What Do We Know So Far About Ventricular Arrhythmias and Sudden Cardiac Death Prediction in the Mitral Valve Prolapse Population? Could Biomarkers Help Us Predict Their Occurrence?

PURPOSE OF THE REVIEW

To summarize currently available data on the topic of mitral valve prolapse (MVP) and its correlation to the occurrence of atrial and ventricular arrhythmias. To assess the prognostic value of several diagnostic methods such as transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance, cardiac computed tomography, electrocardiography, and electrophysiology concerning arrhythmic episodes. To explore intra and extracellular biochemistry of the cardiovascular system and its biomarkers as diagnostic tools to predict rhythm disturbances in the MVP population.

RECENT FINDINGS

MVP is a common and mainly benign valvular disorder. It affects 2-3% of the general population. MVP is a heterogeneous and highly variable phenomenon with three structural phenotypes: myxomatous degeneration, fibroelastic deficiency, and forme fruste. Exercise intolerance, supraventricular tachycardia, and chest discomfort are the symptoms that are often paired with psychosomatic components. Though MVP is thought to be benign, the association between isolated MVP without mitral regurgitation (MR) or left ventricle dysfunction, with ventricular arrhythmia (VA) and sudden cardiac death (SCD) has been observed. The incidence of SCD in the MVP population is around 0.6% per year, which is 6 times higher than the occurrence of SCD in the general population. Often asymptomatic MVP population poses a challenge to screen for VA and prevent SCD. Therefore, it is crucial to carefully assess the risk of VA and SCD in patients with MVP with the use of various tools such as diagnostic imaging and biochemical and genetic screening.

Lip print evidence: Poland as the Last Bastion of Practical Cheiloscopy

Cheiloscopic examinations have long been conducted, and many scientists have reported the usefulness of cheiloscopy for personal identification with a characteristic and individual pattern of furrows on the vermilion lip. For almost 40 years, research conducted in Poland has determined the patterns of these furrows and the separation and development of their individual features. This was the basis for forming expert opinions and presenting them in court as evidence. In Poland, cheiloscopic expertise is performed and the results of precise procedures that are accredited and assessed serve as evidence. Although the legal system in Poland (continental system) is completely different from the American system, cheiloscopic expertise was also assessed in detail according to the American standards of evidence. This narrative review presents the problem of cheiloscopic expertise as a scientific and practical issue and provides a brief historical overview of this field and the foundations of the Polish cheiloscopic identification method. We conclude that Poland has sufficient historical background and a robust development of cheiloscopy in the field on a scientific and legal basis; however, due to its reports being in the Polish language, its absence from the most relevant specialized literature, or simply a lack of cooperation between countries and experts, the country has unfairly been left out of the discussion. We believe that a new look at the Polish contribution to lip print identification is necessary to reinsert this topic into the current discussion of a new identification paradigm.

Deep learning for evaluating left atrium stress echocardiography: a proof of principle study

Introduction

Left atrial (LA) size is a dynamic variable that changes during stress echocardiography (SE) and provides valuable information within and beyond coronary artery disease. However, its measurement remains subjective, time-consuming and based on manual tracings.

Recent advances in deep learning might save analysis time and deflate variability by removing the subjectivity of LA assessment.

Purpose

In this proof of principle study we aim to validate the potential of an automated machine learning system for the evaluation of LA in SE.

Methods

From the image data bank of Stress Echo 2030 study, we selected 20 consecutive patients who underwent SE (using a variety of stress methods) in 2 recruiting centers. Imaging data was acquired in DICOM format and anonymized. The studies were reviewed by an expert cardiologist trained in SE evaluation who selected apical four chamber (A4Ch) view images during stress and rest phases and marked end-systolic (ES) and end-diastolic frames to be used in further evaluation. Endocardial borders for LA were traced in ES. The tracings were repeated by three different evaluators (expert cardiologist [C1], cardiologist from external center [C2] and a machine learning [ML] model – a convolutional neural network trained on an unrelated set of images). LA area (LAA), volume (LAV) using area-length formula and proportional LAV changes between stress and rest (ΔLAV = [rest − stress] / rest) were calculated. Each evaluator was blinded from each other's measurements.

Results

In total, 40 A4Ch images were acquired (20 at rest and 20 at stress) of which all were of sufficient quality for performing LA measurements using an automated system. Pearson correlation coefficients (R) for LAA were 0.95 (C1-ML), 0.96 (C2-ML) at rest and 0.88 (C1-ML), 0.79 (C2-ML) at stress. The C1-C2 pair had R of 0.98 and 0.86 for LAA at rest and stress.

LAV also showed good correlation between different raters with R values of 0.90 (C1-ML), 0.94 (C2-ML), 0.94 (C1-C2) at rest and 0.86 (C1-ML), 0.87 (C2-ML), 0.84 (C1-C2) at stress. Root mean squared errors (RMSEs) for LAV were 13.48 ml (C1-ML), 7.44 ml (C2-ML), 10.26 ml (C1-C2) at rest and 14.03 ml (C1-ML), 8.53 ml (C2-ML), 13.69 ml (C1-C2) at stress.

There were high level correlations between all raters for ΔLAV with R values of 0.93, 0.94 and 0.95 for C1-ML, C2-ML and C1-C2 pairs respectively. Mean (95% CI) ΔLAV values were −20.1 (−51.59 to +11.39), −14.95 (−43.77 to +13.87) and −14.37 (−34.46 to +5.72) for ML, C1 and C2. Comparison with one-way ANOVA did not show significant differences in mean ΔLAV values between operators (p=0.94).

Conclusions

Automated ML based system produces LA measurements that are comparable to human operators and can reduce the need for manual tracing. There was a tendency for all operators to have lower levels of agreement in stress images compared to rest, further showing the need for additional standardization of SE evaluation for machine and human operators.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Comparison of coronary flow reserve feasibility and values in different stress echocardiography protocols: dobutamine, dipyridamole, exercise and rapid pacing

Background and aims

To compare the feasibility of Coronary Flow Velocity Reserve (CFVR) assessment in the left anterior descending (LAD) artery in four types of stress echocardiography (SE): dobutamine (DOB), dipyridamole (DIP), rapid pacing (PAC) and bicycle exercise (EXE).

Methods and results

We subjected 369 patients (mean age: 67±11 years) to SE with DOB (up to 40 mcg/kg/min, n=230), DIP (0.84 mg/kg, n=73), PAC (n=22) or EXE (n=44). CFVR was measured as the ratio of peak diastolic coronary flow velocity (CFV) during exercise, pharmacological stress or pacing and peak diastolic CFV at rest in distal or mid LAD.

The feasibility was excellent during PAC (100%), DOB (95%) and DIP (95%) and lower during EXE (73%, p<0.01 vs other groups) when assessed in all consecutive patients. When assessed in patients having readable LAD flow at rest the feasibility achieved even higher values, being however still lowered in EXE group, see Figure 1.

In multivariate analysis only the EXE protocol was a predictor of LAD flow loss during SE, with OR = 8.23 (95% CI 2.17 – 31.33), p=0.0019. CFVR was lower with PAC (1.8±0.4) as compared to DIP (2.2±0.6, p=0.0061) and DOB (2.2±0.6, p=0.0025), but similar to EXE (2.0±0.6, p=0.178), and correlated best with the peak heart rate in EXE and PAC, see Figure 2.

Conclusion

CFVR in LAD can be obtained during all forms of SE, but the feasibility is significantly higher with PAC and pharmacological tests as compared to EXE, which was identified in our study as the independent predictor of the loss of LAD flow recording at the peak of stress test. Moreover, CFVR values were the lowest in PAC group which however encompassed the older patients with more advanced coronary artery disease. Significant correlation between HR and CFVR observed in EXE and PAC suggests that in this type of SE cut-off value of CFVR should be probably indexed to maximal HR achieved.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Pharmacological cardioversion of recent-onset atrial fibrillation in patients with chronic kidney disease: sub-analysis of the CANT study

Purpose

Pharmacological cardioversion (PCV) is commonly a primary option for termination of recent-onset atrial fibrillation (AF) at the emergency departments (ED), and there are reports proving that antazoline is a noteworthy agent to restore sinus rhythm. This is a sub-analysis of the CANT study evaluating the effectiveness and safety of antazoline in patients with AF at different stages of chronic kidney disease (CKD).

Methods

Total n=777 patients admitted to ED for the urgent termination of AF were included into this analysis. We analysed the results concerning effectiveness and safety of PCV with special consideration of antazoline, in patients at 3 stages of CKD defined on the basis of eGFR (CKD-EPI): Group I ≥60 mL/min (n=531), Group II 45–59 mL/min (n=149), and Group III <45 mL/min (n=97). Primary end-point was the termination of AF, a restoration of a sinus rhythm and its persistence until discharge.

Results

Patients of group III were older and with higher prevalence of comorbidities, however, we have not found statistically significant differences in overall effectiveness of PCV in comparison with the other groups. In patients receiving amiodarone, the PCV success rate was similar in all the studied groups, but along with a renal function decline, it decreased in patients receiving antazoline (79.1 vs 35%; p<0.001), and it increased close to a significant manner in patients receiving propafenone (69.9 vs 100%; p=0.067; Figure). In patients of Group I, antazoline restored a sinus rhythm as effectively as propafenone and amiodarone, however in patients of Group III, both antazoline and amiodarone became less effective in restoring a sinus rhythm than propafenone (p=0.002 and p=0.034, respectively). The rate of safety endpoint was highest in patients of Group III (eGFR<45 mL/min), and it was significantly higher than in patients of Group I and II (p=0.008 and p=0.036, respectively). We have not observed antazoline-related adverse events in any of studied groups of patients.

Conclusion

This real-world registry analysis revealed a different influence of CKD on individual drug effectiveness, and while propafenone and amiodarone maintained their AF termination efficacy, antazoline became significantly less effective in restoring sinus rhythm. Its favourable safety profile has not changed.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The study received no external funding

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.

Strict compliance with ESC therapeutic guidelines after myocardial infarction treated with invasive strategy correlates with improved 18-month outcomes

Background

Despite improved early outcomes in patients (pts) with acute myocardial infarction (MI) in Poland with prevalent strategy of primary angioplasty by radial access, mid- and long-term outcomes are unsatisfactory.

Objective

We hypothesized that strict implementation of secondary prevention ESC guidelines in post-infarction management may be related with improved mid-term clinical outcomes

Methods

We compared 18-month outcomes of pts treated for MI with primary invasive strategy in a tertiary university hospital (NSTEMI 470/47%, or STEMI 535/53%; N=1005; Gr-L) with similar subset from national databases AMI-PL and PL-ACS (N=117307; NSTEMI 50966/43%, STEMI 64078/57%; Gr-Pol). Females represented 38.5% / 35.7% of Gr-L/Gr-Pol and mean age was 66.1±11.5 vs 65.8±11.9% (NS). The center implemented a strict policy of optimization prognosis-modifying prescriptions at discharge according to ESC guidelines. Endpoints over 18-month follow-up were defined as total mortality and combined clinical endpoint (death, stroke, recurrent MI, recurrent revascularization).

Results

30-days survival was comparable between Gr-L and national cohort. Key medicationrates were significantly higher for Gr-L vs most recent national estimates: renin-angiotensin blockers: 94% vs 79%, statins: 98% vs 75%, beta-blockers 95% vs 85%; ASA: 99% vs 94.5%, P2Y12 inhibitors 100% vs 83%. Rehabilitation was completed in 32% and 51% (after NSTEMI/STEMI) with national average around 20% - all differences p<0.05. Long-term mortality rate (overall 10.6% vs 14.5%, p=0.0005) and composite outcome rate was significantly improved in Gr-L – details shown in the table.

Conclusions

Outcomes of MI patients in primary PCI era are related to optimized medical therapy and rehabilitation planned at discharge. Our study does not prove causality but indicates on strong association of strict compliance with ESC guidelines and improved 18-month outcomes including overall survival.

Funding Acknowledgement

Type of funding source: None

Hemodynamic heterogeneity of inadequate cardiac output increase identified by 2-dimensional volumetric exercise echocardiography: slow, stiff or weak heart?

Background

Two-dimensional (2-D) volumetric exercise stress echocardiography (ESE) provides an integrated view of preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) through end-systolic volume (ESV) changes.

Purpose

To assess the dependence of stroke volume (SV) and cardiac output (CO) upon LVCR EDV changes and heart rate (HR) during ESE.

Methods

We prospectively performed semi-supine bicycle or treadmill ESE in 1,344 patients (age 59.8±11.4 years; 550 female; ejection fraction = 62.5±8%) referred for known or suspected coronary artery disease in 20 quality controlled laboratories of 16 countries from 2016 to 2019. SV was calculated at rest and peak stress from raw measurement of LV EDV and ESV by biplane Simpson rule, 2-D echo. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values <2.0 identify a “weak” heart). Preload reserve was defined by an increase in LV EDV. Abnormal values (lack of EDV increase, peak EDV ≤ rest EDV) identify a “stiff” heart. Cardiac output was calculated as SV * HR (measured with standard EKG). HR reserve (stress/rest ratio) <1.85 identifies a “slow” heart with chronotropic incompetence.

Results

By selection, all patients had negative SE by wall motion criteria. Of the 1,344 patients included in the study, 448 belonged to the lowest tertile of CO increase. Of them 326 (73%) achieved HR reserve <1.85; 220 (49%) had a blunted LVCR and 374 (83%) a reduction of preload reserve, with 348 patients (78%) showing ≥2 abnormalities. The more the abnormal criteria, the worse the CO response, which was lowest in slow, stiff and weak hearts: see figure.

Conclusion

Patients with normal CO reserve during exercise usually have a fast, compliant and strong heart. Abnormal CO reserve is associated with heterogeneous hemodynamic responses, with slow, stiff and/or weak hearts. The clarification of underlying hemodynamic heterogeneity is the prerequisite for a personalized treatment, and can be easily extracted from a standard 2-D volumetric SE. Hearts with normal CO are all alike; every heart with abnormal CO is abnormal in its own way.

CO % changes in subsets (*p<0.001)

Funding Acknowledgement

Type of funding source: None

Decreased layer specific longitudinal strain in myocardial segments supplied by stenosed LAD coronary artery: analysis for baseline, peak and recovery phase of stress echocardiography

Background

Despite wide utility of global longitudinal strain in the assessment of left ventricular function up to now little is known about layer specific quantification of myocardial function during stress tests and its potential for ischemia detection.

Purpose

To investigate diagnostic utility of layer specific LS during stress echocardiography using marker segments in patients with established Left Anterior Descending (LAD) coronary artery status.

Methods

We retrospectively analyzed 63 patients (mean age 62.5±9.9 years, 62% males) with suspected coronary artery disease, who had performed dobutamine stress echocardiography (DSE). Layer specific speckle tracking LS analyses were performed during rest, maximal stress and recovery. As a marker for LAD (segment most probably supplied by this artery) we used mid-anterior left ventricle segments. LAD status were established with coronary angiography or angioCT and consider as significant if ≥70% stenosis was present.

Results

In our study group 14 patients had significantly stenosed LAD (group 1) and 24 had normal coronaries (group 2). We detected significantly lowered absolute values of strain in endocardial and mid-myocardial layers of segments supplied by stenosed LAD at rest for endocardium −8.6% (group 1) vs −13.4% (group 2); p=0.045; and mid-myocardium −7.3% (group 1) vs −11.2% (group 2); p=0.044. Moreover, we observed similar trend at recovery, however without reaching statistical significance.

Conclusions

Longitudinal strain analysis focused on segments supplied by assessed coronary artery my provide quantitative data confirming ischemia in the settings of rest and stress echocardiography. Our pilot study suggest that for inotropic agents like dobutamine the potential ischemic dysfunction may be however masked at peak stage of the test.

Funding Acknowledgement

Type of funding source: None

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<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

Early overexpression of miR-499 in non-ST elevation acute coronary syndromes predicts long-term risk of major adverse cardiac events

Background

Some studies reported utility of microRNAs in myocardial infarction diagnostic process, whereas their prognostic remains unclear.

Aim

To evaluate the prognostic value of five circulating miRs (miR-1, miR-21, miR-133a, miR-208, miR-499) levels for predicting major adverse cardiac events (MACE), including death, nonfatal myocardial infarction (MI) or cardiovascular rehospitalization (reh.) in patients with NSTE-ACS.

Material and methods

In our prospective, single-center observational study we recruited patients (pts) with NSTE-ACS with symptoms onset <24 hours before the hospital admission and age, gender-matched patients with stable coronary artery disease (SCAD) as controls. Blood was sampled twice (at admission and 4h after in NSTE-ACS and once in SCAD). Relative expression of miRs were calculated using the ΔΔCt method after normalization to the cel-miR-39 spiked-in control. The mean value of miRs relative expression from two time samples in NSTE-ACS pts were used for further analysis. Subjects were categorized according to mean miRs expression at hospital admission into two group (≤ or > median level of miRs).

Results

103 NSTE-ACS pts (median age 67 years, 68% male) were included in this study. During median 1569 (IQR 935–1842) days of follow-up the primary endpoint (MACE) occurred in 66 (64.1%) pts: 18 pts (18.7%) died, 30 pts (20%) presented with MI and 85 pts (56.7%) were readmitted. In a Cox proportional-hazards regression model miR-499 expression > median level (HR=1.82, 95% CI 1.07–3.09) and high-sensitivity troponin T level (HR=1.24, 95% CI 1.05–1.46) were independent predictors of MACE in long term observation, even after adjustment for other covariates (including other miRNAs). Incidence of MI [34% vs 10%, HR=4.1 (2.0–8.5)], rehospitalization for cardiovascular reasons [67% vs 49%, HR=2.1 (1.3–3.3)] and MACE [76% vs 55%, HR=2.2 (1.5–3.5)] was significantly higher in pts with elevated (> median) miR-499 levels at hospital admission. None of analyzed miRNAs was related to long-term mortality, whereas the left ventricular ejection fraction (EF) has been identified as the only one survival predictor (HR=0.95, 95% CI 0.92–0.98).

Conclusions

Elevated miR-499 levels independently of high sensitivity troponin T levels in early phase of NSTE-ACS are related to increased rate of MACE in 4-year follow-up.

Figure 1. miR499 and MACE

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Polish Ministry of Science and Higher Education “Diamond Grant” program.

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

Early change in left atrial and left ventricular strain predicts sinus rhythm maintenance after cardioversion

Background

Atrial fibrillation (AF) impairs mechanical function of the heart, especially atria and restoration of sinus rhythm (SR) leads to improvement of mechanics. The predicting role of changes in strain parameters for AF recurrence is not established yet.

Purpose

To analyse changes in left atrial (LA) and left ventricular (LV) mechanical function after conversion to SR and their prognostic values for AF recurrence during 24 months follow-up.

Methods

Prospective study involved 59 patients after successful electrical cardioversion (EC) because of nonvalvular AF (mean age 65±4 years, 47% female). Speckle tracking analysis (STE) was applied to calculate longitudinal strain of LV and LA before EC and within 24 hours after restoration of SR and additionally total left heart strain (TS) defined as a sum of absolute peak LV and LA strain. We calculated change in strain between AF and SR analyses expressed as delta (Δ). During follow-up we noticed AF recurrence in 42 (71%) patients, most of them (93%) during 1st year after EC. Median time of AF recurrence was 3 months.

Results

We noticed significant immediate post-EC improvement in peak LA longitudinal strain (PALS) and LV global longitudinal strain (LVGLS) (table). Unlike CHA2DS2-VASc score, strain parameters were predictors of AF recurrence. Every 1% increment in ΔLVGLS was related with 13% increase in AF recurrence risk (p=0.02) and every 1% increment in ΔPALS and ΔTS were related with 9% decrease in AF recurrence risk (p=0.007 and p=0.0014, respectively). Multivariate analysis revealed ΔTS as a strongest predictor with 9% decrease in AF risk per every 1% increment. The criterion of ΔTS ≤7.5% allows to predict AF recurrence with 81% sensitivity and 63% specificity.

Conclusions

Speckle tracking measurements are able to detect early mechanical changes in LA even within 24 hours of SR and these absolute changes in LVGLS as well as PALS can predict AF recurrence, with optimal stratification by novel parameter - TS.

Funding Acknowledgement

Type of funding source: None

P1711 Exploring the full spectrum of right ventricular exercise contractile reserve among health and disease: a prospective clinical and echocardiography observational multicenter study

Funding Acknowledgements

None

OnBehalf

RIGHT-NET

Background

Exercise Doppler echocardiography (EDE) has been implemented for applications beyond coronary artery disease detection, but its role in assessing subclinical pulmonary vascular disease and right ventricle (RV) impairment is less clear. The RIGHT heart international NETwork (RIGHT-NET) is a prospective clinical and echocardiography observational multicenter study designed to explore the full spectrum of RV function and non-invasive pulmonary circulation hemodynamics during exercise in a large cohort of subjects, from healthy individuals and elite athletes to patients with overt or at risk of developing pulmonary hypertension (PH). Right ventricular (RV) exercise contractile reserve (RVECR) can be assessed through the ratio between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) and has proved to provide prognostic value in patients with left heart disease (LHD) and pulmonary arterial hypertension (PAH).

Methods

We enrolled 1424 patients (age 55.4 ± 15 years old, 44.4% males): 353 healthy controls, 40 athletes, 369 patients with cardiovascular risk factors (CVRF: arterial hypertension and/or diabetes mellitus), 46 with PAH (confirmed by right heart catheterization), 487 with systemic sclerosis (SSc) without overt PH, and 129 with LHD (including coronary artery disease and heart failure with reduced or preserved ejection fraction).

All enrolled subjects underwent resting and EDE examinations on a semirecumbent cycle ergometer with an incremental workload of 25 Watts every 2 minutes up to the symptom-limited maximal tolerated workload, according to standardised protocols. Key echocardiographic measurements have been acquired at baseline, at 50 Watts, at peak exercise, and after 5-minutes recovery, including but not limited to RV function (TAPSE) and sPAP.

Results

In all six groups the ratio TAPSE/sPAP was significantly different at peak exercise compared to rest values (all p < 0.01). At rest, TAPSE/sPAP values were not significantly different among controls, athletes and CVRF patients, whereas during exercise TAPSE/sPAP values were significantly different, with CVRF showing the lowest values (p < 0.0001 vs controls and athletes). Patients with PAH and LHD had the worst RVECR both at rest and at peak exercise (all p < 0.0001 vs the other groups), while SSc groups reported intermediate values, which were lower than controls (p < 0.0001) and athletes (p < 0.0001), but higher than CVRF subjects (p = 0.003). (Figure)

Conclusions

EDE can non-invasively characterise different dynamic behaviours of the RVECR among healthy subjects, athletes and patients with various pathologic conditions. Whether a thorough EDE assessment of non-invasive hemodynamics, RVECR and coupling may predict later development of manifest PH, clinical deterioration or decreased survival will be further investigated during the ongoing follow-up.

Abstract P1711 Figure

P3527Echocardiographic assessment of the right ventricle in chronic heart failure with focus on patients with atrial fibrillation

Background

Assessment of the right ventricle (RV) in heart failure (HF) is challenging and requires applicable methods and parameters. Atrial fibrillation (AF) is a common and clinically significant arrhythmia in 30–50% of HF patients. Assessment of the RV function in patients with AF is problematic. Still little is known about RV function in HF and AF patients. The aim of the study was to assess RV function in HF with focus on AF patients.

Methods

Patients with HF of ischemic etiology, NYHA II-III, LVEF ≤40%, with AF and sinus rhythm (SR), underwent two- and three- dimensional echocardiography (2DE and 3DE) for assessment of the RV with use of multiple parameters. The RV was examined for: linear dimensions, end-diastolic and end-systolic areas adjusted to body surface area (RV EDA and RV ESA/BSA) and end-diastolic and end-systolic volumes adjusted to lean body mass (RV EDV and RV ESV/LBM) to reflect volume overload and in terms of right ventricular pressure (RVSP) as an index of pressure overload. RV systolic function was assessed with 2DE: tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV FAC), tricuspid lateral annular systolic velocity (s') and 3DE parameters: right ventricular ejection fraction (RVEF) and free wall right ventricular longitudinal strain (FW RVLS). Also, TAPSE/RVSP parameter was included.

Results

The study included 126 patients: 94 with AF and 32 with SR. Within the AF group 28 patients were treated medically, 41 had RV pacing (pacemaker or an implantable cardioverter-defibrillator, ICD) and 25 had cardiac resynchronisation therapy (CRT). In comparison with SR group AF patients had: larger RV inflow tract dimension (4.49±0.85 vs. 3.95±0.72 cm; p=0.0017), RV EDA/BSA (12.7±3.9 vs. 11.1±3.0 cm2/m2; p=0.0358) and RV ESA/BSA (8.0±3.0 vs. 6.7±2.4 cm2/m2; p=0.0226). Similarly, patients with AF had greater RV volumes in 3DE than patients with SR: RV EDV/LBM (1.82±0.60 vs. 1.61±0.38ml/kg, p=0.0267) and RV ESV/LBM (1.11±0.40 ml/kg vs. 0.81±0.28, p<0,0001). Also, in patients with AF right ventricular systolic pressure (RVSP) was higher (40.8±10.2 vs. 34.0±8.1 mmHg, p=0,0010). No differences in TAPSE and RVFAC were found but the relation TAPSE/RVSP was higher in AF than in SR group (0.51±0.21 vs. 0.65±0.24 cm/mmHg; p=0.0046). Also, in AF patients in comparison to SR group some parameters had worse values: s' (9.7±2.31 vs. 12.1±3.83, p=0.014), RVEF (37.2±7.3 vs. 48.2±7.5, p<0.0001 and FW RVLS (−18.3±4.6 vs. −23.9±4.23%, p<0,0001). Within the AF group no significant differences in studied variables depending on RV pacing or CRT were found.

Conclusions

Larger volumes and higher pressure overload of the RV were observed in patients with AF in comparison to SR. Systolic function of the RV seems to be more depressed in AF compared to SR patients with systolic heart failure. Further research in larger groups is required to identify the most applicable and valuable methods of RV evaluation.

Harvesting, Coupling, and Control of Single-Exciton Coherences in Photonic Waveguide Antennas

We perform coherent nonlinear spectroscopy of individual excitons strongly confined in single InAs quantum dots (QDs). The retrieval of their intrinsically weak four-wave mixing (FWM) response is enabled by a one-dimensional dielectric waveguide antenna. Compared to a similar QD embedded in bulk media, the FWM detection sensitivity is enhanced by up to 4 orders of magnitude, over a broad operation bandwidth. Three-beam FWM is employed to investigate coherence and population dynamics within individual QD transitions. We retrieve their homogenous dephasing in a presence of low-frequency spectral wandering. Two-dimensional FWM reveals off-resonant Förster coupling between a pair of distinct QDs embedded in the antenna. We also detect a higher order QD nonlinearity (six-wave mixing) and use it to coherently control the FWM transient. Waveguide antennas enable us to conceive multicolor coherent manipulation schemes of individual emitters.

Microcavity controlled coupling of excitonic qubits

Controlled non-local energy and coherence transfer enables light harvesting in photosynthesis and non-local logical operations in quantum computing. This process is intuitively pictured by a pair of mechanical oscillators, coupled by a spring, allowing for a reversible exchange of excitation. On a microscopic level, the most relevant mechanism of coherent coupling of distant quantum bits—like trapped ions, superconducting qubits or excitons confined in semiconductor quantum dots—is coupling via the electromagnetic field. Here we demonstrate the controlled coherent coupling of spatially separated quantum dots via the photon mode of a solid state microresonator using the strong exciton–photon coupling regime. This is enabled by two-dimensional spectroscopy of the sample’s coherent response, a sensitive probe of the coherent coupling. The results are quantitatively understood in a rigorous description of the cavity-mediated coupling of the quantum dot excitons. This mechanism can be used, for instance in photonic crystal cavity networks, to enable a long-range, non-local coherent coupling.

Controlling coupling between distant quantum objects is important for implementation of quantum technologies. Providing an important step towards using semiconductor structures for hosting optically controlled qubits, this work shows coherent coupling between three quantum dot excitons via a cavity.

Up on the Jaynes-Cummings ladder of a quantum-dot/microcavity system

In spite of their different natures, light and matter can be unified under the strong-coupling regime, yielding superpositions of the two, referred to as dressed states or polaritons. After initially being demonstrated in bulk semiconductors and atomic systems, strong-coupling phenomena have been recently realized in solid-state optical microcavities. Strong coupling is an essential ingredient in the physics spanning from many-body quantum coherence phenomena, such as Bose-Einstein condensation and superfluidity, to cavity quantum electrodynamics. Within cavity quantum electrodynamics, the Jaynes-Cummings model describes the interaction of a single fermionic two-level system with a single bosonic photon mode. For a photon number larger than one, known as quantum strong coupling, a significant anharmonicity is predicted for the ladder-like spectrum of dressed states. For optical transitions in semiconductor nanostructures, first signatures of the quantum strong coupling were recently reported. Here we use advanced coherent nonlinear spectroscopy to explore a strongly coupled exciton-cavity system. We measure and simulate its four-wave mixing response, granting direct access to the coherent dynamics of the first and second rungs of the Jaynes-Cummings ladder. The agreement of the rich experimental evidence with the predictions of the Jaynes-Cummings model is proof of the quantum strong-coupling regime in the investigated solid-state system.

The relation between the sagittal and transversal diameters in eyes with retinal detachment

Using A-mode ultrasonography, the axial length and the width (transversal or equatorial diameter) of both eyes--fellow and affected--have been measured in patients with retinal detachment. For comparison, the same measurements have been performed in healthy controls. The patients have been divided into different groups. It was found that there are some changes in the relation between the axial length and the width of the eyes in patients with retinal detachment, according to the comparison with healthy people, in most cases.

Formation of an exciton polariton condensate: thermodynamic versus kinetic regimes

We measure the polariton distribution function and the condensation threshold versus the photon-exciton detuning and the lattice temperature in a CdTe microcavity under nonresonant pumping. The results are reproduced by simulations using semiclassical Boltzmann equations. At negative detuning we find a kinetic condensation regime: the distribution is not thermal and the threshold is governed by the relaxation kinetics. At positive detuning, the distribution becomes thermal and the threshold is governed by the thermodynamic parameters of the system. Both regimes are a manifestation of polariton lasing, whereas only the latter is related to Bose-Einstein condensation defined as an equilibrium phase transition.