Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Inhibition of asparagine synthetase effectively retards polycystic kidney disease progression

Polycystic kidney disease (PKD) is a genetic disorder characterized by bilateral cyst formation. We showed that PKD cells and kidneys display metabolic alterations, including the Warburg effect and glutaminolysis, sustained in vitro by the enzyme asparagine synthetase (ASNS). Here, we used antisense oligonucleotides (ASO) against Asns in orthologous and slowly progressive PKD murine models and show that treatment leads to a drastic reduction of total kidney volume (measured by MRI) and a prominent rescue of renal function in the mouse. Mechanistically, the upregulation of an ATF4-ASNS axis in PKD is driven by the amino acid response (AAR) branch of the integrated stress response (ISR). Metabolic profiling of PKD or control kidneys treated with Asns-ASO or Scr-ASO revealed major changes in the mutants, several of which are rescued by Asns silencing in vivo. Indeed, ASNS drives glutamine-dependent de novo pyrimidine synthesis and proliferation in cystic epithelia. Notably, while several metabolic pathways were completely corrected by Asns-ASO, glycolysis was only partially restored. Accordingly, combining the glycolytic inhibitor 2DG with Asns-ASO further improved efficacy. Our studies identify a new therapeutic target and novel metabolic vulnerabilities in PKD.

Value of a short non-contrast CMR protocol in MINOCA

OBJECTIVES

To evaluate the diagnostic performance of a short non-contrast CMR (ShtCMR) protocol relative to a matched standard comprehensive CMR (StdCMR) protocol in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA).

METHODS

This multicenter retrospective study included patients with a working diagnosis of MINOCA who underwent a StdCMR between January 2019 and December 2020. An expert and a non-expert reader performed a blinded reading with the ShtCMR (long-axis cine images, T2w-STIR, T1- and T2-mapping). A consensus reading of the StdCMR (reference standard) was performed at least 3 months after the ShtCMR reading session. Readers were asked to report the following: (1) diagnosis; (2) level of confidence in their diagnosis with the ShtCMR; (3) number of myocardial segments involved, and (4) functional parameters.

RESULTS

A total of 179 patients were enrolled. The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). ShtCMR allowed reaching the same diagnosis as StdCMR in 85% of patients when interpreted by expert readers (rising from 66% for poor confidence to 99% for good, p = 0.0001) and in 73% (p = 0.01) by non-expert ones (60% for poor vs 89% for good confidence, p = 0.0001). Overall, the ShtCMR overestimated the ejection fraction, underestimated cardiac volumes (p < 0.01), and underestimated the number of segments involved by pathology (p = 0.0008) when compared with the StdCMR.

CONCLUSION

The ShtCMR was found to be a debatable alternative to the StdCMR in patients with MINOCA. Nevertheless, when an experienced reader reaches a good or very good diagnostic confidence using the ShtCMR, the reader may choose to stop the examination, reducing the length of the CMR without affecting the patient's diagnosis.

CLINICAL RELEVANCE STATEMENT

A short non-contrast CMR protocol may be a viable alternative to standard protocols in selected CMR studies of patients with MINOCA, allowing for faster diagnosis while reducing time and resources and increasing the number of patients who can be scanned.

KEY POINTS

• The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). • In 57% of patients with MINOCA, the experienced reader considers that contrast medium is probably not necessary for diagnosis without affecting the patient's diagnosis (99% of agreement rate between ShtCMR and StdCMR).

Diagnostic accuracy of fully hybrid [68Ga]Ga-PSMA-11 PET/MRI and [68Ga]Ga-RM2 PET/MRI in patients with biochemically recurrent prostate cancer: a prospective single-center phase II clinical trial

PURPOSE

To compare the diagnostic accuracy and detection rates of PET/MRI with [68Ga]Ga-PSMA-11 and [68Ga]Ga-M2 in patients with biochemical recurrence of prostate cancer (PCa).

METHODS

Sixty patients were enrolled in this prospective single-center phase II clinical trial from June 2020 to October 2022. Forty-four/60 completed all study examinations and were available at follow-up (median: 22.8 months, range: 6-31.5 months). Two nuclear medicine physicians analyzed PET images and two radiologists interpreted MRI; images were then re-examined to produce an integrated PET/MRI report for both [68Ga]Ga-PSMA-11 and [68Ga]Ga-RM2 examinations. A composite reference standard including histological specimens, response to treatment, and conventional imaging gathered during follow-up was used to validate imaging findings. Detection rates, accuracy, sensitivity, specificity, positive, and negative predictive value were assessed. McNemar's test was used to compare sensitivity and specificity on a per-patient base and detection rate on a per-region base. Prostate bed, locoregional lymph nodes, non-skeletal distant metastases, and bone metastases were considered. p-value significance was defined below the 0.05 level after correction for multiple testing.

RESULTS

Patients' median age was 69.8 years (interquartile range (IQR): 61.8-75.1) and median PSA level at time of imaging was 0.53 ng/mL (IQR: 0.33-2.04). During follow-up, evidence of recurrence was observed in 31/44 patients. Combining MRI with [68Ga]Ga-PSMA-11 PET and [68Ga]Ga-RM2 PET resulted in sensitivity = 100% and 93.5% and specificity of 69.2% and 69.2%, respectively. When considering the individual imaging modalities, [68Ga]Ga-RM2 PET showed lower sensitivity compared to [68Ga]Ga-PSMA-11 PET and MRI (61.3% vs 83.9% and 87.1%, p = 0.046 and 0.043, respectively), while specificity was comparable among the imaging modalities (100% vs 84.6% and 69.2%, p = 0.479 and 0.134, respectively).

CONCLUSION

This study brings further evidence on the utility of fully hybrid PET/MRI for disease characterization in patients with biochemically recurrent PCa. Imaging with [68Ga]Ga-PSMA-11 PET showed high sensitivity, while the utility of [68Ga]Ga-RM2 PET in absence of a simultaneous whole-body/multiparametric MRI remains to be determined.

Real-time estimation of EEG-based engagement in different tasks

Objective.Recent trends in brain-computer interface (BCI) research concern the passive monitoring of brain activity, which aim to monitor a wide variety of cognitive states. Engagement is such a cognitive state, which is of interest in contexts such as learning, entertainment or rehabilitation. This study proposes a novel approach for real-time estimation of engagement during different tasks using electroencephalography (EEG).Approach.Twenty-three healthy subjects participated in the BCI experiment. A modified version of the d2 test was used to elicit engagement. Within-subject classification models which discriminate between engaging and resting states were trained based on EEG recorded during a d2 test based paradigm. The EEG was recorded using eight electrodes and the classification model was based on filter-bank common spatial patterns and a linear discriminant analysis. The classification models were evaluated in cross-task applications, namely when playing Tetris at different speeds (i.e. slow, medium, fast) and when watching two videos (i.e. advertisement and landscape video). Additionally, subjects' perceived engagement was quantified using a questionnaire.Main results.The models achieved a classification accuracy of 90% on average when tested on an independent d2 test paradigm recording. Subjects' perceived and estimated engagement were found to be greater during the advertisement compared to the landscape video (p= 0.025 andp<0.001, respectively); greater during medium and fast compared to slow Tetris speed (p<0.001, respectively); not different between medium and fast Tetris speeds. Additionally, a common linear relationship was observed for perceived and estimated engagement (rrm= 0.44,p<0.001). Finally, theta and alpha band powers were investigated, which respectively increased and decreased during more engaging states.Significance.This study proposes a task-specific EEG engagement estimation model with cross-task capabilities, offering a framework for real-world applications.

Coronary physiology thresholds associated with microvascular obstruction in myocardial infarction

OBJECTIVES

To ascertain whether invasive assessment of coronary physiology soon after recanalisation of the culprit artery by primary percutaneous coronary intervention is associated with the development of microvascular obstruction by cardiac magnetic resonance in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

Between November 2020 and December 2021, 102 consecutive patients were prospectively enrolled in five tertiary centres in Italy. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured in the culprit vessel soon after successful primary percutaneous coronary intervention. Optimal cut-off points of IMR and CFR to predict the presence of microvascular obstruction were estimated, stratifying the population accordingly in four groups. A comparison with previously proposed stratification models was carried out.

RESULTS

IMR>31 units and CFR≤1.25 yielded the best accuracy. Patients with IMR>31 and CFR≤1.25 exhibited higher microvascular obstruction prevalence (83% vs 38%, p<0.001) and lower left ventricular ejection fraction (45±9% vs 52±9%, p=0.043) compared with those with IMR≤31 and CFR>1.25, and lower left ventricular ejection fraction compared with patients with CFR≤1.25 and IMR≤31 (45±9% vs 54±7%, p=0.025). Infarct size and area at risk were larger in the former, compared with other groups.

CONCLUSIONS

IMR and CFR are associated with the presence of microvascular obstruction in STEMI. Patients with an IMR>31 units and a CFR≤1.25 have higher prevalence of microvascular obstruction, lower left ventricular ejection fraction, larger infarct size and area at risk.

TRIAL REGISTRATION NUMBER

NCT04677257.

Cardiac Masses and Pseudomasses: An Overview about Diagnostic Imaging and Clinical Background

A cardiac lesion detected at ultrasonography might turn out to be a normal structure, a benign tumor or rarely a malignancy, and lesion characterization is very important to appropriately manage the lesion itself. The exact relationship of the mass with coronary arteries and the knowledge of possible concomitant coronary artery disease are necessary preoperative information. Moreover, the increasingly performed coronary CT angiography to evaluate non-invasively coronary artery disease leads to a rising number of incidental findings. Therefore, CT and MRI are frequently performed imaging modalities when echocardiography is deemed insufficient to evaluate a lesion. A brief comprehensive overview about diagnostic radiological imaging and the clinical background of cardiac masses and pseudomasses is reported.

Imaging for the assessment of the arrhythmogenic potential of mitral valve prolapse

Mitral valve prolapse (MVP) is the most common valve disease in the western world and recently emerged as a possible substrate for sudden cardiac death (SCD). It is estimated an annual risk of sudden cardiac death of 0.2 to 1.9% mostly caused by complex ventricular arrhythmias (VA). Several mechanisms have been recognized as potentially responsible for arrhythmia onset in MVP, resulting from the combination of morpho-functional abnormality of the mitral valve, structural substrates (regional myocardial hypertrophy, fibrosis, Purkinje fibers activity, inflammation), and mechanical stretch. Echocardiography plays a central role in MVP diagnosis and assessment of severity of regurgitation. Several abnormalities detectable by echocardiography can be prognostic for the occurrence of VA, from morphological alteration including leaflet redundancy and thickness, mitral annular dilatation, and mitral annulus disjunction (MAD), to motion abnormalities detectable with "Pickelhaube" sign. Additionally, speckle-tracking echocardiography may identify MVP patients at higher risk for VA by detection of increased mechanical dispersion. On the other hand, cardiac magnetic resonance (CMR) has the capability to provide a comprehensive risk stratification combining the identification of morphological and motion alteration with the detection of myocardial replacement and interstitial fibrosis, making CMR an ideal method for arrhythmia risk stratification in patients with MVP. Finally, recent studies have suggested a potential role in risk stratification of new techniques such as hybrid PET-MR and late contrast enhancement CT. The purpose of this review is to provide an overview of the mitral valve prolapse syndrome with a focus on the role of imaging in arrhythmic risk stratification. CLINICAL RELEVANCE STATEMENT: Mitral valve prolapse is the most frequent valve condition potentially associated with arrhythmias. Imaging has a central role in the identification of anatomical, functional, mechanical, and structural alterations potentially associated with a higher risk of developing complex ventricular arrhythmia and sudden cardiac death. KEY POINTS: • Mitral valve prolapse is a common valve disease potentially associated with complex ventricular arrhythmia and sudden cardiac death. • The mechanism of arrhythmogenesis in mitral valve prolapse is complex and multifactorial, due to the interplay among multiple conditions including valve morphological alteration, mechanical stretch, myocardial structure remodeling with fibrosis, and inflammation. • Cardiac imaging, especially echocardiography and cardiac magnetic resonance, is crucial in the identification of several features associated with the potential risk of serious cardiac events. In particular, cardiac magnetic resonance has the advantage of being able to detect myocardial fibrosis which is currently the strongest prognosticator.

FLT3-targeted therapy restores GATA1 pathway function in NPM1/FLT3-ITD mutated acute myeloid leukaemia

One-third of newly diagnosed adult acute myeloid leukaemia (AML) carry FLT3 mutations, which frequently occur together with nucleophosmin (NPM1) mutations and are associated with worse prognosis. FLT3 inhibitors are widely used in clinics with limitations due to drug resistance. AML cells carrying FLT3 mutations in both mouse models and patients present low expression of GATA1, a gene involved in haematopoietic changes preceding AML. Here, we show that FLT3 inhibition induces cellular responses and restores the GATA1 pathway and functions in NPM1/FLT3-ITD mutated AML, thus providing a new mechanism of action for this drug.

Chest CT opportunistic biomarkers for phenotyping high-risk COVID-19 patients: a retrospective multicentre study

OBJECTIVE

To assess the value of opportunistic biomarkers derived from chest CT performed at hospital admission of COVID-19 patients for the phenotypization of high-risk patients.

METHODS

In this multicentre retrospective study, 1845 consecutive COVID-19 patients with chest CT performed within 72 h from hospital admission were analysed. Clinical and outcome data were collected by each center 30 and 80 days after hospital admission. Patients with unknown outcomes were excluded. Chest CT was analysed in a single core lab and behind pneumonia CT scores were extracted opportunistic data about atherosclerotic profile (calcium score according to Agatston method), liver steatosis (≤ 40 HU), myosteatosis (paraspinal muscle F < 31.3 HU, M < 37.5 HU), and osteoporosis (D12 bone attenuation < 134 HU). Differences according to treatment and outcome were assessed with ANOVA. Prediction models were obtained using multivariate binary logistic regression and their AUCs were compared with the DeLong test.

RESULTS

The final cohort included 1669 patients (age 67.5 [58.5-77.4] yo) mainly men 1105/1669, 66.2%) and with reduced oxygen saturation (92% [88-95%]). Pneumonia severity, high Agatston score, myosteatosis, liver steatosis, and osteoporosis derived from CT were more prevalent in patients with more aggressive treatment, access to ICU, and in-hospital death (always p < 0.05). A multivariable model including clinical and CT variables improved the capability to predict non-critical pneumonia compared to a model including only clinical variables (AUC 0.801 vs 0.789; p = 0.0198) to predict patient death (AUC 0.815 vs 0.800; p = 0.001).

CONCLUSION

Opportunistic biomarkers derived from chest CT can improve the characterization of COVID-19 high-risk patients.

CLINICAL RELEVANCE STATEMENT

In COVID-19 patients, opportunistic biomarkers of cardiometabolic risk extracted from chest CT improve patient risk stratification.

KEY POINTS

• In COVID-19 patients, several information about patient comorbidities can be quantitatively extracted from chest CT, resulting associated with the severity of oxygen treatment, access to ICU, and death. • A prediction model based on multiparametric opportunistic biomarkers derived from chest CT resulted superior to a model including only clinical variables in a large cohort of 1669 patients suffering from SARS- CoV2 infection. • Opportunistic biomarkers of cardiometabolic comorbidities derived from chest CT may improve COVID-19 patients' risk stratification also in absence of detailed clinical data and laboratory tests identifying subclinical and previously unknown conditions.

Clinical profiling and outcomes of viral myocarditis manifesting with ventricular arrhythmias

Aims

Clinical features and risk stratification of patients with viral myocarditis (VM) complicated by ventricular arrhythmias (VA) are incompletely understood. We aim to describe arrhythmia patterns and outcomes in patients with VM and early-onset VA.

Methods and results

We present a single-centre study, enrolling patients with VM proven by endomyocardial biopsy, and evidence of VA within 24 h of hospitalization. The incidence of major adverse events (MAE), including all-cause death, severe heart failure, advanced atrioventricular blocks, or major VA, was evaluated during a 24-month follow-up (FU) and compared with a matched group of virus-negative myocarditis. Of patients with VM (n = 74, mean age 47 ± 16 years, 66% males, and left ventricular ejection fraction 51 ± 13%), 20 (27%) presented with major VA [ventricular tachycardia/ventricular fibrillation (VT/VF)], and 32 (44%) had polymorphic VA. Patients with polymorphic VA more commonly had evidence of ongoing systemic infection (24/32 vs. 10/42, P = 0.004) and experienced greater occurrence of MAE at discharge (15/32 vs. 2/42, P < 0.001). However, the incidence of MAE during FU was higher in patients with monomorphic VA compared to those with polymorphic VA (17/42 vs. 2/28, P = 0.002). Patients with monomorphic VA displayed frequently signs of chronic cardiomyopathy and had outcomes comparable with virus-negative myocarditis (log rank P = 0.929). Presentation with VT/VF was independently associated with MAE [at discharge: hazard ratio (HR) 4.7, 95% confidence interval (CI) 1.6-14.0, P = 0.005; during FU: HR 6.3, 95% CI 2.3-17.6, P < 0.001].

Conclusion

In patients with VM, polymorphic VA point to ongoing systemic infection and early adverse outcomes, whereas monomorphic VA suggest chronic cardiomyopathy and greater incidence of MAE during FU. Presentation with VT/VF is independently associated with MAE.

Myocarditis in anti-synthetase syndrome: clinical features and diagnostic modalities

OBJECTIVES

Myocarditis is an overlooked manifestation of anti-synthetase syndrome (ASS). Our study describes the clinical and instrumental features of ASS-myocarditis and evaluates the diagnostic performance of cardiac magnetic resonance (CMR) with mapping techniques.

METHODS

Data from ASS-patients were retrospectively analyzed. CMR data of patients diagnosed with myocarditis, including late gadolinium enhancement (LGE), T2-ratio, T1-mapping, extra-cellular volume (ECV) and T2-mapping, were reviewed. Myocarditis was defined by the presence of symptoms of heart involvement with increased high-sensitive troponin T (hs-TnT) and/or NT-proBNP and at least an instrumental abnormality. Clinical features of ASS patients with and without myocarditis were compared. A p value<0.05 was considered.

RESULTS

Among a cohort of 43 ASS-patients (median age 58[48.0-66.0] years; females 74.4%; anti-Jo1 53.5%), 13(30%) were diagnosed with myocarditis. In 54% of patients, myocarditis was diagnosed at clinical onset. All ASS-myocarditis patients had at least one CMR abnormality: increased ECV in all cases, presence of LGE, increased T1 and T2-mapping in 91%. The 2009-Lake Louis criteria (LLC) were satisfied by 6 patients, the 2018-LLC by 10. With the updated LLC, the sensitivity for myocarditis improved from 54.6% to 91.0%. ASS-patients with myocarditis were more frequently males(53% vs 13%;p=0.009) with fever(69% vs 17%;p=0.001), and had higher hs-TnT (88.0[23.55-311.5] vs 9.80[5.0-23.0]ng/L; p < 0.001), NT-proBNP(525.5[243.5-1575.25] vs 59.0[32.0-165.5;p=0.013]pg/ml;p=0.013) and C-reactive protein(CRP)(7.0[1.7-15.75] vs 1.85[0.5-2.86]mg/L;p=0.011) compared to those without myocarditis.

CONCLUSION

In ASS, myocarditis is frequent, even at clinical onset. ASS-patients with myocarditis frequently presented with fever and increased CRP, suggesting the existence of an inflammatory phenotype. The use of novel CMR mapping techniques may increase the diagnostic sensitivity for myocarditis in ASS.

Accuracy and Reliability of Left Atrial Appendage Morphology Assessment by Three-Dimensional Transesophageal Echocardiographic Glass Rendering Modality: A Comparative Study With Computed Tomography

BACKGROUND

Contrast-enhanced computed tomography is the reference-standard imaging technique to assess left atrial appendage (LAA) morphology. The aim of this study was to evaluate the accuracy and reliability of two-dimensional and new three-dimensional (3D) transesophageal echocardiographic rendering modalities in assessing LAA morphology.

METHODS

Seventy consecutive patients who underwent both computed tomography and transesophageal echocardiography (TEE) were retrospectively enrolled. The traditional LAA morphology classification system (LAAcs; chicken wing, cauliflower, cactus, and windsock) and a new simplified LAAcs based on the LAA bend angle were used for the analysis. LAA morphology was independently assessed by two trained readers using three different modalities: two-dimensional TEE, 3D TEE with multiplanar reconstruction, and a new 3D transesophageal echocardiographic rendering modality with improved transparency (Glass). The new LAAcs and traditional LAAcs were compared in terms of intra- and interrater reliability.

RESULTS

With the new LAAcs, two-dimensional TEE was fairly accurate in identifying LAA morphology (κ = 0.43, P < .05), with moderate interrater (κ = 0.50, P < .05) and substantial intrarater (κ = 0.65, P < .005) agreement. Three-dimensional TEE showed higher accuracy and reliability: 3D TEE with multiplanar reconstruction had almost perfect accuracy (κ = 0.85, P < .001) and substantial (κ = 0.79, P < .001) interrater reliability, while 3D TEE with Glass had substantial accuracy (κ = 0.70, P < .001) and almost perfect (κ = 0.84, P < .001) interrater reliability. Intrarater agreement was almost perfect for both 3D transesophageal echocardiographic modalities (κ = 0.85, P < .001). Accuracy was considerably lower when the traditional LAAcs was used, with 3D TEE with Glass being the most reliable technique (κ = 0.75, P < .05). The new LAAcs showed higher inter- and intrarater reliability compared with the traditional LAAcs (interrater, κ = 0.85 vs κ = 0.49; intrarater, κ = 0.94 vs κ = 0.68; P < .05).

CONCLUSIONS

Three-dimensional TEE is an accurate, reliable, and feasible alternative to computed tomography in assessing LAA morphology with the new LAAcs. The new LAAcs shows higher reliability rates than the traditional one.

Sex-based differences in late gadolinium enhancement among patients with acute myocarditis

OBJECTIVE

The aims of our study were to investigate the sex differences in late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) in a single-centre cohort of consecutive patients with acute myocarditis (AM).

METHOD

This retrospective study performed CMR scans in 135 consecutive patients with AM that met the Lake Louise criteria. On CMR, LV ventricular strain functions were performed on conventional cine SSFP sequences. Besides myocardial strain measurements, myocardial scar location, extension, and size were assigned and quantified by LGE imaging.

RESULTS

There was no difference in age (age 42.51 ± 19.64 years vs 40.92 ± 19.94 years; p = 0.74) and cardiovascular risk profile between women and men. Despite similar comorbidities, women were more like to present with dyspnea (p = 0.001). Women demonstrated higher prevalence of septal LGE (p = 0.004) and increased global circumferential strain parameters (p = 0.008) in comparison with men. In multivariate analysis, female sex remained an independent determinant of septal LGE (β coefficient = -0.520, p = 0.001).

CONCLUSION

This is the first study reporting sex differences in LGE localization in AM. Women have more septal LGE involvement independent of age, cardiovascular risk factors, and CMR parameters. These findings further emphasize the sex-based differences in cardiovascular diseases.

A Single-Channel and Non-Invasive Wearable Brain-Computer Interface for Industry and Healthcare

The present work focuses on how to build a wearable brain-computer interface (BCI). BCIs are a novel means of human-computer interaction that relies on direct measurements of brain signals to assist both people with disabilities and those who are able-bodied. Application examples include robotic control, industrial inspection, and neurorehabilitation. Notably, recent studies have shown that steady-state visually evoked potentials (SSVEPs) are particularly suited for communication and control applications, and efforts are currently being made to bring BCI technology into daily life. To achieve this aim, the final system must rely on wearable, portable, and low-cost instrumentation. In exploiting SSVEPs, a flickering visual stimulus with fixed frequencies is required. Thus, in considering daily-life constraints, the possibility to provide visual stimuli by means of smart glasses was explored in this study. Moreover, to detect the elicited potentials, a commercial device for electroencephalography (EEG) was considered. This consists of a single differential channel with dry electrodes (no conductive gel), thus achieving the utmost wearability and portability. In such a BCI, the user can interact with the smart glasses by merely staring at icons appearing on the display. Upon this simple principle, a user-friendly, low-cost BCI was built by integrating extended reality (XR) glasses with a commercially available EEG device. The functionality of this wearable XR-BCI was examined with an experimental campaign involving 20 subjects. The classification accuracy was between 80%-95% on average depending on the stimulation time. Given these results, the system can be used as a human-machine interface for industrial inspection but also for rehabilitation in ADHD and autism.

Multimodal Detection and Targeting of Biopsy-Proven Myocardial Inflammation in Genetic Cardiomyopathies: A Pilot Report

The authors present a clinical report focused on the overlap between myocarditis and genetic cardiomyopathies of the dilated and arrhythmogenic spectrum. Our cohort was composed of 25 patients undergoing extensive baseline characterization and prospective reassessment by a dedicated multidisciplinary disease unit during a median follow-up of 69 months. We showed that the use of multimodal imaging allowed both discrimination of specific genotypes and identification of myocardial inflammation proven using endomyocardial biopsy. In addition, we showed that the use of immunomodulatory therapy was beneficial for most patients.

Paving the Way for Motor Imagery-Based Tele-Rehabilitation through a Fully Wearable BCI System

The present study introduces a brain-computer interface designed and prototyped to be wearable and usable in daily life. Eight dry electroencephalographic sensors were adopted to acquire the brain activity associated with motor imagery. Multimodal feedback in extended reality was exploited to improve the online detection of neurological phenomena. Twenty-seven healthy subjects used the proposed system in five sessions to investigate the effects of feedback on motor imagery. The sample was divided into two equal-sized groups: a "neurofeedback" group, which performed motor imagery while receiving feedback, and a "control" group, which performed motor imagery with no feedback. Questionnaires were administered to participants aiming to investigate the usability of the proposed system and an individual's ability to imagine movements. The highest mean classification accuracy across the subjects of the control group was about 62% with 3% associated type A uncertainty, and it was 69% with 3% uncertainty for the neurofeedback group. Moreover, the results in some cases were significantly higher for the neurofeedback group. The perceived usability by all participants was high. Overall, the study aimed at highlighting the advantages and the pitfalls of using a wearable brain-computer interface with dry sensors. Notably, this technology can be adopted for safe and economically viable tele-rehabilitation.

Practical Guide to Interpreting Cardiac Magnetic Resonance in Patients with Cardiac Masses

It is common for a cardiac mass to be discovered accidentally during an echocardiographic examination. Following the relief of a cardiac mass, being able to evaluate and characterize it using non-invasive imaging methods is critical. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) are the main imaging modalities used to evaluate cardiac masses. Although multimodal imaging often allows for a better assessment, CMR is the best technique for the non-invasive characterization of tissues, as the different MR sequences help in the diagnosis of cardiac masses. This article provides detailed descriptions of each CMR sequence employed in the evaluation of cardiac masses, underlining the potential information it can provide. The description in the individual sequences provides useful guidance to the radiologist in performing the examination.

The impact of mitral valve surgery on ventricular arrhythmias in patients with Barlow's disease: preliminary results of a prospective study

OBJECTIVES

Aim of this study was to evaluate arrhythmic burden of patients with Barlow's disease and significant mitral regurgitation (MR) and assess the impact of mitral repair on ventricular arrhythmias (VA) in this group of subjects.

METHODS

We prospectively included 88 consecutive patients with Barlow's disease referred to our Institution from February 2021 to May 2022. All enrolled patients underwent 24-hour Holter monitoring before surgery. Sixty-three of them completed 3 months echocardiographic and Holter follow-up. Significant arrhythmic burden was defined as ≥ 1% premature ventricular beats/24 hours or at least one episode of non-sustained ventricular tachycardia (VT), VT or ventricular fibrillation.

RESULTS

At baseline, 29 patients (33%) were arrhythmogenic (AR) while 59 (67%) were not (NAR). AR subjects tended to be more often females with history of palpitations. Sixty-three patients completed 3-months follow-up. Twenty of them (31.7%) were AR at baseline and 43 (68.3%) were not. Among AR patients, 9 (45%) remained AR after mitral surgery, while 11 (55%) became NAR. Considering NAR subjects at baseline, after mitral valve repair 8 (18.6%) evolved into AR, while 35 (81.4%) remained NAR. A higher prevalence of pre-operative MAD was found among patients experiencing VA reduction if compared with patients who remained arrhythmogenic (63.6% vs 11.1%, p = 0.028).

CONCLUSIONS

In our experience, 1/3 of Barlow's patients referred for mitral surgery showed a significant arrhythmic burden. Almost half of the subjects arrhythmogenic at baseline were free from significant VA after mitral repair. However, a minority (18.6%) of subjects without arrhythmic burden at baseline experienced significant VA at follow-up.

Cardiac magnetic resonance findings in acute and post-acute COVID-19 patients with suspected myocarditis

INTRODUCTION

Cardiac injury is commonly reported in COVID-19 patients, resulting associated to pre-existing cardiovascular disease, disease severity, and unfavorable outcome. Aim is to report cardiac magnetic resonance (CMR) findings in patients with myocarditis-like syndrome during the acute phase of SARS-CoV-2 infection (AMCovS) and post-acute phase (cPACS).

METHODS

Between September 2020 and January 2022, 39 consecutive patients (24 males, 58%) were referred to our department to perform a CMR for the suspicion of myocarditis related to AMCovS (n = 17) and cPACS (n = 22) at multimodality evaluation (clinical, laboratory, ECG, and echocardiography). CMR was performed for the assessment of volume, function, edema and fibrosis with standard sequences and mapping techniques. CMR diagnosis and the extension and amount of CMR alterations were recorded.

RESULTS

Patients with suspected myocarditis in acute and post-COVID settings were mainly men (10 (59%) and 12 (54.5%), respectively) with older age in AMCovS (58 [48-64]) compared to cPACS (38 [26-53]). Myocarditis was confirmed by CMR in most of cases: 53% of AMCovS and 50% of cPACS with negligible LGE burden (3 [IQR, 1-5] % and 2 [IQR, 1-4] %, respectively). Myocardial infarction was identified in 4/17 (24%) patients with AMCovS. Cardiomyopathies were identified in 12% (3/17) and 27% (6/22) of patients with AMCovS and cPACS, including DCM, HCM and mitral valve prolapse.

CONCLUSIONS

In patients with acute and post-acute COVID-19 related suspected myocarditis, CMR improves diagnostic accuracy characterizing ischemic and non-ischemic injury and unraveling subclinical cardiomyopathies.

Impact of prostate imaging quality (PI-QUAL) score on the detection of clinically significant prostate cancer at biopsy

PURPOSE

To investigate the impact of Prostate Imaging Quality (PI-QUAL) scores on the diagnostic performance of multiparametric MRI (mpMRI) in a targeted biopsy cohort.

PATIENTS AND METHODS

300 patients who underwent both mpMRI and biopsy were included. PI-QUAL scores were retrospectively assigned by two radiologists in consensus and were correlated to pre-biopsy PI-RADS scores and biopsy outcomes. Clinically significant prostate cancer (csPCa) was defined as ISUP grade ≥ 2.

RESULTS

Image quality was optimal (PI-QUAL ≥ 4) in 249/300 (83%) and suboptimal (PI-QUAL < 4) in 51/300 (17%). The proportion of PI-RADS 3 scores referred for biopsy was higher in scans of suboptimal vs optimal quality (51% vs 33%). For PI-QUAL < 4 scans, the positive predictive value (PPV) was lower compared to PI-QUAL ≥ 4 (35% [95%CI: 22, 48] vs 48% [95%CI: 41, 55]; difference -13% [95%CI: -27, 2]; p 0.090), as was the detection rate of csPCa in both PI-RADS 3 and PI-RADS 4-5 (15% vs 23% and 56 vs 63%, respectively). The overall MRI quality increased over time.

CONCLUSIONS

Scan quality may affect the diagnostic performance of prostate mpMRI in patients undergoing MRI-guided biopsy. Scans of suboptimal quality (PI-QUAL < 4) were associated with lower PPV for csPCa.

Exploring the EVolution in PrognOstic CapabiLity of MUltisequence Cardiac MagneTIc ResOnance in PatieNts Affected by Takotsubo Cardiomyopathy Based on Machine Learning Analysis: Design and Rationale of the EVOLUTION Study

PURPOSE

Takotsubo cardiomyopathy (TTC) is a transient but severe acute myocardial dysfunction with a wide range of outcomes from favorable to life-threatening. The current risk stratification scores of TTC patients do not include cardiac magnetic resonance (CMR) parameters. To date, it is still unknown whether and how clinical, trans-thoracic echocardiography (TTE), and CMR data can be integrated to improve risk stratification.

METHODS

EVOLUTION (Exploring the eVolution in prognOstic capabiLity of mUlti-sequence cardiac magneTIc resOnance in patieNts affected by Takotsubo cardiomyopathy) is a multicenter, international registry of TTC patients who will undergo a clinical, TTE, and CMR evaluation. Clinical data including demographics, risk factors, comorbidities, laboratory values, ECG, and results from TTE and CMR analysis will be collected, and each patient will be followed-up for in-hospital and long-term outcomes. Clinical outcome measures during hospitalization will include cardiovascular death, pulmonary edema, arrhythmias, stroke, or transient ischemic attack.Clinical long-term outcome measures will include cardiovascular death, pulmonary edema, heart failure, arrhythmias, sudden cardiac death, and major adverse cardiac and cerebrovascular events defined as a composite endpoint of death from any cause, myocardial infarction, recurrence of TTC, transient ischemic attack, and stroke. We will develop a comprehensive clinical and imaging score that predicts TTC outcomes and test the value of machine learning models, incorporating clinical and imaging parameters to predict prognosis.

CONCLUSIONS

The main goal of the study is to develop a comprehensive clinical and imaging score, that includes TTE and CMR data, in a large cohort of TTC patients for risk stratification and outcome prediction as a basis for possible changes in patient management.

Cardiovascular involvement in Erdheim-Chester diseases is associated with myocardial fibrosis and atrial dysfunction

PURPOSE

Erdheim-Chester disease (ECD) is a rare multisystem histiocytosis, whose cardiovascular involvement has not been systematically characterized so far. We aimed to systematically (qualitatively and quantitatively) describe the features of cardiovascular involvement in a large cohort of ECD patients and to evaluate its impact on myocardial fibrosis extension and cardiac function.

MATERIAL AND METHODS

Among 54 patients with biopsy-proven ECD, 29 patients (59 ± 12 years, 79% males) underwent 1.5-T CMR using a standardized protocol for qualitative and quantitative assessment of disease localization, evaluation of atrial and ventricular function, and assessment of non-dense and dense myocardial fibrosis.

RESULTS

The right atrioventricular (AV) groove was the most commonly affected cardiac site (76%) followed by the right atrial walls (63%), thoracic aorta (59%), and superior vena cava (38%). Right AV groove involvement, encasing the right ventricular artery, was associated with non-dense myocardial fibrosis in the infero-septal (20/26 patients) and the inferior (14/26 patients) mid-basal left ventricular (LV) wall. In two patients with right AV groove localization, LGE revealed myocardial infarction in the same myocardial segments. Three out of five patients with left AV groove involvement had non-dense LGE on the lateral LV mid-basal wall. Bulky right atrial pseudomass was associated with atrial dysfunction and superior and inferior vena cava stenosis.

CONCLUSIONS

In ECD patients, AV groove localization is associated with LV wall fibrosis in the downstream coronary territories, suggesting hemodynamic alterations due to coronary encasement. Conversely, atrial pseudomass ECD localizations impact on atrial contractility causing atrial dysfunction and are associated with atrio-caval junction stenosis.

Extracellular volume fraction (ECV) derived from pre-operative computed tomography predicts prognosis in patients undergoing transcatheter aortic valve implantation (TAVI)

AIMS

Transcatheter aortic valve implantation (TAVI) is the treatment of choice for high-risk patients with severe aortic stenosis (AS). A portion of TAVI recipients has no long-term clinical benefit, and myocardial fibrosis may contribute to unfavourable outcomes. We aimed to assess the prognostic value of an interstitial fibrosis marker, extracellular volume fraction (ECV), measured at planning computed tomography (CT) before TAVI.

METHODS AND RESULTS

From October 2020 to July 2021, 159 consecutive patients undergoing TAVI planning CT were prospectively enroled. ECV was calculated as the ratio of myocardium and blood pool differential attenuations before and 5 min after contrast administration, pondered for haematocrit. A composite endpoint including heart failure hospitalization (HFH) and death was collected by telehealth or in-person follow-up visits in the 113 patients constituting the final study population. Cox proportional hazards model was used to assess association between ECV and the composite endpoint.Median follow-up was 13 (11-15) months. The composite endpoint occurred in 23/113 (20%) patients. These patients had lower aortic valve mean pressure gradient [39 (29-48) vs. 46 (40-54) mmHg, P = 0.002] and left ventricular and right ventricular ejection fraction [51 (37-69) vs. 66 (54-74)%, P = 0.014; 45 (31-53) vs. 49 (44-55)%, P = 0.010] and higher ECV [31.5 (26.9-34.3) vs. 27.8 (25.3-30.2)%, P = 0.006]. At multivariable Cox analysis, ECV higher than 31.3% was associated to increased risk of death or HFH at follow-up (hazard ratio = 5.92, 95% confidence interval 2.37-14.75, P < 0.001).

CONCLUSION

In this prospective observational cohort study, ECV measured at TAVI planning CT predicts the composite endpoint (HFH or death) in high-risk severe AS patients.

Cardiac magnetic resonance abnormalities in patients with acute myocarditis proven by septal endomyocardial biopsy

BACKGROUND

Previous studies suggest low diagnostic sensitivity of cardiac magnetic resonance (CMR) imaging based on Lake Louise criteria (LLC) to identify patients with complicated presentations of acute myocarditis (AM). We evaluated classic and updated LLC in patients with AM proven by right ventricular septal endomyocardial biopsy (RVS-EMB).

METHODS

From an initial population of 499 patients with clinically suspected AM from a multicenter retrospective cohort, we included 74 patients with histologically proven myocarditis on RVS-EMB and available CMR within 30 days since admission. The prevalence of total and septal CMR abnormalities [namely, T2-weighted images (T2W), late gadolinium enhancement (LGE), T2 and T1 mapping, and extracellular volume (ECV)] were assessed in patients with complicated vs. uncomplicated AM.

RESULTS

Among 74 patients [mean age 38 ± 15 years, 65% males, left ventricular ejection fraction (LVEF) 40 ± 18%] with RVS-EMB-proven AM, 53 (72%) had a complicated presentation. The classic LLC were positive in 56/74 patients (76%), whereas the updated ones were positive in 41/41 of cases (100%). Septal involvement, documented in 48/74 patients (65%) by conventional T2W/LGE and in 39/41 cases (95%) by mapping techniques (p < 0.001), was more common in patients with complicated AM. In the 41 patients undergoing both evaluations, CMR sensitivity for myocarditis was 85% for the classic LLC vs. 100% for the updated LLC (p = 0.006).

CONCLUSION

In patients with myocarditis on RVS-EMB, CMR using updated LLC has high sensitivity in the detection of AM when performed within 30 days. Septal abnormalities are more common in patients with complicated AM.

Feasibility and reliability of comprehensive three-dimensional transoesophageal echocardiography screening process for transcatheter mitral valve replacement

AIMS

The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transoesophageal echocardiography (TOE) are lacking. We evaluated the feasibility and reliability of a comprehensive 3D-TOE screening in TMVR candidates.

METHODS AND RESULTS

We performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TOE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT), and predicted neo-LVOT acquired with CT and 3D-TOE were compared using a novel semi-automated software for post processing analysis (3 mensio Structural Heart 10.1-3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions. Among 72 patients screened, all patients had adequate image quality for 3D-TOE analysis. 3D-TOE and CT measurements for AML length (r = 0.97), MA area (r = 0.90), perimeter (r = 0.68), anteroposterior (r = 0.88), and posteromedial-anterolateral (r = 0.74) diameters were found highly correlated, as well as for native LVOT (r = 0.86) and predicted neo-LVOT areas (r = 0.96) (all P-values <0.0001). An almost perfect agreement between CT and 3DTOE was found in assessing the eligibility for TMVR implantation (Cohen kappa 0.83, P < 0.001).

CONCLUSION

3D-TOE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success.

Expanded Polytetrafluoroethylene Membranes for Vascular Stent Coating: Manufacturing, Biomedical and Surgical Applications, Innovations and Case Reports

Coated stents are defined as innovative stents surrounded by a thin polymer membrane based on polytetrafluoroethylene (PTFE)useful in the treatment of numerous vascular pathologies. Endovascular methodology involves the use of such devices to restore blood flow in small-, medium- and large-calibre arteries, both centrally and peripherally. These membranes cross the stent struts and act as a physical barrier to block the growth of intimal tissue in the lumen, preventing so-called intimal hyperplasia and late stent thrombosis. PTFE for vascular applications is known as expanded polytetrafluoroethylene (e-PTFE) and it can be rolled up to form a thin multilayer membrane expandable by 4 to 5 times its original diameter. This membrane plays an important role in initiating the restenotic process because wrapped graft stent could be used as the treatment option for trauma devices during emergency situations and to treat a number of pathological vascular disease. In this review, we will investigate the multidisciplinary techniques used for the production of e-PTFE membranes, the advantages and disadvantages of their use, the innovations and the results in biomedical and surgery field when used to cover graft stents.

Machine learning approach in diagnosing Takotsubo cardiomyopathy: The role of the combined evaluation of atrial and ventricular strain, and parametric mapping

BACKGROUND

Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) is a key diagnostic tool in the differential diagnosis between non-ischemic cause of cardiac chest pain. Some patients are not eligible for a gadolinium contrast-enhanced CMR; in this scenario, the diagnosis remains challenging without invasive examination. Our purpose was to derive a machine learning model integrating some non-contrast CMR parameters and demographic factors to identify Takotsubo cardiomyopathy (TTC) in subjects with cardiac chest pain.

MATERIAL AND METHODS

Three groups of patients were retrospectively studied: TTC, acute myocarditis, and healthy controls. Global and regional left ventricular longitudinal, circumferential, and radial strain (RS) analysis included were assessed. Reservoir, conduit, and booster bi-atrial functions were evaluated by tissue-tracking. Parametric mapping values were also assessed in all the patients. Five different tree-based ensemble learning algorithms were tested concerning their ability in recognizing TTC in a fully cross-validated framework.

RESULTS

The CMR-based machine learning (ML) ensemble model, by using the Extremely Randomized Trees algorithm with Elastic Net feature selection, showed a sensitivity of 92% (95% CI 78-100), specificity of 86% (95% CI 80-92) and area under the ROC of 0.94 (95% CI 0.90-0.99) in diagnosing TTC. Among non-contrast CMR parameters, the Shapley additive explanations analysis revealed that left atrial (LA) strain and strain rate were the top imaging markers in identifying TTC patients.

CONCLUSIONS

Our study demonstrated that using a tree-based ensemble learning algorithm on non-contrast CMR parameters and demographic factors enables the identification of subjects with TTC with good diagnostic accuracy.

TRANSLATIONAL OUTLOOK

Our results suggest that non-contrast CMR features can be implemented in a ML model to accurately identify TTC subjects. This model could be a valuable tool for aiding in the diagnosis of subjects with a contraindication to the contrast media. Furthermore, the left atrial conduit strain and strain rate were imaging markers that had a strong impact on TTC identification. Further prospective and longitudinal studies are needed to validate these findings and assess predictive performance in different cohorts, such as those with different ethnicities, and social backgrounds and undergoing different treatments.

Cardiac magnetic resonance predictors of left ventricular remodelling following acute ST elevation myocardial infarction: The VavirimS study

BACKGROUND

Left ventricular (LV) remodelling (REM) ensuing after ST-elevation myocardial infarction (STEMI), has typically been studied by echocardiography, which has limitations, or cardiac magnetic resonance (CMR) in early phase that may overestimate infarct size (IS) due to tissue edema and stunning. This prospective, multicenter study investigated LV-REM performing CMR in the subacute phase, and 6 months after STEMI.

METHODS AND RESULTS

patients with first STEMI undergoing successful primary angioplasty were consecutively enrolled. CMR was done at 30-days and 6-months. Primary endpoint was prevalence at 6 months of LV-REM [≥12% increase in LV end-diastolic volume index (LV-REMEDV)]; LV-REM by end-systolic volume index increase ≥12% (LV-REMESV) was also calculated. Of 325 patients enrolled, 193 with a full set of research-quality CMR images were analyzed. LV-REMEDV and LV-REMESV were present in 36/193 (19%) and 34/193 (18%) patients, respectively. At follow up, LV ejection fraction (EF) improved in patients with or without LV-REMEDV, whilst it decreased in those with LV-REMESV (p < 0.001 for interaction). Considering predictors of LV-REM, IS in the highest tertile was clearly separated from the two lower tertiles. In LV-REMEDV, the highest tertile was associated with significantly higher LV-EDV, LV-ESV, and lower EF.

CONCLUSIONS

In a contemporary cohort of STEMI patients studied by CMR, prevalence of LV-REMEDV was lower than previously reported. Importantly, our data indicate that LV-REMEDV might not be "adverse" per se, but rather "compensatory", being associated with LV-EF improvement at follow-up. Conversely, LV-REMESV might be an "adverse" phenomenon associated with decreased LV-EF, driven by IS.

80 GENETIC MYOCARDITIS: ADVANCED WORKUP AND TREATMENT

Background

Preclinical data support the rationale for targeting myocardial inflammation in genetic nonischemic cardiomyopathies. However, no consistent clinical reports have been provided so far.

Methods

We describe a series of patients (n=25) with genetic cardiomyopathy and active myocardial inflammation (AMI) proven by multimodal diagnostic workup. Patient-tailored immunosuppressive therapy was empirically started to target myocardial inflammation whenever feasible. Multiple outcomes were retrospectively assessed by a dedicated multidisciplinary disease unit.

Results

Patients carrying desmosomal (DGV), cytoskeletal (CGV) and membrane gene variants (MGV), were 12 (48%), 10 (40%), and 3 (12%), respectively. DGV carriers uniformly presented with myocarditis-like chest pain and ventricular arrhythmias, whereas heart failure symptoms were found only in CGV carriers. Dilated cardiomyopathy phenotype and ring-like pattern on cardiac magnetic resonance allowed the best discrimination among genotypes. AMI was proven by endomyocardial biopsy in all cases, and by noninvasive imaging in 21 (83%). IST was started in 17 patients (71%) with no safety issues. By the end of follow-up (median 69 months, range 21-182), signs of AMI were documented in 6/18 IST receivers (33%) and 4/7 untreated cases (57%). For most genotypes, paucity of adverse events was noted while on immunosuppression as compared to the off-treatment period.

Conclusion

Our preliminary data provide the clinical rationale for the research and targeting of AMI in a spectrum of genetic nonischemic cardiomyopathies.

1032 FEASIBILITY AND RELIABILITY OF COMPREHENSIVE THREE DIMENSIONAL TRANSESOPHAGEAL ECHOCARDIOGRAPHY SCREENING PROCESS FOR TRANSCATHETER MITRAL VALVE REPLACEMENT

The procedural planning of transcatheter mitral valve replacement (TMVR) requires a specific imaging assessment to establish patient eligibility. Computed tomography (CT) is considered the reference method. In this setting, data regarding the role of transesophageal echocardiography (TEE) are lacking.

Aims

To evaluate the feasibility and reliability of a comprehensive 3D-TEE screening in TMVR candidates.

Methods

we performed a retrospective observational study including 72 consecutive patients who underwent a pre-procedural CT and 3D-TEE for TMVR evaluation. The measurements of mitral annulus (MA), length of anterior mitral leaflet (AML), native left ventricular outflow tract (LVOT) and predicted neo-LVOT acquired with CT and 3DTEE were compared using a novel semi-automated software for post processing analysis (3mensio Structural Heart 10.1 - 3mSH, Pie Medical Imaging, Bilthoven, Netherlands). The final suitability decision was given by the valve manufacturer based on CT measurements and clinical conditions.

Results

Among 72 patients screened, all patients had adequate image quality for 3D-TEE analysis. 3D-TEE and CT measurements for AML length (r=0.97), MA area (r=0.90), perimeter (r=0.68), anteroposterior (r=0.88) and posteromedial-anterolateral (r=0.74) diameters were found highly correlated, as well as for native LVOT (r=0.86) and predicted neo-LVOT areas (r=0.96) (all P -values &lt;0.0001). An almost perfect agreement among CT and 3d TEE was found in assessing the eligibility for TMVR implantation (Cohen Kappa 0.83, p&lt;0.001).

Conclusions

3D-TEE appraisements showed good correlations with CT measurements and high accuracy to predict TMVR screening success.

Central Illustration. Mitral annulus segmentation and neo-LVOT area measurement performed by means of the 3mensio software (Pie Medical Imaging, Bilthoven, Netherlands) in a step-by-step fashion by TEE and CT imaging. After the virtual simulation of a valve implantation, the minimal systolic neo-LVOT area is manually measured by planimetry on a plane orthogonal to the centerline.

Multimodality imaging in acute myocarditis

The diagnosis of acute myocarditis often involves several noninvasive techniques that can provide information regarding volumes, ejection fraction, and tissue characterization. In particular, echocardiography is extremely helpful for the evaluation of biventricular volumes, strain and ejection fraction. Cardiac magnetic resonance, beyond biventricular volumes, strain, and ejection fraction allows to characterize myocardial tissue providing information regarding edema, hyperemia, and fibrosis. Contemporary cardiac computed tomography angiography (CCTA) can not only be extremely important for the assessment of coronary arteries, pulmonary arteries and aorta but also tissue characterization using CCTA can be an additional tool that can explain chest pain with a diagnosis of myocarditis.

Quantitative and qualitative features of carotid and coronary atherosclerotic plaque among men and women

Cardiovascular diseases (CVDs), particularly ischemic heart disease (IHD) and stroke, present epidemiologically in a different way among sexes. The reasons of these sex-based differences should be delved into sex-specific cardiovascular (CV) risk factors and different mechanisms of atherosclerotic progression. Imaging techniques of both carotid and coronary atherosclerotic plaques represent a tool to demonstrate sex-related features which might be used to further and better assess CV risk of male and female population. The aim of this review is to evaluate current knowledge on sex-specific qualitative and quantitative plaque features of coronary and carotid atherosclerosis. We also discuss the clinical implication of a sex-based plaque phenotype, evaluated with non-invasive imaging techniques, such as CT-angiography and MRI-angiography, to stratify CV risk.

AI-SCoRE (artificial intelligence-SARS CoV2 risk evaluation): a fast, objective and fully automated platform to predict the outcome in COVID-19 patients

Purpose

To develop and validate an effective and user-friendly AI platform based on a few unbiased clinical variables integrated with advanced CT automatic analysis for COVID-19 patients’ risk stratification.

Material and Methods

In total, 1575 consecutive COVID-19 adults admitted to 16 hospitals during wave 1 (February 16-April 29, 2020), submitted to chest CT within 72 h from admission, were retrospectively enrolled.

In total, 107 variables were initially collected; 64 extracted from CT. The outcome was survival.

A rigorous AI model selection framework was adopted for models selection and automatic CT data extraction. Model performances were compared in terms of AUC. A web–mobile interface was developed using Microsoft PowerApps environment. The platform was externally validated on 213 COVID-19 adults prospectively enrolled during wave 2 (October 14-December 31, 2020).

Results

The final cohort included 1125 patients (292 non-survivors, 26%) and 24 variables. Logistic showed the best performance on the complete set of variables (AUC = 0.839 ± 0.009) as in models including a limited set of 13 and 5 variables (AUC = 0.840 ± 0.0093 and AUC = 0.834 ± 0.007). For non-inferior performance, the 5 variables model (age, sex, saturation, well-aerated lung parenchyma and cardiothoracic vascular calcium) was selected as the final model and the extraction of CT-derived parameters was fully automatized. The fully automatic model showed AUC = 0.842 (95% CI: 0.816–0.867) on wave 1 and was used to build a 0–100 scale risk score (AI-SCoRE). The predictive performance was confirmed on wave 2 (AUC 0.808; 95% CI: 0.7402–0.8766).

Conclusions

AI-SCoRE is an effective and reliable platform for automatic risk stratification of COVID-19 patients based on a few unbiased clinical data and CT automatic analysis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11547-022-01518-0.

The key role of levator ani thickness for early urinary continence recovery in patients undergoing robot-assisted radical prostatectomy: A multi-institutional study

BACKGROUND

Urinary continence (UC) recovery dramatically affects quality of life after robot-assisted radical prostatectomy (RARP). Membranous urethral length (MUL) has been the most studied anatomical variable associated with UC recovery.

OBJECTIVE

To investigate whether levator ani thickness (LAT), assessed with multi-parametric magnetic resonance imaging (mpMRI), correlates with UC recovery after RARP.

DESIGN, SETTING, AND PARTICIPANTS

The study included 209 patients treated with RARP by expert surgeons with extensive robotic experience from 2017 to 2019. All patients had complete, clinical, mpMRI, pathological, and postoperative data including pelvic floor muscle training (PFMT) protocols.

INTERVENTION

After a radiologist-specific training, two urologists independently examined the files, blinded to clinical and pathological findings as well as to postoperative continence status.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

On mpMRI, LAT, bladder neck (BN) shape, MUL, and apex overlapping (AO) were measured. UC recovery was defined as use of 0 or 1 safety pad at follow-up. Multivariable models were used to assess the association between variables and UC recovery.

RESULTS AND LIMITATIONS

Overall, 173 (82.8%) patients were continent after a median follow-up of 23 months (interquartile range [IQR]: 17-28). Of these, 98 (46.9%) recovered within 3 months after surgery, 42 (20.1%) from 3 to 6 months, and 33 (15.8%) from 6 months onwards. A significant higher rate of patients with LAT > 10 mm (88.1 vs.75.8%; p = 0.03) experienced UC recovery, compared to those with LAT < 10 mm. This difference was observed in the first 3 months after surgery. At multivariable analysis, LAT (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.37; p = 0.02), Preoperative ICIQ score (OR: 0.91, 95% CI: 0.82-0.98, p = 0.03) and PFMT (OR: 1.98, 95% CI: 1.01-3.93; p = 0.04) independently predict higher UC recovery within 3 months, after accounting for age, BMI, preoperative PSA, D'Amico risk group, MUL, BN shape and AO.

CONCLUSIONS

LAT greater than 1 cm was associated with greater UC recovery. Specifically, LAT greater than 1 cm seems to be associated with higher UC rate at 3 months after RARP, compared to those with LAT < 1 cm.

PATIENT SUMMARY

Magnetic resonance features can help in predicting the risk of incontinence after robot-assisted radical prostatectomy and should be taken into account when counseling patients before surgery.

Family Pediatrician and Public Health collaboration, an alliance to increase vaccination coverage: an experience with MenB vaccination in Italy

BACKGROUND

Invasive Meningococcal Disease is a severe disease mainly affecting infants and young children. Most infections are caused by serogroups A, B, C, W, X, and Y. In the last 10 years, serogroup B has been the main cause of Invasive Meningococcal Disease in Europe. Recent data resulting from an observational study conducted in Italy show a significant reduction in the number of Invasive Meningococcal Disease cases due to Neisseria meningitidis B after the introduction of vaccine 4CMenB. Thus, the Naples Team of Federation of Italian Primary Care Pediatricians and the Public Health Department started an active collaboration focused on vaccination process management (named "Progetto Via") with the aim of increasing Meningococcal B vaccination coverage.

STUDY DESIGN

Source of data is the regional platform "GE.VA.". Every Primary care Pediatrician uses daily to record vaccination activity. This platform is integrated with data entered by operators of the District/Vaccination Center.

METHODS

Time: January 2019 - December 2019. The Federation of Italian Primary Care Pediatricians/Naples organized a meeting to identify six coordinators. The pediatricians could choose to counsel in their own offices and send children to the vaccination center or to counsel and vaccinate directly in their own clinics.

RESULTS

A total of 78 pediatricians took part in the project: 46 did only counseling and 32 did both counseling and vaccination in their medical clinic. Data obtained show an overall average vaccination coverage growth of about 13% in the first 4 months of the survey, and a further growth of about 11% in the following seven months, with a total growth in the entire period of 24%. The pediatricians' counseling is essential to recover non-compliant subjects, considering both the relationship of trust with the families and the visits already scheduled as an ideal moment for vaccinations' status check.

CONCLUSIONS

The project highlights how an effective collaboration between family pediatricians and the Local Health Authority becomes valuable in getting closer to reach the Ministerial goal of 95%. Vaccination coverage increased significantly when family pediatricians supported the activity of vaccine centers in distress in many regional situations. The trust relationship, the hourly availability and the capillary network of family pediatricians' clinics were key elements for the success of this project and were also recognized by parents.

O-286 Bisphenol A in blood serum and follicular fluid of women undergoing to cycle of IVF living in areas with different environmental impact. (EcoFoodFertility Project)

Study question

Bisphenol A (BPA) is a constituent of polycarbonate and epoxy resin plastics and is also a by-product of combustion of plastics, resulting harmful for health.

Summary answer

To evaluate the presence of BPA in the blood and Follicular Fluids, in women, subjected to IVF cycles, living in areas with different environmental impact.

What is known already

BPA is used in the production of polycarbonate plastics and epoxy resins. 1,3,5-triphenylbenzene is a tracer for burning plastic and has been related to levels of bisphenol A in the air, so the actual release of bisphenol A to the atmosphere could result from burning the plastic. Bisphenol A belongs to the group of endocrine disruptors.

Little is known about the effects of BPA on human female reproduction. BPA levels appear to be inversely related to the number of oocytes retrieved in IVF cycles, and it also appears to negatively affect the ovulatory peak of estradiol.

Study design, size, duration

In the frame of EcoFoodFertility project a cross sectional study conducted in Campania Region (Southern Italy), between January 2019 and December 2020, 74 women, no smokers, no chronic diseases, not exposed to occupational risk factors. living for at least 5 years in areas with low environmental impact (LEI, 31 women), Alto-Medio Sele in province of Salerno and high environmental impact (HEI, 43 women), so-called “Land of Fires” in province of Naples, were selected.

Participants/materials, setting, methods

Participants have a normal ovarian reserve, average age 32.05 + 3.49, with infertility duration between 26 and 39 months and at the first experience of an IVF cycle. ELISA was used for measuring bisphenol A in blood and Follicular Fluids (FFs), expressed in ng/ mL. 5 mL glass tubes, without additives, not siliconized and kept in a horizontal position were used. FFs were bloodless with a negative albumin test.

Main results and the role of chance

Differents levels of BPA were found in all processed samples.

In the LEI (Low Environmental Impact) group, serum levels vary from a minimum of 3.1 ng/mL to a maximum of 7.7 ng/mL (4.1 ± 1.6) and the Follicular Fluids levels vary from a minimum of 7,1 ng/mL to a maximum of 55.3 ng/mL (13.8 ± 10.9).

In the HEI (High Environmental Impact) group, serum levels vary from a minimum of 69.2 ng/mL to a maximum of 167.8 ng/mL (95.5 ± 24.3) and Follicular Fluids levels vary from a minimum of 4.2 ng/mL to a maximum of 34.3 ng/mL (19.9 ± 9.2).

Statistical processing of the data shows a highly significant variation in serum levels (p &lt; 0.0001) with higher values in the HEI group (95.5 ± 24.3) than in the LEI group (4.1 ± 1.6).

A moderately significant change (p &lt; 0.01) for Follicular Fluids levels, higher in the HEI group (19.9 ± 9.2) than in the LEI group (13.8 ± 10.9).

Furthermore, the data did not show any correspondence between serum and Follicular Fluids for any of the participants tested.

Limitations, reasons for caution

The ELISA method for the determination of BPA seems suitable to us, however, the subject requires further biomonitoring studies, with a larger sample and greater selection of participants, to better understand the effects of BPA and its metabolites in FF and in other districts of the female reproductive system.

Wider implications of the findings

The results indicate that the greater bioaccumulation in women of the HEI group appears consistent with the environmental condition of the area and with the comparative studies already carried out within the EcoFoodFertility project. This is further evidence that pollution in this area can interfere with female fertility and beyond.

Trial registration number

G003