Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.256
J. Tomala, S. Ulbrich, U. Richter, Y. Huo, T. Gaspar
Type of funding sources: None. As a standard of care, ablation of typical atrial flutter involves performing cardiac catheterization under x-ray fluoroscopy. The unique ability of magnetic resonance (MR) to provide real-time functional imaging in multiple views without ionizing radiation exposure has the potential to be a powerful tool for diagnostic and interventional procedures. Real-time MR imaging-guided radiofrequency (RF) ablation has been used as a part of clinical trials. To implement the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine. From January to July 2020, 15 consecutive patients with typical atrial flutter have been referred for ablation. Patient preparation, conscious sedation and groin puncture took place inside the 1.5 Tesla MR scanner as a part of an MR-only workflow. The catheter advancement as well as the RF ablation procedure have been performed under direct visualisation of catheters with integrated micro-coils using an interactive sequence with active tip tracking and automatic slice positioning in the plane where the catheter tip has been detected. During catheter advancement a single frontal plane has been used to visualize the passage of the catheter through femoral veins and inferior vena cava. With both diagnostic and ablation catheters in the right atrium, an axial stack of balanced steady-state free precession acquisitions has been acquired and used to reconstruct planes in the short- and long cardiac axis. These have been used to provide a "left- and right anterior oblique" view familiar to an interventional electrophysiologist. The subsequent catheter placement and ablation have been performed under direct visualisation in these two planes (see figure). The ablation was successful in 14 patients, one patient had to undergo a conventional procedure on the following day. The mean time to reach right atrium and coronary sinus was 4 [3,5] and 7 [6,10] minutes, respectively. The mean total ablation duration and procedure time was 18 [12,26] and 43 [33,58] minutes, respectively. There were no adverse events. The implementation of the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine is feasible and leads to similar success rates and procedure times as the conventional fluoroscopy-based ablation. Abstract Figure.
{"title":"Early results for iCMR in atrial flutter","authors":"J. Tomala, S. Ulbrich, U. Richter, Y. Huo, T. Gaspar","doi":"10.1093/EHJCI/JEAA356.256","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.256","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 As a standard of care, ablation of typical atrial flutter involves performing cardiac catheterization under x-ray fluoroscopy. The unique ability of magnetic resonance (MR) to provide real-time functional imaging in multiple views without ionizing radiation exposure has the potential to be a powerful tool for diagnostic and interventional procedures. Real-time MR imaging-guided radiofrequency (RF) ablation has been used as a part of clinical trials.\u0000 \u0000 \u0000 \u0000 To implement the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine.\u0000 \u0000 \u0000 \u0000 From January to July 2020, 15 consecutive patients with typical atrial flutter have been referred for ablation. Patient preparation, conscious sedation and groin puncture took place inside the 1.5 Tesla MR scanner as a part of an MR-only workflow. The catheter advancement as well as the RF ablation procedure have been performed under direct visualisation of catheters with integrated micro-coils using an interactive sequence with active tip tracking and automatic slice positioning in the plane where the catheter tip has been detected. During catheter advancement a single frontal plane has been used to visualize the passage of the catheter through femoral veins and inferior vena cava. With both diagnostic and ablation catheters in the right atrium, an axial stack of balanced steady-state free precession acquisitions has been acquired and used to reconstruct planes in the short- and long cardiac axis. These have been used to provide a \"left- and right anterior oblique\" view familiar to an interventional electrophysiologist. The subsequent catheter placement and ablation have been performed under direct visualisation in these two planes (see figure).\u0000 \u0000 \u0000 \u0000 The ablation was successful in 14 patients, one patient had to undergo a conventional procedure on the following day. The mean time to reach right atrium and coronary sinus was 4 [3,5] and 7 [6,10] minutes, respectively. The mean total ablation duration and procedure time was 18 [12,26] and 43 [33,58] minutes, respectively. There were no adverse events.\u0000 \u0000 \u0000 \u0000 The implementation of the MR imaging-guided RF ablation of typical atrial flutter in the clinical routine is feasible and leads to similar success rates and procedure times as the conventional fluoroscopy-based ablation.\u0000 Abstract Figure.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"10 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90384791","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.399
M. Sobh, D. Gabbert, A. Uebing, I. Voges
Type of funding sources: None. Patients with hypoplastic left heart syndrome (HLHS) are at risk for right ventricular (RV) dysfunction over the course of the three-stage surgical palliation with the final step being the completion of the total cavopulmonary connection (TCPC). However, less is known about RV function during follow-up after TCPC completion. We assessed RV function by analysing serial cardiovascular magnetic resonance (CMR) studies in a large cohort of HLHS patients. CMR studies from 95 HLHS patients (67 males) were retrospectively analysed. Short axis cine images were used to measure RV end systolic and end diastolic volumes and ejection fraction (RVEF). Oblique cine images showing the atria and right ventricle in a similar manner like a standard "4-chamber view" were used to measure tricuspid annular plane systolic excursion (TAPSE) and long axis strain (LAS). From the 95 patients, all had at least two and 32 patients had three CMR scans. The first scan was performed at a mean age of 4.9 ± 2.8 years, the second scan at a mean age of 9.3 ± 4 years and the third at a mean age of 14.3 ± 3.7 years. The mean values of RV end diastolic and end systolic volume indexed to body surface area (REDVi, RVESVi) as well as RV ejection fraction (RVEF) at the three time points were: 1) REDVi 92.6 ± 21.9 ml/m2, RVESVi 43 ± 15.1 ml/m2, RVEF 54.2 ± 7.1%; 2) REDVi 93.9 ± 25.6 ml/m2, RVESVi 44.6 ± 18.3 ml/m2, RVEF 53.6 ± 7.8%; 3) REDVi 110.9 ± 41.9 ml/m2, RVESVi 58.1 ± 35 ml/m2, RVEF 50.1 ± 10.1%. There was a statistically significant increase in RVEDVi and RVESVi from the first and the second scan to the third scan (p < 0.01). RVEF was lower at the time of the third scan compared to the first and second scan, but this difference was not statistically significant. TAPSE increased slightly from the first to the third scan (p < 0.05). There was no change in stroke volume and LAS from the first to the third scan. Strong correlations were found between RVEF and LAS as well as between RVEF and TAPSE (r = 0.49 and r=-0.50; p < 0.001, respectively). Serial assessment of CMR studies in HLHS patients after TCPC completion could demonstrate an increase in indexed RV volumes over time, whereas RV stroke volume, RVEF and LAS largely remain stable.
{"title":"Serial right ventricular assessment in patients with hypoplastic left heart syndrome patients (HLHS): a cardiovascular magnetic resonance study","authors":"M. Sobh, D. Gabbert, A. Uebing, I. Voges","doi":"10.1093/EHJCI/JEAA356.399","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.399","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 Patients with hypoplastic left heart syndrome (HLHS) are at risk for right ventricular (RV) dysfunction over the course of the three-stage surgical palliation with the final step being the completion of the total cavopulmonary connection (TCPC). However, less is known about RV function during follow-up after TCPC completion. We assessed RV function by analysing serial cardiovascular magnetic resonance (CMR) studies in a large cohort of HLHS patients.\u0000 \u0000 \u0000 \u0000 CMR studies from 95 HLHS patients (67 males) were retrospectively analysed. Short axis cine images were used to measure RV end systolic and end diastolic volumes and ejection fraction (RVEF). Oblique cine images showing the atria and right ventricle in a similar manner like a standard \"4-chamber view\" were used to measure tricuspid annular plane systolic excursion (TAPSE) and long axis strain (LAS).\u0000 \u0000 \u0000 \u0000 From the 95 patients, all had at least two and 32 patients had three CMR scans. The first scan was performed at a mean age of 4.9 ± 2.8 years, the second scan at a mean age of 9.3 ± 4 years and the third at a mean age of 14.3 ± 3.7 years. The mean values of RV end diastolic and end systolic volume indexed to body surface area (REDVi, RVESVi) as well as RV ejection fraction (RVEF) at the three time points were: 1) REDVi 92.6 ± 21.9 ml/m2, RVESVi 43 ± 15.1 ml/m2, RVEF 54.2 ± 7.1%; 2) REDVi 93.9 ± 25.6 ml/m2, RVESVi 44.6 ± 18.3 ml/m2, RVEF 53.6 ± 7.8%; 3) REDVi 110.9 ± 41.9 ml/m2, RVESVi 58.1 ± 35 ml/m2, RVEF 50.1 ± 10.1%. There was a statistically significant increase in RVEDVi and RVESVi from the first and the second scan to the third scan (p < 0.01). RVEF was lower at the time of the third scan compared to the first and second scan, but this difference was not statistically significant. TAPSE increased slightly from the first to the third scan (p < 0.05). There was no change in stroke volume and LAS from the first to the third scan. Strong correlations were found between RVEF and LAS as well as between RVEF and TAPSE (r = 0.49 and r=-0.50; p < 0.001, respectively).\u0000 \u0000 \u0000 \u0000 Serial assessment of CMR studies in HLHS patients after TCPC completion could demonstrate an increase in indexed RV volumes over time, whereas RV stroke volume, RVEF and LAS largely remain stable.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"39 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79267934","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.299
T. Lange, T. Stiermaier, S. Backhaus, P. Boom, J. Kowallick, J. Lotz, S. Kutty, B. Bigalke, M. Gutberlet, S. Waha-Thiele, S. Desch, G. Hasenfuss, H. Thiele, I. Eitel, A. Schuster
Type of funding sources: None. Background Myocardial infarct size (IS) remains one of the strongest predictors of adverse cardiac events following acute myocardial infarction (AMI). Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can precisely quantify the extent of injury but requires manual post-processing. Whether novel user-independent artificial intelligence (AI) based fully-automated analyses may facilitate clinical workflow and deliver similar information for risk stratification is unknown. Methods 913 AMI patients from two multi-center trials (AIDA-STEMI n = 704 with ST-elevation myocardial infarction [STEMI] and TATORT-NSTEMI n = 245 with non-ST-elevation-infarction [NSTEMI]) were included in this sub-study. IS was quantified manually using conventional software (Medis, Leiden Netherlands) and fully automated AI-based software (NeoSoft). All automatically detected IS were evaluated visually and corrected if necessary. Analyzed data were tested for agreement and prediction of major adverse clinical events (MACE) within one year after AMI. Results Automated and manual IS were similarly associated with outcome in cox regression analyses (HR 1.05 [95% CI 1-02-1.07] p < 0.001 for automated IS and HR 1.04 [95% CI 1.02-1.06]; p < 0.001 for manual IS). Comparison of C-statistics derived area under the curve (AUC) resulted in equivalent MACE prediction (AUC 0.65 for automated vs. AUC 0.66 for manual, p = 0.53). Manual correction of the automated scar detection did not lead to an improved risk prediction of MACE (AUC 0.65 to 0.66, p = 0.43). There was good agreement of automated and manually derived IS (intraclass correlation coefficient [ICC] 0.75 [0.07-0.89]) which was further improved after manual correction of the underlying contours (ICC 0.98 [0.97-0.98]). Conclusion AI-based software enables automated scar quantification with similar prognostic value compared to conventional methods in patients following AMI.
资金来源类型:无。背景心肌梗死面积(IS)仍然是急性心肌梗死(AMI)后不良心脏事件的最强预测因子之一。晚期钆增强(LGE)心脏磁共振(CMR)可以精确量化损伤程度，但需要人工后处理。新的基于用户独立的人工智能(AI)的全自动分析是否可以促进临床工作流程并为风险分层提供类似的信息尚不清楚。方法将两项多中心试验(AIDA-STEMI n = 704 st段抬高型心肌梗死[STEMI]和TATORT-NSTEMI n = 245非st段抬高型心肌梗死[NSTEMI])的913例AMI患者纳入本亚研究。使用传统软件(mediis, Leiden Netherlands)和全自动人工智能软件(NeoSoft)对IS进行人工量化。对所有自动检测到的IS进行目视评估，必要时进行纠正。分析的数据用于AMI后一年内主要不良临床事件(MACE)的一致性和预测。结果在cox回归分析中，自动IS和手动IS与预后的相关性相似(HR 1.05 [95% CI 1-02-1.07] p < 0.001, HR 1.04 [95% CI 1.02-1.06];手动IS的p < 0.001)。比较c -统计导出的曲线下面积(AUC)，得出等效的MACE预测(自动的AUC为0.65，手动的AUC为0.66,p = 0.53)。自动疤痕检测的人工校正并不能提高MACE的风险预测(AUC为0.65 ~ 0.66,p = 0.43)。自动和手动导出的IS(类内相关系数[ICC] 0.75[0.07-0.89])的一致性很好，在人工校正底层轮廓后进一步得到改善(ICC 0.98[0.97-0.98])。结论与传统方法相比，基于人工智能的软件能够自动量化AMI患者的疤痕，具有相似的预后价值。
{"title":"Fully automated artificial intelligence-based myocardial scar quantification for diagnostic and prognostic stratification in patients following acute myocardial infarction","authors":"T. Lange, T. Stiermaier, S. Backhaus, P. Boom, J. Kowallick, J. Lotz, S. Kutty, B. Bigalke, M. Gutberlet, S. Waha-Thiele, S. Desch, G. Hasenfuss, H. Thiele, I. Eitel, A. Schuster","doi":"10.1093/EHJCI/JEAA356.299","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.299","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 Background Myocardial infarct size (IS) remains one of the strongest predictors of adverse cardiac events following acute myocardial infarction (AMI). Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can precisely quantify the extent of injury but requires manual post-processing. Whether novel user-independent artificial intelligence (AI) based fully-automated analyses may facilitate clinical workflow and deliver similar information for risk stratification is unknown.\u0000 Methods 913 AMI patients from two multi-center trials (AIDA-STEMI n = 704 with ST-elevation myocardial infarction [STEMI] and TATORT-NSTEMI n = 245 with non-ST-elevation-infarction [NSTEMI]) were included in this sub-study. IS was quantified manually using conventional software (Medis, Leiden Netherlands) and fully automated AI-based software (NeoSoft). All automatically detected IS were evaluated visually and corrected if necessary. Analyzed data were tested for agreement and prediction of major adverse clinical events (MACE) within one year after AMI.\u0000 Results Automated and manual IS were similarly associated with outcome in cox regression analyses (HR 1.05 [95% CI 1-02-1.07] p < 0.001 for automated IS and HR 1.04 [95% CI 1.02-1.06]; p < 0.001 for manual IS). Comparison of C-statistics derived area under the curve (AUC) resulted in equivalent MACE prediction (AUC 0.65 for automated vs. AUC 0.66 for manual, p = 0.53). Manual correction of the automated scar detection did not lead to an improved risk prediction of MACE (AUC 0.65 to 0.66, p = 0.43). There was good agreement of automated and manually derived IS (intraclass correlation coefficient [ICC] 0.75 [0.07-0.89]) which was further improved after manual correction of the underlying contours (ICC 0.98 [0.97-0.98]).\u0000 Conclusion AI-based software enables automated scar quantification with similar prognostic value compared to conventional methods in patients following AMI.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79340734","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.324
A. Neto, Itamar Pereira de Oliveira, I. Cruz, D. Seabra, R. Santos, A. Andrade, J. Azevedo, Paulo Feytor Pinto
Type of funding sources: None. The HCM Risk-SCD estimates the risk of sudden cardiac death at 5 years in patients (pts) with hypertrophic cardiomyopathy (HCM). According to ESC Guidelines, in pts with a 5-year risk of SCD <4%, an implantable cardioverter defibrillator (ICD) is generally not indicated, in pts with a risk of 4 to less than 6%, an ICD may be considered and in pts with a 5-year risk ≥6%, an ICD should be considered. The association between the degree of LVH and sudden cardiac death (SCD) has been based on measurements of maximum LVWT by echocardiography which is part of HCM Risk-SCD score. However, cardiac magnetic resonance (CMR) has shown a superior resolution in characterization of cardiac structures, with additional role in SCD risk stratification. Whether measurements of LVWT by echocardiography and CMR are interchangeable has been brought to question. We sought to evaluate the incidence of discrepant measurements of maximal LVWT between echocardiography and CMR and determine its implication in HCM Risk-SCD score and ICD indication. Unicentric, retrospective analysis of pts submitted to CMR who had HCM as definitive diagnosis, between 1/2013 and 9/2019. CMR and echocardiographic measures were compared, as well as HCM Risk-SCD score calculated with these values (maximum LVWT was the only variable that differed between measures). Subsequently, pts were divided in three groups according to HCM Risk-SCD score: pts with a 5-year risk of SCD <4% (G1), risk of 4 to less than 6% (G2) and risk ≥6% (G3). Out of the 781 CMR studies evaluated, 59 pts were found to have HCM (7.6%) with mean age of 62 ± 11 years and female predominance (50.8%). 12 pts had obstructive phenotype (20.3%). Mean LVWT was 20.0 ± 4.6mm when measured by CMR and 18.8 ± 4.6mm by echo; when comparing the measures by echo with CMR, there was a positive correlation between them (p < 0.001; r 0.719). Mean HCM Risk-SCD was 2.80 ± 1.51% when measured by CMR and 2.69 ± 1.53% by echo; there was a positive correlation between these measures too (p < 0.001; r 0.963). Maximum LV thickness evaluated by CMR showed a positive correlation (p = 0.006, r 0.384) with the HCM risk-score assessed by CMR. Only 1 pt changed risk group with CMR measurement of maximum LVWT (from G1 to G2). Conclusion: In this cohort, there was a positive, linear relationship between maximum LVWT and HCM Risk-SCD score measured by CMR and echocardiogram. Only 1 pt changed risk stratification group (5-year risk of SCD <4% to 4 to less than 6%). Although CMR measurements, when interpreted correctly, are more precise compared with echocardiography, in this cohort there was no impact on the patient"s future clinical orientation regarding ICD implantation.
{"title":"What if HCM Risk-SCD was assessed with CMR maximum LV wall thickness measurements?","authors":"A. Neto, Itamar Pereira de Oliveira, I. Cruz, D. Seabra, R. Santos, A. Andrade, J. Azevedo, Paulo Feytor Pinto","doi":"10.1093/EHJCI/JEAA356.324","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.324","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 The HCM Risk-SCD estimates the risk of sudden cardiac death at 5 years in patients (pts) with hypertrophic cardiomyopathy (HCM). According to ESC Guidelines, in pts with a 5-year risk of SCD <4%, an implantable cardioverter defibrillator (ICD) is generally not indicated, in pts with a risk of 4 to less than 6%, an ICD may be considered and in pts with a 5-year risk ≥6%, an ICD should be considered. The association between the degree of LVH and sudden cardiac death (SCD) has been based on measurements of maximum LVWT by echocardiography which is part of HCM Risk-SCD score. However, cardiac magnetic resonance (CMR) has shown a superior resolution in characterization of cardiac structures, with additional role in SCD risk stratification. Whether measurements of LVWT by echocardiography and CMR are interchangeable has been brought to question.\u0000 \u0000 \u0000 \u0000 We sought to evaluate the incidence of discrepant measurements of maximal LVWT between echocardiography and CMR and determine its implication in HCM Risk-SCD score and ICD indication.\u0000 \u0000 \u0000 \u0000 Unicentric, retrospective analysis of pts submitted to CMR who had HCM as definitive diagnosis, between 1/2013 and 9/2019. CMR and echocardiographic measures were compared, as well as HCM Risk-SCD score calculated with these values (maximum LVWT was the only variable that differed between measures). Subsequently, pts were divided in three groups according to HCM Risk-SCD score: pts with a 5-year risk of SCD <4% (G1), risk of 4 to less than 6% (G2) and risk ≥6% (G3).\u0000 \u0000 \u0000 \u0000 Out of the 781 CMR studies evaluated, 59 pts were found to have HCM (7.6%) with mean age of 62 ± 11 years and female predominance (50.8%). 12 pts had obstructive phenotype (20.3%). Mean LVWT was 20.0 ± 4.6mm when measured by CMR and 18.8 ± 4.6mm by echo; when comparing the measures by echo with CMR, there was a positive correlation between them (p < 0.001; r 0.719). Mean HCM Risk-SCD was 2.80 ± 1.51% when measured by CMR and 2.69 ± 1.53% by echo; there was a positive correlation between these measures too (p < 0.001; r 0.963). Maximum LV thickness evaluated by CMR showed a positive correlation (p = 0.006, r 0.384) with the HCM risk-score assessed by CMR. Only 1 pt changed risk group with CMR measurement of maximum LVWT (from G1 to G2). Conclusion: In this cohort, there was a positive, linear relationship between maximum LVWT and HCM Risk-SCD score measured by CMR and echocardiogram. Only 1 pt changed risk stratification group (5-year risk of SCD <4% to 4 to less than 6%). Although CMR measurements, when interpreted correctly, are more precise compared with echocardiography, in this cohort there was no impact on the patient\"s future clinical orientation regarding ICD implantation.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"92 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75650224","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.248
G. Hashimoto, B. Lopes, M. Fukui, M. Sarano, S. Garcia, Mario Goessl, P. Sorajja, J. Lesser, J. Cavalcante
Type of funding sources: None. Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population. A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR. A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients. Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not. Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm² 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm² 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm² 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm² 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.
{"title":"Computed tomography characteristics of patients with functional MR receiving MitraClip","authors":"G. Hashimoto, B. Lopes, M. Fukui, M. Sarano, S. Garcia, Mario Goessl, P. Sorajja, J. Lesser, J. Cavalcante","doi":"10.1093/EHJCI/JEAA356.248","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.248","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 Percutaneous leaflet repair with the MitraClip device (Abbott Vascular, Menlo Park, CA) is safe and effective in patients with severe functional mitral regurgitation (FMR). Residual or recurrent MR may occur in up to 40% of patients and is associated with persistent symptoms and impaired survival. The anatomical characteristics associated with residual or recurrent MR after MitraClip are not well defined by computed tomography angiography (CTA) in FMR population.\u0000 \u0000 \u0000 \u0000 A retrospective analysis of patients with significant FMR, who underwent retrospective-gated CTA at Minneapolis Heart Institute between July 2015 to January 2020, identified those who underwent percutaneous leaflet repair with MitraClip. Anatomical and functional parameters were assessed by pre-procedure CTA and compared between those with and without residual (≥2) MR.\u0000 \u0000 \u0000 \u0000 A total of 25 patients were included (median[Q1, Q3]; age, 80[75, 85]; 44% men) and classified into ventricular FMR (V-FMR, n = 12) and atrial FMR (A-FMR, n = 13) according to anatomical and functional characteristics by CTA. 50% of V-FMR and 38% of A-FMR had residual/worsening MR. Among V-FMR patients with residual/worsening MR, shorter coaptation length was observed (2.2[2, 2.3] mm vs. 3.5[3, 4], p = 0.006) (Figure). No differences in anatomical or functional characteristics were seen in A-FMR patients.\u0000 \u0000 \u0000 \u0000 Longer coaptation length in V-FMR is predictive of successful MitraClip procedure, whereas mitral annulus size and cardiac volumes are not.\u0000 <Ventricular FMR> Total (N = 12) No residual/no worsening MR (N = 6) Residual/worsening MR (N = 6) P value Septal-lateral diameter, mm 31.9 (30.5, 37.9) 32.2 (30.1, 39.8) 31.9 (29.5, 35) 0.749 Annulus area, cm² 11.2 (10.4, 13.6) 11.3 (10.1, 14.6) 11.1 (9.6, 12.6) 0.631 Tenting area, cm² 1.6 (1.3, 2.1) 1.6 (1.2, 2.2) 1.7 (1.2, 2.3) 0.873 Tenting height, mm 8.5 (6.5, 9.7) 8.5 (6.6, 9.3) 8.3 (6.3, 10.1) 0.749 Coaptation length, mm 2.6 (2.1, 3.5) 3.5 (3.0, 4.0) 2.2 (2.0, 2.3) 0.006 <Atrial FMR> Total (N = 13) No residual/no worsening MR (N = 8) Residual/worsening MR (N = 5) P value Septal-lateral diameter, mm 32.3 (29.5, 39.0) 32.0 (29.2, 39.9) 34.3 (30.8, 39.02) 0.464 Annulus area, cm² 10.3 (9.2, 14.7) 10.2 (9.0, 14.6) 12.4 (9.4, 14.7) 0.661 Tenting area, cm² 1.2 (0.8, 1.8) 1.1 (0.7, 2.2) 1.3 (0.7, 1.8) 0.884 Tenting height, mm 5.5 (4.1, 6.9) 6.3 (4.1, 8.7) 4.6 (3.7, 5.8) 0.213 Coaptation length, mm 2.3 (1.5, 2.8) 2.5 (1.4, 3.5) 1.9 (1.5, 2.6) 0.464 Comparison of baseline CT parameters between no residual/ no worsening MR and residual/ worsening MR Abstract Figure.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"20 1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83046808","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.228
M. Guglielmo, L. Fusini, M. Muratori, G. Tamborini, V. Mantegazza, G. Muscogiuri, A. Baggiano, S. Stefano, M. Babbaro, R. Mollace, S. Mushtaq, E. Conte, A. Guaricci, M. Pepi, G. Pontone
Type of funding sources: None. Computed tomography (CT) provides excellent anatomy assessment of the aortic annulus (AoA) and is currently routinely utilized for pre-procedural planning of transcatheter aortic valve implantation (TAVI). This study sought to investigate if geometrical characteristics of the AoA determined by CT may represent predictors of structural valve deterioration (SVD) in patients undergoing transcatheter aortic implantation (TAVI) with balloon-expandable valves. AoA maximum diameter (Dmax), minimum diameter (Dmin), and area were assessed using pre-procedural CT in patients undergoing TAVI in our Institution. SVD was identified with transthoracic echocardiography at 5.9 ± 1.7 follow-up years. 124 consecutive patients (mean age: 79 ± 7 years old; female: 61%) were retrospectively enrolled. AoA Dmax, Dmin and area were significantly smaller in patients with SVD compared to patients without SVD (27.1 ± 2.8 mm vs 25.6 ± 2.2 mm, p = 0.012; 21.8 ± 2.1 mm vs 20.5 ± 2.1 mm, p = 0.001 and 467 ± 88 mm2 vs 419 ± 77 mm2 p = 0.002 respectively). At univariate analysis, female sex, body surface area, the use of a -23 mm prosthetic valve a Dmax <27.1 mm and a Dmin < 19.9 mm were all variables independently associated with SVD whereas at multivariate analysis, only Dmin <19.9 mm (OR = 2.873, 95% CI: 1.191-6.929, p = 0.019) and female sex (OR = 2.659, 95% CI: 1.095-6.458, p = 0.031) were independent predictors of SVD. Female sex and AoA Dmin < 19.9 mm are associated to SVD in patients undergoing TAVI with balloon explandable valves. Abstract Figure.
资金来源类型:无。计算机断层扫描(CT)提供了主动脉环(AoA)的良好解剖评估，目前通常用于经导管主动脉瓣植入术(TAVI)的术前规划。本研究旨在探讨CT确定的AoA的几何特征是否可以预测经导管主动脉瓣植入术(TAVI)患者的结构性瓣膜恶化(SVD)。应用术前CT对我院TAVI患者的AoA最大直径(Dmax)、最小直径(Dmin)和面积进行评估。随访5.9±1.7年时经胸超声心动图发现SVD。连续124例患者(平均年龄79±7岁;女性:61%)回顾性入组。SVD患者AoA Dmax、Dmin和面积明显小于无SVD患者(27.1±2.8 mm vs 25.6±2.2 mm, p = 0.012;21.8±2.1 mm vs 20.5±2.1 mm, p = 0.001, 467±88 mm2 vs 419±77 mm2 p = 0.002)。在单因素分析中，女性性别、体表面积、使用-23 mm人工瓣膜、Dmax <27.1 mm和Dmin <19.9 mm都是与SVD独立相关的变量，而在多因素分析中，只有Dmin <19.9 mm (OR = 2.873, 95% CI: 1.191-6.929, p = 0.019)和女性性别(OR = 2.659, 95% CI: 1.095-6.458, p = 0.031)是SVD的独立预测因子。女性和AoA Dmin < 19.9 mm与球囊可解释瓣膜TAVI患者SVD相关。抽象的图。
{"title":"Computed tomography for the prediction of structural valve deterioration in patients undergoing transcatheter aortic valve implantation","authors":"M. Guglielmo, L. Fusini, M. Muratori, G. Tamborini, V. Mantegazza, G. Muscogiuri, A. Baggiano, S. Stefano, M. Babbaro, R. Mollace, S. Mushtaq, E. Conte, A. Guaricci, M. Pepi, G. Pontone","doi":"10.1093/EHJCI/JEAA356.228","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.228","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 Computed tomography (CT) provides excellent anatomy assessment of the aortic annulus (AoA) and is currently routinely utilized for pre-procedural planning of transcatheter aortic valve implantation (TAVI). This study sought to investigate if geometrical characteristics of the AoA determined by CT may represent predictors of structural valve deterioration (SVD) in patients undergoing transcatheter aortic implantation (TAVI) with balloon-expandable valves.\u0000 \u0000 \u0000 \u0000 AoA maximum diameter (Dmax), minimum diameter (Dmin), and area were assessed using pre-procedural CT in patients undergoing TAVI in our Institution. SVD was identified with transthoracic echocardiography at 5.9 ± 1.7 follow-up years.\u0000 \u0000 \u0000 \u0000 124 consecutive patients (mean age: 79 ± 7 years old; female: 61%) were retrospectively enrolled. AoA Dmax, Dmin and area were significantly smaller in patients with SVD compared to patients without SVD (27.1 ± 2.8 mm vs 25.6 ± 2.2 mm, p = 0.012; 21.8 ± 2.1 mm vs 20.5 ± 2.1 mm, p = 0.001 and 467 ± 88 mm2 vs 419 ± 77 mm2 p = 0.002 respectively). At univariate analysis, female sex, body surface area, the use of a -23 mm prosthetic valve a Dmax <27.1 mm and a Dmin < 19.9 mm were all variables independently associated with SVD whereas at multivariate analysis, only Dmin <19.9 mm (OR = 2.873, 95% CI: 1.191-6.929, p = 0.019) and female sex (OR = 2.659, 95% CI: 1.095-6.458, p = 0.031) were independent predictors of SVD.\u0000 \u0000 \u0000 \u0000 Female sex and AoA Dmin < 19.9 mm are associated to SVD in patients undergoing TAVI with balloon explandable valves.\u0000 Abstract Figure.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"36 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72832346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.034
A. Gurgu, L. Petrescu, C. Văcărescu, C. Luca, C. Mornoş, S. Crișan, M. Lazăr, D. Cozma
Type of funding sources: None. CRT improves both systolic and diastolic function, thus increasing cardiac output. However, less data is available concerning diastolic dyssynchrony and fusion pacing CRT. The aim of our study was to assess the outcome of LV diastolic asynchrony in a population of fusion pacing CRT without right ventricular (RV) lead. Prospective data were collected from a cohort of patients (pts) with right atrium/left ventricle leads (RA/LV CRT). Baseline and every 6 months follow-up included standard ETT and classical dyssynchrony parameter measurements. Diastolic dyssynchrony was done by offline speckle-tracking derived TDI timing assesment of the simultaneity of E" and A" basal septal and lateral wall 4 chamber view. New parameters were introduced: E" and respectively A" time (E"T / A"T) as the time difference between E" (respectively A" ) peaks septal and lateral wall. Exercise tests, drugs optimization and device individual programmimg were systematically performed in order to maintain constant fusion and improve CRT response. Patients were divided in three groups: super-responders (SR), responders (R) and non responders (NR). Sixty-two pts (35 male) aged 62 ± 11 y.o. with idiopathic DCM implanted with a RA/LV CRT were analyzed: 34%SR / 61%R / 5%NR. Baseline initial characteristics: QRS 164 ± 18 ms; EF 27 ± 5.2; 29% had type III diastolic dysfunction (DD), 63% type II DD, 8% type I DD. Average follow-up was 45 ± 19 months; mean LVEF at the last follow-up was 37 ± 7.9%. The E"T decreased from 90 ± 20 ms to 25 ± 10 ms in SR with significant LV reverse remodelling (LV end-diastolic volume 193.7 ± 81 vs 243.2 ± 82 ml at baseline, p < 0.0028) and lower LV filling pressures (E/E" 13.2 ± 4.6 vs 11.4 ± 4.5, p =0.0295). DD profile improved in 65% of R with a reduction in E/A ratio (1.46 ± 5.3 vs. 0.82 ± 3.9 at baseline, p= 0.4453). Non-sudden cardiac death occurred in 3 NR pts (2%) with type III DD, severe LA volume and larger E" T /A"T (E"T> 85 msec A"T > 30 msec). Significant cut off value calculated by ROC curve for LV diastolic dyssynchrony is E"T > 80 ms and A"T of > 25 msec. Fusion pacing CRT without RV lead showed a positive outcome; improving LV diastolic dyssynchrony in responders and super-responders patients is obvious. Larger randomized studies are needed to define the role of diastolic asynchronism as a predictor of favorable response in fusion pacing. Abstract Figure. Typical TDI patterns in LV fusion pacing
{"title":"Diastolic dyssynchrony in patients with LV only fusion pacing CRT without RV lead","authors":"A. Gurgu, L. Petrescu, C. Văcărescu, C. Luca, C. Mornoş, S. Crișan, M. Lazăr, D. Cozma","doi":"10.1093/EHJCI/JEAA356.034","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.034","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 CRT improves both systolic and diastolic function, thus increasing cardiac output. However, less data is available concerning diastolic dyssynchrony and fusion pacing CRT. The aim of our study was to assess the outcome of LV diastolic asynchrony in a population of fusion pacing CRT without right ventricular (RV) lead.\u0000 \u0000 \u0000 \u0000 Prospective data were collected from a cohort of patients (pts) with right atrium/left ventricle leads (RA/LV CRT). Baseline and every 6 months follow-up included standard ETT and classical dyssynchrony parameter measurements. Diastolic dyssynchrony was done by offline speckle-tracking derived TDI timing assesment of the simultaneity of E\" and A\" basal septal and lateral wall 4 chamber view. New parameters were introduced: E\" and respectively A\" time (E\"T / A\"T) as the time difference between E\" (respectively A\" ) peaks septal and lateral wall. Exercise tests, drugs optimization and device individual programmimg were systematically performed in order to maintain constant fusion and improve CRT response. Patients were divided in three groups: super-responders (SR), responders (R) and non responders (NR).\u0000 \u0000 \u0000 \u0000 Sixty-two pts (35 male) aged 62 ± 11 y.o. with idiopathic DCM implanted with a RA/LV CRT were analyzed: 34%SR / 61%R / 5%NR. Baseline initial characteristics: QRS 164 ± 18 ms; EF 27 ± 5.2; 29% had type III diastolic dysfunction (DD), 63% type II DD, 8% type I DD. Average follow-up was 45 ± 19 months; mean LVEF at the last follow-up was 37 ± 7.9%. The E\"T decreased from 90 ± 20 ms to 25 ± 10 ms in SR with significant LV reverse remodelling (LV end-diastolic volume 193.7 ± 81 vs 243.2 ± 82 ml at baseline, p < 0.0028) and lower LV filling pressures (E/E\" 13.2 ± 4.6 vs 11.4 ± 4.5, p =0.0295). DD profile improved in 65% of R with a reduction in E/A ratio (1.46 ± 5.3 vs. 0.82 ± 3.9 at baseline, p= 0.4453). Non-sudden cardiac death occurred in 3 NR pts (2%) with type III DD, severe LA volume and larger E\" T /A\"T (E\"T> 85 msec A\"T > 30 msec). Significant cut off value calculated by ROC curve for LV diastolic dyssynchrony is E\"T > 80 ms and A\"T of > 25 msec.\u0000 \u0000 \u0000 \u0000 Fusion pacing CRT without RV lead showed a positive outcome; improving LV diastolic dyssynchrony in responders and super-responders patients is obvious. Larger randomized studies are needed to define the role of diastolic asynchronism as a predictor of favorable response in fusion pacing.\u0000 Abstract Figure. Typical TDI patterns in LV fusion pacing\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"27 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75056973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.343
B. Harris, Stafford G. Warren, E. Persson, R. Bhindi, M. Ringborn, M. Ugander, U. Allahwala
Type of funding sources: None. The coronary collateral circulation is a preformed network of anastomotic connections acting as a "natural bypass" mechanism. Whilst the prevalence of collaterals varies between species, approximately 25% of patients have angiographically visible robust collaterals at the time of ST elevation myocardial infarction. While the presence of collaterals is associated with improved outcomes, the magnitude of myocardial perfusion which can be provided by the collateral circulation remains uncertain. The aim was to quantify collateral myocardial perfusion during experimental coronary balloon occlusion in patients with CAD. The study was approved by the local investigational review board, and all patients provided informed consent. Patients without prior infarction, bypass surgery, or angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel, underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 hours after PTCA. The study included 21 patients (median [interquartile range] age 70 [56-74] years, 52% male). The degree of diameter stenosis of treated vessels ranged from 60-99%, with successful PTCA performed with a mean 5-minute balloon occlusion time, resulting in ≤20% residual stenosis in all cases. The vessels undergoing PTCA were 6 in the LAD, 5 in the LCx, and 10 in the RCA. For the cohort, the size of the perfusion defect was 16 [8-30]% of the LV and the collateral perfusion at rest within the perfusion defect was 64 [58-68]% of normal perfusion within that region. Collateral perfusion was negatively correlated with perfusion defect size (R2 = 0.85, p < 0.001), but did not differ by sex (p = 0.27) or age (p = 0.58). CONCLUSIONS: This is the first study to describe the magnitude of microvascular collateral perfusion in CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provide approximately 60% of the perfusion that reaches the jeopardized myocardium during coronary occlusion. This magnitude of collateral perfusion is much higher than previously speculated. A previous study using microspheres in dogs found that collateral perfusion in the setting of an occluded vessel was 6% of normal. By comparison, the current study found ten times greater collateral perfusion in patients with CAD. Abstract Figure. Collateral perfusion during occlusion.
{"title":"Coronary collaterals provide more than half of normal perfusion in patients with coronary artery disease - quantification by myocardial perfusion SPECT during elective balloon occlusion","authors":"B. Harris, Stafford G. Warren, E. Persson, R. Bhindi, M. Ringborn, M. Ugander, U. Allahwala","doi":"10.1093/EHJCI/JEAA356.343","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.343","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 The coronary collateral circulation is a preformed network of anastomotic connections acting as a \"natural bypass\" mechanism. Whilst the prevalence of collaterals varies between species, approximately 25% of patients have angiographically visible robust collaterals at the time of ST elevation myocardial infarction. While the presence of collaterals is associated with improved outcomes, the magnitude of myocardial perfusion which can be provided by the collateral circulation remains uncertain.\u0000 \u0000 \u0000 \u0000 The aim was to quantify collateral myocardial perfusion during experimental coronary balloon occlusion in patients with CAD.\u0000 \u0000 \u0000 \u0000 The study was approved by the local investigational review board, and all patients provided informed consent. Patients without prior infarction, bypass surgery, or angiographically visible collaterals undergoing elective percutaneous transluminal coronary angioplasty (PTCA) to a single epicardial vessel, underwent two scans with 99mTc-sestamibi myocardial perfusion single-photon emission computed tomography (SPECT). All subjects underwent at least three minutes of angiographically verified complete balloon occlusion, at which time an intravenous injection of the radiotracer was administered, followed by SPECT imaging. A second radiotracer injection followed by SPECT imaging was performed 24 hours after PTCA.\u0000 \u0000 \u0000 \u0000 The study included 21 patients (median [interquartile range] age 70 [56-74] years, 52% male). The degree of diameter stenosis of treated vessels ranged from 60-99%, with successful PTCA performed with a mean 5-minute balloon occlusion time, resulting in ≤20% residual stenosis in all cases. The vessels undergoing PTCA were 6 in the LAD, 5 in the LCx, and 10 in the RCA. For the cohort, the size of the perfusion defect was 16 [8-30]% of the LV and the collateral perfusion at rest within the perfusion defect was 64 [58-68]% of normal perfusion within that region. Collateral perfusion was negatively correlated with perfusion defect size (R2 = 0.85, p < 0.001), but did not differ by sex (p = 0.27) or age (p = 0.58). CONCLUSIONS: This is the first study to describe the magnitude of microvascular collateral perfusion in CAD. On average, despite coronary occlusion and an absence of angiographically visible collateral vessels, collaterals provide approximately 60% of the perfusion that reaches the jeopardized myocardium during coronary occlusion. This magnitude of collateral perfusion is much higher than previously speculated. A previous study using microspheres in dogs found that collateral perfusion in the setting of an occluded vessel was 6% of normal. By comparison, the current study found ten times greater collateral perfusion in patients with CAD.\u0000 Abstract Figure. Collateral perfusion during occlusion.\u0000","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"26 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77283931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.286
M. M. Córdova, A. Guala, X. Morales, G. Jiménez-Pérez, L. Dux-Santoy, A. Ruiz-Muñoz, G. Teixidó-Tura, I. Ferreira, A. Evangelista, J. Rodríguez-Palomares, O. Camara
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; La Marató de TV3 Automatic analysis of medical imaging data may improve their clinical impact by reducing analysis time and improving reproducibility. Many medical imaging data, like 4D-flow magnetic resonance imaging (MRI), are often quantified regionally, implying the need for anatomical landmark identification to locate correspondences in the extracted data and compare among patients. Machine learning (ML) techniques hold potential for automatic analysis of medical imaging. Phase-contrast enhanced magnetic resonance angiography (PC-MRA) is a class of angiograms not requiring the administration of contrast agents. We aimed to test whether a machine learning algorithm can be trained to identify key anatomical cardiovascular landmarks on PC-MRA images and compare its performance with humans. Three-hundred twenty-three aortic PC-MRA were manually annotated with the location of 4 landmarks: sinotubular junction, pulmonary artery bifurcation and first and third supra-aortic vessels (Figure 1), often used to separate the aorta in sub-regions. Patients included in the training dataset comprised healthy volunteers (40), bicuspid aortic valve patients (141), patients with degenerative aortic disease (60) and patients with genetically-triggered aortic disease (82), all without previous aortic surgery and with native aortic valve. PC-MRA images and manual annotations were used to train a DQN, a reinforcement learning algorithm that combines Q-learning with deep neural networks. The agents can navigate the images and optimally find the landmarks by following the policies learned during training. Data from thirty patients, distributed in terms of aortic condition as the training set, unseen by the algorithm in the training phase, were used to quantify intra-observer reproducibility and to assess ML algorithm performance. Distance between points was used as metric for comparisons, original human annotation was used as ground-truth and repeated-measures ANOVA was used for statistical testing. Human and machine learning performed similarly in the identification of the sinotubular junction (distance between points of 11.0 ± 8.1 vs. 11.1 ± 8.6 mm, respectively, p = 0.949) and first (6.6 ± 3.9 vs. 6.8 ± 5.6 mm, p = 0.886) and third (6.8 ± 4.0 vs. 8.4 ± 7.4 mm, p = 0.161) supra-aortic vessels branches but human annotation outperformed ML landmark detection in the identification of the pulmonary artery bifurcation (10.2 ± 7.0 vs. 15.2 ± 13.1 mm, p = 0.008). Computation time for landmark detection by ML was between 0.8 and 1.6 seconds on a standard computer while human annotation took approximatively two minutes. ML-based aortic landmarks detection from phase-contrast enhanced magnetic resonance angiography is feasible and fast and performs similarly to human. Reinforced learning a
{"title":"Reinforcement machine learning-based aortic anatomical landmarks detection from phase-contrast enhanced magnetic resonance angiography","authors":"M. M. Córdova, A. Guala, X. Morales, G. Jiménez-Pérez, L. Dux-Santoy, A. Ruiz-Muñoz, G. Teixidó-Tura, I. Ferreira, A. Evangelista, J. Rodríguez-Palomares, O. Camara","doi":"10.1093/EHJCI/JEAA356.286","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.286","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Spanish Ministry of Science, Innovation and Universities; La Marató de TV3\u0000 \u0000 \u0000 \u0000 Automatic analysis of medical imaging data may improve their clinical impact by reducing analysis time and improving reproducibility. Many medical imaging data, like 4D-flow magnetic resonance imaging (MRI), are often quantified regionally, implying the need for anatomical landmark identification to locate correspondences in the extracted data and compare among patients. Machine learning (ML) techniques hold potential for automatic analysis of medical imaging. Phase-contrast enhanced magnetic resonance angiography (PC-MRA) is a class of angiograms not requiring the administration of contrast agents.\u0000 \u0000 \u0000 \u0000 We aimed to test whether a machine learning algorithm can be trained to identify key anatomical cardiovascular landmarks on PC-MRA images and compare its performance with humans.\u0000 \u0000 \u0000 \u0000 Three-hundred twenty-three aortic PC-MRA were manually annotated with the location of 4 landmarks: sinotubular junction, pulmonary artery bifurcation and first and third supra-aortic vessels (Figure 1), often used to separate the aorta in sub-regions. Patients included in the training dataset comprised healthy volunteers (40), bicuspid aortic valve patients (141), patients with degenerative aortic disease (60) and patients with genetically-triggered aortic disease (82), all without previous aortic surgery and with native aortic valve. PC-MRA images and manual annotations were used to train a DQN, a reinforcement learning algorithm that combines Q-learning with deep neural networks. The agents can navigate the images and optimally find the landmarks by following the policies learned during training. Data from thirty patients, distributed in terms of aortic condition as the training set, unseen by the algorithm in the training phase, were used to quantify intra-observer reproducibility and to assess ML algorithm performance. Distance between points was used as metric for comparisons, original human annotation was used as ground-truth and repeated-measures ANOVA was used for statistical testing.\u0000 \u0000 \u0000 \u0000 Human and machine learning performed similarly in the identification of the sinotubular junction (distance between points of 11.0 ± 8.1 vs. 11.1 ± 8.6 mm, respectively, p = 0.949) and first (6.6 ± 3.9 vs. 6.8 ± 5.6 mm, p = 0.886) and third (6.8 ± 4.0 vs. 8.4 ± 7.4 mm, p = 0.161) supra-aortic vessels branches but human annotation outperformed ML landmark detection in the identification of the pulmonary artery bifurcation (10.2 ± 7.0 vs. 15.2 ± 13.1 mm, p = 0.008). Computation time for landmark detection by ML was between 0.8 and 1.6 seconds on a standard computer while human annotation took approximatively two minutes.\u0000 \u0000 \u0000 \u0000 ML-based aortic landmarks detection from phase-contrast enhanced magnetic resonance angiography is feasible and fast and performs similarly to human. Reinforced learning a","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"46 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80600340","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-02-08DOI: 10.1093/EHJCI/JEAA356.263
D. Arangalage, A. Pavon, S. Hugelshofer, T. Rutz, O. Muller, J. Schwitter, P. Monney
Type of funding sources: None. According to current guidelines indication for surgery is straightforward with a class I recommendation in case of severe symptomatic aortic regurgitation (AR) and/or left ventricular ejection fraction (LVEF) decrease ≤50%. However, the management of patients with asymptomatic severe AR with preserved LVEF remains debated, with a cruel lack of prognostic factors to identify patients who may benefit from early intervention. An explanation to the absence of such factors is that the determinants of symptoms, a strong prognostic parameter, have been poorly identified. Beyond LV dilation and systolic dysfunction, which are both recognized prognostic factors in chronic AR, we hypothesized that interstitial myocardial fibrosis, as an early indicator of LV remodeling, may also influence the occurrence of symptoms. Cardiovascular magnetic resonance (CMR)-based myocardial extracellular volume (ECV) quantification by T1 mapping has emerged as a valuable tool to quantify diffuse myocardial fibrosis. To study the relationship between myocardial interstitial fibrosis quantified by T1 mapping and the symptomatic status of patients with chronic aortic valve regurgitation. We retrospectively included 38 consecutive patients with chronic, isolated, mild to severe AR who underwent a CMR at our institution. Exclusion criteria were the presence of any other heart condition that may induce myocardial fibrosis, ≥ mild associated valve disease, AR secondary to endocarditis, genetic, inflammatory or congenital disease except bicuspid aortic valve. T1 mapping of the basal segments was performed before and after contrast administration measuring native and post-contrast T1 relaxation time and ECV. Mean age was 56 ± 20 years, 30 patients (79%) were males, and symptoms were reported in 11 patients (29%). Mean LVEF was 57 ± 9% and ≥50% in 30 patients (79%). Aortic valve regurgitation fraction (RF) was 25 ± 13%, ECV 0.27 ± 0.04%, indexed LV end-diastolic volume (LVEDVi) 98 ± 32 ml/m2, end-systolic volume (LVESVi) 46 ± 19 ml/m2, and LV mass 79 ± 21 g/m2. LVESVi (r = 0.41,p = 0.01), LVEF (r=-0.59,p = 0.0001), and ECV (r = 0.42,p = 0.008) were correlated with symptoms, whereas age (r = 0.16,p = 0.33), gender (r=-0.24,p = 0.15), LVEDVi (r = 0.28,p = 0.09), LV mass index (r = 0.08,p = 0.62), and RF (r = 0.31,p = 0.06) were not. In the subgroup of patients with preserved LVEF (≥50%), after adjustment for LVESVi and RF, only ECV remained independently associated with symptoms (p = 0.046). Interestingly, when including the patients with a reduced LVEF < 50% in the multivariable analysis only LVESVi was an independent determinant of symptoms (p = 0.04) and ECV was not (p = 0.07) myocardial fibrosis quantified by ECV calculation is a determinant of symptoms in AR with preserved LVEF. Further studies are warranted to determine the prognostic value of ECV that may justify earlier intervention. Abstract Figure. ECV in
资金来源类型:无。根据目前的指南，在严重症状性主动脉瓣反流(AR)和/或左心室射血分数(LVEF)下降≤50%的情况下，手术适应症是直接的，推荐I级。然而，无症状严重AR患者保留LVEF的管理仍然存在争议，严重缺乏预后因素来确定可能从早期干预中受益的患者。缺乏这些因素的一种解释是，症状的决定因素(一个强有力的预后参数)没有得到很好的确定。除了左室扩张和收缩功能障碍这两个公认的慢性AR预后因素外，我们假设间质性心肌纤维化作为左室重构的早期指标，也可能影响症状的发生。以心血管磁共振(CMR)为基础的心肌细胞外体积(ECV)量化已成为量化弥漫性心肌纤维化的一种有价值的工具。探讨T1测图量化心肌间质纤维化与慢性主动脉瓣反流患者症状状态的关系。我们回顾性地纳入了38例连续的慢性、孤立性、轻至重度AR患者，这些患者在我们的机构接受了CMR。排除标准是存在任何其他可能诱发心肌纤维化的心脏疾病，≥轻度相关瓣膜疾病，心内膜炎继发的AR，除二尖瓣主动脉瓣外的遗传性、炎症性或先天性疾病。对比剂给药前后分别对基底节进行T1映射，测量原始和对比后T1松弛时间和ECV。平均年龄56±20岁，男性30例(79%)，有症状11例(29%)。30例(79%)患者平均LVEF为57±9%和≥50%。主动脉瓣返流分数(RF) 25±13%，ECV 0.27±0.04%，指标左室舒张末期容积(LVEDVi) 98±32 ml/m2，收缩末期容积(LVESVi) 46±19 ml/m2，左室质量79±21 g/m2。LVESVi (r = 0.41, p = 0.01), LVEF (r = -0.59, p = 0.0001),和ECV (r = 0.42, p = 0.008)与症状相关,而年龄(r = 0.16, p = 0.33),性别(r = -0.24, p = 0.15), LVEDVi (r = 0.28, p = 0.09),左室质量指数(r = 0.08, p = 0.62),和RF (r = 0.31, p = 0.06)。在保留LVEF(≥50%)的患者亚组中，调整LVESVi和RF后，只有ECV仍然与症状独立相关(p = 0.046)。有趣的是，当纳入LVEF降低< 50%的患者进行多变量分析时，只有LVESVi是症状的独立决定因素(p = 0.04)，而ECV不是(p = 0.07)。通过计算ECV量化的心肌纤维化是LVEF保留的AR症状的决定因素。需要进一步的研究来确定ECV的预后价值，从而证明早期干预是合理的。抽象的图。AR中的ECV与保留的LVEF
{"title":"Myocardial interstitial fibrosis assessed by extracellular volume quantification is a determinant of symptoms in aortic valve regurgitation with preserved ejection fraction","authors":"D. Arangalage, A. Pavon, S. Hugelshofer, T. Rutz, O. Muller, J. Schwitter, P. Monney","doi":"10.1093/EHJCI/JEAA356.263","DOIUrl":"https://doi.org/10.1093/EHJCI/JEAA356.263","url":null,"abstract":"\u0000 \u0000 \u0000 Type of funding sources: None.\u0000 \u0000 \u0000 \u0000 According to current guidelines indication for surgery is straightforward with a class I recommendation in case of severe symptomatic aortic regurgitation (AR) and/or left ventricular ejection fraction (LVEF) decrease ≤50%. However, the management of patients with asymptomatic severe AR with preserved LVEF remains debated, with a cruel lack of prognostic factors to identify patients who may benefit from early intervention. An explanation to the absence of such factors is that the determinants of symptoms, a strong prognostic parameter, have been poorly identified. Beyond LV dilation and systolic dysfunction, which are both recognized prognostic factors in chronic AR, we hypothesized that interstitial myocardial fibrosis, as an early indicator of LV remodeling, may also influence the occurrence of symptoms. Cardiovascular magnetic resonance (CMR)-based myocardial extracellular volume (ECV) quantification by T1 mapping has emerged as a valuable tool to quantify diffuse myocardial fibrosis.\u0000 \u0000 \u0000 \u0000 To study the relationship between myocardial interstitial fibrosis quantified by T1 mapping and the symptomatic status of patients with chronic aortic valve regurgitation.\u0000 \u0000 \u0000 \u0000 We retrospectively included 38 consecutive patients with chronic, isolated, mild to severe AR who underwent a CMR at our institution. Exclusion criteria were the presence of any other heart condition that may induce myocardial fibrosis, ≥ mild associated valve disease, AR secondary to endocarditis, genetic, inflammatory or congenital disease except bicuspid aortic valve. T1 mapping of the basal segments was performed before and after contrast administration measuring native and post-contrast T1 relaxation time and ECV.\u0000 \u0000 \u0000 \u0000 Mean age was 56 ± 20 years, 30 patients (79%) were males, and symptoms were reported in 11 patients (29%). Mean LVEF was 57 ± 9% and ≥50% in 30 patients (79%). Aortic valve regurgitation fraction (RF) was 25 ± 13%, ECV 0.27 ± 0.04%, indexed LV end-diastolic volume (LVEDVi) 98 ± 32 ml/m2, end-systolic volume (LVESVi) 46 ± 19 ml/m2, and LV mass 79 ± 21 g/m2. LVESVi (r = 0.41,p = 0.01), LVEF (r=-0.59,p = 0.0001), and ECV (r = 0.42,p = 0.008) were correlated with symptoms, whereas age (r = 0.16,p = 0.33), gender (r=-0.24,p = 0.15), LVEDVi (r = 0.28,p = 0.09), LV mass index (r = 0.08,p = 0.62), and RF (r = 0.31,p = 0.06) were not. In the subgroup of patients with preserved LVEF (≥50%), after adjustment for LVESVi and RF, only ECV remained independently associated with symptoms (p = 0.046). Interestingly, when including the patients with a reduced LVEF < 50% in the multivariable analysis only LVESVi was an independent determinant of symptoms (p = 0.04) and ECV was not (p = 0.07)\u0000 \u0000 \u0000 \u0000 myocardial fibrosis quantified by ECV calculation is a determinant of symptoms in AR with preserved LVEF. Further studies are warranted to determine the prognostic value of ECV that may justify earlier intervention.\u0000 Abstract Figure. ECV in","PeriodicalId":11963,"journal":{"name":"European Journal of Echocardiography","volume":"43 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-02-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80257537","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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