Archives of Cardiovascular Diseases Supplements最新文献

Introduction

Background: the best management of symptomatic patients with low gradient (LG) severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF) has not been established in randomized controlled trials. The ROTAS trial aimed to assess the superiority of aortic valve replacement (AVR) versus optimized medical therapy (OMT) in symptomatic patients with LG severe AS and preserved LVEF.

Method

Fifty-two patients (age 79 ± 7 years; males 46%, mean aortic gradient: 31 ± 5 mmHg; aortic surface: 0.8 ± 0.1 cm²) who were randomized 1:1 to AVR or OMT. The follow-up lasted 14 ± 7 months. The study was interrupted early because of the low inclusion rate during the COVID-2019 pandemic. The AS severity was confirmed by a multimodality approach including dobutamine stress echocardiography and/or aortic calcium score. The primary end-point (overall death and/or hospitalisation for heart failure) occurred in 13 (25%) patients.

Results

Patients undergoing AVR showed a similar recurrence of events (overall death, heart failure hospitalisation) compared to patients receiving OMT (5 vs. 8 events). Patients receiving OMT did not experience worse survival compared to patients receiving AVR (HR 1.57, 95% CI: 0.51–4.83, P = 0.4275). Kaplan-Meier curves showed similar event-free survival (logrank P = 0.4236) among the 2 groups (Fig. 1).

Conclusion

In the randomized ROTAS trial, AVR is not associated with a better prognosis in symptomatic patients with LG severe AS and preserved LVEF.

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Introduction

Structural changes and myocardial fibrosis quantification by cardiac imaging have become increasingly important to predict cardiovascular events in hypertrophic cardiomyopathy patients. In this setting, it is likely that a supervised approach, using machine learning, may improve their risk assessment.

Method

We retrospectively included patients with confirmed HCM (n = 265, 52 ± 17 years) through clinical and echocardiographic. A supervised machine learning prognosis algorithm, based on echocardiographic data, was obtained to predict cardiovascular (CV) outcomes, and subsequently investigated for their association with myocardial fibrosis (n = 185) assessed by CMR imaging.

Results

At follow-up at 57 months, 13 (4.9%) of patients died and 114 (43%) had been hospitalized for CV events. Patient with CV events had higher indexed LV mass, worse diastolic dysfunction, and more severe LV obstruction. HCM-patients with myocardial fibrosis have more severe LV hypertrophy (OR: 3.1; P = 0.003) and longitudinal myocardial deformation (OR: 0.8; P = 0.008). Prognosis algorithm established using machine learning identified left atrium area (> 24 cm²), mechanical dispersion (> 49 ms), posterior wall thickness (> 1.8 cm), and TAPSE (27 mm) as the four most relevant variables to correctly predict cardiovascular events.

Conclusion

Our findings suggest that a simple algorithm based on four key variables (posterior wall thickness, mechanical dispersion, LA area and TAPSE) may help risk stratification and decision-making in patients with HCM. Using new treatments to target these parameters might improve outcomes in HCM-patients (Fig. 1).

Introduction

Transthoracic echocardiography (TEE) plays a major role in the baseline assessment and follow-up of cardio-oncology patients. While left ventricular ejection fraction (LVEF) still has its place in cardiac monitoring, new modalities like myocardial deformation imaging with speckle tracking strain analysis has been validated for early detection of subclinical LV dysfunction.

Method

We conducted a longitudinal prospective study including all the breast cancer patients treated with anthracyclines and trastuzumab from January 2017 to March 2022. All patients underwent baseline TEE, and were followed-up every 3 months after that, with GLS assessment whenever it was possible. We evaluated the frequency of GLS drop and its correlation to LVEF reduction.

Results

Out of a total of 1583 patients, 677 had available LV GLS assessment. Among them, 83 (12.3%) decreased their GLS during follow-up, 67% of which had no concomitant drop in LVEF. In these patients, impaired LV GLS values were noted at 3 months after chemotherapy and at 6, and 12 months compared with baseline (−22.3 ± 1.8% at baseline, −18.1 ± 2.3% at 3 months, −17.7 ± 2.1% at 6 months, and −16.9 ± 2.1% at 12 months). LV GLS at 3 months was strongly correlated to cardiotoxicity (LVEF < 50%) at 12 months (P < 0.05). A cut-off LV GLS value of −16.9% was then retained to identify LVEF alteration at the end of follow-up. Finally, our study found that GLS at 3 months and 6 months had a prognostic value, since the lower GLS was, the poorest the patient's clinical outcome was, with further development of symptomatic heart failure.

Conclusion

Our study demonstrates that myocardial deformation analysis enables detection of early and progressive subclinical cardiac dysfunction, and GLS at 3 months was positively correlated to LVEF drop at 12 months.

Introduction

The role of speckle tracking echocardiography has been expanding thanks to its utility in detecting subtle changes in cardiac function, and has prognostic value. Right atrial (RA) strain has shown promise in prognostication amongst patients with pulmonary hypertension and heart failure. It is associated with RA size, RV function and IVC size. However, its clinical utility and application remain under investigation. We evaluated the associations of right atrial strain with both invasive and non-invasive measure of RV function and the association of RA strain with heart failure hospitalisations and death across a heterogeneous cohort.

Method

A single-centre retrospective analysis of 225 consecutive patients (age 72 ± 11.6 years old; male 56%) with both right heart catheterization (RHC) and TTE. Data regarding unplanned heart failure hospitalisations and death were recorded. Statistical analysis was performed using SAS 15.1 to assess the association between right atrial strain and prespecified echo and haemodynamic measures of right and left heart function and prognosis defined by heart failure hospitalisations and death.

Results

Over a median follow-up of 28 ± 16 months, there were 59 events. RA strain was associated with non-invasive and invasive measures of right and left heart function (see Table 1) with a P-value of < 0.05. Despite the association of impaired RV strain with prognosis, HR: 2.94 (1.14–7.60), RA strain did not appear to be associated independently with prognosis HR: 0.98 (0.95–1.0) P-value = 0.0676.

Conclusion

Right atrial strain is independently associated with both invasive and non-invasive measures of RV function and may be a useful tool to help us assess right heart function. It did not appear to be associated with prognosis despite being independently linked with RV strain, which was strongly associated with prognosis in our cohort.

Introduction

Transthyretin cardiac amyloidosis (ATTR-CA) is an emerging cause of heart failure. The screening of ATTR-CA remains difficult since its echocardiographic features are analogous to those observed in patients with age- and hypertension-related cardiac remodeling.

Method

We retrospectively included 264 patients (76 ± 13 years old, 59% male) referred for suspected ATTR-CA. A supervised machine learning diagnosis algorithm differentiating patients with (n = 112) and without (n = 152) ATTR-CA was constructed based on echocardiographic data, and subsequently validated in an external multicenter cohort of 455 patients (76 ± 13 years old, 61% male).

Results

Patients with ATTR-CA had a lower systolic function (LVEF 47.4 ± 11 vs. 54.3 ± 12%, P < 0.001), left ventricular (LV) global longitudinal strain (GLS) (11.0 ± 3.7 vs. 14.2 ± 4.5%, P < 0.001) and more significant relative apical longitudinal sparing (RALS) (1.5 ± 1.2 vs. 0.9 ± 0.4, P < 0.001) compared to controls. Machine learning identified right ventricular free wall thickness (RVFWT), RALS, relative wall thickness (RWT), and LV mass index as key variables for identifying ATTR-CA (AUC 0.88 [0.84–0.92]; P < 0.001). The diagnostic value of this R3M (RVFWT, RALS, RWT and LV Mass index) algorithm was good in the validation multicenter cohort with an AUC of 0.79 [0.75–0.83] P < 0.001. The R3M algorithm further improved diagnostic accuracy over the IWT (Increased Wall Thickness) guidelines score (increase in C-index of 0.15 [0.10–0.21], P < 0.001).

Conclusion

The simple R3M algorithm based on echocardiographic data exploring RVFWT, apical sparing, and concentric hypertrophy displays good diagnostic accuracy for ATTR-CA and could represent an efficient screening tool (Fig. 1).

Introduction

We report our experience working with cardiac sonographers (SONO) in outpatient settings between April 2019 and December 2022.

Method

Our observation focused on 7 outpatient cardiac centers in the Auvergne Rhône Alpes region, 35,743 patients had at least one consultation between April 2019 and December 2022. In total, 23,657 patients an echocardiogram (ECHO) performed (66%). Seven SONOs were involved, supervised by 15 cardiologists. All ECHOs were technically performed based on a standard acquisition protocol. Data was saved on a dedicated cloud-based Picture Archiving and Communication System (PACS) allowing the cardiologist to check the image quality, results and complete the report, automatically included in the electronic health record.

Results

Out of a total of 25,686 ECHO (i.e., an average of 1.1 ECHO/patient), ∼19,800 (77%) were performed by SONOs (range from 72% to 92% depending on the medical center). In total, ∼2000 ECHO (∼10%) required technical expertise and additional acquisition of images by the referring cardiologist (range from 5% to 25% depending on the experience level of the SONO). Based on a study sample, the average ECHO acquisition time was 12 ± 7 minutes. Thus, over the entire period of 33-month period, the total medical time saved was estimated up to 4,700 hours.

Conclusion

Teamwork is mandatory to improve access to outpatient care in cardiology. Working with cardiac sonographers is efficient and saves cardiologists up to 700 hours/SONO/year of medical time. This organizational workflow should be paired with dedicated imaging data management systems and HER (Fig. 1).

Introduction

Echocardiographic assessment of the athlete's heart remains challenging because of a phenotypic overlap between reactive physiological adaptation and pathological remodelling. The lower range of normal values of left ventricle systolic ejection fraction (LVEF) and global longitudinal strain (GLS) in athletes makes it difficult to differentiate changes related to adaptive remodelling or indicative of early cardiomyopathy. This study sought to identify echocardiographic phenotype of endurance athletes using 2D speckle tracking imaging with a multi-layer approach and to define predictive factors of subtle LV systolic dysfunction.

Method

Healthy male athletes who underwent a pre-participation medical evaluation at the University Hospital of Nancy between 2013 and 2020 were included. Clinical and echocardiographic data were compared with healthy men from the STANISLAS cohort. Subtle LV dysfunction was defined as a GLS < 17.5%.

Results

A total of 191 athletes and 161 control subjects were studied. Athletes demonstrated lower LVEF (57.9% vs. 62.6%; P < 0.01) and lower GLS (17.8% vs. 21.1%; P < 0.01). No significant differences were found between athletes with and without subtle LV dysfunction regarding clinical characteristics, structural echocardiographic features, and exercise capacity. Athletes with subtle LV dysfunction exhibited a lower endocardial GLS (18.8% vs. 22.7%; P < 0.02), a lower epicardial GLS (14.0% vs. 16.6%; P < 0.01) and a greater endocardial/epicardial GLS ratio (1.36 vs. 1.32; P < 0.01). No significant difference was found regarding mechanical dispersion (P = 0.46).

Conclusion

The endurance athlete's heart is characterized by a specific myocardial deformation pattern with a greater endocardial/epicardial GLS ratio. Subtle LV dysfunction seems mainly driven by a decreased epicardial GLS and not related to exercise capacity, structural remodelling or mechanical dispersion (Fig. 1).

Introduction

To determine whether fully automated artificial intelligence-based global circumferential strain (GCS) assessed during vasodilator stress cardiovascular magnetic resonance (CMR) can provide incremental prognostic value.

Method

Between 2016 and 2018, a longitudinal study included all consecutive patients with abnormal stress CMR defined by the presence of inducible ischaemia and/or late gadolinium enhancement (LGE). Control subjects with normal stress CMR were selected using a propensity score-matching. Stress-GCS was assessed using a fully automatic machine learning algorithm based on featured-tracking imaging from short-axis cine images. The primary outcome was the occurrence of major adverse clinical events (MACE) defined as cardiovascular mortality or nonfatal myocardial infarction. Cox regressions evaluated the association between stress-GCS and the primary outcome after adjustment for traditional prognosticators.

Results

In 2670 patients [65 ± 12 years, 68% men, 1:1 matched patients (1335 with normal and 1335 with abnormal CMR)], stress-GCS was associated with MACE [median follow-up 5.2 (4.8–5.5) years] after adjustment for risk factors in the propensity-matched population (adjusted hazard ratio [HR]: 1.12 [95% CI: 1.06–1.18]) and patients with normal CMR (HR: 1.43 [95% CI: 1.30–1.57], both P < 0.001), but not in patients with abnormal CMR (P = 0.33). In patients with normal CMR, an increased stress-GCS > −10% showed the best improvement in model discrimination and reclassification above traditional and stress CMR findings (C-statistic improvement: 0.27; NRI = 0.538; IDI = 0.108, all P < 0.001; LR-test P < 0.001).

Conclusion

Stress-GCS is independently associated with MACE in patients undergoing stress CMR, with an incremental prognostic value over traditional risk factors and stress CMR findings in the group of patients with normal CMR. Prognostic value of AI-based Stress-GCS (Fig. 1).

Introduction

The assessment of mitral bioprosthetic area remains a technical challenge, and its calculation by the continuity equation using transthoracic echocardiography (TTE) may be invalidated in several situations, especially after transcatheter mitral valve implantation (TMVI). This study aims to develop a new technique to measure the mitral valve area after a TMVI using a multimodal three-dimensional echocardiographic and computed tomography (CT) approach.

Method

Among the patients hospitalized for TMVI at Bichat Hospital between June 2017 and February 2021, we selected 24 who had both a transesophageal echocardiography (TEE) and a cardiac CT after TMVI and before discharge. We performed two area measurements by planimetry: the geometric orifice area (GOA) corresponding to the area delimited by the edges of the open valve leaflets after alignment in the plane of the proximal coaptation point of the bioprosthesis leaflets; and the smallest valve area (SVA) defined by the smallest measurable area of the open prosthesis, at the free edges of the leaflets.

Results

In our cohort, the GOA was 1.73 ± 0.41 cm² on 3D TEE and 1.75 ± 0.42 cm² on CT. The SVA was 1.40 ± 0.31 cm² on 3D TEE and 1.49 ± 0.37 cm² on CT. There was a good agreement between the two techniques for GOA and SVA (ICC > 0.6, P < 0.01) and a good correlation between the two measurements on 3D TEE as well as on CT (Pearson 0.88 and 0.91 respectively, P < 0.001).

Conclusion

Our work suggests a new approach to multimodal assessment of prosthetic mitral valve area after TMVI, using 3D TEE and CT scan. Further studies are needed to complete our results, especially to confirm the feasibility and reproducibility of the measurements. It would also be interesting to correlate these area measurements with the clinical prognosis of patients after TMVI. Agreement between 3D TEE and CT measurements (Fig. 1).