Long-Term Outcomes of Aortic Stenosis Patients with Different Flow/Gradient Patterns Undergoing Transcatheter Aortic Valve Implantation

Background: Few data exist on the comparative long-term outcomes of severe aortic stenosis (AS) patients with different flow-gradient patterns undergoing transcatheter aortic valve implantation (TAVI). This study sought to evaluate the impact of the pre-TAVI flow-gradient pattern on long-term clinical outcomes after TAVI and assess changes in the left ventricular ejection fraction (LVEF) of different subtypes of AS patients following TAVI. Methods: Consecutive patients with severe AS undergoing TAVI in our institution were screened and prospectively enrolled. Patients were divided into four subgroups according to pre-TAVI flow/gradient pattern: (i) low flow-low gradient (LF-LG): stroke volume indexed (SVi) ≤ 35 mL/m2 and mean gradient (MG) < 40 mmHg); (ii) normal flow-low gradient (NF-LG): SVi > 35 mL/m2 and MG < 40 mmHg; (iii) low flow-high gradient (LF-HG): Svi 35 mL/m2 and MG ≥ 40 mmHg and (iv) normal flow-high gradient (NF-HG): SVi > 35 mL/m2 and MG ≥ 40 mmHg. Transthoracic echocardiography was repeated at 1-year follow-up. Clinical follow-up was obtained at 12 months, and yearly thereafter until 5-year follow-up was complete for all patients. Results: A total of 272 patients with complete echocardiographic and clinical follow-up were included in our analysis. Their mean age was 80 ± 7 years and the majority of patients (N = 138, 50.8%) were women. 62 patients (22.8% of the study population) were distributed in the LF-LG group, 98 patients (36%) were LF-HG patients, 95 patients (34.9%) were NF-HG, and 17 patients (6.3%) were NF-LG. There was a greater prevalence of comorbidities among LF-LG AS patients. One-year all-cause mortality differed significantly between the four subgroups of AS patients (log-rank p: 0.022) and was more prevalent among LF-LG patients (25.8%) compared to LF-HG (11.3%), NF-HG (6.3%) and NF-LG patients (18.8%). At 5-year follow-up, global mortality remained persistently higher among LF-LG patients (64.5%) compared to LF-HG (47.9%), NF-HG (42.9%), and NF-LG patients (58.8%) (log-rank p: 0.029). At multivariable Cox hazard regression analysis, baseline SVi (HR: 0.951, 95% C.I.; 0.918-0.984), the presence of at least moderate tricuspid regurgitation at baseline (HR: 3.091, 95% C.I: 1.645-5.809) and at least moderate paravalvular leak (PVL) post-TAVI (HR: 1.456, 95% C.I.: 1.106-1.792) were significant independent predictors of late global mortality. LF-LG patients and LF-HG patients exhibited a significant increase in LVEF at 1-year follow-up. A lower LVEF (p < 0.001) and a lower Svi (p < 0.001) at baseline were associated with LVEF improvement at 1-year. Conclusions: Patients with LF-LG AS have acceptable 1-year outcomes with significant improvement in LVEF at 1-year follow-up, but exhibit exceedingly high 5-year mortality following TAVI. The presence of low transvalvular flow and at least moderate tricuspid regurgitation at baseline and significant paravalvular leak post-TAVI were associated with poorer long-term outcomes in the entire cohort of AS patients. The presence of a low LVEF or a low SVi predicts LVEF improvement at 1-year.

Sex-stratified genome-wide association and transcriptome-wide Mendelian randomization studies reveal drug targets of heart failure

The prevalence of heart failure (HF) subtypes, which are classified by left ventricular ejection fraction (LVEF), demonstrate significant sex differences. Here, we perform sex-stratified genome-wide association studies (GWASs) on LVEF and transcriptome-wide Mendelian randomization (MR) on LVEF, all-cause HF, HF with reduced ejection fraction (HFrEF), and HF with preserved ejection fraction (HFpEF). The sex-stratified GWASs of LVEF identified three sex-specific loci that were exclusively detected in the sex-stratified GWASs. Three drug target genes show sex-differential effects on HF/HFrEF via influencing LVEF, with NPR2 as the target gene for the HF drug Cenderitide under phase 2 clinical trial. Our study highlights the importance of considering sex-differential genetic effects in sex-balanced diseases such as HF and emphasizes the value of sex-stratified GWASs and MR in identifying putative genetic variants, causal genes, and candidate drug targets for HF, which is not identifiable using a sex-combined strategy.

Possible Correlations between Mean Platelet Volume and Biological, Electrocardiographic, and Echocardiographic Parameters in Patients with Heart Failure

(1) Background: Despite advancements in medical research and discoveries, heart failure (HF) still represents a significant and prevalent public health challenge. It is characterized by persistently high mortality and morbidity rates, along with increased rates of readmissions, particularly among the elderly population. (2) Methods: This study was conducted retrospectively on 260 patients with stable or decompensated chronic HF. The parameter of interest in the study population was the mean platelet volume (MPV), and the main objective of the research was to identify a possible relationship between MPV and several variables-biological (NT-proBNP, presepsin, red cell distribution width (RDW)), electrocardiographic (atrial fibrillation (AFib) rhythm, sinus rhythm (SR)), and echocardiographic (left ventricle ejection fraction (LVEF), left atrial (LA) diameter, left ventricle (LV) diameter, pulmonary hypertension (PH)). (3) Results: By applying logistic and linear regression models, we assessed whether there is a correlation between MPV and biological, electrocardiographic, and echocardiographic variables in patients with HF. The results revealed linear relationships between MPV and NT pro-BNP values and between MPV and RDW values, and an increased probability for the patients to have an AFib rhythm, reduced LVEF, dilated LA, dilated LV, and PH as their MPV value increases. The results were deemed statistically relevant based on a p-value below 0.05. (4) Conclusions: Through regression model analyses, our research revealed that certain negative variables in HF patients such as increased levels of NT-proBNP, increased levels of RDW, AFib rhythm, reduced LVEF, dilated LA, dilated LV, and PH, could be predicted based on MPV values.

Impact of Epicardial Adipose Tissue on Infarct Size and Left Ventricular Systolic Function in Patients with Anterior ST-Segment Elevation Myocardial Infarction

We aimed to assess the correlation of cardiovascular magnetic resonance (CMR)-derived epicardial adipose tissue (EAT) with infarct size (IS) and residual systolic function in ST-segment elevation myocardial infarction (STEMI). We enrolled patients discharged for a first anterior reperfused STEMI submitted to undergo CMR. EAT, left ventricular (LV) ejection fraction (LVEF), and IS were quantified at the 1-week (n = 221) and at 6-month CMR (n = 167). At 1-week CMR, mean EAT was 31 ± 13 mL/m2. Patients with high EAT volume (n = 72) showed larger 1-week IS. After adjustment, EAT extent was independently related to 1-week IS. In patients with large IS at 1 week (>30% of LV mass, n = 88), those with high EAT showed more preserved 6-month LVEF. This association persisted after adjustment and in a 1:1 propensity score-matched patient subset. Overall, EAT decreased at 6 months. In patients with large IS, a greater reduction of EAT was associated with more preserved 6-month LVEF. In STEMI, a higher presence of EAT was associated with a larger IS. Nevertheless, in patients with large infarctions, high EAT and greater subsequent EAT reduction were linked to more preserved LVEF in the chronic phase. This dual and paradoxical effect of EAT fuels the need for further research in this field.

Left ventricular ejection fraction: clinical, pathophysiological, and technical limitations

Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.

Predictors of left ventricular ejection fraction in high-risk percutaneous coronary interventions

Revascularization completeness after percutaneous coronary intervention (PCI) is associated with improved long-term outcomes. Mechanical circulatory support [intra-aortic balloon pump (IABP) or Impella] is used during high-risk PCI (HR-PCI) to enhance peri-procedural safety and achieve more complete revascularization. The relationship between revascularization completeness [post-PCI residual SYNTAX Score (rSS)] and left ventricular ejection fraction (LVEF) in HR-PCI has not been established. We investigated LVEF predictors at 90 days post-PCI with Impella or IABP support. Individual patient data (IPD) were analyzed from PROTECT II (NCT00562016) in the base case. IPD from PROTECT II and RESTORE-EF (NCT04648306) were naïvely pooled in the sensitivity analysis. Using complete cases only, linear regression was used to explore the predictors of LVEF at 90 days post-PCI. Models were refined using stepwise selection based on Akaike Information Criterion and included: treatment group (Impella, IABP), baseline characteristics [age, gender, race, New York Heart Association Functional Classification, LVEF, SYNTAX Score (SS)], and rSS. Impella treatment and higher baseline LVEF were significant predictors of LVEF improvement at 90 days post-PCI (p ≤ 0.05), and a lower rSS contributed to the model (p = 0.082). In the sensitivity analysis, Impella treatment, higher baseline LVEF, and lower rSS were significant predictors of LVEF improvement at 90 days (p ≤ 0.05), and SS pre-PCI contributed to the model (p = 0.070). Higher baseline LVEF, higher SS pre-PCI, lower rSS (i.e. completeness of revascularization), and Impella treatment were predictors of post-PCI LVEF improvement. The findings suggest potential mechanisms of Impella include improving the extent and quality of revascularization, and intraprocedural ventricular unloading.

Fulminant Myocarditis and Venoarterial Extracorporeal Membrane Oxygenation: A Systematic Review

This systematic review aimed to look at the effectiveness of venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy in treating fulminant myocarditis and evaluating the optimal length of time a patient should be placed on VA-ECMO. Fulminant myocarditis is a potentially life-threatening medical condition most commonly brought on by cardiogenic shock, which often progresses to severe circulatory compromise, requiring the patient to be placed on some form of mechanical circulatory assistance to maintain adequate tissue perfusion. Medical centers have multiple mechanical assistive devices available for treatment at their disposal, but our area of focus was placed on one system in particular: VA-ECMO therapy. Although the technology has been around for more than 30 years, there is limited information on how effective VA-ECMO is regarding the treatment of fulminant myocarditis. Due to the lack of data regarding the treatment administration of VA-ECMO for fulminant myocarditis, standard treatment duration guidelines do not exist, resulting in a wide variation of treatment administrations among medical centers. In regard to short-term outcomes, VA-ECMO has shown to be effective in treating fulminant myocarditis, with a one-year post-hospital survival rate ranging from 57.1% to 78% at discharge. For long-term health and survival, the studies that recorded long-term survival ranged from 65% to 94.1%. However, given the small number of studies that pursue this, more research is needed to prove the efficacy of VA-ECMO for the treatment of fulminant myocarditis.

Establishment and validation of a prediction model for nonrecovery of left ventricular ejection fraction in acute myocardial infarction patients combined with decreased left ventricular ejection fraction

BACKGROUND

This study aimed to investigate the risk factors for nonrecovery of left ventricular ejection fraction (LVEF) during follow-up in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI) combined with reduced LVEF, and establish and verify a risk prediction model based on these factors.

METHODS

In this study, patients with AMI who underwent PCI in a high-volume PCI center between December 2018 and December 2021 were consecutively enrolled, screened, and randomly assigned to the model establishment and validation cohorts. A predictive model method based on least absolute shrinkage and selection operator regression was used for establishment and validation.

RESULTS

Cardiac troponin I, myoglobin, left ventricular end-diastolic dimension, multivessel disease, and no-reflow were identified as potential predictors of LVEF recovery failure. The areas under the curve were 0.703 and 0.665 in the model establishment and validation cohorts, respectively, proving that the prediction model had some predictive ability. The calibration curves of the two cohorts showed good agreement with those of the nomogram model. In addition, the decision curve analysis showed that the model had a net clinical benefit.

CONCLUSION

This prediction model can assess the risk of nonrecovery of LVEF in patients with AMI undergoing PCI combined with LVEF reduction during follow-up, and conveniently screen high-risk patients with nonrecoverable LVEF early.

Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice

BACKGROUND

Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice.

METHODS

We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF.

RESULTS

Among 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40).

CONCLUSIONS

Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.

Echocardiographic Myocardial Work: A Novel Method to Assess Left Ventricular Function in Patients with Coronary Artery Disease and Diabetes Mellitus

Myocardial ischemia caused by coronary artery disease (CAD) and the presence of metabolic abnormalities and microvascular impairments detected in patients with diabetes mellitus (DM) are a common cause of left ventricular (LV) dysfunction. Transthoracic echocardiography is the most-used, non-invasive imaging method for the assessment of myocardial contractility. The accurate evaluation of LV function is crucial for identifying patients who are at high risk or may have worse outcomes. Myocardial work (MW) is emerging as an alternative tool for the evaluation of LV systolic function, providing additional information on cardiac performance when compared to conventional parameters such as left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) because it incorporates deformation and load into its analysis. The potential of MW in various conditions is promising and it has gained increased attention. However, larger studies are necessary to further investigate its role and application before giving an answer to the question of whether it can have widespread implementation into clinical practice. The aim of this review is to summarize the actual knowledge of MW for the analysis of LV dysfunction caused by myocardial ischemia and hyperglycemia.

Features of trastuzumab-related cardiac dysfunction: deformation analysis outside left ventricular global longitudinal strain

Background

Cancer therapy-related cardiac dysfunction due to trastuzumab has been well-known for many years, and echocardiographic surveillance is recommended every 3 months in patients undergoing trastuzumab treatment, irrespective of the baseline cardiotoxicity risk. However, the potential harm and cost of overscreening in low- and moderate-risk patients have become great concerns.

Objectives

This study aimed to identify the incidence of early cancer therapy-related cardiac dysfunction (CTRCD) and the behaviours of left and right heart deformations during trastuzumab chemotherapy in low- and moderate-risk patients.

Methods

We prospectively enrolled 110 anthracycline-naïve women with breast cancer and cardiovascular risk factors who were scheduled to receive trastuzumab. The left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LV-GLS), and right ventricular and left atrial longitudinal strains were evaluated using echocardiography at baseline, before every subsequent cycle and 3 weeks after the final dose of trastuzumab. The baseline risk of CTRCD was graded according to the risk score proposed by the Heart Failure Association (HFA) Cardio-Oncology Working Group and the International Cardio-Oncology Society (ICOS). CTRCD and its severity were defined according to the current European Society of Cardiology (ESC) guidelines.

Results

Twelve (10.9%) patients had asymptomatic CTRCD. All CTRCD occurred sporadically during the first 9 months of the active trastuzumab regimen in both low- and moderate-risk patients. While CTRCD was graded as moderate severity in 41.7% of patients and heart failure therapy was initiated promptly, no irreversible cardiotoxicity or trastuzumab interruption was recorded at the end of follow-up. Among the left and right heart deformation indices, only LV-GLS decreased significantly in the CTRCD group during the trastuzumab regimen.

Conclusions

CTRCD is prevalent in patients with non-high-risk breast cancer undergoing trastuzumab chemotherapy. Low- and moderate-risk patients show distinct responses to trastuzumab. The LV-GLS is the only deformation index sensitive to early trastuzumab-related cardiac dysfunction.

Assessment of left ventricular ejection fraction in artificial intelligence based on left ventricular opacification

Background

Left ventricular opacification (LVO) improves the accuracy of left ventricular ejection fraction (LVEF) by enhancing the visualization of the endocardium. Manual delineation of the endocardium by sonographers has observer variability. Artificial intelligence (AI) has the potential to improve the reproducibility of LVO to assess LVEF.

Objectives

The aim was to develop an AI model and evaluate the feasibility and reproducibility of LVO in the assessment of LVEF.

Methods

This retrospective study included 1305 echocardiography of 797 patients who had LVO at the Department of Ultrasound Medicine, Union Hospital, Huazhong University of Science and Technology from 2013 to 2021. The AI model was developed by 5-fold cross validation. The validation datasets included 50 patients prospectively collected in our center and 42 patients retrospectively collected in the external institution. To evaluate the differences between LV function determined by AI and sonographers, the median absolute error (MAE), spearman correlation coefficient, and intraclass correlation coefficient (ICC) were calculated.

Results

In LVO, the MAE of LVEF between AI and manual measurements was 2.6% in the development cohort, 2.5% in the internal validation cohort, and 2.7% in the external validation cohort. Compared with two-dimensional echocardiography (2DE), the left ventricular (LV) volumes and LVEF of LVO measured by AI correlated significantly with manual measurements. AI model provided excellent reliability for the LV parameters of LVO (ICC > 0.95).

Conclusions

AI-assisted LVO enables more accurate identification of the LV endocardium and reduces observer variability, providing a more reliable way for assessing LV function.

Naples Prognostic Score and Prediction of Left Ventricular Ejection Fraction in STEMI Patients

The Naples score is a new prognostic score developed according to inflammatory and nutritional status and frequently evaluated in cancer patients. The present study aimed to evaluate using the Naples prognostic score (NPS) to predict the development of decreased left ventricular ejection fraction (LVEF) after acute ST-segment elevation myocardial infarction (STEMI). The study has a multicenter and retrospective design and included 2280 patients with STEMI who underwent primary percutaneous coronary intervention (pPCI) between 2017 and 2022. All participants were divided into 2 groups according to their NPS. The relationship between these 2 groups and LVEF was evaluated. The low-Naples risk group (Group-1) included 799 patients, and the high-Naples risk group (Group-2) had 1481 patients. Hospital mortality, shock, and no-reflow rates were found to be higher in Group 2 compared with Group 1 (P < .001, P = .032, P = .004). The NPS was significantly inversely associated with discharge LVEF (B coefficient: -1.51, 95% CI-2.26; -.76, P = .001). NPS, a simple and easily calculated risk score, may help identify high-risk STEMI patients. To the best of our knowledge, the present study is the first to demonstrate the relationship between low LVEF and NPS in patients with STEMI.

Clinical outcomes of left bundle branch area pacing: Prognosis and specific applications

Cardiac pacing has become a widely accepted treatment strategy for bradyarrhythmia and heart failure. However, conventional right ventricular pacing (RVP) has been associated with electrical dyssynchrony, which may result in atrial fibrillation and heart failure. To achieve physiological pacing, Deshmukh et al. reported the first case of His bundle pacing (HBP) in 2000. This strategy was reported to have preserved ventricular synchronization by activating the conventional conduction system. Nonetheless, due to the anatomical location of the His bundle (HB), several issues such as high pacing thresholds, lead fixation, and early battery depletion may pose a challenge. Recently, left bundle branch area pacing (LBBAP) has emerged as a novel physiological pacing strategy to achieve conduction system pacing by capturing the left bundle branch through the deep septum. Additionally, several studies have investigated the clinical outcomes of LBBAP. In this paper, we describe the pacing parameters, QRS duration (QRSd), cardiac function, complications, and specific applications of LBBAP in recent years.

Correlates and prognostic implications of LVEF reduction after transcatheter edge-to-edge repair for primary mitral regurgitation

AIMS

To explore the characteristics and outcomes of patients undergoing transcatheter edge-to-edge repair (TEER) for primary mitral regurgitation (MR) according to the presence of left ventricular ejection fraction (LVEF) reduction post-procedure.

METHODS AND RESULTS

We retrospectively analysed 317 individuals [median age 83 (interquartile range, 75-88) years, 197 (62.1%) males] treated with an isolated, first-time TEER that was concluded by a successful clip deployment. Stratified by LVEF change at 1-month compared with baseline, the cohort was evaluated for residual MR and heart failure (HF) indices up to 1-year, as well as all-cause mortality and HF hospitalizations at 2-years. Overall, 212 (66.9%) patients displayed LVEF reduction, which was mainly driven by lowered total stroke volume and diffuse hypocontractility. While post-procedural MR, transmitral mean pressure gradient, and functional status were comparable in the two study groups, patients with LVEF reduction exhibited a greater decline in filling pressures intra-procedurally; left ventricular mass index, pulmonary arterial systolic pressure, and serum natriuretic peptide level at 1-month; and walking limitation at 1-year. Also, by 2 years, they were less likely to die (13.3% vs. 5.7%, P = 0.019), be readmitted for HF (17.1% vs. 9.0%, P = 0.033), and experience either of the two (23.8% vs. 12.7%, P = 0.012). Lastly, LVEF reduction was the only 1-month echocardiographic parameter to independently confer an attenuated risk for the composite of deaths or HF hospitalizations (HR 0.28, 95% CI 0.10-0.78, P = 0.016).

CONCLUSION

LVEF reduction at 1-month post-TEER for primary MR is associated with better clinical outcomes, possibly reflecting a more pronounced unloading effect of the procedure.

A Predictive Model of New-Onset Atrial Fibrillation After Percutaneous Coronary Intervention in Acute Myocardial Infarction Based on the Lymphocyte to C-Reactive Protein Ratio

Purpose

Lymphocyte to C-reactive protein ratio (LCR) is a recognized systemic inflammatory marker and novel prognostic indicator for several cancers. This study investigated the relationship between preoperative LCR and new-onset atrial fibrillation (NOAF) in patients with acute myocardial infarction (AMI) after percutaneous coronary intervention (PCI).

Patients and Methods

Patients with AMI (n=662) with no history of atrial fibrillation (AF) were enrolled and classified into NOAF and non-NOAF groups based on the occurrence of postoperative NOAF during hospitalization. Logistic regression models were used to analyze NOAF risk factors and to assess the association between preoperative LCR and NOAF incidence. We constructed a new nomogram from the selected NOAF risk factors, and tested its predictive performance, degree of calibration, and clinical utility using receiver operating characteristic and calibration curves, decision curve analysis, and clinical impact curves.

Results

Overall, 84 (12.7%) patients developed NOAF during hospitalization. The LCR was significantly lower in the NOAF group. Preoperative LCR accurately predicted NOAF after AMI and was correlated with increased NOAF risk. Age, body mass index, diabetes, serum albumin levels, uric acid levels, left atrium (LA) diameter, left ventricular ejection fraction, left circumflex artery stenosis > 50%, and Killip class II status were independent predictors of NOAF after AMI. In addition, a new nomogram combined with LCR was constructed to stratify the risk of NOAF in patients with AMI. The performance of the new nomogram was satisfactory, as shown by the receiver operating characteristic curve, calibration curve, decision curve analysis and clinical impact curve.

Conclusion

Preoperative LCR was an independent predictor of NOAF in patients with AMI after PCI. The novel nomogram combined with LCR could rapidly and individually identify and treat patients at a high risk of NOAF.

Electrovectorcardiographic study of left ventricular aneurysm in ischemic heart disease

The aim was to characterize the electrovectorcardiographic pattern of ventricular aneurysms in ischemic cardiopathy by analyzing the cardiac ventricular repolarization. The medical records of 2,670 individuals were analyzed in this cross-sectional study. A test phase included 33 patients who underwent transthoracic echocardiogram with ultrasonic enhancing agent, electrocardiogram, and vectorcardiogram (aneurysm group - n = 22, and akinesia group - n = 11). In the validation phase, cardiac magnetic resonance imaging established the left ventricle segmental contractility in 16 patients who underwent electrocardiographic and vectorcardiographic tests (aneurysm group, n = 8, and akinesia group, n = 8). The variables studied were the presence of the T-wave plus-minus pattern and the T-wave loop anterior-posterior pattern in V2-V4. The diagnostic indices used were sensitivity, specificity, and predictive values, with their respective 95% confidence intervals. During the test and validation phases, the analysis of the presence of the T-wave plus-minus pattern identified the aneurysm group with a sensitivity of 91% vs. 87% and specificity of 91% vs. 87% (p < 0.0001 vs. p = 0.01), respectively. Meanwhile, the T-wave loop anterior-posterior pattern evidenced sensitivity of 95% vs. 77% and specificity of 91% vs. 87% (p < 0.0001 vs. p = 0.04), respectively. The electrovectorcardiographic parameters showed high accuracy for recognizing left ventricular aneurysms in ischemic heart disease.

Identification and protection of early cardiotoxicity in acute myeloid leukemia patients undergoing transplantation

Cardiotoxicity of antitumor therapy results in declining survival rates. More specifically, cardiotoxicity is positively correlated with cumulative dose of anthracyclines and eventually develops from reversible to irreversible. In this context, early monitoring methods should be explored for the timely detection of cardiotoxicity and cardioprotective therapy should be performed in patients under consideration for potentially cardiotoxic therapy. This paper reports a 22-year-old male patient with acute myeloid leukemia who underwent whole-course cardiac monitoring after receiving antileukemia therapy. After the early detection of an asymptomatic decrease in left ventricular ejection fraction (LVEF), along with a significant decrease in global longitudinal strain (GLS), the patient was treated with sacubitril/valsartan (Sac/Val). Finally, the patient completed four courses of chemotherapy and subsequent hematopoietic stem cell transplantation as planned. The measurements of LVEF and GLS also recovered after 2 months treatment of Sac/Val. Therefore, the early identification and protection of patients with cardiotoxicity are of paramount importance and future prospective studies are expected to develop the management and treatment of cancer treatment-related cardiac dysfunction.

Structured Cardiac Assessment Outperforms Visual Estimation in Novice Ultrasound Users: A Randomized Controlled Trial

BACKGROUND

Two evidence-based techniques to determine left ventricular (LV) systolic function are taught in emergency medicine curricula. The first is a "structured approach," which qualitatively evaluates LV fractional shortening, E-point septal separation, and LV diameter. The other is the "eyeball method," which qualitatively estimates the LV ejection fraction (LVEF).

OBJECTIVE

The aim of this study was to determine whether the structured approach or the eyeball method was superior for teaching LVEF estimation to novices.

METHODS

Medical students were recruited to participate in our randomized controlled trial. Participants were randomized to the structured approach group or eyeball method group and completed one of two 15-min educational modules. Participants subsequently interpreted 12 echocardiogram clips to determine LV function. The primary outcome was the percentage of correct interpretations as determined by a cardiologist.

RESULTS

Seventy-four participants were invited to participate and 32 completed the study (15 in the structured approach and 17 in the eyeball method groups). The majority (30 of 32 [93.75%]) were first- and second-year medical students with no prior ultrasound training. The mean time to complete the training was similar between groups (16.8 vs. 17.8 min; p = 0.66). The primary outcome of percent of correct interpretations was significantly higher in the structured approach group compared with the eyeball method group (88.9% vs. 73.0%; p < 0.01).

CONCLUSIONS

Training novice ultrasound users in a structured qualitative LV assessment method was more effective than the eyeball method. Learners were able to achieve high accuracy after a brief training intervention. These results may help inform best practices for undergraduate ultrasound curriculum development.

Ischemic Postconditioning Confers No Benefit to Left Ventricular Systolic Function: A Meta-Analysis of Cardiac Magnetic Resonance Imaging Results

Ischemic postconditioning (IPoC) is a technique suggested to reduce reperfusion injury in patients suffering acute ST-elevation myocardial infarction (STEMI), although its use is highly controversial. This meta-analysis aimed to evaluate the effect of IPoC with percutaneous coronary intervention in patients with acute STEMI, as measured by follow-up left ventricular ejection fraction (LVEF) on cardiac magnetic resonance imaging. The investigators searched PubMed, Embase, and Web of Science for all randomized controlled trials published during the last 2 decades. After the removal of duplicates, 2,021 articles from online databases had been identified using relevant search criteria. The included randomized controlled trials had studied patients with acute STEMI and Thrombolysis in Myocardial Infarction flow 0 to 1 at presentation and had measured follow-up LVEF using cardiac magnetic resonance imaging. Overall, 11 studies (n = 1,339 patients) qualified for inclusion. In each study, the control group did not differ significantly from the experimental group. The pooled data from included studies were analyzed using standardized mean difference between IPoC and control groups, and the 95% confidence interval for LVEF; the results were visualized using a forest plot. Bivariate regression analyses and 1-way analyses of LVEF coefficient ratios were done to isolate for various clinical and procedural parameters. An analysis of pooled data of the IPoC (n = 674) and control (n = 665) groups showed that IPoC did not significantly impact follow-up LVEF (using standardized mean difference 0.10, 95% confidence interval 0.00 to 0.21). Further analysis showed that IPoC did not improve follow-up LVEF when isolating for relevant clinical and procedural parameters. In conclusion, the use of IPoC as an adjunctive therapy to percutaneous coronary intervention seemingly provides no benefit to left ventricular systolic function, as quantified with cardiac magnetic resonance imaging, in patients with acute STEMI with Thrombolysis in Myocardial Infarction flow 0 to 1.

Epidemiology, Clinical Characteristics and Cause-specific Outcomes in Heart Failure with Preserved Ejection Fraction

Heart failure (HF) is a global pandemic affecting 64 million people worldwide. HF with preserved ejection fraction (HFpEF) has traditionally received less attention than its main counterpart, HF with reduced ejection fraction (HFrEF). The incidence and prevalence of HFpEF show geographic variation and are increasing over time, soon expected to surpass those of HFrEF. Morbidity and mortality rates of HFpEF are considerable, albeit lower than those of HFrEF. This review focuses on the burden of HFpEF, providing contemporary data on epidemiology, clinical characteristics and comorbidities, cause-specific outcomes, costs and pharmacotherapy.

Supra-Normal Left Ventricular Function

Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.

Temporal Trends in Heart Failure Management and Outcomes: Insights From a Japanese Multicenter Registry of Tertiary Care Centers

Background The management of heart failure (HF) has markedly changed, due to changes in demographics and the emergence of novel pharmacotherapies. However, detailed analyses on the temporal trends in characteristics and outcomes among patients with HF are scarcely available. This study aimed to assess the temporal trends over 11 years in clinical management and outcomes in patients with HF. Methods and Results We analyzed data from a multicenter registry of hospitalized patients with acute HF, including 6877 patients registered from 2011 to 2021. Age-adjusted mortality was calculated using standardized mortality ratios. During the study period, mean age increased from 75.2 years in 2011 to 2012 to 76.4 years in 2020 to 2021 (P for trend <0.001). The proportion of HF with reduced ejection fraction (HFrEF, left ventricular ejection fraction <40%) remained constant (from 43.4% to 42.7%, P for trend=0.38). The median duration of hospital stays (from 15 to 17 days, P for trend<0.001) had increased. As for the implementation of guideline-directed medical therapy, the use of mineralocorticoid receptor antagonist at discharge increased in patients with HFrEF (from 44.3% to 60.2%, P for trend<0.001). There was also an increase in the use of sodium-glucose cotransporter-2 inhibitors following their approval for use. The age-adjusted 1-year mortality decreased in patients with HFrEF (from 18.0% to 9.3%, P for trend<0.001) but not in patients with non-HFrEF (left ventricular ejection fraction ≥40%; from 9.2% to 9.5%, P for trend=0.79). Conclusions Hospitalized patients with HF have been aging over the past decade. Their long-term outcomes after discharge have improved predominantly because of decreased mortality in patients with HFrEF.

Deep Learning to Estimate Left Ventricular Ejection Fraction From Routine Coronary Angiographic Images

Background

Cine images during coronary angiography contain a wealth of information besides the assessment of coronary stenosis. We hypothesized that deep learning (DL) can discern moderate-severe left ventricular dysfunction among patients undergoing coronary angiography.

Objectives

The purpose of this study was to assess the ability of machine learning models in estimating left ventricular ejection fraction (LVEF) from routine coronary angiographic images.

Methods

We developed a combined 3D-convolutional neural network (CNN) and transformer to estimate LVEF for diagnostic coronary angiograms of the left coronary artery (LCA). Two angiograms, left anterior oblique (LAO)-caudal and right anterior oblique (RAO)-cranial projections, were fed into the model simultaneously. The model classified LVEF as significantly reduced (LVEF ≤40%) vs normal or mildly reduced (LVEF>40%). Echocardiogram performed within 30 days served as the gold standard for LVEF.

Results

A collection of 18,809 angiograms from 17,346 patients from Mayo Clinic were included (mean age 67.29; 35% women). Each patient appeared only in the training (70%), validation (10%), or testing set (20%). The model exhibited excellent performance (area under the receiver operator curve [AUC] 0.87; sensitivity 0.77; specificity 0.80) in the training set. The model's performance exceeded human expert assessment (AUC, sensitivity, and specificity of 0.86, 0.76, and 0.77, respectively) vs (AUC, sensitivity, and specificity of 0.76-0.77, 0.50-0.44, and 0.90-0.93, respectively). In additional sensitivity analyses, combining the LAO and RAO views yielded a higher AUC, sensitivity, and specificity than utilizing either LAO or RAO individually. The original model combining CNN and transformer was superior to DL models using either 3D-CNN or transformers.

Conclusions

A novel DL algorithm demonstrated rapid and accurate assessment of LVEF from routine coronary angiography. The algorithm can be used to support clinical decision-making and form the foundation for future models that could extract meaningful data from routine angiography studies.

MRI Investigation of the Differential Impact of Left Ventricular Ejection Fraction After Myocardial Infarction in Elderly vs. Nonelderly Patients to Predict Readmission for Heart Failure

BACKGROUND

Patients with ST-segment elevation myocardial infarction (STEMI), especially elderly individuals, have an increased risk of readmission for acute heart failure (AHF).

PURPOSE

To study the impact of left ventricular ejection fraction (LVEF) by MRI to predict AHF in elderly (>70 years) and nonelderly patients after STEMI.

STUDY TYPE

Prospective.

POPULATION

Multicenter registry of 759 reperfused STEMI patients (23.3% elderly).

FIELD STRENGTH/SEQUENCE

1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences.

ASSESSMENT

One-week MRI-derived LVEF (%) was quantified. Sequential MRI data were recorded in 579 patients. Patients were categorized according to their MRI-derived LVEF as preserved (p-LVEF, ≥50%), mildly reduced (mr-LVEF, 41%-49%), or reduced (r-LVEF, ≤40%). Median follow-up was 5 [2.33-7.54] years.

STATISTICAL TESTS

Univariable (Student's t, Mann-Whitney U, chi-square, and Fisher's exact tests) and multivariable (Cox proportional hazard regression) comparisons and continuous-time multistate Markov model to analyze transitions between LVEF categories and to AHF. Hazard ratios (HR) with 95% confidence intervals (CIs) were computed. P < 0.05 was considered statistically significant.

RESULTS

Over the follow-up period, 79 (10.4%) patients presented AHF. MRI-LVEF was the most robust predictor in nonelderly (HR 0.94 [0.91-0.98]) and elderly patients (HR 0.94 [0.91-0.97]). Elderly patients had an increased AHF risk across the LVEF spectrum. An excess of risk (compared to p-LVEF) was noted in patients with r-LVEF both in nonelderly (HR 11.25 [5.67-22.32]) and elderly patients (HR 7.55 [3.29-17.34]). However, the mr-LVEF category was associated with increased AHF risk only in elderly patients (HR 3.66 [1.54-8.68]). Less transitions to higher LVEF states (n = 19, 30.2% vs. n = 98, 53%) and more transitions to AHF state (n = 34, 53.9% vs. n = 45, 24.3%) were observed in elderly than nonelderly patients.

DATA CONCLUSION

MRI-derived p-LVEF confers a favorable prognosis and r-LVEF identifies individuals at the highest risk of AHF in both elderly and nonelderly patients. Nevertheless, an excess of risk was also found in the mr-LVEF category in the elderly group.

EVIDENCE LEVEL

2.

TECHNICAL EFFICACY

Stage 2.