12.8% were Chinese, and 40.0% were White. The prevalence of HF risk factors was high: hypertension, 61.9%; former or current smoking, 53.7%; obesity 34.8%; diabetes; 24.7%; and chronic kidney disease; 22%. Overt cardiovascular disease, which ranged from 2.1% (HF) to 13.6% (atrial fibrillation), was less common. Of the 3285 participants, 96% underwent proteomics, 94% Kansas City Cardiomyopathy Questionnaire, 93% speckle-tracking echocardiography with passive leg raise, 82% arterial stiffness exam, and 77% 6-minute walk test. Feasibility of resting speckle-tracking echocardiography (87%-99% across cardiac chambers) and passive leg raise Doppler/speckle-tracking echocardiography (>84%) measurements was high. A total of 120 unique echocardiographic indices were measured.

CONCLUSIONS

The MESA Early HF study is a key resource for cardiovascular researchers who are interested in improving the epidemiological and phenotypic characterization of early HF.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005487.

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.

Percutaneous coronary intervention for ventricular fibrillation in the setting of an anomalous right coronary artery

We present a case of a quadriplegic male who developed ventricular fibrillation associated with an anomalous aortic origin of the right coronary artery. Successful revascularization was achieved with percutaneous coronary intervention. This case highlights the application of an unconventional approach to resolve ischemia in a patient with prohibitive surgical risk.

Characteristics of Right Ventricular to Pulmonary Arterial Coupling and Association With Functional Status Among Older Aged Adults from the Multi-Ethnic Study of Atherosclerosis

Although the echocardiographic:derived ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) is an important prognostic tool in heart failure (HF), the relation with 6-minute walk distance (6MWD) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) is less established. We sought to establish the normative values of TAPSE:PASP among older adults without cardiovascular disease (CVD) and evaluate the relation with NT-proBNP and 6MWD. Among 1,542 participants of the Multi-Ethnic Study of Atherosclerosis-HF ancillary study, the cross-sectional association of TAPSE:PASP with the outcomes of 6MWD and NT-proBNP was analyzed using multivariable linear regression, with progressive adjustment for sociodemographic and CVD risk factors. Our cohort had a mean age (SD) of 73 ± 8 years, 55% women, and a mean TAPSE:PASP ratio of 0.68 ± 0.16. In the unadjusted analysis, increasing tertiles of TAPSE:PASP were associated with younger age, less diabetes, higher estimated glomerular filtration rate, and less antihypertensive medication use. The TAPSE:PASP ratio significantly correlated with both 6MWD and NT-proBNP in the fully adjusted models. A 1-unit increment in TAPSE:PASP was associated with an adjusted 9.9% (4.8% to 15.2%) higher 6MWD, whereas a 1-unit increment in TAPSE:PASP was associated with an adjusted 38.0% (16.0% to 54.2%) lower NT-proBNP. There was a significant gender interaction of the association of TAPSE:PASP ratio and 6MWD, with stronger association seen in women. Among multiethnic older adults free of clinical CVD, the TAPSE:PASP ratio decreased with age, especially in women and was associated with decreased 6MWD and increasing NT-proBNP, the markers of subclinical HF.

Echocardiographic correlates of major adverse cardiac events at 1 year in patients with apical ballooning takotsubo syndrome

INTRODUCTION

Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction and associated with considerable morbidity and mortality. We sought to evaluate the association between change in cardiac mechanics after diagnosis of TTS with 1-year incidence of major adverse cardiovascular events (MACE).

METHODS

We retrospectively identified 85 patients with apical TTS based on ICD 9/10 codes and chart adjudication, who had a follow-up echocardiogram within 6 months of diagnosis. Echocardiograms were analyzed for left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), GLS ratio, global circumferential strain (GCS), and global radial strain (GRS). Multivariable logistic regression was performed to identify parameters associated with MACE (all-cause mortality, heart failure, stroke, and coronary artery disease [CAD] requiring percutaneous coronary intervention [PCI]) at 1 year. Event-free survival was assessed in patients with GLS (≤-18% vs. >18%) and LVEF (≥53% vs. <53%).

RESULTS

Within 1 year of diagnosis, MACE occurred in 15 (18%) patients. Between baseline and follow-up echocardiogram (median 15 [range 1-151] days), there were significant differences in change in LVEF and GLS in patients with versus without incident MACE. In multivariate analysis, change in LVEF (odds ratio [OR] = .93 [.87, .98], p = .013) and change in GLS (OR = 1.32 [1.04, 1.67], p = .022) were independently associated with MACE; however, the association with change in GLS was attenuated (odds ratio [OR] = 1.13 [.94, 1.36], p = .21) after adjustment for baseline and change in LVEF. Among patients with normalized LVEF at follow-up, there were five (14.7%) MACE; whereas, there were no events among patients with normalized GLS.

CONCLUSIONS

In patients with apical TTS, recovery in GLS and LVEF at follow-up was associated with significantly lower MACE at 1 year. Normalization of GLS at follow-up was better able to discriminate event-free survival than normalization of LVEF.

Left Atrial Strain and the Risk of Atrial Arrhythmias From Extended Ambulatory Cardiac Monitoring: MESA

Background Abnormalities in left atrial (LA) function often occur before LA structural changes and clinically identified atrial fibrillation (AF). Little is known about the relationship between LA strain and the risk of subclinical atrial arrhythmias detected from extended ambulatory cardiac monitoring. Methods and Results A total of 1441 participants of MESA (Multi-Ethnic Study of Atherosclerosis) completed speckle-tracking echocardiography and cardiac monitoring during 2016 to 2018 (mean age, 73 years); participants in AF during echocardiography or during the entire cardiac monitoring period were excluded. Absolute values of LA reservoir, booster pump, and conduit strains were measured. We evaluated associations of LA strain with monitor-detected AF, premature atrial contractions, and supraventricular tachycardia. Primary analyses adjusted for demographic variables, blood pressure, diabetes, smoking, and clinical cardiovascular disease. Cardiac monitoring (median, 14 days) detected AF in 3%. Each SD (4.0%) lower (worse) LA booster pump strain was associated with 84% higher risk of monitor-detected AF (95% CI, 30%-162%), 39% higher premature atrial contraction frequency (95% CI, 27%-53%), and 19% higher supraventricular tachycardia frequency (95% CI, 10%-29%). Additional adjustment for NT-proBNP (N-terminal pro-B-type natriuretic peptide), LA volume index, tissue Doppler a' peak velocity, left ventricular ejection fraction, and global longitudinal strain had little impact on associations. Findings were similar for LA reservoir strain and null for LA conduit strain. Conclusions In a multiethnic community-based cohort, impaired LA strain was an important correlate of subclinical atrial arrhythmias, even after adjustment for conventional measures of LA structure and function.

Cardiovascular Imaging for Systemic Sclerosis Monitoring and Management

Systemic sclerosis (SSc) is a complex connective tissue disease with multiple clinical and subclinical cardiac manifestations. SSc can affect most structural components of the heart, including the pericardium, myocardium, valves, and conduction system through a damaging cycle of inflammation, ischemia, and fibrosis. While cardiac involvement is the second leading SSc-related cause of death, it is frequently clinically silent in early disease and often missed with routine screening. To facilitate identification of cardiac disease in this susceptible population, we present here a review of cardiac imaging modalities and potential uses in the SSc patient population. We describe well-characterized techniques including electrocardiography and 2D echocardiography with Doppler, but also discuss more advanced imaging approaches, such as speckle-tracking echocardiography, cardiovascular magnetic resonance imaging (CMR), and stress imaging, among others. We also suggest an algorithm for the appropriate application of these modalities in the workup and management of patients with SSc. Finally, we discuss future opportunities for cardiac imaging in SSc research to achieve early detection and to optimize treatment.

Rationale and Design of a Pharmacist-led Intervention for the Risk-Based Prevention of Heart Failure: The FIT-HF Pilot Study

Background: Given rising morbidity, mortality, and costs due to heart failure (HF), new approaches for prevention are needed. A quantitative risk-based strategy, in line with established guidelines for atherosclerotic cardiovascular disease prevention, may efficiently select patients most likely to benefit from intensification of preventive care, but a risk-based strategy has not yet been applied to HF prevention. Methods and Results: The Feasibility of the Implementation of Tools for Heart Failure Risk Prediction (FIT-HF) pilot study will enroll 100 participants free of cardiovascular disease who receive primary care at a single integrated health system and have a 10-year predicted risk of HF of ≥5% based on the previously validated Pooled Cohort equations to Prevent Heart Failure. All participants will complete a health and lifestyle questionnaire and undergo cardiac biomarker (B-type natriuretic peptide [BNP] and high-sensitivity cardiac troponin I [hs-cTn]) and echocardiography screening at baseline and 1-year follow-up. Participants will be randomized 1:1 to either a pharmacist-led intervention or usual care for 1 year. Participants in the intervention arm will undergo consultation with a pharmacist operating under a collaborative practice agreement with a supervising cardiologist. The pharmacist will perform lifestyle counseling and recommend initiation or intensification of therapies to optimize risk factor (hypertension, diabetes, and cholesterol) management according to the most recent clinical practice guidelines. The primary outcome is change in BNP at 1-year, and secondary and exploratory outcomes include changes in hs-cTn, risk factor levels, and cardiac mechanics at follow-up. Feasibility will be examined by monitoring retention rates. Conclusions: The FIT-HF pilot study will offer insight into the feasibility of a strategy of quantitative risk-based enrollment into a pharmacist-led prevention program to reduce heart failure risk. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04684264.

Associations of Cardiac Mechanics With Exercise Capacity: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Lower exercise capacity, as measured by 6-minute walk distance (6MWD), is associated with incident heart failure (HF). Among those without HF, the associations of measures of cardiac function with 6MWD are unclear, and may provide insight regarding the risk of incident HF.

OBJECTIVES

The purpose of this study was to understand the relationships between cardiac function and exercise capacity.

METHODS

This study evaluated the associations of cardiac mechanics with 6MWD in the sixth examination of the Multi-Ethnic Study of Atherosclerosis. Echocardiography (2-dimensional, Doppler, and speckle-tracking) was performed at rest and after passive leg raise to evaluate functional reserve after intravascular volume challenge.

RESULTS

Of 2,096 participants without HF (mean age 73 years, 48% men, 58% non-White), individuals with lower (worse) left atrial (LA) reservoir strain were older and had higher blood pressure. Lower resting LA reservoir strain (β coefficient per SD decrease: -5.0; 95% confidence interval [CI]: -8.8 to -1.3 m; p = 0.009), inability to augment LA reservoir strain after passive leg raise (β coefficient per SD decrease: -5.8; 95% CI: -9.1 to -2.5 m; p < 0.001), and lower right atrial reservoir strain (β coefficient per SD decrease: -4.4; 95% CI: -7.8 to -1.1 m; p = 0.01) were associated with shorter 6MWD. Worse left ventricular (LV) diastolic function was also associated with lower 6MWD. There were no independent associations of measures of LV systolic function (global longitudinal strain, circumferential strain, ejection fraction) with 6MWD.

CONCLUSIONS

Among individuals without HF, worse biatrial function, lack of LA functional reserve, and worse LV diastolic function were associated with reduced submaximal exercise capacity. Therapies aimed to improve these functional domains may increase exercise capacity and prevent HF.

Echocardiographic parameters associated with in-hospital adverse outcomes in patients with Takotsubo syndrome

INTRODUCTION

Takotsubo syndrome (TTS) is an acute heart failure syndrome that leads to significant morbidity and mortality. We sought to evaluate the association of cardiac mechanics on presentation with in-hospital adverse outcomes in patients with apical TTS.

METHODS

We retrospectively identified 468 patients with TTS based on ICD-9/10 codes between 2006 and 2017. The association of echocardiographic parameters with a composite outcome of heart failure and all-cause mortality during the index hospitalization was analyzed.

RESULTS

One hundred and forty one patients with the apical subtype and adequate imaging were included. 113 (80.1%) were female, left ventricular ejection fraction (LVEF) was 41.7% ± 12.4%, and global longitudinal strain was -10.1% ± 3.2%. The composite outcome occurred in 58 patients (41%), with heart failure occurring in 55 patients and death occurring in nine patients. Global longitudinal strain, global circumferential strain, global radial strain, right ventricular fractional area change, tricuspid annular plane systolic excursion, and right ventricular free wall strain were significantly worse in patients who experienced the composite outcome in univariate analyses. However, only LVEF was independently associated with the composite outcome in multivariable-adjusted analysis.

CONCLUSIONS

In patients with apical TTS, the strain has limited prognostic utility in the acute setting compared to LVEF, which was the only echocardiographic parameter associated with in-hospital heart failure and all-cause mortality.

Improvement in left atrial reservoir strain following hematopoietic stem cell transplant in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Systemic sclerosis (SSc) can cause cardiac complications as a result of multi-organ fibrosis. The study of left atrial (LA) mechanics can offer insights into the pathophysiology of cardiac involvement in SSc. LA strain measured by speckle-tracking echocardiography (STE) has been shown to be a sensitive marker of LA function. The impact of a disease modifying treatment like hematopoietic stem cell transplant (HSCT) on LA mechanics is not known.

Aim

To study the effect of HSCT on LA mechanics using both conventional echocardiography and STE.

Methods

Patients with SSc who underwent comprehensive 2D echo evaluation pre- and post-HSCT were identified. Patients with pulmonary hypertension on right heart catheterization (RHC) were excluded. The modified Rodnan skin score (mRSS) was evaluated for each patient pre- and post-HSCT. Speckle tracking software was utilized to measure myocardial strain (TomTec, Unterschleissheim, Germany). LA reservoir strain was measured from the apical 2-, and 4-chamber views. The ratio of E/e’ to LA reservoir strain was used to non-invasively estimate LA stiffness. Paired student’s t-test and Pearson"s correlation were used in data analysis.

Results

Among 89 patients with SSc (average age 46 ± 11 years, 75% female) who underwent HSCT, the mRSS significantly improved after HSCT. The mean pulmonary capillary wedge pressure (PCWP) measured by RHC prior to HSCT was 9.6 ± 4.1 mmHg. LA reservoir strain was abnormal at baseline and significantly improved following HSCT. Although LA volume index and E/e’ remained unchanged, LA stiffness index decreased significantly post-HSCT. There was no correlation between LA reservoir strain and PCWP at baseline or between change in LA reservoir strain and change in LA volume index or E/e’.

Conclusions

Patients undergoing HSCT for SSc show significant improvement in LA reservoir strain and LA stiffness despite no significant change in LA volumes or estimates of LV filling pressures. This improvement in LA mechanics following HSCT thus appears to be independent of loading conditions and could represent an improvement in intrinsic LA performance.

Key clinical and echo characteristics Pre-HSCT Post-HSCT P value Median mRSS (25th - 75th percentile) 20 (13-34) 9 (4-20) &lt;0.01 LA volume index (ml/m2) 24.6 ± 8.3 24.1 ± 7.1 0.66 E/e’ 8.0 ± 2.4 8.3 ± 2.6 0.30 LA stiffness index 0.24 ± 0.12 0.18 ± 0.08 &lt;0.01 LA reservoir strain (%)* 35.8 ± 8.6 47.7 ± 11.2 &lt;0.01 All values are presented as mean ± SD unless indicated otherwise. *Normal LA reservoir strain is defined in this study as being greater than 39%.

Heterogeneous pattern of improvement in right ventricular mechanics following hematopoietic stem cell transplant in patients with systemic sclerosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Systemic sclerosis (SSc) is an autoimmune disorder that causes fibrosis in the skin and internal organs, including the heart. Patients with SSc can have right ventricular (RV) systolic dysfunction in the absence of pulmonary hypertension. Studies have shown a predilection for impairment of the mid and apical segments of the RV free wall compared to controls. The effect of hematopoietic stem cell transplant (HSCT) – a disease modifying treatment for SSc – on RV mechanics is not known.

Aim

To study the effect of HSCT on RV mechanics using speckle-tracking echocardiography.

Methods

Patients with SSc who underwent comprehensive 2D echocardiographic evaluation pre- and post-HSCT were identified. The modified Rodnan skin score (mRSS) was evaluated for each patient pre- and post-HSCT. Speckle tracking software was utilized to measure myocardial strain (TomTec, Unterschleissheim, Germany). RV strain was measured from the RV focused apical 4-chamber view. Paired student’s t-test and linear regression analysis were used in data analysis.

Results

Among 89 patients with SSc (average age 46 ± 11 years, 75% female) who underwent HSCT, the mRSS significantly improved after HSCT. The mean pulmonary arterial pressure measured by right heart catheterization prior to HSCT was 18.5 ± 4.5 mmHg. There was a significant improvement in RV global longitudinal strain (GLS) and free wall strain (FWS) following HSCT. The improvement in strain was significant in the mid and apical segments of the RV free wall, but not so in the basal segment. The change in RV strain was linearly related to pre-HSCT strain. The lower the RV GLS and FWS, the greater the improvement in strain after HSCT.

Conclusions

There was a significant improvement in RV strain in patients undergoing HSCT, specifically within the mid and apical segments of the RV free wall. The improvement in strain after HSCT was directly related to the baseline strain. This suggests that HSCT may directly improve RV mechanics with the preferential enhancement of the less robust mid and apical RV free wall segments.

Key clinical and echo characteristics Pre-HSCT Post-HSCT P value Median mRSS (25th - 75th percentile) 20 (13-34) 9 (4-20) &lt;0.01 RV GLS (%) -18.13 ± 3.88 -20.06 ± 4.51 &lt;0.01 RV FWS (%) -20.79 ± 5.30 -23.21 ± 5.61 &lt;0.01 RV basal free wall (%) -27.97 ± 9.33 -27.84 ± 7.94 0.93 RV mid free wall (%) -20.68 ± 9.61 -23.75 ± 7.91 0.05 RV apical free wall (%) -15.26 ± 8.57 -20.84 ± 8.92 &lt;0.01 All values are presented as mean ± SD unless indicated otherwise. Abstract Figure. Pre-HSCT RV strain vs change in strain

Rapid reconstruction of highly undersampled, non-Cartesian real-time cine k-space data using a perceptual complex neural network (PCNN)

Highly accelerated real-time cine MRI using compressed sensing (CS) is a promising approach to achieve high spatio-temporal resolution and clinically acceptable image quality in patients with arrhythmia and/or dyspnea. However, its lengthy image reconstruction time may hinder its clinical translation. The purpose of this study was to develop a neural network for reconstruction of non-Cartesian real-time cine MRI k-space data faster (<1 min per slice with 80 frames) than graphics processing unit (GPU)-accelerated CS reconstruction, without significant loss in image quality or accuracy in left ventricular (LV) functional parameters. We introduce a perceptual complex neural network (PCNN) that trains on complex-valued MRI signal and incorporates a perceptual loss term to suppress incoherent image details. This PCNN was trained and tested with multi-slice, multi-phase, cine images from 40 patients (20 for training, 20 for testing), where the zero-filled images were used as input and the corresponding CS reconstructed images were used as practical ground truth. The resulting images were compared using quantitative metrics (structural similarity index (SSIM) and normalized root mean square error (NRMSE)) and visual scores (conspicuity, temporal fidelity, artifacts, and noise scores), individually graded on a five-point scale (1, worst; 3, acceptable; 5, best), and LV ejection fraction (LVEF). The mean processing time per slice with 80 frames for PCNN was 23.7 ± 1.9 s for pre-processing (Step 1, same as CS) and 0.822 ± 0.004 s for dealiasing (Step 2, 166 times faster than CS). Our PCNN produced higher data fidelity metrics (SSIM = 0.88 ± 0.02, NRMSE = 0.014 ± 0.004) compared with CS. While all the visual scores were significantly different (P < 0.05), the median scores were all 4.0 or higher for both CS and PCNN. LVEFs measured from CS and PCNN were strongly correlated (R² = 0.92) and in good agreement (mean difference = -1.4% [2.3% of mean]; limit of agreement = 10.6% [17.6% of mean]). The proposed PCNN is capable of rapid reconstruction (25 s per slice with 80 frames) of non-Cartesian real-time cine MRI k-space data, without significant loss in image quality or accuracy in LV functional parameters.

Cardiac safe hematopoietic stem cell transplantation for systemic sclerosis with poor cardiac function: a pilot safety study that decreases neutropenic interval to 5 days

We compared three fludarabine-based regimens for systemic sclerosis patients with a high-risk cardiac phenotype that according to EBMT criteria would be a contraindication for a high-dose cyclophosphamide (200 mg/kg) transplant regimen. All three regimens included fludarabine, ATG, and cyclophosphamide (60 mg/kg), while two regimens also included rituximab with or without IVIG. Treatment related mortality (TRM) was 2.4%. The mean number of days of neutropenia (ANC < 500) was 5.2, the mean number of platelet and red blood cell transfusions was 0.3 and 1.85, respectively. Skin score, forced vital capacity (FVC), and total lung capacity (TLC) improved with all three regimens. For patients whose regimen did not include rituximab versus those that included rituximab, 1-year overall relapse rate was higher 36% (5/14) versus 3.6% (1 of 28) (p = 0.01), secondary autoimmune diseases were higher 21% (3/14) versus 0% (0/28) (p = 0.03), and upper respiratory tract infections were higher 28% (4/14) versus 3.6% (1/28) (p = 0.04). In this safety study, a fludarabine-based regimen was relatively safe with a TRM of 2.4% and a neutropenic interval of only 5.2 days in systemic sclerosis patients with a high-risk cardiac phenotype. The addition of rituximab decreased 1-year relapse rate, risk of late secondary autoimmune diseases, and upper-respiratory tract infections.

Rapid dealiasing of undersampled, non-Cartesian cardiac perfusion images using U-net

Compressed sensing (CS) is a promising method for accelerating cardiac perfusion MRI to achieve clinically acceptable image quality with high spatial resolution (1.6 × 1.6 × 8 mm³ ) and extensive myocardial coverage (6-8 slices per heartbeat). A major disadvantage of CS is its relatively lengthy processing time (~8 min per slice with 64 frames using a graphics processing unit), thereby making it impractical for clinical translation. The purpose of this study was to implement and test whether an image reconstruction pipeline including a neural network is capable of reconstructing 6.4-fold accelerated, non-Cartesian (radial) cardiac perfusion k-space data at least 10 times faster than CS, without significant loss in image quality. We implemented a 3D (2D + time) U-Net and trained it with 132 2D + time datasets (coil combined, zero filled as input; CS reconstruction as reference) with 64 time frames from 28 patients (8448 2D images in total). For testing, we used 56 2D + time coil-combined, zero-filled datasets (3584 2D images in total) from 12 different patients as input to our trained U-Net, and compared the resulting images with CS reconstructed images using quantitative metrics of image quality and visual scores (conspicuity of wall enhancement, noise, artifacts; each score ranging from 1 (worst) to 5 (best), with 3 defined as clinically acceptable) evaluated by readers. Including pre- and post-processing steps, compared with CS, U-Net significantly reduced the reconstruction time by 14.4-fold (32.1 ± 1.4 s for U-Net versus 461.3 ± 16.9 s for CS, p < 0.001), while maintaining high data fidelity (structural similarity index = 0.914 ± 0.023, normalized root mean square error = 1.7 ± 0.3%, identical mean edge sharpness of 1.2 mm). The median visual summed score was not significantly different (p = 0.053) between CS (14; interquartile range (IQR) = 0.5) and U-Net (12; IQR = 0.5). This study shows that the proposed pipeline with a U-Net is capable of reconstructing 6.4-fold accelerated, non-Cartesian cardiac perfusion k-space data 14.4 times faster than CS, without significant loss in data fidelity or image quality.

Accelerated Wideband Myocardial Perfusion Pulse Sequence with Compressed Sensing Reconstruction for Myocardial Blood Flow Quantification in Patients with a Cardiac Implantable Electronic Device

Purpose

To develop an accelerated wideband cardiac perfusion pulse sequence and test whether it can produce diagnostically acceptable image quality and whether it can be used to reliably quantify myocardial blood flow (MBF) in patients with a cardiac implantable electronic device (CIED).

Materials and Methods

A fivefold-accelerated wideband perfusion pulse sequence was developed using compressed sensing to sample one arterial input function plane and three myocardial perfusion (MP) planes per heartbeat in patients with a CIED with heart rates as high as 102 beats per minute. Resting perfusion scans were performed in 10 patients with a CIED and in 10 patients with no device as a control group. Two clinical readers compared the resulting images and retrospective images of the 10 patients with a CIED, which were obtained by using a previously described twofold-accelerated wideband perfusion pulse sequence with temporal generalized autocalibrating partially parallel acquisition. Summed visual score (SVS) was defined as the sum of conspicuity, artifact, and noise scores individually ranging from 1 (worst) to 5 (best). Resting MBF in the remote zones was quantified using Fermi deconvolution.

Results

Median SVS was significantly different (P < .05) between the prospective and retrospective CIED groups (13 vs nine) and between the nondevice group and the retrospective CIED group (13.5 vs nine); all median SVSs were nine or greater (clinically acceptable cut point). The median resting MBF in remote zones was not significantly different (P = .27) between patients with a CIED (1.1 mL/min/g; median left ventricular ejection fraction [LVEF], 52.5%) and patients with no device (1.3 mL/min/g; median LVEF, 64.0%). Mean MBF values were consistent with those (mean resting MBF range, 1.0-1.2 mL/min/g) reported by two prior state-of-the-art cardiac perfusion MRI studies.

Conclusion

The proposed scan yielded diagnostically acceptable image quality and enabled reliable quantification of MBF with three MP planes per heartbeat in patients with a CIED with heart rates as high as 102 beats per minute. Supplemental material is available for this article. © RSNA, 2020.

Diffuse right ventricular fibrosis in heart failure with preserved ejection fraction and pulmonary hypertension

Aims

While right ventricular (RV) dysfunction is associated with worse prognosis in co‐morbid pulmonary hypertension and heart failure with preserved ejection fraction (PH‐HFpEF), the mechanisms driving RV dysfunction are unclear. We evaluated the extent and clinical correlates of diffuse RV myocardial fibrosis in PH‐HFpEF, as measured by cardiovascular magnetic resonance‐derived extracellular volume (ECV).

Methods and results

We prospectively enrolled participants with PH‐HFpEF (n = 14), pulmonary arterial hypertension (PAH; n = 13), and controls (n = 8). All participants underwent high‐resolution cardiovascular magnetic resonance, and case subjects (PH‐HFpEF and PAH) additionally underwent right heart catheterization. T1 mapping was performed using high‐resolution modified look‐locker inversion recovery with a 1 × 1 mm² in‐plane resolution. RV free wall T1 values were quantified, and ECV was calculated. Participants with PH‐HFpEF were older and carried higher rates of hypertension and obstructive sleep apnoea than those with PAH. While RV ECV was similar between PH‐HFpEF and PAH (33.1 ± 8.0 vs. 34.0 ± 4.5%; P = 0.57), total pulmonary resistance was lower in PH‐HFpEF compared with PAH [PH‐HFpEF: 5.68 WU (4.70, 7.66 WU) vs. PAH: 8.59 WU (8.14, 12.57 WU); P = 0.01]. RV ECV in PH‐HFpEF was associated with worse indices of RV structure (RV end‐diastolic volume: r = 0.67, P = 0.01) and RV function (RV free wall strain: r = 0.59, P = 0.03) but was not associated with RV afterload (total pulmonary resistance: r = 0.08, P = 0.79). Conversely, there was a strong correlation between RV ECV and RV afterload in PAH (r = 0.57, P = 0.04).

Conclusions

Diffuse RV fibrosis, as measured by ECV, is present in PH‐HFpEF and is associated with adverse RV structural and functional remodelling but not degree of pulmonary vasculopathy. In PH‐HFpEF, diffuse RV fibrosis may occur out of proportion to the degree of RV afterload.

Meta-Analysis Global Group in Chronic (MAGGIC) Heart Failure Risk Score: Validation of a Simple Tool for the Prediction of Morbidity and Mortality in Heart Failure With Preserved Ejection Fraction

Background The Meta-Analysis Global Group in Chronic Heart Failure ( MAGGIC ) mortality risk score, derived from a large sample of patients with heart failure ( HF ) across the spectrum of ejection fraction ( EF ), has not yet been externally validated in a well-characterized HF with preserved EF cohort with adjudicated morbidity outcomes. Methods and Results We evaluated the MAGGIC risk score (composed of 13 clinical variables) in 407 patients with HF with preserved EF enrolled in a prospective registry and used Cox regression to evaluate its association with morbidity/mortality. We used receiver-operating characteristic analysis to compare the predictive ability of the MAGGIC risk score with the more complex Seattle Heart Failure Model, and we determined the value of adding B-type natriuretic peptide to the MAGGIC risk score for risk prediction. During a mean follow-up time of 3.6±1.8 years, 28% died, 32% were hospitalized for HF , and 55% had a cardiovascular hospitalization and/or death. The MAGGIC score, a mean± SD of 18±7, was significantly associated with mortality ( P<0.0001), HF hospitalizations ( P<0.0001), and the combined end point of cardiovascular-related hospitalizations or death (hazard ratio, 1.8 [95% confidence interval, 1.6-2.1], per 1- SD increase in the MAGGIC score; P<0.0001). Receiver-operating characteristic analyses showed that MAGGIC and Seattle Heart Failure Model performed similarly in predicting HF with preserved EF outcomes, but the MAGGIC score demonstrated better calibration for hospitalization outcomes. Further analyses showed that B-type natriuretic peptide was additive to the MAGGIC risk score for predicting outcomes ( P<0.01 by likelihood ratio test). Conclusions The MAGGIC risk score is a simple, yet powerful method of risk stratification for both morbidity and mortality in HF with preserved EF . Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01030991.

Baseline Longitudinal Strain Predicts Recovery of Left Ventricular Ejection Fraction in Hospitalized Patients With Nonischemic Cardiomyopathy

Background

Heart failure (HF) with “recovered” ejection fraction (HFrecEF) is an emerging phenotype, but no tools exist to predict ejection fraction (EF) recovery in acute HF. We hypothesized that indices of baseline cardiac structure and function predict HFrecEF in nonischemic cardiomyopathy and reduced EF.

Methods and Results

We identified a nonischemic cardiomyopathy cohort with EF<40% during the first HF hospitalization (n=166). We performed speckle‐tracking echocardiography to measure longitudinal, circumferential, and radial strain, and the average of these measures (myocardial systolic performance). HFrecEF was defined as follow‐up EF ≥40% and ≥10% improvement from baseline EF. Fifty‐nine patients (36%) achieved HFrecEF (baseline EF 26±7%; follow‐up EF 51±7%) within a median of 135 (interquartile range 58‐239) days after the first HF hospitalization. Baseline demographics, biomarker profiles, and comorbid conditions (except lower chronic kidney disease in HFrecEF) were similar between HFrecEF and persistent reduced‐EF groups. HFrecEF patients had smaller baseline left ventricular end‐systolic dimension (3.6 versus 4.8 cm; P<0.01), higher baseline myocardial systolic performance (9.2% versus 8.1%; P=0.02), and improved survival (adjusted hazard ratio 0.27, 95% confidence interval 0.11, 0.62). We found a significant interaction between baseline left ventricular end‐systolic dimension and absolute longitudinal strain. Among patients with left ventricular end‐systolic dimension >4.35 cm, higher absolute longitudinal strain (≥8%) was associated with HFrecEF (unadjusted odds ratio=3.9, 95% CI)confidence interval 1.2, 12.8). Incorporation of baseline indices of cardiac mechanics with clinical variables resulted in a predictive model for HFrecEF with c‐statistic=0.85.

Conclusions

Factors associated with achieving HFrecEF were specific to cardiac structure and indices of cardiac mechanics. Higher baseline absolute longitudinal strain is associated with HFrecEF among nonischemic cardiomyopathy patients with reduced EF and larger left ventricular dimensions.

Lack of Association Between Anemia and Intrinsic Left Ventricular Diastolic Function or Cardiac Mechanics in Heart Failure With Preserved Ejection Fraction

Anemia is associated with a poor prognosis in heart failure with preserved ejection fraction (HFpEF), but the reasons underlying this association are unclear. Previous studies have reported an association between anemia and diastolic dysfunction. However, these studies used volume- and flow-dependent indexes of diastolic dysfunction. We hypothesized that in HFpEF, anemia is more closely associated with volume status and not markers of intrinsic myocardial dysfunction. We prospectively studied 419 outpatients in a systematic HFpEF program, all of whom underwent hemoglobin measurement and comprehensive echocardiography. Longitudinal, radial, and circumferential strain were also measured in 311 patients. We defined anemia as hemoglobin <12g/dL in women and <13g/dL in men. Linear and Cox regression analyses were used to determine the association between anemia and echocardiographic/strain variables and adverse outcomes, respectively. Over half (224/419 [53%]) of the HFpEF patients had anemia. Anemia was associated with volume (preload)-dependent markers of diastolic dysfunction including echocardiographic E/A (p = 0.004) and E/e' ratio (p = 0.014) and elevated right heart pressures such as right atrial pressure (p = 0.002) and pulmonary artery systolic pressure (p<0.001). Anemia was not associated with markers of intrinsic myocardial dysfunction such as lateral e' (p = 0.16) and septal e' (p = 0.65) velocities or echocardiographic strain parameters (p > 0.05 for all comparisons). Anemia was associated with the combined outcome of cardiovascular hospitalization or death (hazard ratio = 1.50 [95% confidence interval 1.20, 1.88]; p < 0.001). In conclusion, anemia in HFpEF is associated with markers of volume status and not intrinsic markers of myocardial dysfunction.

MR and CT Imaging for the Evaluation of Pulmonary Hypertension

Imaging plays a central role in the diagnosis and management of all forms of pulmonary hypertension (PH). Although Doppler echocardiography is essential for the evaluation of PH, its ability to optimally evaluate the right ventricle and pulmonary vasculature is limited by its 2-dimensional planar capabilities. Magnetic resonance and computed tomography are capable of determining the etiology and pathophysiology of PH, and can be very useful in the management of these patients. Exciting new techniques such as right ventricle tissue characterization with T1 mapping, 4-dimensional flow of the right ventricle and pulmonary arteries, and computed tomography lung perfusion imaging are paving the way for a new era of imaging in PH. These imaging modalities complement echocardiography and invasive hemodynamic testing and may be useful as surrogate endpoints for early phase PH clinical trials. Here we discuss the role of magnetic resonance imaging and computed tomography in the diagnosis and management of PH, including current uses and novel research applications, and we discuss the role of value-based imaging in PH.

A Papillary Fibroelastoma Involving Aortic and Pulmonary Valves: Findings on Multimodality Imaging

Cardiac papillary fibroelastoma, a rare entity, is the second most common benign primary cardiac tumor. Commonly involving the cardiac valves, this entity is increasingly diagnosed using different imaging modalities. We present a rare case of simultaneous involvement of both the aortic and pulmonary valves in an asymptomatic patient who underwent different imaging modalities, including transthoracic and transesophageal echocardiography, nongated and gated computed tomography, and magnetic resonance imaging. We will discuss the imaging findings and differential diagnosis.

Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging

BACKGROUND

Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized.

MATERIALS AND METHODS

15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results.

RESULTS

Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility).

CONCLUSIONS

Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."

Prognostic Utility and Clinical Significance of Cardiac Mechanics in Heart Failure With Preserved Ejection Fraction: Importance of Left Atrial Strain

BACKGROUND

Left atrial (LA) enlargement is associated with adverse events in heart failure with preserved ejection fraction (HFpEF). However, the role of LA mechanics (ie, LA strain measures) in HFpEF has not been well studied. We hypothesized that in HFpEF, reduced (worse) LA strain is a key pathophysiologic abnormality and is a stronger correlate of adverse events than left ventricular or right ventricular longitudinal strain.

METHODS AND RESULTS

We evaluated baseline LA function in 308 patients with HFpEF who were followed up longitudinally for adverse outcomes. All patients underwent speckle-tracking echocardiography for measurement of left ventricular longitudinal strain, right ventricular free wall strain, and LA booster, conduit, and reservoir strains. The clinical and prognostic significance of left ventricular, right ventricular, and LA strain measures was assessed by regression analyses. The mean age was 65±13 years, 64% were women, 26% had atrial fibrillation, and LA enlargement was present in the majority of patients (67%). Decreased LA reservoir strain was associated with increased pulmonary vascular resistance (P<0.0001) and decreased peak oxygen consumption (P=0.0001). Of the left ventricular, right ventricular, and LA strain measures, LA reservoir strain was the strongest correlate of adverse events and was independently associated with the composite outcome of cardiovascular hospitalization or death (adjusted hazard ratio per 1-SD decrease in LA strain, 1.54; 95% CI, 1.15-2.07; P=0.006).

CONCLUSIONS

Abnormal indices of LA mechanics (particularly LA reservoir strain) are powerful clinical and prognostic factors in HFpEF. Unloading the LA and augmentation of LA function may be important future therapeutic targets in HFpEF.

REGISTRATION INFORMATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01030991.

Right ventricular assessment at cardiac MRI: initial clinical experience utilizing an IS-SENSE reconstruction

Cardiac MR is considered the gold standard in assessing RV function. The purpose of this study is to evaluate the clinical utility of an investigational iterative reconstruction algorithm in the quantitative assessment of RV function. This technique has the potential to improve the clinical utility of CMR in the evaluation of RV pathologies, particularly in patients with dyspnea, by shortening acquisition times without adversely influencing imaging performance. Segmented cine images were acquired on 9 healthy volunteers and 29 patients without documented RV pathologies using conventional GRAPPA acquisition with factor 2 acceleration (GRAPPA 2), a spatio-temporal TSENSE acquisition with factor 4 acceleration (TSENSE 4), and iteratively reconstructed Sparse SENSE acquisition with factor 4 acceleration (IS-SENSE 4). 14 subjects were re-analyzed and intraclass correlation coefficients (ICC) were calculated and Bland-Altman plots generated to assess agreement. Two independent reviewers qualitatively scored images. Comparison of acquisition techniques was performed using univariate analysis of variance (ANOVA). Differences in RV EF, BSA-indexed ESV (ESVi), BSA-indexed EDV (EDVi), and BSA-indexed SV (SVi) were shown to be statistically insignificant via ANOVA testing. R(2) values for linear regression of TSENSE 4 and IS-SENSE 4 versus GRAPPA 2 were 0.34 and 0.72 for RV-EF, and 0.61 and 0.76 for RV-EDVi. ICC values for intraobserver and interobserver quantification yielded excellent agreement, and Bland-Altman plots assessing agreement were generated as well. Qualitative review yielded small, but statistically significant differences in image quality and noise between TSENSE 4 and IS-SENSE 4. All three techniques were rated nearly artifact free. Segmented imaging acquisitions with IS-SENSE reconstruction and an acceleration factor of 4 accurately and reliably quantitates RV systolic function parameters, while maintaining image quality. TSENSE-4 accelerated acquisitions showed poorer correlation to standard imaging, and inferior interobserver and intraobserver agreement. IS-SENSE has the potential to shorten cine acquisition times by 50 %, improving imaging options in patients with intermittent arrhythmias or difficulties with breath holding.

Three-dimensional quantification of myocardial perfusion during regadenoson stress computed tomography

BACKGROUND

There is no accepted methodology for CT-based vasodilator stress myocardial perfusion imaging and analysis. We developed a technique for quantitative 3D analysis of CT images, which provides several indices of myocardial perfusion. We sought to determine the ability of these indices during vasodilator stress to identify segments supplied by coronary arteries with obstructive disease and to test the accuracy of the detection of perfusion abnormalities against SPECT.

METHODS

We studied 93 patients referred for CT coronary angiography (CTCA) who underwent regadenoson stress. 3D analysis of stress CT images yielded segmental perfusion indices: mean X-ray attenuation, severity of defect and relative defect volume. Each index was averaged for myocardial segments, grouped by severity of stenosis: 0%, <50%, 50-70%, and >70%. Objective detection of perfusion abnormalities was optimized in 47 patients and then independently tested in the remaining 46 patients.

RESULTS

CTCA depicted normal coronary arteries or non-obstructive disease in 62 patients and stenosis of >50% in 31. With increasing stenosis, segmental attenuation showed a 7% decrease, defect severity increased 11%, but relative defect volume was 7-fold higher in segments with obstructive disease (p<0.001). In the test group, detection of perfusion abnormalities associated with stenosis >50% showed sensitivity 0.78, specificity 0.54, accuracy 0.59. When compared to SPECT in a subset of 21 patients (14 with abnormal SPECT), stress CT perfusion analysis showed sensitivity 0.79, specificity 0.71, accuracy 0.76.

CONCLUSIONS

3D analysis of vasodilator stress CT images provides quantitative indices of myocardial perfusion, of which relative defect volume was most robust in identifying segments supplied by arteries with obstructive disease. This study may have implications on how CT stress perfusion imaging is performed and analyzed.

Association of chronic kidney disease with abnormal cardiac mechanics and adverse outcomes in patients with heart failure and preserved ejection fraction

AIMS

Chronic kidney disease (CKD) is associated with worse outcomes in heart failure with preserved ejection fraction (HFpEF). Whether this association is due the effect of CKD on intrinsic abnormalities in cardiac function is unknown. We hypothesized that CKD is independently associated with worse cardiac mechanics in HFpEF.

METHODS AND RESULTS

We prospectively studied 299 patients enrolled in the Northwestern University HFpEF Program. Using the creatinine-based CKD-Epi equation to calculate estimated glomerular filtration rate (eGFR), study participants were analysed by CKD status (using eGFR <60 mL/min/1.73 m(2) to denote CKD). Indices of cardiac mechanics (longitudinal strain parameters) were measured using speckle-tracking echocardiography. Using multivariable-adjusted linear and Cox regression analyses, we determined the association between CKD and echocardiographic parameters and clinical outcomes (cardiovascular hospitalization or death). Of 299 study participants, 48% had CKD. CKD (dichotomous variable) and reduced eGFR (continuous variable) were both associated with worse cardiac mechanics indices including left atrial (LA) reservoir strain, LV longitudinal strain, and right ventricular free wall strain even after adjusting for potential confounders, including co-morbidities, EF, and volume status. For example, for each 1-SD decrease in eGFR, LA reservoir strain was 3.52% units lower (P < 0.0001) after multivariable adjustment. Reduced eGFR was also associated with worse outcomes [adjusted hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.01-1.61 per 1-SD decrease in eGFR; P = 0.039]. The association was attenuated after adjustment for indices of cardiac mechanics (P = 0.064).

CONCLUSION

In HFpEF, CKD is independently associated with worse cardiac mechanics, which may explain why HFpEF patients with CKD have worse outcomes.

TRIAL REGISTRATION

NCT01030991.

Three-dimensional echocardiography-based analysis of right ventricular shape in pulmonary arterial hypertension

AIMS

Right ventricular (RV) remodelling involves changes in size, function, and shape. Although three-dimensional echocardiography (3DE) allows imaging of RV morphology, regional RV shape analysis has not been evaluated using 3DE. We developed a technique to quantify RV shape and tested its ability to differentiate normal from pressure overloaded right ventricles. Methods Transthoracic 3DE RV images were acquired in 54 subjects, including 39 patients with pulmonary artery hypertension (PAH) and 15 normal controls (NL). 3D RV surfaces were reconstructed (TomTec) at end-diastole and end-systole (ED, ES) and processed using custom software to calculate mean curvature of the inflow and outflow tracts (RVIT, RVOT), apex, and body (both divided into free wall and septum).

METHODS AND RESULTS

Septal segments (apical and body) in NLs were characterized by concavity (curvature < 0) in ED and slight convexity (curvature > 0) in ES. In PAH, however, the septum remained convex, bulging into the left ventricle throughout the cardiac cycle. In keeping with the 'bellows-like' action of RV contraction in the NL group, the body free wall transitioned from a convex surface at ED to a more flattened surface at ES, while the apex free wall progressed from a less convex surface at ED to a more convex surface at ES. In contrast, in PAH, both RV free-wall segments (apical and body) remained equally convex throughout the cardiac cycle.

CONCLUSIONS

Curvature analysis using 3D echocardiography allows quantitative evaluation of RV remodelling, which could be used to track differential changes in regional RV shape, as a way to assess disease progression or regression.

Extracellular volume fraction is more closely associated with altered regional left ventricular velocities than left ventricular ejection fraction in nonischemic cardiomyopathy

BACKGROUND

Nonischemic cardiomyopathy is a common cause of left ventricular (LV) dysfunction and myocardial fibrosis. The purpose of this study was to noninvasively evaluate changes in segmental LV extracellular volume (ECV) fraction, LV velocities, myocardial scar, and wall motion in nonischemic cardiomyopathy patients.

METHODS AND RESULTS

Cardiac MRI including pre- and postcontrast myocardial T1 mapping and velocity quantification (tissue phase mapping) of the LV (basal, midventricular, and apical short axis) was applied in 31 patients with nonischemic cardiomyopathy (50±18 years). Analysis based on the 16-segment American Heart Association model was used to evaluate the segmental distribution of ECV, peak systolic and diastolic myocardial velocities, scar determined by late gadolinium enhancement, and wall motion abnormalities. LV segments with scar or impaired wall motion were significantly associated with elevated ECV (rs =0.26; P<0.001) and reduced peak systolic radial velocities (r=-0.43; P<0.001). Regional myocardial velocities and ECV were similar for patients with reduced (n=12; ECV=0.28±0.06) and preserved left ventricular ejection fraction (n=19; ECV=0.30±0.09). Patients with preserved left ventricular ejection fraction showed significant relationships between increasing ECV and reduced systolic (r=-0.19; r=-0.30) and diastolic (r=0.34; r=0.26) radial and long-axis peak velocities (P<0.001). Even after excluding myocardial segments with late gadolinium enhancement, significant relationships between ECV and segmental LV velocities were maintained indicating the potential of elevated ECV to identify regional diffuse fibrosis not visible by late gadolinium enhancement, which was associated with impaired regional LV function.

CONCLUSIONS

Regionally elevated ECV negatively affected myocardial velocities. The association of elevated regional ECV with reduced myocardial velocities independent of left ventricular ejection fraction suggests a structure-function relationship between altered ECV and segmental myocardial function in nonischemic cardiomyopathy.

Right ventricular strain in pulmonary arterial hypertension: a 2D echocardiography and cardiac magnetic resonance study

BACKGROUND

Right ventricular (RV) strain is a potentially useful prognostic marker in patients with pulmonary arterial hypertension (PAH). However, published reports regarding the accuracy of two-dimensional echocardiography (2DE)-derived RV strain against an independent reference in this patient population are limited. The aims of this study were: (1) to study the relationship between 2DE RV longitudinal strain and cardiovascular magnetic resonance (CMR)-derived RV ejection fraction (RVEF) in patients with PAH; (2) to compare 2DE-derived and CMR-derived RV longitudinal strain in these patients; and (3) to determine the reproducibility of these measurements.

METHODS

Thirty patients with PAH underwent 2DE and CMR imaging within a 2-hour time period. 2DE RV longitudinal strain was measured from a focused RV apical four-chamber view using speckle tracking software. CMR RV longitudinal strain was measured from short-axis slices acquired using fast-strain-encoded sequence. Global peak systolic RV longitudinal strain was calculated for both 2DE and CMR.

RESULTS

RV longitudinal strain using 2DE software correlated well with CMR-derived RVEF (R = 0.69, P = 0.0006). There was moderate agreement when comparing 2DE to CMR RV longitudinal strain (R = 0.74, P = 0.0002; bias -1%, limits of agreement -9 to 7%). Inter-observer variability and intra-observer variability for RV longitudinal strain were lower for 2DE than CMR.

CONCLUSIONS

RV longitudinal strain by 2DE provides a good alternative for CMR-derived RVEF in patients with PAH. The moderate agreement in strain measurements between 2DE and CMR suggests that further software improvements are needed before these measurements can be used interchangeably in clinical practice.