Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

Effects of high-sensitivity C-reactive protein and left ventricular hypertrophy on cognitive function in hemodialysis patients

OBJECTIVES

To examine the effects of high-sensitivity C-reactive protein (hs-CRP) and left ventricular hypertrophy (LVH) on the cognitive function of hemodialysis (HD) patients, and to explore the relationship between hs-CRP, LVH, and cognitive impairment (CI).

METHODS

A cross-sectional study was conducted on 232 HD patients. Besides, general clinical data were gathered, and patients' cognitive functions were assessed using the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ). CI risk factors were screened using logistic regression modeling based on hs-CRP values (low risk <1 mg/L, intermediate risk 1-3 mg/L, and high risk >3 mg/L) and LVH status (normal and hypertrophic) groupings. The synergistic effect of hs-CRP and LVH on CI was also analyzed using the EpiR package.

RESULTS

Among HD patients, 122 (52.59%) patients had CI. Multifactorial logistic regression analysis showed that the following factors were associated with an increased risk of CI in HD patients: age (OR = 1.048; 95% CI 1.014-1.083; p = 0.005), LVH (OR = 3.741; 95% CI 1.828-7.657; p < 0.001), and high-risk hs-CRP levels (>3 mg/L; OR = 3.238; 95% CI 1.349-7.768; p = 0.009). In addition, there was a significant synergy between hs-CRP high risk (>3 mg/L) and LVH.

CONCLUSION

Age, LVH, and high risk of hs-CRP (>3 mg/L) were independent risk factors for CI in HD patients. Moreover, HD patients with both hs-CRP high risk (>3.0 mg/L) and LVH were at higher risk of developing CI, and lowering hs-CRP levels and preventing LVH may prevent CI.

Point-of-care ultrasonography in nephrology: Growing applications, misconceptions and future outlook

Ultrasound has long been an essential tool in nephrology, traditionally used for procedures like vascular access and kidney biopsies. Point-of-care ultrasonography (POCUS), a rapidly evolving bedside technology, is now gaining momentum in nephrology by providing real-time imaging to enhance physical examination findings. Unlike comprehensive radiology-performed ultrasound, POCUS focuses on specific clinical questions, providing immediate and actionable insights. This narrative review examines the philosophy behind POCUS, its expanding applications in nephrology, and its impact on patient care, including its role in diagnosing obstructive uropathy, guiding fluid management, and evaluating hemodynamics in cardiorenal syndrome. Additionally, the review addresses barriers to widespread adoption, such as the need for structured training, competency validation, and interdisciplinary cooperation. By integrating POCUS into routine practice, nephrologists can refine diagnostic accuracy, improve patient outcomes, and strengthen the role of bedside medicine.

Relative interventricular septal brightness for subtype diagnosis of cardiac amyloidosis: Results from the JSE J-CASE study

AIMS

In cardiac amyloidosis (CA), transthyretin-related (ATTR) CA is reported to have more microcalcifications in the interventricular septum (IVS) than other subtypes. This study investigates whether IVS microcalcifications can differentiate CA subtypes.

METHODS AND RESULTS

A total of 442 patients with CA were enrolled at 18 collaborating institutions of the Japan Cardiac Amyloidosis Survey of typical Echocardiographic findings (J-CASE) Study: 139 light chain/amyloid A (AL/AA) type, 255 wild type ATTR (ATTRwt), 48 variant ATTR (ATTRv), and 19 patients with hypertensive heart disease (HHD). Echocardiographic pixel brightness quantification of the IVS was performed using public domain software. The IVS brightness index (IVSBI) was defined as the ratio of the average pixel brightness in the IVS to the opposite left ventricular (LV) wall. The IVSBI from the apical 4-chamber view was higher in both the ATTRwt group (median 1.40, IQR 1.22 to 1.67) and the ATTRv group (1.59, 1.32 to 2.00) compared to the HHD group (1.20, 1.02 to 1.37) and the AL/AA group (1.25, 1.11 to 1.46), respectively (P < 0.05). In the Cox proportional hazards analysis, a 0.5 increase in IVSBI from the apical 4-chamber view was associated with a hazard ratio of 2.54 (95 % CI: 1.42-4.56, P = 0.002) for all-cause mortality in ATTRwt-CA (n = 157), adjusted for age, gender, LVEF, and National Amyloidosis Centre staging.

CONCLUSION

An IVSBI obtained from the apical 4-chamber view may be useful in distinguishing ATTR-CA from other forms of CA, potentially identifying subtle septal calcifications. Elevated IVSBI in ATTRwt-CA may have prognostic value.

Non-classical monocytes are associated with functional markers of left ventricular diastolic dysfunction and heart failure with preserved ejection fraction

BACKGROUND

Inflammatory conditions such as obesity and diabetes are linked to intermediate/non-classical monocyte activation, contributing to left ventricular diastolic dysfunction (LVDD) and heart failure with preserved ejection fraction (HFpEF).

OBJECTIVE

To investigate whether circulating monocyte subtypes and their activity are associated with the presence LVDD and HFpEF.

METHODS

We analyzed peripheral blood mononuclear cells (PBMCs) from 73 patients with or without LVDD/HFpEF. Cytokine secretion was measured post-stimulation, and gene expression was assessed via RNA sequencing. Monocyte subtypes were characterized using flow cytometry, and macrophage polarization was evaluated. We also examined the relationship between immunological markers and echocardiographic indicators of LVDD.

RESULTS

Among the participants, 24 were controls, 23 had LVDD, and 26 had HFpEF. PBMCs from LVDD patients secreted significantly less Interleukin-6 compared to controls (2053 ± 708 pg/mL vs 12,273 ± 3357 pg/mL, p = 0.008). RNA sequencing indicated increased estrogen receptor pathway activity in LVDD. HFpEF patients exhibited a 1.5-fold increase in intermediate monocytes and a significant rise in non-classical monocytes compared to controls. Stimulated macrophages from LVDD and HFpEF patients showed less CD206/CD80 expression, indicating a shift towards M2-macrophage polarization. Notably, higher non-classical monocyte counts correlated with lower E' septal velocity, suggesting an association with diastolic impairment (β = -0.15, p = 0.041).

CONCLUSIONS

LVDD and HFpEF are associated with a shift towards non-classical monocyte subtypes and higher numbers of non-classical monocytes are associated with signs of diastolic impairment. These findings highlight the importance of the inflammatory component in LVDD and HFpEF.

Cardiac manifestations in adult patients with inherited metabolic disease: A single-center experience

Background

Inherited metabolic diseases (IMDs) can affect the heart, but data on cardiac manifestations in adults are scarce. This study examines the clinical and radiological features of cardiac complications in adults with IMDs.

Methods

This retrospective study included adult patients at our metabolic clinic with a biochemical and/or genetic diagnosis of IMD who underwent cardiac investigations. Records were reviewed for clinical features, echocardiograms, electrocardiograms, and treatment. Patients were categorized into three IMD subgroups: disorders of small molecules, complex molecules, and energy production.

Results

Of the 115 adult patients with IMD, 48 underwent cardiac testing (mean age 39.1 ± 14.8 years). Abnormal cardiac findings were reported in 23 of these patients (47.9 %, 14 men). Five (21.7 %) were symptomatic with dyspnea, peripheral edema, or chest pain. Fourteen patients (60.9 %) had heart muscle disease, 6 (26.1 %) had valvular involvement, and 5 (21.7 %) had arrhythmia. Valvular and heart muscle disease predominated in complex and small molecule disorders (3/4 and 7/9 respectively). Energy production disorders showed mixed involvement: heart muscle disease (5/10) and arrhythmia (5/10). Twelve of the 23 patients with abnormal findings (52.2 %) received specific cardiac therapy. All but one patient remained stable under treatment.

Discussion

In this cohort, cardiac disease was diagnosed in 23 of 115 adults with IMD (20 %), including structural heart defects and arrhythmia. The pattern and severity of cardiac involvement varied between disorders, with arrhythmia mainly associated with energy production disorders. Outcomes were favorable in most cases, likely due to collaboration between metabolic physicians and cardiologists and timely follow-up and treatment.

Monitoring SGLT2 inhibition effectiveness on pulmonary systolic pressure in heart failure with reduced ejection fraction

BACKGROUND AND AIMS

Pulmonary hypertension (PH) and right ventricular (RV) dysfunction worsen outcomes in heart failure with reduced ejection fraction (HFrEF). Angiotensin receptor-neprilysin inhibitors (ARNI) and sodium-glucose cotransporter-2 inhibitors (SGLT2-I) may influence pulmonary hemodynamics, yet their combined effects on tricuspid regurgitation velocity (TRV) and RV function remain matter of interest. We sought to evaluate the effects of ARNI alone versus ARNI + SGLT2-I on TRV, PH echocardiographic probability, and RV remodeling in HFrEF patients.

METHODS

This single-center observational study involved outpatients with HFrEF receiving optimal medical treatment (OMT), either with ARNI alone or a combination of ARNI + SGLT2-I. Baseline and 12-month echocardiographic assessments included TRV, RV function parameters (TAPSE, FAC), and PH probability. Clinical outcomes were tracked for heart failure-related hospitalizations and mortality.

RESULTS

179 HFrEF outpatients starting ARNI on top of OMT were included, with 58 receiving additional SGLT2-I. At follow-up, TRV significantly decreased in the ARNI + SGLT2-I group (from 276 ± 36 to 241 ± 46 cm/s, p = 0.0003) but not in the ARNI group. High PH probability declined from 23 % to 5 % (p < 0.001) in the ARNI + SGLT2-I group, with no significant change in the ARNI group. RV function improved significantly in the combination group (from 47 % to 19 %; p = 0.003) with greater TAPSE/sPAP and FAC increases (p = 0.03 and p = 0.01, respectively).

CONCLUSIONS

Combining SGLT2-I with ARNI was associated with a specific modulating effect on TRV, improved RV coupling, and enhanced symptom relief compared to ARNI alone. These findings support the hypothesis that pulmonary vascular disease may be targeted by SGLT2-I, overall impacting on pulmonary hemodynamics and RV remodeling.

Clinical phenotypes of severe atrial cardiomyopathy and their outcome: A cluster analysis

Background

Atrial cardiomyopathy (AtCM) encompasses patients with diverse demographics and comorbidities. This study aimed to identify phenotype groups with similar clinical characteristics, compare their mortality and atrial fibrillation (AF) event rates, and assess predictors of mortality.

Methods and Results

We performed a hierarchical cluster analysis using Ward's Method, based on 11 clinical variables. Among 724 consecutive patients with a dilated left atrium (LA), only 196 met the criterion for severe AtCM- defined as a dilated LA with a volume index ≥ 50 ml/m2. We identified 4 clusters: Cluster 1 -younger overweight patients with paroxysmal AF; Cluster 2 -older patients with heart failure (HF) and low BMI; Cluster 3 - diabetic patients with HF; and Cluster 4 - older patients with tachycardia-bradycardia syndrome and implanted pacemakers. Over a median follow-up of 20.6 months, Cluster 2 had the highest mortality rate (29.1 %), followed by Cluster 3 (20.6 %), compared to Clusters 1 and 4 (11.4 % and 10.8 %, respectively, p = 0.045). For AF events, Cluster 1 had the highest incidence (37 %), followed by Cluster 3 (35 %), Cluster 2 (24 %), and Cluster 4 (19 %, p = 0.309). Heart failure (HR 4.4, CI 1.5-12.7, p = 0.006), cancer (HR 3.3, CI 1.6-6.9, p = 0.002), and severe tricuspid regurgitation (HR 5.4, CI 2.6-11.3, p < 0.001) were predictors of poor outcomes.

Conclusion

In severe AtCM patients, four clusters were identified, each with unique comorbidities and mortality rates but similar AF event rates. Clinical and echocardiographic factors were linked to higher mortality risk.

Automated structured data extraction from intraoperative echocardiography reports using large language models

BACKGROUND

Consensus-based large language model (LLM) ensembles might provide an automated solution for extracting structured data from unstructured text in echocardiography reports.

METHODS

This cross-sectional study utilised 600 intraoperative transoesophageal reports (100 for prompt engineering; 500 for testing) randomly sampled from 7106 adult patients undergoing cardiac surgery at two hospitals within the University of Pennsylvania Healthcare System. Three echocardiographic parameters (left ventricular ejection fraction, right ventricular systolic function, and tricuspid regurgitation) were extracted from both the presurgical and postsurgical sections of the reports. LLM ensembles were generated using five open-source LLMs and four voting strategies: (1) unanimous (five out of five in agreement); (2) supermajority (four or more of five in agreement); (3) majority (three or more of five in agreement); and (4) plurality (two or more of five in agreement). Returned LLM ensemble responses were compared with the reference standard dataset to calculate raw accuracy, consensus accuracy, error rate, and yield.

RESULTS

Of the four LLM ensembles, the unanimous LLM ensemble achieved the highest consensus accuracies (99.4% presurgical; 97.9% postsurgical) and the lowest error rates (0.6% presurgical; 2.1% postsurgical) but had the lowest data extraction yields (81.7% presurgical; 80.5% postsurgical) and the lowest raw accuracies (81.2% presurgical; 78.9% postsurgical). In contrast, the plurality LLM ensemble achieved the highest raw accuracies (96.1% presurgical; 93.7% postsurgical) and the highest data extraction yields (99.4% presurgical; 98.9% postsurgical) but had the lowest consensus accuracies (96.7% presurgical; 94.7% postsurgical) and highest error rates (3.3% presurgical; 5.3% postsurgical).

CONCLUSIONS

A consensus-based LLM ensemble successfully generated structured data from unstructured text contained in intraoperative transoesophageal reports.

A probabilistic reduced-order modeling framework for patient-specific cardio-mechanical analysis

Cardio-mechanical models can be used to support clinical decision-making. Unfortunately, the substantial computational effort involved in many cardiac models hinders their application in the clinic, despite the fact that they may provide valuable information. In this work, we present a probabilistic reduced-order modeling (ROM) framework to dramatically reduce the computational effort of such models while providing a credibility interval. In the online stage, a fast-to-evaluate generalized one-fiber model is considered. This generalized one-fiber model incorporates correction factors to emulate patient-specific attributes, such as local geometry variations. In the offline stage, Bayesian inference is used to calibrate these correction factors on training data generated using a full-order isogeometric cardiac model (FOM). A Gaussian process is used in the online stage to predict the correction factors for geometries that are not in the training data. The proposed framework is demonstrated using two examples. The first example considers idealized left-ventricle geometries, for which the behavior of the ROM framework can be studied in detail. In the second example, the ROM framework is applied to scan-based geometries, based on which the application of the ROM framework in the clinical setting is discussed. The results for the two examples convey that the ROM framework can provide accurate online predictions, provided that adequate FOM training data is available. The uncertainty bands provided by the ROM framework give insight into the trustworthiness of its results. Large uncertainty bands can be considered as an indicator for the further population of the training data set.

Evaluation of Tissue Annular Motion Displacement in Patients With Severe Aortic Stenosis With Normal Ejection Fraction

AIM

The purpose of this study was to investigate the value of the tissue annular motion displacement (TMAD) parameter in assessing left ventricular systolic function in patients with severe aortic stenosis (AS) and to investigate the risk factors for major adverse cardiovascular events (MACEs) in patients with severe AS with a biplane Simpson's method ejection fraction (LVEF-Simpson) ≥ 50%.

METHODS

We enrolled 81 patients diagnosed with severe AS and 22 controls. Comparative analyses were performed between the groups, and longitudinal follow-up assessments tracked the incidence of MACEs. Survival analysis, utilizing Kaplan-Meier curves, was employed to determine the prognostic significance of TMAD parameters.

RESULTS

TMAD parameters showed negative linear correlations with left ventricle global longitudinal strain (LVGLS). Overall, 69 patients (85.2%) underwent successful transcatheter aortic valve replacement (TAVR), which significantly improves myocardial longitudinal systolic function. MACE occurred in 12 (14.8%) AS patients during the follow-up period.

CONCLUSION

TMAD parameters allowed early detection of left ventricle systolic dysfunction (LVSF) in severe AS patients with normal ejection fraction and correlated well with LVGLS, and TMADmid-A4C was a strong predictor of MACE in severe AS patients with preserved LVEF.

The Effect of Smoothing and Drift Compensation on Fetal Strain

OBJECTIVE

The aim of this study was to assess the effect of user-regulated image-processing settings (spatial smoothing, temporal smoothing and drift compensation) on fetal left ventricular strain.

METHODS

Left ventricular average longitudinal strain was acquired from the four-chamber view of the fetal heart from 34 fetuses, with 30 fetuses presenting adequate quality. A total of 18 different settings for spatial smoothing, temporal smoothing and drift compensation were examined. At each setting the average strain for the 30 fetuses was calculated, whereby one could examine whether there was an average difference in fetal strain at the different settings. Furthermore, the difference between the highest and lowest strain values across the 18 settings was assessed for each fetus (min-max difference). The average min-max difference was then calculated across the 30 fetuses to calculate the mean discrepancy in fetal strain due to smoothing settings.

RESULTS

The average effect of the smoothing settings as well as drift compensation by them was small. However, when examining the discrepancy induced by the different settings together, they induced average proportional differences of approximately 18% for the endocardial and epicardial layers and 15% for the mid-wall layer.

CONCLUSION

This study shows that while the average effect of different smoothing settings and drift compensation was small, they induced significant discrepancy in strain values on the individual level. We recommend that examiners be consistent with regard to smoothing and drift compensation settings.

Impact of Mitral Regurgitation on Outcomes of Catheter Ablation for AF With Left Ventricular Systolic Dysfunction

BACKGROUND

Atrial fibrillation (AF) and left ventricular (LV) systolic dysfunction (LVSD) may be associated with function mitral and tricuspid regurgitation (FMR/FTR). Prior studies have largely assessed impact of MR on AF ablation outcomes in the presence of preserved LV ejection fraction.

OBJECTIVES

This study sought to determine the impact of FMR on the outcomes of catheter ablation (CA) in patients with AF and LVSD.

METHODS

We examined baseline clinical characteristics, CA outcomes, and change in echocardiographic parameters (FMR and FTR severity, LV and left atrial [LA] dimensions, LVEF) at baseline and 12 months in individuals with AF and LVSD with at least mild FMR undergoing CA. Patients with primary mitral valve disease were excluded.

RESULTS

235 patients (age 62.8 years,16.2% female, NYHA functional class III (Q1-Q3: II-III)) underwent CA and were categorized by FMR severity at baseline (mild n = 117; moderate/severe n = 118). Baseline characteristics were comparable irrespective of degree of FMR, other than lower LVEF (LVEF 29% [Q1-Q3: 22.8%-35.0%] vs 35% [Q1-Q3: 30.0%-41.0%]; P < 0.001) and increased tricuspid regurgitation in moderate/severe MR (22%) vs mild MR (8%, P < 0.001). LA size did not differ significantly across FMR groups (P = 0.233). At 12 months following CA, recurrent atrial arrhythmia occurred in 101 of 235 (43.0%) including 42.7% in mild vs 43.2% in moderate-to-severe MR (P = 0.940). The severity of FMR did not influence arrhythmia recurrence (OR: 1.15; 95% CI: 0.54-1.86; P = 0.601) nor LV recovery (OR: 1.07; 95% CI: 0.67-1.25; P = 0.153). After CA, 89% of those with significant FMR and 85% with significant FTR exhibited ≥1 grade reduction at 12 months. Change in LV dimensions was associated with MR responders (OR: 0.93; 95% CI: 0.87-0.99; P = 0.022) with a greater reduction in LV size at 12 months in MR improvement (-5.0 (Q1-Q3: -9.3 to -1.0) vs non-improvement -1.0 (Q1-Q3: -5.0 to 2.5), P = 0.004) whereas change in LA size was not (OR: 0.98; 95% CI: 0.97-1.03; P = 0.984).

CONCLUSIONS

In patients with AF and LVSD, the degree of FMR did not impact the success of ablation. There was a significant reduction in FMR and FTR at 12 months following CA. Patients with AF and LVSD should be strongly considered for AF ablation irrespective of the degree of mitral regurgitation.

Structural and Functional Changes of the Heart in Young Adult Tennis Players

ABSTRACT

This cross-sectional observational study investigated undetermined cardiac remodeling and functional adaptation in young tennis players. Fourteen males with regular tennis training (at least three times a week, mean playing age 8.3 ± 3.8 years, tennis group, tennis) and 12 males without any racket sports engagement (the control group, [CTL]) underwent comprehensive cardiac measurements using real-time three-dimensional echocardiography, recording of baseline characteristics, blood tests, and estimation of VO2 max by 12-min running. Data were analyzed to compare the two groups. Two groups were of similar age (mean age, CTL 20.9 ± 2.4 vs. tennis 22.5 ± 4.4 years, P = 0.235) and with similar body size. Compared with the CTL, Tennis group had slower pulse rate (70.9 ± 7.0/min vs. CTL 85.5 ± 9.6/min, P < 0.001), greater VO2 max (43.4 ± 3.8 mL/Kg/min vs. CTL 33.1 ± 4.8 mL/Kg/min, P < 0.001), but similar blood levels of hematocrit, NT-pro-brain natriuretic peptide, and creatinine phosphokinase. The tennis group had greater left ventricle posterior wall thickness (0.90 ± 0.06 cm vs. CTL 0.81 ± 0.10 cm, P < 0.001), greater right ventricle (RV) volume index (77.8 ± 9.6 mL vs. CTL 64.9 ± 10.1 mL, P = 0.003), and greater left atrial volume index (26.9 ± 5.5 mL/m2 vs. CTL 21.9 ± 2.7 mL/m2, P = 0.006). The tennis group had significantly increased RV strain (free wall strain, -26.5 ± 3.7% vs. CTL -23.3 ±2.8%, P = 0.025). However, the global longitudinal strains in the left atrium and left ventricle were similar between the two groups. Cardiac remodeling in young tennis players includes right ventricular dilatation with enhanced dynamic function, an enlarged left atrium with well-preserved function, and a predominant posterior wall thickening of the left ventricle.

The Chagas non-endemic (ChaNoE) cohort: Aims and study protocol

Chagas disease (CD), caused by Trypanosoma cruzi, is a neglected tropical disease with significant public health implications. While its primary transmission occurs in endemic regions via triatomine vectors, migratory processes have led to an increased prevalence in non-endemic areas as in Spain where an estimated 50,000 people live with CD. Chronic Chagas cardiomyopathy (CCC) and digestive complications are the primary manifestations, yet diagnostic criteria, especially regarding organic involvement, and treatment indications are still a matter of debate. There is an urgent need for standardized approaches to improve care and identify biomarkers for progression and treatment response. The Chagas non-endemic cohort (ChaNoE) aims to recruit individuals with chronic CD across multiple centers in Spain. Inclusion criteria involve a confirmed diagnosis based on two serological tests. Participants will receive comprehensive diagnostic evaluations, including electrocardiography, echocardiography, and periodic serological and PCR assessments. Follow-up will focus on disease progression, particularly CCC and digestive involvement, using standardized protocols. The study also establishes a biobank for serum samples to facilitate biomarker research. The ChaNoE cohort addresses critical gaps in the understanding of CD in non-endemic regions. By standardizing diagnostic and treatment protocols, it seeks to harmonize care and enable comparisons with cohorts in endemic areas. The creation of a biobank supports the identification of biomarkers for disease progression and treatment efficacy, a current unmet need in CD management. This initiative also strengthens research networks and informs public health strategies to mitigate the burden of CD in non-endemic settings. Findings will be disseminated to key stakeholders to improve the clinical and epidemiological understanding of this neglected disease.

Clinical and plasma proteomic characterization of heart failure with supranormal left ventricular ejection fraction: An emerging entity of heart failure

AIMS

The clinical guidelines categorize heart failure (HF) based on left ventricular ejection fraction (LVEF). However, the current LVEF cutoffs, 40% and 50%, may not fully address the underlying characteristics and cardiovascular risk of HF, particularly for HF with higher LVEF. This study aimed to characterize HF with supranormal ejection fraction (HFsnEF) using different LVEF cutoffs (35%, 55%, and 70% for men, and 40%, 60%, and 75% for women).

METHODS AND RESULTS

This study divided 442 patients from the CHART-Omics study into four groups: HF with reduced ejection fraction (HFrEF) (n = 55, 65.5 years), HF with mildly reduced ejection fraction (HFmrEF) (n = 125, 69.3 years), HF with normal ejection fraction (HFnEF) (n = 215, 69.0 years) and HFsnEF (n = 47, 67.1 years). When clinical backgrounds were adjusted and HFnEF served as the reference, HFsnEF carried an increased hazard ratio (HR) for the composite of cardiovascular death and HF hospitalization of 2.71 (95% confidence interval [CI] 1.10-6.66, p = 0.030), while HFrEF had a HR of 3.14 (95% CI 1.36-7.23, p = 0.007). HFsnEF was characterized by an increase in relative left ventricular wall thickness and a decrease in left ventricular dimensions, whereas increased left ventricular mass and dimensions characterized HFrEF. Quantitative analysis of 4670 plasma proteins showed essential differences between HFsnEF and HFrEF, for example, 'protein synthesis' versus 'cell morphology', 'cellular assembly and organization' and 'nucleic acid metabolism' for underlying pathophysiology, and 'energy production' versus 'connective tissue disorders' and 'cell-to-cell signalling and interaction' for prognostication.

CONCLUSIONS

Heart failure with supranormal ejection fraction, an unnoticed but emerging entity in HF, carries a similarly increased cardiovascular risk as HFrEF but has unique structural and plasma proteomic characteristics.

Effect of neurohormonal therapeutic in left ventricle global and regional function in Chagas cardiomyopathy in a translational animal experimental model

Neurohormonal benefits of Chronic Chagas' Cardiomyopathy (CCC) remain controversial. This study aimed to assess therapeutic interventions on CCC evolution in T. cruzi-infected hamsters at pre and post-treatment (2 months with beta-blocker (CH + BB) or ACE inhibitor (CH + ACEI)). Echocardiography was performed through evolution and compared to histopathological myocardial analysis. At post-treatment, a significant reduction of LV global systolic function and segmental function was observed between the control group and all Chagas' groups. Compared to the Control, a reduction in LV regional strain was observed in three LV segments, regardless of treatment. No differences were observed in apoptosis, myocardial fibrosis, and the number of inflammatory cells among the groups. In an experimental model of CCC, LV global and regional function is compromised, and the treatment with ACEi and BB did not change LV remodeling. Regional LV function was slightly better in animals treated with BB, and this difference was not observed in the CH + ACEi group.

Impact of Tricuspid Regurgitation From a Population-Based Chronic Heart Failure Registry in Japan - Insights From the KUNIUMI Registry Chronic Cohort

BACKGROUND

Although tricuspid regurgitation (TR) is no longer considered a negligible disease, its detailed status in real-world heart failure (HF) patients remains unknown.

METHODS AND RESULTS

From the KUNIUMI registry, we evaluated data for 1,646 consecutive HF patients. The primary endpoint was all-cause mortality over a median follow-up period of 3.0 years (interquartile range 1.4-3.0 years). Of the 1,646 HF patients, 369 (22.4%) had moderate or greater TR; the mean (±SD) age of these patients was 82.0±8.5 years. Atrial functional TR was the most common etiology of TR in HF patients with moderate or greater TR (70.7%), and was more common in HF patients with severe than moderate TR (75.5% vs. 65.3%; P=0.032). The mortality rate was high in HF patients with severe and moderate TR (27.1% and 17.0%, respectively). During follow-up, 33.1% of HF patients with moderate TR progressed to severe TR, and showed unfavorable all-cause mortality compared with those with unchanged TR. Atrial functional TR was a more common etiology in HF patients with moderate TR and worsened TR than in those with unchanged TR (84.6% vs. 59.5%; P=0.004). Right atrial enlargement was independently correlated with worsened TR.

CONCLUSIONS

Moderate or greater TR was prevalent in 22.4% of the real-world super-aged HF population. Even HF patients with moderate TR had poor outcomes, with right atrial remodeling a key factor for worsened TR.

Prognostic implications of multiple chamber longitudinal strains and myocardial work in restrictive cardiomyopathy

The prognosis for restrictive cardiomyopathy (RCM) is typically poor, which primarily influenced by the restrictive physiology. This study aimed to evaluate the prognostic significance of longitudinal strains and myocardial work (MW) indices in RCM patients and to create and validate a multivariable model for predicting major adverse cardiac events (MACEs). We enrolled 191 patients with RCM, divided into a training cohort of 128 and a validation cohort of 63, along with 132 healthy controls. Echocardiography was used to assess right ventricular free wall strain (RV-FWS), left ventricular global longitudinal strain (LV-GLS), left atrial peak strain (LAPS), right atrial peak strain (RAPS), and MW indices. Univariate and multivariate stepwise Cox regressions were applied to identify independent prognostic factors and develop a nomogram. With a median follow-up of 977 days, 111 patients experienced MACEs and 76 died. In patients with preserved left ventricular ejection fraction (LVEF), LV-GLS and MW indices were impaired. Longitudinal strains and MW indices were significantly associated with prognosis. We constructed a predictive nomogram including LAPS, RV-FWS, global myocardial work efficiency (GWE), and established clinical predictors, which demonstrated excellent discriminative and calibration properties. Thorough evaluation of longitudinal strains and MW indices is essential, particularly focusing on LAPS, RV-FWS, and GWE.

The power of the left atrioventricular coupling index in cardiovascular disease

The left atrioventricular coupling index (LACI) has emerged as a novel and transformative biomarker in cardiovascular research, addressing long-standing limitations in traditional cardiac function assessments. By quantifying the ratio of left atrial to left ventricular end-diastolic volumes, LACI offers unprecedented prognostic insights into a wide range of cardiovascular diseases, including atrial fibrillation, heart failure, and myocardial infarction, as well as other conditions such as hypertension and cardiomyopathies. Recent evidence highlights its unique ability to integrate atrial and ventricular dynamics, offering a more comprehensive perspective on cardiac health and disease progression. This review synthesizes the latest advancements in LACI research, elucidates its underlying pathophysiological mechanisms, and explores its expanding clinical applications as a pivotal tool for risk stratification, precision diagnostics, and personalized therapy in cardiovascular medicine.

Biomarkers of Inflammation and Association with Cardiovascular Magnetic Resonance Imaging for Risk Stratification and Outcome in Patients with Severe Aortic Stenosis

Background: Inflammatory indices have been proposed as simple and routinely obtainable markers of systemic inflammation in cardiac disease. This study investigated whether the neutrophil-to-lymphocyte ratio (NLR), the monocyte-to-lymphocyte ratio (MLR), and the pan-immune inflammation value (PIV) serve as biomarkers for risk stratification and outcomes measures in patients with severe aortic stenosis (AS) following valve replacement (AVR). Methods: In this retrospective analysis (January 2017-June 2022), patients with AS underwent pre-procedural cardiovascular magnetic resonance (CMR) imaging and were assigned a treatment strategy by a multidisciplinary Heart Team: (1) transcatheter AVR, (2) surgical AVR, or (3) no valvular intervention. Kaplan-Meier estimates and regression analyses were used to demonstrate associations between the NLR, MLR, and PIV with myocardial fibrosis-assessed by late gadolinium enhancement (LGE) and extracellular volume (ECV) on CMR-and a combined endpoint of heart failure hospitalizations and all-cause mortality. Results: A total of 356 patients (median age: 80 years, 50% male) were followed for a median of 40 months, during which 162 (46%) reached the combined endpoint. Linear regression identified C-reactive protein, but not the presence of LGE or elevated ECV, as the only independent predictor of all three inflammatory indices (p for all <0.001). After multivariable adjustment for clinical (EuroSCORE II), laboratory (baseline N-terminal prohormone of brain natriuretic peptide [NT-proBNP] and C-reactive protein), and imaging parameters (AV mean pressure gradient, right ventricular ejection fraction, and ECV), the above-the-upper-quartile NLR (adjusted hazard ratio [aHR]: 1.45, 95%-confidence interval [CI]: 1.01-1.92, p = 0.042), MLR (aHR: 1.48, 95%-CI: 1.05-2.09, p = 0.025), and PIV (aHR: 1.56, 95%-CI: 1.11-2.21, p = 0.011) remained significantly associated with adverse outcomes. Following AVR, the median NLR (3.5 to 3.4) and PIV (460 to 376) showed a significant post-procedural decline compared to baseline (p ≤ 0.019 for both). Conclusions: Inflammatory indices are readily available biomarkers independently associated with adverse outcomes in severe AS following AVR. However, no significant relationship was observed between the NLR, MLR, PIV, and myocardial fibrosis on CMR.

The prognostic value of HFA-PEFF score in connective tissue disease-associated PAH: evidence from a cohort study

BACKGROUND

Connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) patients with left heart dysfunction may have worse prognosis. This study was to investigate the prognostic value of HFA-PEFF score in connective tissue disease-associated PAH.

METHODS

This single-center retrospective cohort study enrolled 147 CTD-PAH patients diagnosed via right heart catheterization (RHC), divided into two groups based on their HFA-PEFF scores: < 5 (n = 74) and ≥ 5 (n = 73). The clinical characteristics were compared between the two groups. The primary end point was all-cause mortality, and the secondary end point was clinical worsening events. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards models.

RESULTS

Compared to the HFA-PEFF score < 5 group, the ≥ 5 group exhibited significantly higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), a greater proportion of WHO functional class III-IV, shorter 6-min walk distance (6MWD), larger right ventricular (RV) volume, worse RV function, smaller left ventricular (LV) volume, and higher native T1 values. An HFA-PEFF score ≥ 5 was a predictor for all-cause mortality in CTD-PAH (HR 5.022, P = 0.020) and for clinical worsening events (HR 2.670, P = 0.020). At follow-up, 17.9% of CTD-PAH had an HFA-PEFF score ≥ 5. Patients with follow-up HFA-PEFF scores ≥ 5 had a significantly lower event-free survival rate (P < 0.001).

CONCLUSION

An HFA-PEFF score ≥ 5 was associated with all-cause mortality and clinical worsening events in CTD-PAH patients.

TRIAL REGISTRATION

NCT05980728. Connective Tissue Disease Patients With Pulmonary Hypertension. Oct 17, 2023.

Clinical Outcomes After Valve Intervention in Rheumatic Mitral Valve Disease

Background

Rheumatic heart disease (RHD) remains one of the leading causes of mitral valve (MV) disease in developing countries. Despite the availability of percutaneous and surgical interventions, long-term outcomes remain unclear. This study aims to identify determinants of outcomes following percutaneous or surgical intervention in patients with rheumatic MV disease, addressing critical gaps in treatment selection.

Methods

A retrospective, intention-to-treat study was conducted on patients with symptomatic rheumatic MV disease, primarily characterized by mitral stenosis, who underwent either percutaneous mitral valvuloplasty (PMV) or MV replacement (MVR). Demographic, clinical, and echocardiographic variables were collected. The long-term outcome was defined as a composite of death, repeat PMV, need for cardiac surgery, and stroke.

Results

A total of 246 patients were enrolled (mean age 43.8 ± 13 years, 80% women, with 45% in New York Heart Association [NYHA] class III/IV). Of these, 90 patients (37%) underwent MVR, while 156 patients (63%) underwent PMV, with similar clinical characteristics at baseline. During a mean follow-up of 2.8 years, ranging from 1 day to 7.8 years, 45 patients (18%) reached the composite outcome, including 11 deaths (4%). Long-term outcomes were comparable between PMV and MVR (P = 0.231). Independent predictors of composite outcomes included baseline NYHA class III/IV (adjusted hazard ratio [HR] 2.10, 95% confidence interval [CI] 1.10-4.11, P = 0.023) and older age (HR 1.03, 95% CI 1.01-1.06, p = 0.020). Predictors of all-cause mortality following either PMV or MVR were older age (HR 1.08, 95% CI 1.03-1.14, P = 0.002) and lower left ventricular ejection fraction (HR 0.93, 95% CI 0.88-0.99, P = 0.021).

Conclusions

This study identified older age and higher NYHA functional class as significant predictors of composite outcomes in patients with rheumatic MV disease requiring intervention. Left ventricular systolic dysfunction was independently associated with increased mortality following both percutaneous and surgical intervention. Long-term outcomes were comparable between patients undergoing PMV and MVR, reinforcing PMV as an effective alternative to surgery in appropriately selected patients.

Long-term left atrial adaptations to reduced training load in former elite athletes: a long-term follow-up longitudinal observational study

Objective

Our objective was to evaluate the effects of long-term reduced training on the left atrium (LA) in elite endurance athletes and to elucidate sex-specific differences in LA detraining patterns.

Methods

In this long-term longitudinal echocardiographic study of 50 active elite endurance athletes a follow-up examination was performed 7 years after retirement from the elite programme. All echocardiographic measurements were indexed for body surface area. We analysed the changes between baseline and follow-up measures using analysis of covariance models adjusted for baseline level, sex and enrolment age as covariates. Results are reported as least squares means with two-sided 95% CIs.

Results

LA enlargement (left atrial maximum volume index) remained unchanged from baseline (change from baseline: 1.4mL/m2, 95% CI: -0.7 to 3.5 mL/m2) despite significant reductions in VO2max (change from baseline: -864mL/min, 95% CI: -1091 to -637 mL/min). In contrast, left ventricular (LV) end-diastolic volume was reduced (change from baseline: -8mL/m2, 95% CI: -11 to -5 mL/m2), consistent with reduced VO2max. LA contraction strain was increased (change from baseline: 1.4%, 95% CI: 0.4% to 2.5%), while LV filling pressure increased (E/e' change from baseline: 0.4, 95% CI: 0.1 to 0.7).

Conclusions

7 years of reduced training does not reverse exercise-induced LA enlargement in former elite endurance athletes. LA contractile function improved with higher LV filling pressure, suggesting that age-related LV pressure increases may contribute to chronic LA dilation, though irreversible adaptations like fibrosis cannot be ruled out.

Trial registration number

NCT05555849.

Short-term outcomes of rotational atherectomy in patients with reduced left ventricular ejection fraction: A retrospective review from a tertiary referral centre

OBJECTIVE

Rotational atherectomy (RA), a commonly used technique for the percutaneous intervention of calcific coronary lesions, produces micro-debris which cause downstream microvascular obstruction, slow flow, and myocardial stunning leading to adverse outcomes in patients with left ventricular (LV) systolic dysfunction. Hence, the presence of LV dysfunction was considered a relative contraindication for RA. We aimed to assess the safety of RA in patients with LV dysfunction.

METHOD

This is a retrospective review of all consecutive patients who underwent RA at our tertiary referral centre over a 6-year period (2018-2023). All medical records, procedural details, and in-hospital outcomes were recorded. The primary outcome of the study was in-hospital mortality.

RESULTS

504 patients who underwent RA during the study duration were divided into two groups: Group 1 (n = 209) with left ventricular ejection fraction (LVEF) ≤35 % (mean 29.14 ± 4.95 %) and group 2 (n = 295) with moderately reduced or preserved LVEF >35 % (mean 47.86 ± 6.68 %). There was no significant difference in the baseline demographic characteristics, risk factors, angiographic profile, stent length, contrast volume, and procedure time between the two groups. The in-hospital mortality was not different between the two groups (2.3 % vs 0.7 % p = 0.63). LVEF was not found to be an independent predictor of mortality in patients undergoing RA.

CONCLUSION

The in-hospital mortality of patients undergoing PCI with RA was not affected by the presence of LV dysfunction. Additional studies with a longer follow-up duration and a larger sample or a meta-analysis incorporating our study are needed to confirm these results.

Hemodynamic Patterns and Left Ventricular Function Recovery in Peripartum Cardiomyopathy: A Comprehensive Echocardiographic Analysis

BACKGROUND

The influence of hemodynamic changes at presentation on the recovery of left ventricular (LV) function in peripartum cardiomyopathy (PPCM) patients remains uncertain.

OBJECTIVES

This study aims to identify hemodynamic patterns in individuals with PPCM.

METHODS

This study included women with PPCM from 2 databases in Israel and Indonesia. Conventional echocardiography, 2-dimensional strain, myocardial work, and noninvasive pressure-volume loop analysis were performed with subsequent data clustering.

RESULTS

Among 89 women (median age 32 years, IQR: 8.7 years; LV ejection fraction [EF] 36.0%, IQR: 11.5%), 63 (70.8%) experienced LV function recovery (LVEF ≥50%) during 6 months of follow-up. Gestation hypertension/pre-eclampsia and LVEF >35% and LVDD ≤55 mm at presentation were associated with LV recovery. Significant hemodynamic variability was observed, indicating a nonuniform PPCM pattern. Cluster analysis of 43 patients identified 3 hemodynamic subtypes. In cluster 1, patients exhibited the lowest rate of LV recovery (12.5%), profound contractility impairment, severe LV remodeling, and reduced cardiac output (CO). Cluster 2 showed a high LV recovery rate of 78.6%, prevalent in Southeast Asian patients with gestational hypertension. These patients displayed decreased CO and extremely elevated afterload. Load-dependent contractility indexes, like LVEF and global longitudinal strain, were markedly reduced, while load-independent end-systolic elastance remained unaffected, indicating afterload-dependent contractility impairment. All patients in cluster 3 recovered LVEF, presenting mildly reduced contractility indexes, mild ventricular dilatation, slightly increased afterload, and preserved CO.

CONCLUSIONS

PPCM exhibits heterogeneous hemodynamic patterns, with 3 distinct phenotypes displaying varying rates of LV recovery. Understanding the heterogeneity in PPCM hemodynamic phenotypes can guide optimal treatment.

Long-term outcomes and worse clinical course in Takotsubo syndrome patients with amyotrophic lateral sclerosis

AIMS

Takotsubo syndrome (TTS) is usually triggered by either physical/psychological stressors or comorbidities, neurological among others. The prevalence of amyotrophic lateral sclerosis (ALS) among TTS and whether it has a worse clinical course is not known. We aim to describe ALS prevalence and its impact on clinical presentation, clinical course, and long-term mortality.

METHODS

We retrospectively screened the overall TTS population admitted and followed up at our institution between 2007 and 2020. Clinical, electrocardiographic, and echocardiographic data were collected. Kaplan-Meier method was applied for time-to-event analysis to assess the outcome of interest of all-cause death.

RESULTS

Eighty-five patients with TTS were included in our study. Overall, the mean age was 70 ± 12 years, 86% were females. Six patients (7% prevalence) were affected by ALS. At admission, patients with ALS were more likely to present left ventricular systolic dysfunction (P = 0.007). The clinical course of ALS patients was more likely complicated by cardiogenic shock (P = 0.003) which required catecholamines infusion (P = 0.001) and mechanical ventilation (P = 0.009). Despite similar in-hospital mortality rates, ALS patients exhibited significantly elevated all-cause mortality during a median 6-year follow-up (hazard ratio, 19.189, 95% confidence interval 5.639-65.296, log-rank test P < 0.001) with significantly shorter hospitalization to death time (P = 0.039).

CONCLUSIONS

Our findings highlight a notable prevalence of ALS among TTS patients, with worse clinical presentation and in-hospital course in ALS-affected individuals. While in-hospital mortality rates were comparable, highlighting the reversible nature of TTS in both groups, long-term follow-up revealed significantly heightened all-cause mortality in ALS patients, emphasizing the impact of ALS on patient prognosis.

Prognostic role of TAPSE to PASP ratio in outpatients with left ventricular systolic dysfunction

AIMS

Few data are available regarding the role of tricuspid annulus plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP), a measurement of right ventricular to pulmonary artery coupling, in patients with chronic heart failure and left ventricular systolic dysfunction.

METHODS AND RESULTS

This retrospective single-centre study included outpatients with left ventricular systolic dysfunction (ejection fraction ≤ 50%) evaluated between January 2022 and December 2022. TAPSE/PASP was evaluated as a continuous variable and as tertiles according to its value on the first visit. The primary outcome of the study was a composite of all-cause mortality or heart failure (HF) events at the last available follow-up.

RESULTS

A total of 642 patients were included (mean age 71 ± 13 years, 78% male, mean left ventricular ejection fraction 40% [interquatile range 35-46]). Patients with lower TAPSE/PASP had more co-morbidities (i.e., atrial fibrillation, chronic kidney disease or previous cardiovascular implantable electronic device), an higher New York Heart Association class (P < 0.001), more signs of congestion (P = 0.007), and had more probability to receive intravenous furosemide during the visit (P < 0.001). After a median follow-up of 474 days [interquartile range 392-507 days], a total of 51 patients (8.0%) died (with 24 patients [3.8%] experiencing cardiovascular-related deaths), a total of 179 patients (28.1%) experienced a composite outcome, and 158 patients (24.8%) had HF events. Kaplan-Meier analysis showed that the estimated 1-year rate of the primary outcome was higher in the lowest tertile (38.0%), as compared with the intermediate (19.6%) and highest tertiles (14.9%; P-value log-rank <0.001). TAPSE/PASP ratio as a continuous variable was independently associated with the primary outcome (adjusted hazard ratio for 0.1 mm/mmHg increase 0.91, 95% CI 0.84-0.98, P = 0.009), predominantly driven by a higher risk of HF events during follow-up. Analysing the impact of TAPSE/PASP tertiles on the primary outcome, an independent associated was confirmed at multivariate analisys for the highest versus lowest tertile (adjusted hazard ratio 0.61, 95% CI 0.38-0.99, P = 0.044).

CONCLUSIONS

TAPSE/PASP was independently associated with mortality or HF events among ambulatory patients with left ventricular systolic dysfunction.

Sex Differences in Embolic Stroke of Undetermined Source: Echocardiographic Features and Clinical Outcomes

BACKGROUND

Sex differences in stroke are well-documented, but in embolic stroke of undetermined source (ESUS) remains underexplored. This study aims to investigate sex-related differences in clinical and cardiac features and stroke outcomes in ESUS.

METHODS

Retrospective observational single-center study including consecutive ESUS patients. Multivariate regression analyses evaluated the association between sex, echocardiographic features, and 90-day outcomes. Cox regression assessed the independent effect of sex on ischemic stroke recurrence, all-cause death, and atrial fibrillation detection after stroke (AFDAS).

RESULTS

Among 556 patients, 248 (44.6%) were women, who were older and had more severe strokes. Women exhibited larger left atria (LA) as evidenced by a higher LA volume index (adjusted β-coefficient = 2.59, 95% CI 0.53-4.65, p = 0.014) and more valve abnormalities, such as mitral annulus calcification (aOR 2.72; 95% CI 1.43-5.20, p = 0.002). Men showed more markers of left ventricular (LV) disease, including reduced ejection fraction < 50% (aOR 0.44; 95% CI 0.20-0.93, p = 0.033) and LV wall motion abnormalities (aOR 0.37; 95% CI 0.19-0.74, p = 0.005). In multivariate analyses, the female sex was independently associated with reduced all-cause death (aHR 0.59; 95% CI 0.38-0.91, p = 0.019) and showed a trend toward higher AFDAS risk (aHR 1.57; 95% CI 0.99-2.49, p = 0.053). No association was found with 90-day outcomes or stroke recurrence.

CONCLUSION

ESUS patients exhibit significant sex-based differences in echocardiographic features, with women showing larger LA and more valve abnormalities, while men present greater LV dysfunction. Female sex is independently associated with a lower risk of long-term mortality and a potentially higher risk of AFDAS. These findings underscore the need for individualized, sex-specific ESUS management strategies.

Right ventricular-pulmonary artery coupling assessed by two-dimensional strain predicts in-hospital complications in Takotsubo syndrome

BACKGROUND

Takotsubo syndrome (TTS) is an acute condition characterized by a reversible left ventricular (LV) systolic dysfunction leading to serious in-hospital complications (IHC). The aim of our study is to investigate the prognostic impact of right ventricular-to-pulmonary artery (RV-PA) coupling in patients with TTS.

METHODS

Consecutive TTS patients were prospectively enrolled. In all patients, standard and speckle tracking transthoracic echocardiography was performed within 48 h from hospital admission. RV function was evaluated by RV global longitudinal strain (RV-GLS) and RV free wall strain (RV-FWS) and RV-PA coupling was measured as the ratio of either tricuspid annular plane systolic excursion (TAPSE), RV-GLS or RV-FWS to pulmonary artery systolic pressure (PASP). Data about IHC (acute heart failure, life-threatening arrhythmias and death) were collected.

RESULTS

A total of 80 patients were analyzed (71 ± 11 years, female 77.5 %) and IHC occurred in 33 (41 %). Patients who experienced IHC had lower LV ejection fraction (LVEF), lower left atrial (LA) reservoir strain, TAPSE/PASP, RV-FWS/PASP and RV-GLS/PASP and higher left atrial volume indexed (LAVi) values. At multivariate analysis, only LVEF (OR 0.913, 95 % CI [0.858-0.971], p = 0.004) was an independent predictor of IHC. Receiver operating characteristics (ROC) curve analysis showed an additional prognostic value of a combined model including RV-GLS/PASP and LVEF compared to LVEF alone in the prediction of IHC (AUC of 0.756 vs 0.736, differences between AUCs: 0.02 [p = 0.73]).

CONCLUSION

RV-PA coupling assessed by RV-GLS/PASP may help in identifying TTS patients at higher risk of cardiovascular complications with an additional prognostic value to LVEF alone.

Machine learning based radiomics model to predict radiotherapy induced cardiotoxicity in breast cancer

PURPOSE

Cardiotoxicity is one of the major concerns in breast cancer treatment, significantly affecting patient outcomes. To improve the likelihood of favorable outcomes for breast cancer survivors, it is essential to carefully balance the potential advantages of treatment methods with the risks of harm to healthy tissues, including the heart. There is currently a lack of comprehensive, data-driven evidence on effective risk stratification strategies. The aim of this study is to investigate the prediction of cardiotoxicity using machine learning methods combined with radiomics, clinical, and dosimetric features.

MATERIALS AND METHODS

A cohort of 83 left-sided breast cancer patients without a history of cardiac disease was examined. Two- and three-dimensional echocardiography were performed before and after 6 months of treatment to evaluate cardiotoxicity. Cardiac dose-volume histograms, demographic data, echocardiographic parameters, and ultrasound imaging radiomics features were collected for all patients. Toxicity modeling was developed with three feature selection methods and five classifiers in four separate groups (Dosimetric, Dosimetric + Demographic, Dosimetric + Demographic + Clinical, and Dosimetric + Demographic + Clinical + Imaging). The prediction performance of the models was validated using five-fold cross-validation and evaluated by AUCs.

RESULTS

58% of patients showed cardiotoxicity 6 months after treatment. Mean left ventricular ejection fraction and Global longitudinal strain decreased significantly compared to pre-treatment (p-value < 0.001). After feature selection and prediction modeling, the Dosimetric, Dosimetric + Demographic, Dosimetric + Demographic + Clinical, Dosimetric + Demographic + Clinical + Imaging models showed prediction performance (AUC) up to 73%, 75%, 85%, and 97%, respectively.

CONCLUSION

Incorporating clinical and imaging features along with dose descriptors are beneficial for predicting cardiotoxicity after radiotherapy.

Markers of Left Atrial Myopathy: Prognostic Usefulness for Ischemic Stroke and Dementia in People in Sinus Rhythm

BACKGROUND

Various measures of abnormal left atrial (LA) structure or function (LA myopathy) are associated with a higher risk of ischemic stroke and dementia, independent of atrial fibrillation. However, limited data exist on their prognostic usefulness. Therefore, we aimed to assess the ability of markers of LA myopathy to improve the prediction of ischemic stroke and dementia.

METHODS

The ARIC study (Atherosclerosis Risk in Communities) is a prospective community-based cohort study. For this analysis, we included participants who attended visit 5 (2011-2013) without a history of stroke or atrial fibrillation and had a 12-lead ECG and a transthoracic echocardiogram. Markers of LA myopathy included P wave abnormalities from 12-lead ECG, NT-proBNP (N-terminal pro-B-type natriuretic peptide), and LA volume and strain parameters from the echocardiogram. The primary composite outcome comprised ischemic stroke and dementia, which were ascertained through hospital surveillance, cohort follow-up, and death registries. To determine improvement in risk prediction of the composite outcome, each marker was individually added to a model that included CHA2DS2-VASc variables, and Akaike information criterion, C statistic, and its change were computed. Cox proportional hazards models were used to assess the independent association of LA myopathy markers with the outcome.

RESULTS

Among 4712 participants (59% female; mean age, 74 years), 193 ischemic strokes and 769 dementia cases were ascertained over a median follow-up of 8.3 years. Of LA myopathy markers, only LA reservoir strain and NT-proBNP significantly improved C statistic when added to the CHA2DS2-VASc model (base C statistic, 0.677) for the prediction of the composite outcome. Adding the LA reservoir yielded the highest increase in C statistic (0.010 [95% CI, 0.003-0.017]), and the model including the LA reservoir showed the lowest Akaike information criterion. In multivariable regression models, LA volume index, NT-proBNP, and LA strain parameters were significantly associated with the composite outcome.

CONCLUSIONS

Of various LA myopathy markers, LA reservoir yields the greatest improvement in the prediction of ischemic stroke and dementia, supporting its use to identify people at high risk of cerebrovascular events and dementia.

Treatment Strategies to Control Blood Pressure in People With Hypertension in Tanzania and Lesotho: A Randomized Clinical Trial

Importance

Hypertension is the primary cardiovascular risk factor in Africa. Recently revised World Health Organization guidelines recommend starting antihypertensive dual therapy; clinical efficacy and tolerability of low-dose triple combination remain unclear.

Objectives

To compare the effect of 3 treatment strategies on blood pressure control among persons with untreated hypertension in Africa.

Design, Setting, and Participants

This was an open-label, parallel, 3-arm randomized clinical trial to evaluate noninferiority of a strategy starting 2 pills vs full-dose monotherapy with stepped escalation (noninferiority margin 10%) and superiority of starting low-dose 3 pills vs monotherapy allowing for monthly up titration. Recruitment lasted from March 5, 2020, to March 30, 2022. The setting was 2 hospitals in rural Lesotho and Tanzania. Participants included nonpregnant Black African individuals 18 years and older with uncomplicated, untreated hypertension (standardized office blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic).

Interventions

Participants were randomized 2:2:1 to stepped monotherapy (amlodipine, 10 mg, with escalation to add hydrochlorothiazide if needed), 2-pill strategy (amlodipine, 5 mg; losartan, 50 mg), or 3-pill strategy (amlodipine, 2.5 mg; losartan, 12.5 mg; hydrochlorothiazide, 6.25 mg). Drugs were up titrated monthly until reaching the target blood pressure (≤ 130/80 mm Hg for participants aged <65 years; ≤140/90 mm Hg for those aged ≥65 years).

Main Outcomes and Measures

Proportion of participants reaching target blood pressure at 12 weeks.

Results

Of 1761 participants screened, 1268 were enrolled (median [IQR] age, 54 [45-65] years; 914 female [72%]), with 505 in the monotherapy cohort, 510 in the 2-pill cohort, and 253 in the 3-pill cohort. In noninferiority analyses, 207 of 370 participants (56%) receiving the 2-pill strategy and 173 of 338 participants (51%) receiving the stepped monotherapy strategy achieved the blood pressure target (adjusted odds ratio [aOR], 1.18; 95% CI, 0.87-1.61), fulfilling noninferiority. In superiority analyses after multiple imputation for missing outcome data, 57% of participants receiving the 3-pill strategy, 55% receiving the 2-pill strategy, and 49% receiving the stepped monotherapy strategy reached the target blood pressure (aOR, 1.24; 95% CI, 0.94-1.63; P = .12 and aOR, 1.28; 95% CI, 0.91-1.79; P = .16 for the 2-pill and 3-pill vs stepped monotherapy strategies, respectively).

Conclusions and Relevance

Results of this randomized clinical trial show that in 2 African settings, for adults with uncomplicated untreated hypertension, a strategy starting a 2-pill low-dose treatment was noninferior to starting stepped monotherapy. Two-pill and 3-pill low-dose strategies were not superior to stepped monotherapy. Wide CIs preclude the ability to rule out potentially clinically important effects of the additional pill strategies for hypertension control.

Trial Registration

ClinicalTrials.gov Identifier: NCT04129840.

Age- and sex-based normal reference ranges of the cardiac time intervals: the Copenhagen City Heart Study

BACKGROUND

Color tissue Doppler imaging (TDI) M-mode can be used to measure the cardiac time intervals including the isovolumic contraction time (IVCT), the left ventricular ejection time (LVET), the isovolumic relaxation time (IVRT), and the combination of all the cardiac time intervals in the myocardial performance index (MPI) defined as [(IVCT + IVRT)/LVET]. The aim of this study was to establish normal age- and sex-based reference ranges for the cardiac time intervals.

METHODS AND RESULTS

A total of 1969 participants free of cardiovascular diseases and risk factors from the general population with limited age range underwent an echocardiographic examination including TDI. The median age was 46 years (25th-75th percentile: 33-58 years), and 61.5% were females. In the entire study population, the IVCT was observed to be 40 ± 10 ms [95% prediction interval (PI) 20-59 ms], the LVET 292 ± 23 ms (95% PI 248-336 ms), the IVRT 96 ± 19 ms (95% PI 59-134 ms) and MPI 0.47 ± 0.09 (95% PI 0.29-0.65). All the cardiac time intervals differed significantly between females and males. With increasing age, the IVCT increased in females, but not in males. The LVET did not change with age in both sexes, while the IVRT increased in both sexes with increasing age. Furthermore, we developed regression equations relating the heart rate to the cardiac time intervals and age- and sex-based normal reference ranges corrected for heart rate.

CONCLUSION

In this study, we established normal age- and sex-based reference ranges for the cardiac time intervals. These normal reference ranges differed significantly with sex.

HFpEF correlated with better improvement of left atrial function in post-ablation patients with paroxysmal atrial fibrillation

The extent of improvement in left atrial (LA) function after radiofrequency catheter ablation (RFCA) in patients with paroxysmal atrial fibrillation (PxAF) and its association with heart failure with preserved ejection fraction (HFpEF) remain unclear. This study aims to explore whether there is a difference in the improvement of LA function after RFCA in patients with PxAF combined with HFpEF compared to those without HFpEF. Patients with PxAF receiving RFCA were enrolled. LA volume index (LAVI), LA emptying fraction (LAEF), and LA peak reservoir strain (LA RS) were assessed using echocardiography at baseline and three months after RFCA. Changes in these parameters were compared between patients with a high probability of HFpEF (hp-HFpEF) and those with a medium or low probability of HFpEF (lp-HFpEF), as determined by the H2FPEF score. A total of 147 patients (mean age 62.6 years; 63.3% males) were recruited (hp-HFpEF = 30). Baseline LA function differed significantly between patients with hp-HFpEF and those with lp-HFpEF. Differences included LAVI, LAEF, and LA RS (all P < 0.01). The improvement in LA function 3 months after RFCA was significantly different between the two groups, even after adjusting for confounding factors. Specifically, patients with hp-HFpEF experienced greater reductions in LAVI, more improvement in LAEF, and greater improvement in LA RS compared to patients with lp-HFpEF. A high probability of HFpEF was correlated with greater improvement in LA function following RFCA in patients with PxAF. The clinical trial registration number: ClinicalTrials.gov NCT05266144.

Snapshot artificial intelligence-determination of ejection fraction from a single frame still image: a multi-institutional, retrospective model development and validation study

BACKGROUND

Artificial intelligence (AI) is poised to transform point-of-care practice by providing rapid snapshots of cardiac functioning. Although previous AI models have been developed to estimate left ventricular ejection fraction (LVEF), they have typically used video clips as input, which can be computationally intensive. In the current study, we aimed to develop an LVEF estimation model that takes in static frames as input.

METHODS

Using retrospective transthoracic echocardiography (TTE) data from Mayo Clinic Rochester and Mayo Clinic Health System sites (training: n=19 627; interval validation: n=862), we developed a two-dimensional convolutional neural network model that provides an LVEF estimate associated with an input frame from an echocardiogram video. We then evaluated model performance for Mayo Clinic TTE data (Rochester, n=1890; Arizona, n=1695; Florida, n=1862), the EchoNet-Dynamic TTE dataset (n=10 015), a prospective cohort of patients from whom TTE and handheld cardiac ultrasound (HCU) were simultaneously collected (n=625), and a prospective cohort of patients from whom HCU clips were collected by expert sonographers and novice users (n=100, distributed across three external sites).

FINDINGS

We observed consistently strong model performance when estimates from single frames were averaged across multiple video clips, even when only one frame was taken per video (for classifying LVEF ≤40% vs LVEF>40%, area under the receiver operating characteristic curve [AUC]>0·90 for all datasets except for HCU clips collected by novice users, for which AUC>0·85). We also observed that LVEF estimates differed slightly depending on the phase of the cardiac cycle when images were captured.

INTERPRETATION

When aiming to rapidly deploy such models, single frames from multiple videos might be sufficient for LVEF classification. Furthermore, the observed sensitivity to the cardiac cycle offers some insights on model performance from an explainability perspective.

FUNDING

Internal institutional funds provided by the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.

Sex and resting heart rate influence the relation between arterial stiffness and cardiac structure and function - insights from the general population

Arterial stiffness, a risk factor for cardiovascular disease, can be measured using pulse wave velocity (PWV) and augmentation index (AIx). We studied sex-specific associations between carotid-femoral PWV (cfPWV), brachial-ankle PWV (baPWV), aortic PWV (aoPWV), aortic (aoAIx), and brachial (baAIx) AIx with echocardiographic parameters. Data of 1150 participants of the Study of Health in Pomerania (SHIP-Trend 1; 530 men; median age 53 years; inter quartile range (IQR) 44 to 64) were used. Echocardiography assessed common structural and functional cardiac parameters. PWV and AIx were measured using the Vascular Explorer. Multivariable linear regression models were applied. In men, a higher brAIx was related to a greater right ventricular diameter (RV) (β 0.037; CI 0.003 to 0.148). A one m/s higher baPWV was associated with a smaller RV (β -0.037; CI -0.168 to -0.021) and right ventricular outflow tract (RVOT; β -0.029; CI -0.141 to -0.026). In men, a higher aoAIx (β 0.028; CI 0.01 to 0.122) and brAIx (β 0.029; CI 0.017 to 0.13) were associated with a greater RVOT. In women, a one m/s higher aoPWV (β 0.025; CI 0.006 to 0.105) was associated with a larger RV and a one m/s higher baPWV (β -0.031; CI -0.124 to -0.001) was inversely related to RVOT. In women, PWV associated with right ventricular dimensions, while in men, baPWV and AIx were related to right ventricular parameters. This suggests potentially sex-specific relations between PWV and cardiac structure and function.

Effect of Dapagliflozin on Ventricular Arrhythmic Events in Heart Failure Patients With an Implantable Cardioverter Defibrillator

Background

The aim of our study was to evaluate the effects of dapagliflozin on the ventricular arrhythmia burden (VAb) in patients with heart failure with reduced ejection fraction (HFrEF) and an implantable cardioverter defibrillator (ICD), correlating the possible reduction in arrhythmic events and ICD therapies with the basal functional capacity, as well as the remodeling parameters induced by treatment.

Methods

A total of 117 outpatient ICD patients with a known diagnosis of HFrEF who underwent treatment with dapagliflozin were evaluated according to a prospective observational protocol. VAb (including sustained ventricular tachycardia, non-sustained ventricular tachycardia, ventricular fibrillation, and total ventricular events) and specific ICD therapies (anti-tachycardia pacing (ATP) and ICD shocks) were extrapolated from the devices' memory (events per patient per month) by comparing events in the observation period before and after the introduction of dapagliflozin.

Results

The VAb was significantly reduced after dapagliflozin introduction (2.9 ± 1.8 vs. 4.5 ± 2.0, P = 0.01). The burden of appropriate ATPs was significantly reduced (0.57 ± 0.80 vs. 0.65 ± 0.91, P = 0.03), but not for ICD shocks. In patients with a more advanced functional class, a greater reduction in VAb was observed than in patients with a better initial functional capacity (2.2 ± 0.8 vs. 5.5 ± 1.8, P = 0.001 in the New York Heart Association (NYHA) III/IV group; 3.5 ± 2.1 vs. 4.5 ± 2.2, P = 0.02 in the NYHA I/II group). Considering two independent groups according to reverse remodeling (Δleft ventricular ejection fraction (LVEF) > 15%), a significant reduction in VAb was observed only in those patients who presented significant reverse remodeling (2.5 ± 1.1 vs. 5.1 ± 1.6, P = 0.01). A statistically significant interaction between the variation of total ventricular arrhythmias (VTA) and the basal NYHA class (F(1,115) = 142.25, P < 0.0001, partial η2 = 0.553), as well as between the variation of VTA and the ΔLVEF (F(1,115) = 107.678, P < 0.0001, partial η2 = 0.484) has been demonstrated using a two-way analysis of variance (ANOVA) test.

Conclusions

In ICD outpatients with HFrEF, dapagliflozin treatment produces a reduction in arrhythmic ventricular events. This improvement is more evident in patients who have a worse functional class and thus a more precarious hemodynamic state, and in patients who present with significant ventricular reverse remodeling. Therefore, we can hypothesize that the hemodynamic and structural improvements induced by treatment represent, at least in the short-medium term, some of the principal elements justifying the significant reduction in VAb.

Impact of Tafamidis on [99mTc]Tc-pyrophosphate Scintigraphy in Ala97Ser Hereditary Transthyretin amyloid cardiomyopathy: significant initial reduction with stable Long-Term effects

OBJECTIVE

Tafamidis has shown potential in slowing disease progression in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). This study aimed to evaluate serial changes on [99mTc]Tc-pyrophosphate (PYP) scintigraphy during tafamidis treatment for hereditary ATTR-CM.

METHODS

We retrospectively analyzed a prospectively collected cohort of Ala97Ser (A97S) hereditary ATTR-CM patients treated with tafamidis (61 mg/day) and a control group comprising A97S hereditary ATTR-CM patients who had not received disease-modifying medications. The tafamidis group was further divided into two cohorts: cohort A received [99mTc]Tc-PYP SPECT/CT scans at baseline, 1 year, and 2 years; cohort B at baseline, 2 years, and 3 years. Visual score, planar heart to contralateral lung (H/CL) ratio, and volumetric heart to lung (H/L) ratio were measured.

RESULTS

Nineteen patients were enrolled in the tafamidis group and nine in the control group. After 2 years of follow-up, a significant decrease in volumetric H/L ratio (3.86 ± 0.91 to 3.01 ± 0.19, p < 0.001) was noted in the tafamidis group, while there was no significant change in the control group. When evaluated over time, a significant decrease in volumetric H/L ratio was observed during the first year of tafamidis treatment (3.75 ± 0.37 to 2.82 ± 0.15, p = 0.004), followed by stable [99mTc]Tc-PYP uptake in the subsequent two years (2.82 ± 0.15 to 2.83 ± 0.18, p = 0.934 and 3.20 ± 0.14 to 3.09 ± 0.16, p = 0.404, respectively).

CONCLUSION

A significant reduction in [99mTc]Tc-PYP uptake was observed in hereditary ATTR-CM patients after tafamidis treatment, particularly within the first year. While the effect appeared to be sustained, stable [99mTc]Tc-PYP uptake without further significant reductions was observed in the subsequent years.

Pediatric Primary Raynaud's Phenomenon: A Comprehensive Cardiovascular Analysis

Our aim in this study is to evaluate the cardiovascular findings of pediatric patients with primary Raynaud's phenomenon (RP) and to determine if there are any pathological findings. Our study included 42 pediatric patients aged between 7 and 18 who were diagnosed with primary RP and did not have any additional underlying structural vascular disease or secondary rheumatological conditions. The control group consisted of 30 healthy volunteers aged 7-18 years, matched by age and sex, without any additional diseases. We evaluated demographic, clinical, and laboratory findings, echocardiographic and capillaroscopic features, as well as carotid intima-media thickness. Compared to the control group, pediatric patients with primary RP showed increased A wave velocity and E/E' ratio parameters in the left ventricle, indicating diastolic dysfunction of the heart. The isovolumetric relaxation time (IVRT) was prolonged in both the left and right ventricles, and the E/A ratio decreased in the left ventricle. The myocardial performance index (MPI), indicating both systolic and diastolic dysfunction, increased in both ventricles. Additionally, the aortic stiffness index, aortic elastic modulus (Ep), and left carotid intima-media thickness (CIMT) significantly increased, while distensibility decreased in pediatric patients with primary RP compared to the control group. The cardiovascular evaluation of pediatric patients with primary RP revealed that diastolic dysfunction is likely present in both the left and right heart. Additionally, based on the aorta and carotid intima measurements, it is suggested that pediatric patients with primary RP are at risk for developing atherosclerosis.

Heart failure with preserved ejection fraction: from echocardiographic characteristics to a cardiovascular damage score in a high-risk hypertensive population

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a high prevalence condition, with high rates of hospitalization and mortality. Arterial hypertension is the main risk factor for HFpEF. Among hypertensive patients, alterations in cardiac and vascular morphology identify hypertension-mediated organ damage (HMOD). Cardiac HMOD in terms of ventricular hypertrophy and diastolic dysfunction is a continuum between the preclinical condition (arterial hypertension) and HFpEF. In hypertensive patients, it is currently unknown what is the prevalence of individuals classifiable as being at high risk of developing HFpEF and whether aortic morphofunctional vascular changes are present.

AIM

This study seeks to retrospectively assess the prevalence of echocardiographic alterations consistent with the diagnosis of HFpEF in a cohort of patients with essential arterial hypertension, and the prevalence of vascular HMOD (V-HMOD) in different risk categories of patients.

METHODS

Hypertensive outpatients referred at the Hypertension Center of Turin from 2003 to 2021 were retrospectively evaluated. Patients with a previous diagnosis of heart failure and known cardiovascular events were excluded. A predictive model associated with the risk of HFpEF development was calculated using echocardiographic variables. V-HMOD morphological and functional parameters were assessed by ascending aorta diameter and arterial stiffness (carotid-femoral pulse wave velocity, cfPWV).

RESULTS

Eight hundred and four patients (34.8% women) were analyzed, age 53.1 ± 14 years; left ventricular mass index (LVMi) and E / e' ratio were impaired in 15.9 and 29.1% of cases, respectively. Dividing them into tertiles according to score: score 1 or less (30.2%); score 2-3 (47.4%); score at least 3 (22.7%). Patients identified at high risk of HFpEF (score ≥3) had higher age, BMI and blood pressure than the other two groups ( P  < 0.05); they showed a significantly higher prevalence of female patients (42.3%), treatment with at least two antihypertensive drugs (40.1%), diabetes (7.1%), and dyslipidemia (28%; P  < 0.05), with a larger ascending aorta diameter (35.5 ± 5.5 mm, P  < 0.05) and higher cfPWV (8.8 ± 2.4 m/s, P  < 0.05).

CONCLUSION

At least one in five hypertensive patients, referred to an outpatient echocardiographic examination, has C-HMOD compatible with a high-risk category of HFpEF and have a significant increase in V-HMOD. This reinforces the notion that arterial hypertension and HFpEF are not two distinctly separate conditions but a continuum of pathophysiologic alterations.

Development of Liver-Heart Score for Early Detection of Myocardial Contractile Dysfunction in Cirrhosis by Strain Imaging

AIM

Cirrhotic cardiomyopathy is characterised by myocardial dysfunction in patients with cirrhosis in the absence of other cardiac conditions. We aimed to develop and validate a scoring system to identify patients at high risk for reduced global longitudinal strain, a newly proposed marker of myocardial dysfunction in the updated diagnostic criteria for cirrhotic cardiomyopathy.

METHODS

Prospectively recruited patients with cirrhosis in the training and validation groups underwent identical hepatological and cardiological evaluations, including strain echocardiography. Risk factors for myocardial dysfunction were identified using logistic regression.

RESULTS

In a cohort of 452 consecutive patients, 278 were excluded due to non-cirrhotic cardiomyopathy or conditions potentially affecting strain measurements. The prevalence of reduced global longitudinal strain was 9.8% (13/133) in the training group and 19.5% (8/41) in the validation group. Multivariate logistic regression revealed BMI ≥ 28 kg/m2 (OR 7.02), CAP > 260 dB/m (OR 8.53), and age > 57 years (OR 4.68) as independent predictors of reduced myocardial contractility. These variables were combined and weighted based on their beta coefficients to develop the Liver-heart score (CAP > 260 dB/m [2 pts], BMI ≥ 28 kg/m2 [2 pts], age > 57 years [1 pt]). The AUC-ROC was 0.84 in the training and 0.83 in the validation cohort. A Liver-heart score of 5 points was associated with increased mortality, observed at 2 years (44.4% vs. 17.3%) and the end of the follow-up period (66.7% vs. 37.7%, HR 1.3, p < 0.01).

CONCLUSION

The Liver-heart score can accurately rule out reduced myocardial contractility and may be useful for risk stratification in cirrhotic patients.

Changes and prognostic significance of autonomic cardiac regulation during ageing

BACKGROUND

Data on the changes of heart rate variability (HRV) and their prognostic significance during ageing are limited.

METHODS

HRV analyzes were done from standardized 45-min ECG recordings, which consisted of 15 min recordings in lying down, sitting positions and during walking. We used time domain-, frequency domain- and non-linear methods to estimate HRV. The baseline ECG recordings were done in 1991-1993 (n = 783) and follow up recordings were done in 2013-2014 (n = 466). Endpoints were reviewed in 2021.

RESULTS

During a mean follow-up of 22.1 ± 0.7 years, high-, low- and very-low-frequency powers (HF, LF, VLF), standard deviation of RR intervals (SDNN), the short-term fractal-like scaling exponent analyzed by the detrended fluctuation analysis (DFA1) and approximate entropy (ApEn) decreased statistically significantly (p-values from <0.05 to <0.001). Larger decrease of VLF(ln) and LF(ln) predicted total and cardiovascular (CV) mortality in the multivariate model (p-values from <0.05 to <0.001). Baseline natural logarithm of LF (LF(ln)) dichotomized and DFA1 had the strongest prognostic value on total and CV-mortality in multivariate analysis after adjustments with relevant clinical characteristics. Also, lower values of baseline ApEn retained their predictive power for total mortality and decreased ratio of LF to HF (LF/HF) for CV-mortality after adjustments.

CONCLUSIONS

Almost all the HRV parameters decreased during ageing. Larger decrease of VLF(ln) and LF(ln) predicted total and CV-mortality after adjustments indicating that larger attenuation in cardiac autonomic regulation during ageing yields prognostic information. Of the baseline HRV parameters LF(ln) dichotomized and DFA1 had the strongest prognostic value on total and CV-mortality.

Echocardiographic assessment of Right Ventricular Diastolic Function in Children and Adults: Present State and Future Directions

Diastolic function plays an important but often overlooked role in overall ventricular performance and is comprised of sequence of events which together result in adequate filling at low filling pressures. From a physiologic point of view there are two distinct, yet related periods that drive diastole: active relaxation and late filling. Much of the literature on diastolic function is based on the left ventricle however there are significant differences in morphology, physiology and adaptation between ventricles. Echocardiographic assessment of RV diastolic function is challenging due to our imperfect understanding in RV physiology, suboptimal imaging tools and the use of models that have been built using the left ventricle. Conventional assessment includes IVC size, RA volume and the use of Doppler to quantify tissue and blood velocity (TV E/A, e', a', E/e', IVRT, hepatic vein and pulmonary artery). In adults, TV E/A used in combination with e', IVC size, may be used to classify diastolic impairment however in children this is dependent to a greater degree on age and pathology. Right atrial and ventricular strain suffers from fewer limitations and may show incremental benefit however remains understudied, particularly in children. Novel methods made possible with ultrafast ultrasound provide a means to non-invasively assess intraventricular pressure differences as a measure of active relaxation, and shear wave velocity to directly assess myocardial stiffness, however these remain in pre-clinical stages. This review discusses right ventricular diastolic physiology, the current state and limitations of echocardiographic evaluation and explores promising new methods for its assessment.

Positive T wave in lead aVR is associated with left atrial and ventricular function and cardiac outcomes in heart failure patients with preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) accounts for a significant proportion of heart failure cases and is associated with high morbidity and mortality. While echocardiography plays a central role in HFpEF assessment, the prognostic value of electrocardiographic (ECG) findings, particularly in lead aVR, remains underexplored. This study investigates the relationship between a positive T wave in lead aVR (TaVR) and left atrial (LA) and left ventricular (LV) function, as well as its prognostic significance in HFpEF patients.

METHODS

This retrospective study included 231 HFpEF patients diagnosed according to ESC guidelines. Patients underwent comprehensive echocardiography and 12‑lead ECG evaluation. Positive TaVR was defined as a T-wave amplitude ≥1 mm in lead aVR. LA and LV functions were assessed using LA reservoir strain (LASr) and LV global longitudinal strain (GLS), respectively. Multivariate Cox regression and Kaplan-Meier survival analyses were performed to evaluate the prognostic significance of TaVR.

RESULTS

Positive TaVR was observed in 34.6 % of patients and was associated with impaired LASr (15.02 ± 6.65 % vs. 17.78 ± 9.10 %, p = 0.023) and LV GLS (-13.66 ± 3.49 % vs. -15.19 ± 3.02 %, p = 0.001). Positive TaVR independently predicted 1-year all-cause mortality (HR = 6.02, p < 0.001) and 6-month all-cause mortality (HR = 9.67, p < 0.001). Patients with positive TaVR had higher hospitalization rates and worse clinical outcomes.

CONCLUSION

Positive TaVR is associated with LA dysfunction, LV remodeling, and poor prognosis in HFpEF. Incorporating this ECG parameter into routine clinical assessments could enhance risk stratification and guide management strategies for HFpEF patients.

Tissue characterization using cardiac magnetic resonance imaging and response to cardiac resynchronization therapy

AIMS

Cardiac magnetic resonance (CMR) imaging for tissue characterization offers valuable insights for risk stratification among patients with cardiomyopathy. This study aimed to assess the prognostic value of CMR-based tissue characterization in predicting response to cardiac resynchronization therapy (CRT) in patients with non-ischaemic cardiomyopathy (NICM).

METHODS AND RESULTS

Retrospective analysis was performed on CMR data from NICM patients before CRT implantation. Various CMR parameters, including the late gadolinium enhancement (LGE), native T1, T2, and extracellular volume (ECV), were analysed. Among the 101 patients (mean age: 66 years, male: 52.5%), 72 (71.3%) were CRT responders. The CRT responders had lower LGE burden (13.1 vs. 35.3%, P < 0.001), native T1 (1334.5 vs. 1371.6 ms, P = 0.012), T2 (42.2 vs. 45.7 ms, P < 0.001), and ECV (30.8 vs. 36.8%, P < 0.001) compared with CRT non-responders. After adjusting for other risk factors, LGE burden ≤ 20% [odds ratio (OR): 22.61, 95% confidence interval (CI): 4.73-176.68, P < 0.001], ECV ≤ 34% (OR: 15.93, 95% CI: 3.01-115.13, P = 0.002), and T2 ≤ 45 ms (OR: 8.10, 95% CI: 1.82-43.75, P = 0.008) were identified as predictors of good CRT response and favourable clinical outcomes (log-rank P < 0.001).

CONCLUSION

Cardiac magnetic resonance-based tissue parameters effectively predict CRT response and clinical outcomes in patients with NICM, independently of conventional predictors.

Impact of valvulo-vascular haemodynamics on left ventricular remodelling and the prevalence of discordant moderate aortic stenosis

AIMS

This study aims to describe the prevalence of discordant mild/moderate aortic stenosis (AS) in a population-based study and to identify the mechanisms that lead to reduced stroke volume (SV) and discordant moderate AS.

METHODS AND RESULTS

Discordant high-gradient (HG)-mild AS, defined as AVA > 1.5 cm2 and mean pressure gradient (MG) of 20-40 mmHg, and discordant low-gradient (LG) moderate AS, defined as AVA 1.0-1.5 cm2 and MG < 20 mmHg, were assessed in 883 individuals from the DANCAVAS screening study with aortic valve calcification and 257 individuals form the PROGRESSA study excluding those with left ventricular (LV) ejection fraction < 50%. In the DANCAVAS cohort, 150 men had mild/moderate AS of which 34% had discordance between MG and AVA, representing 66% with moderate AS. Among 262 patients in the combined cohort, 39% had discordant LG-moderate AS and 6% discordant HG-mild AS. Compared with concordant mild and moderate AS, individuals with discordant LG-moderate AS were more likely to present with LV concentric remodelling geometry (26 vs. 33 vs. 45%, P < 0.001), increased valvulo-arterial impedance (3.3 ± 0.7 vs. 3.6 ± 0.5 vs. 4.1 ± 0.7 mmHg/mL/m2, P < 0.001), and reduced systemic arterial compliance (SAC) (0.74 ± 0.22 vs. 0.81 ± 0.22 vs. 0.64 ± 0.18 mL/m2/mmHg, P < 0.001). Factors associated with SV index were relative wall thickness, LV end-diastolic diameter index, SAC, and LV remodelling pattern.

CONCLUSION

Discordant moderate AS is common, accounting for two-thirds of patients with moderate AS in the general male population. Patients with discordant LG-moderate AS have predominantly a concentric remodelling pattern with reduced SV. Reduced SV index was associated with signs of reduced vascular compliance, suggesting that altered vascular properties drive differences in remodelling patterns and discordant moderate AS.

Impact of the hemoglobin-to-red cell distribution width ratio on 30-day readmission in patients with heart failure

BACKGROUND

Predicting all-cause readmission in patients with heart failure (HF) is crucial. This study investigated the independent risk factors for short-term readmission and assessed the potential mediators involved in this process.

METHODS

We evaluated data from 2,254 patients with HF admitted to our institution between January 2019 and December 2020. Logistic regression analysis was used to examine the association between sarcopenia index (SI), neutrophil-to-lymphocyte ratio (NLR), hemoglobin-to-red cell distribution width ratio (HRR), and all-cause 30-d readmission. A restricted cubic spline regression model with three knots assessed potential non-linear relationships between confounders and readmission risk. A mediation analysis was performed to evaluate the direct and indirect effects, as well as the proportion of mediation.

RESULTS

The mean age of the participants was 72 ± 12 years, with 1,324 males (58.7%). The all-cause 30-d readmission rate was 7.1%. HRR was independently associated with 30-d readmission among the evaluated biomarkers, whereas SI and NLR showed no significant correlation. A non-linear relationship was found between HRR and readmission risk, with an inflection point at 0.94. Patients with HRR < 0.94 exhibited a significantly higher risk of readmission, whereas no significant association was found for HRR ≥ 0.94. Mediation analysis revealed that N-terminal pro-B-type natriuretic peptide (NT-proBNP) partially mediated this relationship, which accounted for 13.6% of the effect.

CONCLUSIONS

HRR is an independent predictor of all-cause 30-d readmission in patients with a non-linear relationship observed. An inverse association was found for HRR < 0.94, whereas no significant association was found for HRR ≥ 0.94. Additionally, NT-proBNP was identified as a partial mediator of this relationship.

Severe Mitral Regurgitation in Paradoxical Low-Flow, Low-Gradient Severe Aortic Stenosis

BACKGROUND

Patients with paradoxical low-flow, low-gradient severe aortic stenosis exhibit low transvalvular flow rate (Q), while maintaining preserved left ventricular ejection fraction. Severe mitral regurgitation (MR) also causes a low-flow state, adding complexity to diagnosis and management. This study aimed to examine the impact of severe MR on outcomes in paradoxical low-flow, low-gradient severe aortic stenosis.

METHODS

Data from an institutional echo database identified 1189 patients with adjudicated severe aortic stenosis (aortic valve area ≤1.0 cm2), low transaortic gradients (mean gradient <40 mm Hg), preserved left ventricular ejection fraction (≥50%), and low-flow rate (Q ≤210 mL/s) to confirm paradoxical low-flow, low-gradient severe aortic stenosis. Subgroups were based on MR severity (severe and nonsevere). Clinical outcomes included all-cause mortality, aortic valve replacement, heart failure hospitalizations, and a composite outcome.

RESULTS

In the severe MR group (n=80), patients had lower flow rates, increased left ventricular dimensions, and a more eccentric hypertrophy pattern compared with nonsevere MR (n=1109). Over a follow-up of up to 5 years, severe MR correlated with higher all-cause mortality (P=0.02) and aortic valve replacement rates (P=0.012). After adjustment, severe MR was independently associated with increased all-cause mortality risk (hazard ratio, 1.43; P=0.011) and composite outcome (hazard ratio, 1.64; P<0.001). Aortic valve replacement significantly reduced mortality at every MR degree, with the most substantial impact in severe MR (hazard ratio, 0.18; P<0.001). Propensity-adjusted models demonstrated a stronger aortic valve replacement impact with increasing MR degree (Pinteraction=0.044).

CONCLUSIONS

Severe MR in paradoxical low-flow, low-gradient severe aortic stenosis is associated with adverse outcomes and distinctive left ventricular remodeling. Aortic valve replacement improves survival across all MR grades, with greater impact in severe MR.

Iron Deficiency in Acute Coronary Syndromes-Clinical Correlates and Outcomes

BACKGROUND

Iron deficiency is common in heart failure and relates to a worse prognosis, but its role in acute coronary syndromes is unclear. This study assessed iron deficiency prevalence, correlation with infarct size and left ventricular function, and association with in-hospital and post-discharge events in such patients.

METHODS

We analyzed 152 acute coronary syndrome patients using multiple iron deficiency definitions: serum iron <6 µmol/L or <13 µmol/L; transferrin saturation (TSAT) <20%; ferritin <100 µg/L; and a combined definition - ferritin <100 µg/L or TSAT<20% if ferritin 100-299 µg/L. Infarct size was approximated by peak cardiac troponin T. Cox regression analysis examined associations with in-hospital complications (death, sustained arrhythmias, or Killip class ≥3) and post-discharge events (death, myocardial infarction, or stroke).

RESULTS

The prevalence of iron deficiency ranged from 21% to 62%, depending on definitions. Patients with deficiency defined by serum iron or TSAT were older, more frequently female, with more cardiovascular risk factors, and higher high-sensitivity C-reactive protein. Serum iron <13 µmol/L and TSAT <20% correlated with lower left ventricular ejection fraction but not with greater infarct size. Iron deficiency did not predict in-hospital complications, whereas serum iron <6 µmol/L was associated with a higher risk of post-discharge events. Such association lost significance after adjustment for hs-CRP. Lower ferritin predicted fewer events.

CONCLUSION

Iron deficiency is frequent in acute coronary syndromes. Definitions by serum iron and TSAT identify patients with worse left ventricular systolic function and more inflammation, potentially influencing prognosis.

Cancer Is a Major Determinant of Postoperative Atrial Fibrillation After Cardiac Surgery

Background/Objectives: Postoperative atrial fibrillation (POAF) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. The pathogenesis of POAF in this setting is complex and not completely understood. Since cancer is a well-known risk factor for AF, the aim of this study was to identify potential predictors, including cancer, of POAF after cardiac surgery. Methods: This prospective study included 400 consecutive patients in sinus rhythm who underwent elective cardiac surgery in Aretaeio Hospital (Nicosia, Cyprus) from January 2020 till January 2023. The primary outcome was the development of POAF during hospitalization, defined as any documented AF episode lasting >30 s. Predictors of the primary outcome were studied using univariable and multivariable logistic regression analysis. Results: Of the 400 patients (68 [61-73] years, 64 [16%] females) studied, 66 (16.5%) developed POAF. Among the variables examined, the only predictors of POAF were cardiopulmonary bypass time (odds ratio [OR] = 1.001, 95% confidence interval = [95% CI, 1.000-1.001], p = -0.031) and cancer (OR = 3.852, 95% CI = [1.535-9.664], p = 0.004). Cancer was present in 13 (4%) and in 10 (15%) of patients without and with POAF, respectively (p < 0.001). Conclusions: Cancer was associated with a dramatic increase in POAF risk early after elective cardiac surgery in this study. Whether patients developing POAF after cardiac surgery should be searched for cancer deserves further investigation.