The prognostic value of speckle tracking echocardiography in patients hospitalized with COVID-19

Introduction

In COVID-19 patients, both preexisting cardiovascular disease as well as cardiac injury resulting from SARS-CoV-2 infection are associated with increased mortality. We hypothesized that novel parameters of myocardial function may be useful in the assessment of in-hospital and long-term prognosis.

Aim

The aim of study was to determine the prevalence of myocardial dysfunction revealed by speckle tracking echocardiography and its association with in-hospital and one-year mortality.

Methods

The study group comprised 192 patients hospitalized in the cardiology department due to COVID-19. All patients underwent transthoracic echocardiographic examination with off-line analysis. Using speckle tracking technique, we measured the following parameters: left ventricular global longitudinal strain (GLS), right ventricular global longitudinal strain (RV-GLS), right ventricular free wall strain (RV-FWS) and myocardial work parameters – global work index (GWI), global wasted work (GWW), global constructive work (GCW) and global work efficiency (GWE). The primary outcome was in-hospital and one-year mortality.

Results

112 patients (mean age 68±14 years, 76 (68%) male) had adequate image quality to evaluate strain-derived parameters. 27 patients died during hospitalization and 44 patients died within one-year after discharge. In-hospital non-survivors were older, had lower baseline oxygen saturation (SpO2) and had higher NTproBNP (Table 1). In non-survivors speckle-tracking echocardiography revealed significant impairment of left and right ventricular function compared to the group of survivors (Table 1). The independent predictors of in-hospital death were GWE (OR 0.85; 95% CI 0.78–0.93) and SpO2 on admission (OR 0.91; 95% CI 0.86–0.96). Based on the ROC curve analysis, the optimal cut-off points for predicting in-hospital death were identified: GWE ≤87% (sensitivity 63%, specificity 89%) and baseline SpO2 value ≤88% (sensitivity 81%, specificity 71%).

The independent predictors of one-year mortality were: age (OR 1.28 [1.13–1.46]), NTproBNP (OR 1.002 [1.001–1.003]), baseline SpO2 (OR 0.71 [0.59–0.86]) and RV-GLS (OR 1.32 [1.12–1.55]). Based on the ROC curve analysis, the cut-off points optimal for predicting death within 12 months after COVID-19 were also identified: baseline SpO2 value ≤88% (sensitivity 69.8%, specificity 77.3%), age >60 years (sensitivity 90%, specificity 43%), NTproBNP >500 pg/ml (sensitivity 95%, specificity 41.8%), RV-GLS >−18.5 (sensitivity 93%, specificity 64.2%).

Conclusions

Two-dimensional speckle tracking echocardiography is a useful technique to evaluate myocardial function in COVID-19 patients and provides good prognostic value for identifying patients at risk of death during hospitalization and in long term follow-up.

Funding Acknowledgement

Type of funding sources: None.

Continuous hands-free monitoring of echocardiographic exercise test using probe fixation device

BACKGROUND

Stress echocardiography has been widely used in clinical practice for decades and has recently gained even more importance in diagnostic approaches to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise tests. The aim herein, is to assess the feasibility of probe fixation for use during exercise echocardiography.

METHODS

Forty-eight subjects (47 men, mean age 42 ± 17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). The semi-quantitative quality of acquired apical views were assessed at each stage using a four-point grading system.

RESULTS

The mean time required for probe fixation was 9 ± 2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. Twenty-five patients required probe repositioning during exercise (more often on a treadmill). During peak exercise quality of images in all views declined, but for diagnostic purposes it remained sufficient in 29 patients. Thus, 76% of performed tests (60% study population) had sufficient image quality.

CONCLUSIONS

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. The device is suitable almost exclusively for male patients and in some patients requires repositioning.

Percutaneous closure of atrial appendage with thrombus - a strategy shift? Report of a case series

Funding Acknowledgements

Type of funding sources: None.

Background. Percutaneous closure of left atrial appendage (LAAO)  is a recent preventive modality in atrial fibrillation. (AF) However, presence of thrombus which is a strong stroke risk multiplier represented a standard contraindication to purely percutaneous approach. 

Aim. To test the safety and feasibility of LAAO in patients (pts) with appendage blood stasis and distal thrombus.

Methods. Using a novel generation transvascular device allowing "shallow dive" implantation we tested the feasibility of LAAO in pts with appendage blood stasis and distal thrombus. Additionally, hybrid transvascular approach with arch protection device was also tested. Indications included development of heart failure in AF or recurrent cerebral events in pts with LAA thrombi.

Results. We successfully performed 3 procedures in pts (2F, 1M, age 73-76) with distal LAA thrombus confirmed in 3D TEE / CT. After 3D echocardiographic sizing omitting appendage angiogram, occluder was implanted from right femoral venous access via septal puncture. In 2 patients right radial access was additionally used to introduce commercially available arch protection device. In all cases the occluder did not engage distal appendage zone and was appropriately deployed. However in patients with arch protection 1-2 mm debris was captured by protection device. No neurological sequelae were noted.

Conclusion. Our initial experience documents safety and feasibility of percutaneous LAAO in presence of appendage blood stasis and distal thrombus based on 3DE sizing and novel genertaion device with optional percutaneous aortic arch protection. The long term efficacy of such unorthodox has yet to be determined in the setting of severely prothrombotic milieu, abnormal left ventricular function but with potential for risk reduction or even reopening options of cardioversion. Abstract Figure. Occlusion of LAA appendage with thrombus

Feasibility and clinical utility of real-time tele-echocardiography using personal mobile device-based pocket echocardiograph

INTRODUCTION

Recently introduced microUSB ultrasound probe, which can be connected to personal mobile device constitutes a new class of diagnostic pocket size imaging devices (PSID).The aim of this study was to assess the feasibility and clinical utility of real-time tele-echocardiography with the use such device.

MATERIAL AND METHODS

The study group comprised 30 patients (18 men and 12 women; mean age: 54 ±14 years; mean body mass index: 27 ±6 kg/m²), admitted to various hospital departments (infectious diseases, internal medicine and cardiology). All patients underwent focused echocardiographic examination performed by an inexperienced operator using PSID and collaborating remotely in real-time with cardiologist by means of tele-consultation. Before commencing the examination, the operators underwent 1 h training in use of the PSID.

RESULTS

In most of patients PSID imaging provided sufficient diagnostic image quality. The dimensions of left ventricle, left atrium and the aorta obtained during the this examination showed good correlation with standard echocardiography (r = 0.89, r = 0.82, r = 0.92 respectively), but the correlation for TAPSE measurements was less pronounced (r = 0.52). The agreement in detection of pathologies (wall motion abnormalities, morphological and functional valvular abnormalities) between the tele-echocardiography and standard echocardiographic examination was good to very good (κ ranged from 0.648 to 0.823).

CONCLUSIONS

Pocket size imaging devices allows an inexperienced operator to perform a focused echocardiographic examination under a remote supervision of an experienced cardiologist. The introduction of new technology in the form of PSID with tele-echocardiography feature can revolutionize access to this imaging technique.

Complexity of changes in right ventricular morphology and function in patients undergoing cardiac surgery - 3D echocardiographic study

BACKGROUND

An impairment of standard echocardiographic parameters of right ventricular (RV) function is a known phenomenon in patients undergoing cardiac surgery, but its significance remains to be clarified.

AIMS

To assess changes in RV function in patients undergoing cardiac surgery using speckle tracking and 3D echocardiography.

METHODS

The study population comprised 122 patients, referred for cardiac surgery. Transthoracic echocardiographic (TTE) examinations were performed: before the surgery (TTE1), 1 week after surgery (TTE2) and 1 year after the surgery (TTE 3). Parameters measured during these examinations included both standard and advanced indices of RV size and function, as well as a new parameter introduced by our team -RV shortening fraction (RVSF).

RESULTS

TTE1 was performed on average (standard deviation [SD]) 24 (15) hours prior to surgery, whereas TTE2 and TTE3 were performed on average 7.2 (3) days and 346 (75) days after the surgery, respectively. A postoperative impairment of parameters of RV longitudinal function was observed (P <0.001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of fractional area change and ejection fraction. Additionally during the postoperative period an increase in the value of a RVSF by 12.9% was observed. After 12 months we observed an improvement in the parameters of the longitudinal RV function.

CONCLUSIONS

Uncomplicated cardiac surgery causes transient impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RVSF. After 12 months, an improvement of the longitudinal function can be observed.

Early increase of high-sensitivity cardiac troponin predicts mortality in cancer patients undergoing chemotherapy

Introduction

High-sensitivity cardiac troponin test (hs-TnT) reveals subclinical myocardial damage in many cardiac conditions. We hypothesized that elevated hs-TnT may predict a development of cancer therapy-related cardiac dysfunction and clinical outcomes linked with antineoplastic therapies. We aimed to evaluate the predictive value of hs-TnT for all-cause mortality in a group of patients (pts) with recent diagnosis of cancer.

Material and methods

We included 80 pts (mean age 57±13 years; 98% women) with recently diagnosed cancer (78 breast cancer, 1 colon cancer, 1 DLBCL lymphoma). Transthoracic echocardiography and hs-TnT tests were performed at baseline and after 3, 6 and 12-months. Pts with LVEF &lt;50% and significant valvular disease were excluded.

Results

In the study group 44% pts had arterial hypertension, 54% dyslipidemia, 9% diabetes mellitus; 94% pts were treated with anthracyclines, 30% with trastuzumab, 54% with hormone therapy, 71% with radiotherapy. A significant decrease of LVEF were observed during follow-up (LVEF at baseline, 3, 6 and 12 months: 61.7±2.0%; 60.9±2.0%*; 60.8±2.9%*; 59.9±2.9%*; *p&lt;0.05 vs baseline). A significant reduction of global longitudinal strain was found only at 6-month follow-up (−19,2±2,2% vs −18,6±2,0%; p=0,003). In 38 pts at least a twofold (fourfold in37) increase in hs-TnT &gt;99th percentile was observed. A rise of hs-TnT was most often seen at 3 month (n=35; 43,8%). During median 1056 (221–1906) days off follow-up 18 (24%) pts died and ROC curve analysis revealed that early (0–3 months) hs-TnT increase more than 10 pg/ml [AUC=0,693 (0,545–0,806); p=0,017)] represented a predictor of death [OR=3,4 (1,99–11,87)].

Conclusions

Increase in hs-TnT in cancer patients detected at 3rd month of chemotherapy predicts mortality.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Exercise stress echocardiography with probe fixated on patient's chest

Background

Stress echocardiography (SE) has been widely used in clinical practice for decades and recently has gained even more importance in diagnostic approach to ischemic heart disease. However, it still has numerous limitations. Despite advantages of physical exercise as most physiologic stressor, it is impossible to continuously monitor the cardiac function during treadmill test and difficult to maintain an optimal acoustic window during cycle ergometer exercise test. We aimed to assess the feasibility of probe fixation for the use during exercise echocardiography.

Methods

48 subjects (47 men, mean age 42±17 years, 25 healthy volunteers, 23 patients with suspected coronary artery disease) were included in this study. All subjects underwent exercise stress test on treadmill (32 cases) or cycle ergometer (16 cases). Both sector and matrix probes were used (in 17 and 31 tests, respectively). We assessed semi-quantitatively the quality of acquired apical views at each stage using four-point grading system (0 = poor, 1 = suboptimal, 2 = acceptable, 3 = optimal).

Results

The mean time required for probe fixation was 9±2 min. At baseline, 10 patients had at least one apical window of quality precluding reliable analysis. 25 patients probe repositioning during exercise (more often on treadmill). During peak exercise quality of images in all views declined, but it remained sufficient in 29 patients for diagnostic purposes. Thus, 76% of performed tests (60% for all study population) were of sufficient image quality.

Conclusion

Probe fixation offers the possibility of continuous acquisition of echocardiographic images during physical exercise. However the device is suitable almost exclusively for male patients. Moreover, in some patients it requires repositioning.

Funding Acknowledgement

Type of funding sources: None.

Artificial Intelligence-Powered Measurement of Left Ventricular Ejection Fraction Using a Handheld Ultrasound Device

The aim of this study was to assess the accuracy of an algorithm for automated measurement of left ventricular ejection fraction (LVEF) available on handheld ultrasound devices (HUDs). One hundred twelve patients admitted to the cardiology department underwent assessment performed with an HUD. In each case, the four-chamber apical view was obtained, and LVEF was calculated with LVivo software. Subsequently, during the examination performed with the use of the stationary echocardiograph, the 3-D measurement of LVEF was recorded. The average LVEFs measured with LVivo and the 3-D reference method were 46 ± 14% and 48 ± 14%, respectively. The correlation between the measurements obtained with the HUD and 3-D evaluation was high (r = 0.92, 95% confidence interval: 0.87-0.95, p < 0.0001). The mean difference between the LVEF obtained with LVivo and the 3-D LVEF was not significant (mean difference: -0.61%, 95% confidence interval: -1.89 to 0.68, p = 0.31). The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality.

Does automated left ventricular ejection fraction assessment available on handheld ultrasound devices represent improvement in the diagnostic accuracy?

Funding Acknowledgements

Type of funding sources: None.

Purpose

To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD).

Methods

112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded.

Results

Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group  In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality.

The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%).

The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between  the LVEF values obtained with the two methods was  r = 0,92; (P &lt; 0,0001). Using paired samples t-test we found that the difference between these two techniques was not significant (mean difference 4,5± 3,4%; P = 0,35).

LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled  r = 0,78; (P &lt; 0,0001).

Conclusion

The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Right ventricular morphology and function undergo complex changes after cardiac surgery

Background

An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique.

Methods

The study population comprised 122 patients (92 men, mean age 65±11 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2±2 days prior to surgery (TTE1), and 7±4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12±2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function (such as TAPSE, systolic velocity of tricuspid annulus (S'), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS), as well as a new parameter introduced by our team - RV shortening fraction (RV SF), calculated as the change in mid RV transverse diameter.

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S' and GLS; p&lt;0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. Additionally during the postoperative period an increase in the value of a RV SF by 12.85% was observed. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Grant Polish Cardiac Society

Mixed reality interactive visualization of cardiovascular anatomy in interventional lab – clinical implementation in transvascular patent ductus arteriosus closure

Aim

Three-dimensional (3D) noninvasively acquired datasets containing anatomical information about the heart are a modern option for procedural support during percutaneous cardiac interventions. We present initial experience of patent ductus arteriosus (PDA) closure with workflow integrated with innovative mixed reality display (MRD) to improve 3D perception and navigation in 3D computed tomography angiographic (CTA) datasets.

Methods

We report incorporation of intraprocedural mixed-reality display of segmented CTA (computed tomography angiography) data using a voice- and gesture controlled head-mounted display during routine percutaneous occlusions of PDA in adults. A dedicated software pathway was used for files conversion, real-time Wi-Fi streaming of 3D rendering from PC to device and manipulation of spatial data during the procedures.

Results

Pre-recorded CTA studies of aorta and ductus were manually segmented and uploaded into custom designed 3D DICOM for realtime export to MRD device. 3D holograms were successfully displayed during the procedure by commercially available head-mounted display allowing touchless control and image sharing within cath-lab. Wiring of PDA aortic orifice was assisted by 3D hologram controlled by the imaging specialist and shared by the operator. Thus, MRD using evolving versions of custom software was successfully executed with segmented data presented as a semitransparent cubic hologram positioned in a convenient part of visual field allowing real-world action and with touchless control by medical team. Operator appreciated the use of MRD hologram realistically visualizing spatial relationships as practical aid to establish anatomical relationships and facilitate entry into ductus orifice. Procedures were successfully completed using arteriovenous guidewire loop to implant vascular occluders.

Conclusions

We demonstrate the methodology and software evolution (segmentation, data fusion) allowing practical implementation of intraprocedural mixed reality display of 3D CTA data, with sterile, touchless control of holographic image shared by interventional and imaging team to support percutaneous PDA closure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): MEDAPP

Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography

OBJECTIVES

The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE).

BACKGROUND

B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE.

METHODS

The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up.

RESULTS

According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction.

CONCLUSIONS

Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638).

RESULTS

Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638).

RESULTS

Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

P1413 Complexity of changes in right ventricular function in patients undergoing cardiac surgery

Background

An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique.

Methods

The study population comprised 105 patients (76 men, mean age 65 ± 16 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2 ± 2 days prior to surgery (TTE1) , and 7 ± 4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12 ± 2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function, such as TAPSE, systolic velocity of tricuspid annulus (S"), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS).

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S’ and GLS; p &lt; 0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. After 12 months, an improvement of the longitudinal function can be observed.

P210 The influence of the right ventricle on the right atrium: a speckle tracking echocardiography study

Purpose

To investigate the relationship between right atrial deformation and the right ventricular size and function.

Methods

94 patients with various cardiovascular pathologies have been included in the study group. All patients underwent transthoracic echocardiography with subsequent off-line analysis using speckle tracking technique and measurement of numerous right atrial deformation parameters, including peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS), as well as established indices of right ventricular size and function, including right ventricular basal diameter in apical four-chamber view (RVITd), tricuspid annular peak systolic excursion (TAPSE) and global longitudinal strain (GLS).

Results

There was a statistically significant weak correlation between RA strain (PACS and PALS) and RV parameters. RV-GLS showed significant correlation with PALS (r = -0,38; p = 0,0015) and PACS (r = - 0,30; p = 0,013). Similarly, TAPSE correlated with PALS and PACS (r = 0,34; p = 0,02) and (r = 0,23; p = 0,04) respectively. However, there was no correlation between right atrial function and RVIT.

Conclusions

Right atrial deformation parameters weakly correlate with right ventricular function indices and show no correlation with the size of the right ventricle.

P1398 Echocardiographic continuous monitoring of exercise stress test using probe fixation device

Background

Stress echocardiography (SE) plays an important role among methods of noninvasive diagnosis of ischemic disease. Despite the advantages of physical exercise as the most physiologic stressor, it is difficult (bicycle ergometer) or impossible (treadmill) to obtain and maintain the acoustic window during the exercise. Recently, an innovative probe fixation device was introduced and a research plan was developed to assess the feasibility of external probe fixation during exercise echocardiography on a supine bicycle and upright treadmill exercise for the first time.

Methods

37 subjects (36 men, mean age 39 ± 16 years, 21 healthy volunteers, 16 patients with suspected coronary artery disease) were included in this study. This preliminary testing stage included mostly men due to more problematic probe fixation in women. All subjects underwent a submaximal exercise stress test on a treadmill (17/37) or bicycle ergometer (11/37). Both sector and matrix probes were used. We assessed semi-quantitatively the quality of acquired apical views at each stage – the four-point grading system was used (0-no view, 1-suboptimal quality, 2-optimal quality, 3-very good quality), 2-3 sufficient for diagnosis.

Results

The mean time required for careful positioning of the probe and image optimization was 12 ± 3 min and shortened from 13,7 to 11,1 minutes (mean) in first vs second half of the cohort documenting learning curve. At baseline, 9 patients had at least one apical view of quality precluding reliable analysis. Those patients were excluded from further assessment. During stress, 17 patients maintained the optimal or very good quality of all apical views, whereas in 11 patients the quality significantly decreased during the stress test and required probe repositioning. The mean image quality score at baseline was 2,61 ± 0,48 and 2,25 ± 0,6 after exercise. Expectedly, good image quality was easier to obtain and maintain in the supine position (score 2,74 ± 0,44) points as compared with upright position (score 2,25 ± 0,57).

Conclusion

This preliminary, unique experience with external probe fixation device indicates that continuous acquisition and monitoring of echocardiographic images is feasible during physical exercise, and for the first time ever - also on the treadmill. This feasibility data stem from almost exclusively male patients and the estimated rate of sufficient image quality throughout the entire test is currently around 60%. We are hoping, that gaining more experience with the product could increase the success rate on exercise tests.

Abstract P1398 Figure. Treadmill and ergometer stress test

P274 Continous echocardiographic monitoring in intensive cardiac care unit with external probe stabilizer - preliminary experience

Background

The role of transthoracic echocardiography (TTE) in the intensive cardiac care unit is crucial. Imaging is currently performed at the bedside for diagnosis but TTE has also potential to noninvasively provide critical views to assist in patient monitoring. Continuous monitoring would be especially helpful when the patient is unstable; however, continuous availability of skilled sonographers to obtain appropriate views represents a limiting factor.

Purpose

Recently, an innovative external fixation device allowing prolonged stabilization of transthoracic ultrasound transducer was introduced. The ring-shaped device fitted for TTE probes is attached to the patient by elastic straps to hold the probe in contact with the skin at a fixed but adjustable angle. We developed a research project to assess for the first time the feasibility of continuous TTE imaging with external probe fixation in the intensive cardiac care unit.

Methods

12 patients (10 men, mean age 66,5 ± 15 years) hospitalized in intensive cardiac care unit due to cardiac arrest, myocardial infarction, pulmonary embolism, end-stage heart failure or respiratory failure were included in the study. The echocardiographic probe be was fixed in the apical window providing a four-chamber view to monitor left ventricular function. We assessed the patient’s tolerance and comfort as well as the quality of images acquired at baseline and at the end of monitoring.

Results

Fixation of the probe was successful in all patients (figure 1). The mean time of fixation was 10 ± 1 minute, with a clear learning curve. The quality of obtained images was sufficient for evaluation and was maintained throughout the entire period of monitoring in all patients. Monitoring was stopped at patients’ request when discomfort caused by the compression of the skin by the probe and the fixation device became significant (figure 2). The mean duration of monitoring was 85 + 64 minutes (range 15 to 240 minutes).

Conclusions

In this preliminary series we have demonstrated for the first time the feasibility of echocardiographic continuous monitoring of patients in the intensive cardiac care unit using TTE probe with the external fixation device. The design of the fixation device opens the evident field for optimization to extend monitoring duration at acceptable levels of discomfort in conscious intensive care patients. We hope the improved version of the fixator will decrease the pressure on the body.

Abstract P274 Figure. Fixation of the device

P4357Implementation of interactive mixed reality display of three-dimensional echocardiography during percutaneous structural interventions

Background

Three-dimensional (3D) echocardiographic data acquired from transesophageal (TEE) window are commonly used in planning and during percutaneous structural cardiac interventions (PSCI).

Purpose

We hypothesized that innovative, interactive mixed reality display can be integrated with procedural PSCI workflow to improve perception and interpretation of 3D data representing cardiac anatomy.

Methods

3D TEE datasets were acquired before, during and after the completion of PSCI in 8 patients (occluders: 2 atrial appendage, 2 patent foramen ovale and 3 atrial septal implantations and percutaneous mitral commissurotomy). 30 Carthesian DICOM files were used to test the feasibility of mixed reality with commercially available head-mounted device (overlying hologram of 3D TEE data onto real-world view) as display for the interventional or imaging operator. Dedicated software was used for files conversion and 3D rendering of data to display device (in 1 case real-time Wi-Fi streaming from echocardiograph) and spatial manipulation of hologram during PSCI. Custom viewer was used to perform volume rendering and adjustment (cropping, transparency and shading control).

Results

Pre- and intraprocedural 3D TEE was performed in all 8 patients (5 women, age 40–83). Thirty selected 3DTEE datasets were successfully transferred and displayed in mixed reality head-mounted device as a holographic image overlying the real world view. The analysis was performed both before and during the procedure and compared with flatscreen 2-D display of the echocardiograph. In one case, real-time data transfer was successfully implemented during mitral balloon commissurotomy. The quality of visualization was judged as good without diagnostic content loss in all (100%) datasets. Both target structures and additional anatomical details were clearly presented including fenestrations of atrial septal defect, prominent Eustachian valve and earlier cardiac implants. Volume rendered views were touchlessly manipulated and displayed with a selection of intensity windows, transfer functions, and filters. Detail display was judged comparable to current 2-D volume-rendering on commercial workstations and touchless user interface - comfortable for optimization of views during PSCI.

Conclusions

Mixed reality display using a commercially available head-mounted device can be successfully integrated with preparation and execution of PSCI. The benefits of this solution include touchless image control and unobstructed real world viewing facilitating intraprocedural use, thus showing superiority over virtual or enhanced reality solutions. Expected progress includes integration of color flow data and optimization of real-time streaming option.

Quality control of B-lines analysis in stress Echo 2020

BACKGROUND

The effectiveness trial "Stress echo (SE) 2020" evaluates novel applications of SE in and beyond coronary artery disease. The core protocol also includes 4-site simplified scan of B-lines by lung ultrasound, useful to assess pulmonary congestion.

PURPOSE

To provide web-based upstream quality control and harmonization of B-lines reading criteria.

METHODS

60 readers (all previously accredited for regional wall motion, 53 B-lines naive) from 52 centers of 16 countries of SE 2020 network read a set of 20 lung ultrasound video-clips selected by the Pisa lab serving as reference standard, after taking an obligatory web-based learning 2-h module ( http://se2020.altervista.org ). Each test clip was scored for B-lines from 0 (black lung, A-lines, no B-lines) to 10 (white lung, coalescing B-lines). The diagnostic gold standard was the concordant assessment of two experienced readers of the Pisa lab. The answer of the reader was considered correct if concordant with reference standard reading ±1 (for instance, reference standard reading of 5 B-lines; correct answer 4, 5, or 6). The a priori determined pass threshold was 18/20 (≥ 90%) with R value (intra-class correlation coefficient) between reference standard and recruiting center) > 0.90. Inter-observer agreement was assessed with intra-class correlation coefficient statistics.

RESULTS

All 60 readers were successfully accredited: 26 (43%) on first, 24 (40%) on second, and 10 (17%) on third attempt. The average diagnostic accuracy of the 60 accredited readers was 95%, with R value of 0.95 compared to reference standard reading. The 53 B-lines naive scored similarly to the 7 B-lines expert on first attempt (90 versus 95%, p = NS). Compared to the step-1 of quality control for regional wall motion abnormalities, the mean reading time per attempt was shorter (17 ± 3 vs 29 ± 12 min, p < .01), the first attempt success rate was higher (43 vs 28%, p < 0.01), and the drop-out of readers smaller (0 vs 28%, p < .01).

CONCLUSIONS

Web-based learning is highly effective for teaching and harmonizing B-lines reading. Echocardiographers without previous experience with B-lines learn quickly.

Association between microRNA-21 concentration and lipid profile in patients with acute coronary syndrome without persistent ST-segment elevation

INTRODUCTION

MicroRNA (miRNAs) are noncoding RNAs involved in the regulation of gene expression. Certain miRNAs, especially miRNA-21 (miR-21), may be involved in lipid metabolism.

OBJECTIVES

The aim of the study was to evaluate the association between plasma free circulating miR-21 levels and lipid fractions: total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), non-HDL-C, and triglycerides (TG), as well as their atherogenic profile expressed as the ratio of individual lipid fractions (TC:LDL-C, TC:non-HDL-C, TG:HDL-C, and HDL-C:LDL-C) in patients with acute coronary syndromes without persistent ST -segment elevation (NSTE ACS).

PATIENTS AND METHODS

The study group consisted of 34 patients diagnosed with NSTE ACS on admission to the emergency department. Plasma miRNA levels were determined by real-time polymerase chain reaction and the ΔΔCt method. Serum lipid fractions were assessed after a minimum of 12-hour fasting during the first day of hospitalization.

RESULTS

MiR-21 levels showed a significant inverse correlation with TC (r = -0.5; P = 0.002), LDLC (r = -0.5; P = 0.001), and non-HDL-C (r = -0.6; P <0.001) levels. Moreover, they were inversely correlated with TC:HDL-Cratio (r = -0.6; P <0.001), LDL-C:HDL-Cratio (r = -0.6; P <0.001), TG:HDL-Cratio (r = -0.4; P = 0.037), and TC:non-HDLratio (r = 0.6; P <0.001). In a multivariate analysis, miR-21 levels (β = -0.41; P = 0.018) and the need for revascularization (β = 0.35; P = 0.027) were independent predictors of non-HDL-C levels.

CONCLUSIONS

Free circulating miR-21 levels inversely correlate with TC, LDL-C, and non-HDL-C and are an independent predictor of non-HDL-C levels in patients with NSTE ACS. Thus, the overexpression of miR-21 is associated with a less atherogenic lipid profile.

Feasibility and clinical benefit of cognitive-behavioral intervention for preparing patients for transesophageal echocardiography

Objective:

Despite premedication, anxiety in patients undergoing transesophageal echocardiography (TEE) is prevalent, often causing adverse physiological and psychological effects and contributing to decreased patient compliance. We aimed to evaluate the feasibility of cognitive–behavioral intervention (CBI) in patients undergoing TEE and to assess its impact on the severity of anxiety, patient’s and physician’s comfort, and administered dose of sedatives.

Methods:

Our study was designed as a prospective, single-center, single-blinded, case-controlled pilot study. The study group comprised 49 patients (26 men, 66±8 years old) referred for TEE. Before the examination, 26 randomly selected patients underwent CBI. Sedatives were administered, if necessary. After the examination, patient anxiety and patient’s and physician’s comfort were evaluated using dedicated questionnaires and scores. Intergroup comparison was performed using Student’s t-test for independent variables and Mann–Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables.

Results:

The mean level of pre-TEE distress and anxiety were significantly lower in patients receiving CBI than in those without intervention (p=0.022). Furthermore, the application of CBI significantly reduced patient’s discomfort (p<0.001) and resulted in increased comfort of physician (p<0.001) during TEE. The need of sedative administration (31% vs. 91%, p<0.001) and its mean dose was significantly lower in patients receiving CBI (1.6±0.5 mg vs. 2.7±1.6 mg midazolam, p=0.009).

Conclusions:

CBI is feasible in patients undergoing TEE. It decreases patient’s anxiety and discomfort and increases physician’s comfort. It also results in reduced use of sedatives during the examination.

Fusion of morphological data obtained by coronary computed tomography angiography with quantitative echocardiographic data on regional myocardial function

BACKGROUND

Three-dimensional (3D) fusion of morphological data obtained by coronary computed tomography angiography (CCTA) with functional data from resting and stress echocardiography could potentially provide additional information compared to examination results analyzed separately and increase the diagnostic and prognostic value of non-invasive imaging in patients with suspected coronary artery disease (CAD). Using vendor-independent software developed in our institution, we aimed to assess the feasibility and reproducibility of 3D fusion of morphological CCTA data with echocardiographic data regarding regional myocardial function.

METHODS

Thirty patients with suspected CAD underwent CCTA and resting transthoracic echocardiography. From CCTA we obtained 3D reconstructions of coronary arteries and left ventricle (LV). Offline speckle-tracking analysis of the echocardiographic images provided parametric maps depicting myocardial longitudinal strain in 17 segments of the LV. Using our software, 3 independent investigators fused echocardiographic maps with CCTA reconstruc-tions in all patients. Based on the obtained fused models, each segment of the LV was assigned to one of the major coronary artery branches.

RESULTS

Mean time necessary for data fusion was 65 ± 7 s. Complete agreement between independent investigators in assignment of LV segments to coronary branches was obtained in 94% of the segments. The average coefficient of agreement (kappa) between the investigators was 0.950 and the intra-class correlation coefficient was 0.9329 (95% CI 0.9227-0.9420).

CONCLUSIONS

Three-dimensional fusion of morphological CCTA data with quantitative echocardiographic data on regional myocardial function is feasible and allows highly repro-ducible assignment of myocardial segments to coronary artery branches.