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Russo G, Hahn RT, Alessandrini H, Andreas M, Badano LP, Braun D, Connelly KA, Denti P, Estevez-Loureiro R, Fam N, Gavazzoni M, Hausleiter J, Himbert D, Kalbacher D, Latib A, Lubos E, Ludwig S, Lurz P, Monivas V, Nickenig G, Pedicino D, Pedrazzini G, Pozzoli A, Praz F, Rodes-Cabau J, Rommel KP, Schofer J, Sievert H, Tang G, Thiele H, Unterhuber M, von Bardeleben RS, Webb J, Windecker S, Leon M, Maisano F, Taramasso M. Effects of tricuspid transcatheter edge-to-edge repair on tricuspid annulus diameter - Data from the TriValve registry. Int J Cardiol 2024; 405:131934. [PMID: 38437953 DOI: 10.1016/j.ijcard.2024.131934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/13/2024] [Accepted: 03/01/2024] [Indexed: 03/06/2024]
Abstract
AIMS T-TEER is an effective therapy for the treatment of tricuspid regurgitation (TR). However, the effects of leaflets clipping on tricuspid valve annulus (TA) have not been investigated in detail. The aim of this study is to investigate the effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on TA diameter. METHODS AND RESULTS The TriValve registry (Transcatheter Tricuspid Valve Therapies, NCT03416166) collected 556 patients from 22 European and North American centres undergoing transcatheter tricuspid valve interventions from 2016 to 2022. Patients undergoing T-TEER with available pre- and post-procedural data on TA diameter measured in the apical 4-chamber view on transthoracic echocardiography were selected for this study. Primary end-point was the reduction of TA diameter after T-TEER. A total of 186 patients were included in the study. In 115 patients (62%) TA diameter was reduced by at least 1 mm as compared to baseline. A significant reduction of TA dimension was observed following T-TEER (mean 2.3 mm [from pre-procedural diameter 46.7 mm to post-procedural diameter 44.4 mm], p < 0.001). In particular, the greatest reduction was observed in those with T-TEER in antero-septal commissure (mean 2.7 mm [from 47.1 mm to 44.4 mm], p < 0.001) as compared to those combining both antero-septal and postero-septal commissures (mean 1.4, from 46.0 mm to 44.6 mm, P = 0.06). A significant reduction of TA dimension was recorded in patients with 1 or 2 clips implanted but not in those patients with ≥3 clips implanted. CONCLUSIONS In almost two third of patients T-TEER reduces TA diameter in addition to leaflet approximation. CONDENSED ABSTRACT The effects of tricuspid transcatheter edge-to-edge repair (T-TEER) on tricuspid valve annulus (TA) have not been studied in details. This study investigates TA diameter as measured in apical 4-chamber view on transthoracic echocardiography before and after T-TEER. A total of 186 patients from the TriValve registry were included in the study. The study results show that 62% of patients have a TA reduction after T-TEER, especially in those receiving 1 or 2 clips in the antero-septal commissure. These suggest that T-TEER reduces tricuspid regurgitation not only by approximation of leaflets, but also by TA diameter reduction.
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Affiliation(s)
- Giulio Russo
- Department of Biomedicine and Prevention, Cardiology Unit, Policlinico Tor Vergata, University of Rome, Italy.
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, NY,USA
| | - Hannes Alessandrini
- MVZ Structural Heart Department, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Luigi P Badano
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy; Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Daniel Braun
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | - Kim A Connelly
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paolo Denti
- Division of Cardiology and Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
| | | | - Neil Fam
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Mara Gavazzoni
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy; Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Joerg Hausleiter
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | | | - Daniel Kalbacher
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | - Edith Lubos
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Philipp Lurz
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Vanessa Monivas
- Division of Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Daniela Pedicino
- Fondazione Policlinico Universitario A Gemelli IRCSS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Pedrazzini
- Division of Cardiology, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland + Biomedical Faculty, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Alberto Pozzoli
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Fabien Praz
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Joseph Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Joachim Schofer
- MVZ Structural Heart Department, Asklepios Clinic St. Georg, Hamburg, Germany
| | - Horst Sievert
- CardioVascular Center Frankfurt CVC, Frankfurt, Germany
| | - Gilbert Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA
| | - Holger Thiele
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | | | | | - John Webb
- St. Paul Hospital, Vancouver, British Columbia, Canada
| | - Stephan Windecker
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Martin Leon
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, NY,USA
| | - Francesco Maisano
- Division of Cardiology and Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
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Tomaselli M, Radu DN, Badano LP, Perelli FP, Heilbron F, Cascella A, Gavazzoni M, Hădăreanu DR, Mihaila S, Oliverio G, Penso M, Caravita S, Baratto C, Fisicaro S, Parati G, Muraru D. Right Atrial Remodeling and Outcome in Patients with Secondary Tricuspid Regurgitation. J Am Soc Echocardiogr 2024; 37:495-505. [PMID: 38218553 DOI: 10.1016/j.echo.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/31/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND In patients with secondary tricuspid regurgitation (STR), right atrial remodeling (RAR) is a proven marker of disease progression. However, the prognostic value of RAR, assessed by indexed right atrial volume (RAVi) and reservoir strain (RAS), remains to be clarified. Accordingly, the aim of our study is to investigate the association with outcome of RAR in patients with STR. METHODS We enrolled 397 patients (44% men, 72.7 ± 13 years old) with mild to severe STR. Complete two-dimensional and speckle-tracking echocardiography analysis of right atrial and right ventricular (RV) size and function were obtained in all patients. The primary end point was the composite of death from any cause and heart failure hospitalization. RESULTS After a median follow-up of 15 months (interquartile range, 6-23), the end point was reached by 158 patients (39%). Patients with RAS <13% and RAVi >48 mL/m2 had significantly lower survival rates compared to patients with RAS ≥13% and RAVi ≤48 mL/m2 (log-rank P < .001). On multivariable analysis, RAS <13% (hazard ratio, 2.11; 95% CI, 1.43-3.11; P < .001) and RAVi > 48 mL/m2 (hazard ratio, 1.49; 95% CI, 1.01-2.18; P = .04) remained associated with the combined end point, even after adjusting for RV free-wall longitudinal strain, significant chronic kidney disease, and New York Heart Association class. Secondary tricuspid regurgitation excess mortality increased exponentially with values of 18.2% and 51.3 mL/m2 for RAS and RAVi, respectively. In nested models, the addition of RAS and RAVi provided incremental prognostic value over clinical, conventional echocardiographic parameters of RV size and function and RV free-wall longitudinal strain. CONCLUSIONS In patients with STR, RAR was independently associated with mortality and heart failure hospitalization. Assessment of RAR could improve risk stratification of patients with STR, potentially identifying those who may benefit from optimization of medical therapy and a closer follow-up.
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Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Daniela N Radu
- Carol Davila University of Medicine and Pharmacy, Prof. Dr. C. C. Iliescu Institute, Bucharest, Romania
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Francesco P Perelli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Andrea Cascella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Diana R Hădăreanu
- Department of Cardiology, Clinical Emergency County Hospital of Craiova, Craiova, Romania
| | - Sorina Mihaila
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; Cardiology and Cardiovascular Surgery Department, Emergency and University Hospital, Bucharest, Romania
| | - Giorgio Oliverio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Samantha Fisicaro
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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3
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Badano LP, Benfari G, Muraru D. The conundrum of the reference values of left atrial size and function. Eur Heart J Cardiovasc Imaging 2024; 25:613-614. [PMID: 38309953 DOI: 10.1093/ehjci/jeae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 02/01/2024] [Indexed: 02/05/2024] Open
Affiliation(s)
- Luigi P Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Piazza Ateneo NUovo 1, 20126 Milan, Italy
- Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Piazz.le Brescia 20, 20149 Milan, Italy
| | - Giovanni Benfari
- Department of Medicine, Cardiology Unit, University of Verona, Verona, Italy
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano Bicocca, Piazza Ateneo NUovo 1, 20126 Milan, Italy
- Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Piazz.le Brescia 20, 20149 Milan, Italy
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Tolvaj M, Kovács A, Radu N, Cascella A, Muraru D, Lakatos B, Fábián A, Tokodi M, Tomaselli M, Gavazzoni M, Perelli F, Merkely B, Badano LP, Surkova E. Significant Disagreement Between Conventional Parameters and 3D Echocardiography-Derived Ejection Fraction in the Detection of Right Ventricular Systolic Dysfunction and Its Association With Outcomes. J Am Soc Echocardiogr 2024:S0894-7317(24)00173-1. [PMID: 38641069 DOI: 10.1016/j.echo.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 03/19/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024]
Abstract
AIMS Conventional echocardiographic parameters such as tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) offer limited insights into the complexity of right ventricular (RV) systolic function, while 3D echocardiography-derived RV ejection fraction (RVEF) enables a comprehensive assessment. We investigated the discordance between TAPSE, FAC, FWLS, and RVEF in RV systolic function grading and associated outcomes. METHODS We analyzed two- and three-dimensional echocardiography data from 2 centers including 750 patients followed up for all-cause mortality. Right ventricular dysfunction was defined as RVEF <45%, with guideline-recommended thresholds (TAPSE <17 mm, FAC <35%, FWLS >-20%) considered. RESULTS Among patients with normal RVEF, significant proportions exhibited impaired TAPSE (21%), FAC (33%), or FWLS (8%). Conversely, numerous patients with reduced RVEF had normal TAPSE (46%), FAC (26%), or FWLS (41%). Using receiver-operating characteristic analysis, FWLS exhibited the highest area under the curve of discrimination for RV dysfunction (RVEF <45%) with 59% sensitivity and 92% specificity. Over a median 3.7-year follow-up, 15% of patients died. Univariable Cox regression identified TAPSE, FAC, FWLS, and RVEF as significant mortality predictors. Combining impaired conventional parameters showed that outcomes are the worst if at least 2 parameters are impaired and gradually better if only one or none of them are impaired (log-rank P < .005). CONCLUSION Guideline-recommended cutoff values of conventional echocardiographic parameters of RV systolic function are only modestly associated with RVEF-based assessment. Impaired values of FWLS showed the closest association with the RVEF cutoff. Our results emphasize a multiparametric approach in the assessment of RV function, especially if 3D echocardiography is not available.
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Affiliation(s)
- Máté Tolvaj
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Experimental Cardiology and Surgical Techniques, Semmelweis University, Budapest, Hungary.
| | - Noela Radu
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Carol Davila University of Medicine and Pharmacy, Prof. Dr. C. C. Iliescu Institute, Bucharest, Romania
| | - Andrea Cascella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Bálint Lakatos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Alexandra Fábián
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Márton Tokodi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Francesco Perelli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
| | - Elena Surkova
- Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
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5
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Adamo M, Russo G, Pagnesi M, Pancaldi E, Alessandrini H, Andreas M, Badano LP, Braun D, Connelly KA, Denti P, Estevez-Loureiro R, Fam N, Gavazzoni M, Hahn RT, Harr C, Hausleiter J, Himbert D, Kalbacher D, Ho E, Latib A, Lubos E, Ludwig S, Lupi L, Lurz P, Monivas V, Nickenig G, Pedicino D, Pedrazzini G, Pozzoli A, Marafon DP, Pastorino R, Praz F, Rodes-Cabau J, Besler C, Schöber AR, Schofer J, Scotti A, Piayda K, Sievert H, Tang GHL, Sticchi A, Messika-Zeitoun D, Thiele H, Schlotter F, von Bardeleben RS, Webb J, Dreyfus J, Windecker S, Leon M, Maisano F, Metra M, Taramasso M. Prediction of Mortality and Heart Failure Hospitalization After Transcatheter Tricuspid Valve Interventions: Validation of TRISCORE. JACC Cardiovasc Interv 2024; 17:859-870. [PMID: 38599688 DOI: 10.1016/j.jcin.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/03/2024] [Accepted: 02/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Data on the prognostic role of the TRI-SCORE in patients undergoing transcatheter tricuspid valve intervention (TTVI) are limited. OBJECTIVES The aim of this study was to evaluate the performance of the TRI-SCORE in predicting outcomes of patients undergoing TTVI. METHODS TriValve (Transcatheter Tricuspid Valve Therapies) is a large multicenter multinational registry including patients undergoing TTVI. The TRI-SCORE is a risk model recently proposed to predict in-hospital mortality after tricuspid valve surgery. The TriValve population was stratified based on the TRI-SCORE tertiles. The outcomes of interest were all-cause death and all-cause death or heart failure hospitalization. Procedural complications and changes in NYHA functional class were also reported. RESULTS Among the 634 patients included, 223 patients (35.2%) had a TRI-SCORE between 0 and 5, 221 (34.8%) had 6 or 7, and 190 (30%) had ≥8 points. Postprocedural blood transfusion, acute kidney injury, new atrial fibrillation, and in-hospital mortality were more frequent in the highest TRI-SCORE tertile. Postprocedure length of stay increased with a TRI-SCORE increase. A TRI-SCORE ≥8 was associated with an increased risk of 30-day all-cause mortality and all-cause mortality and the composite endpoint assessed at a median follow-up of 186 days (OR: 3.00; 95% CI: 1.38-6.55; HR: 2.17; 95% CI: 1.78-4.13; HR: 2.08, 95% CI: 1.57-2.74, respectively) even after adjustment for procedural success and EuroSCORE II or Society of Thoracic Surgeons Predicted Risk of Mortality. The NYHA functional class improved across all TRI-SCORE values. CONCLUSIONS In the TriValve registry, the TRI-SCORE has a suboptimal performance in predicting clinical outcomes. However, a TRISCORE ≥8 is associated with an increased risk of clinical events and a lack of prognostic benefit after successful TTVI.
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Affiliation(s)
- Marianna Adamo
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Giulio Russo
- Department of Biomedicine and Prevention, Cardiology Unit, Policlinico Tor Vergata, University of Rome, Rome, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Edoardo Pancaldi
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Luigi P Badano
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy; Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Daniel Braun
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | - Kim A Connelly
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Paolo Denti
- Division of Cardiology, San Raffaele University Hospital, Milan Italy; Department of Cardiac Surgery, San Raffaele University Hospital, Milan Italy
| | | | - Neil Fam
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Mara Gavazzoni
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy; Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, New York, USA
| | - Claudia Harr
- Department of Cardiology, Asklepios Clinic Sankt Georg, Hamburg, Germany
| | - Joerg Hausleiter
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | | | - Daniel Kalbacher
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Edwin Ho
- Division of Cardiology, Montefiore Medical Center, New York, New York, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, New York, USA
| | - Edith Lubos
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Laura Lupi
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Vanessa Monivas
- Division of Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Daniela Pedicino
- Fondazione Policlinico Universitario A Gemelli IRCSS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Pedrazzini
- Division of Cardiology, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland; Biomedical Faculty, Università della Svizzera Italiana, Lugano, Switzerland
| | - Alberto Pozzoli
- Division of Cardiac Surgery, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Denise Pires Marafon
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica Del Sacro Cuore, Rome, Italy; Department of Woman and Child Health and Public Health, Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabien Praz
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Joseph Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Joachim Schofer
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy
| | - Andrea Scotti
- Division of Cardiology, Montefiore Medical Center, New York, New York, USA
| | | | - Horst Sievert
- CardioVascular Center Frankfurt CVC, Frankfurt, Germany
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York, USA
| | - Alessandro Sticchi
- Interventional Cardiology, Humanitas Research Hospital, Rozzano Milanese, Italy
| | | | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - John Webb
- St. Paul Hospital, Vancouver, British Columbia, Canada
| | - Julien Dreyfus
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Stephan Windecker
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Martin Leon
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, New York, USA
| | - Francesco Maisano
- Department of Cardiac Surgery, San Raffaele University Hospital, Milan Italy
| | - Marco Metra
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Fisicaro S, Clement A, Tomaselli M, Penso M, Rota A, Menna A, Badano LP, Muraru D. Timing and Patient Position During Cuff Blood Pressure Measurement Affect Myocardial Work Parameters Measured by Echocardiography. J Am Soc Echocardiogr 2024:S0894-7317(24)00166-4. [PMID: 38593889 DOI: 10.1016/j.echo.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Although cuff blood pressure measurement is a critical parameter to calculate myocardial work noninvasively, there is no recommendation about when and how to measure it. Accordingly, we sought to evaluate the effects of the timing during the echo study and the patient's position on the scanning bed during the cuff blood pressure measurement on myocardial work parameter calculations. METHODS One hundred one consecutive patients (44 women, 66 ± 14 years) undergoing clinically indicated echocardiography were prospectively enrolled. During the echocardiographic study, we measured the cuff blood pressure 4 times, using a fully automatic digital blood pressure monitor applied to the right and left arm in the same position throughout the study: BP1, before the start of the echo study, with the patient lying in the supine position; BP2, after positioning the patients on their left side to start the echo study; BP3, at the time of the acquisition of the 3 apical views (4- and 2-chamber and long-axis) used to measured left ventricular global longitudinal strain; and BP4, at the end of the echo study with the patient again in the supine position. RESULTS Systolic blood pressureat BP1 was 147 ± 21 mm Hg. Between BP1 and BP2, it dropped by 17 ± 9 mm Hg (P < .05). Systolic blood pressure at BP3 was significantly lower than BP2 (130 ± 20 mm Hg vs 122 ± 18 mm Hg, P < .05), and at BP4 was significantly lower than at BP1 (-9 ± 13 mm Hg, P < .05). The average global longitudinal strain was -16% ± 3%. Accordingly, the global work index was 1,929 ± 441 mm Hg% at BP1, dropped to 1,717 ± 421 at BP2, decreased to 1,602 ± 351 mm Hg% at BP3, and increased to 1,815 ± 386 mm Hg% at BP4 (P < .001). CONCLUSIONS The timing during the echocardiography study and the patient's position on the scanning bed are critical determinants of the measured cuff systolic blood pressure and the resulting values of myocardial work parameters.
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Affiliation(s)
- Samantha Fisicaro
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Alexandra Clement
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Internal Medicine Department, "Grigore T. Popa", University of Medicine and Pharmacy, Iasi, Romania
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Alessandra Rota
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Alessandro Menna
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy.
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
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7
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Tomaselli M, Badano LP, Oliverio G, Curti E, Pece C, Springhetti P, Milazzo S, Clement A, Penso M, Gavazzoni M, Hădăreanu DR, Mihaila SB, Pugliesi GM, Delcea C, Muraru D. Clinical Impact of the Volumetric Quantification of Ventricular Secondary Mitral Regurgitation by Three-Dimensional Echocardiography. J Am Soc Echocardiogr 2024; 37:408-419. [PMID: 38244817 DOI: 10.1016/j.echo.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
BACKGROUND The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients. METHODS We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause. RESULTS After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001). CONCLUSIONS Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.
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Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Giorgio Oliverio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Emanuele Curti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Cinzia Pece
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paolo Springhetti
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Salvatore Milazzo
- Division of Cardiology, University Hospital Paolo Giaccone, Palermo, Italy
| | - Alexandra Clement
- Internal Medicine Department, "Grigore T. Popa", University of Medicine and Pharmacy, Iasi, Romania
| | - Marco Penso
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Diana R Hădăreanu
- Department of Cardiology, Clinical Emergency County Hospital of Craiova, Craiova, Romania
| | - Sorina Baldea Mihaila
- Cardiology Department, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Giordano M Pugliesi
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Caterina Delcea
- Cardiology Department, Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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8
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Muraru D, Badano LP. Leaflet Coaptation Gaps in Severe Tricuspid Regurgitation: Unraveling the Morphological Challenges in the Tricuspid Transcatheter Edge-to-Edge Repair Landscape. J Am Soc Echocardiogr 2024; 37:405-407. [PMID: 38309592 DOI: 10.1016/j.echo.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/27/2024] [Indexed: 02/05/2024]
Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy.
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
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9
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Muraru D, Badano LP, Hahn RT, Lang RM, Delgado V, Wunderlich NC, Donal E, Taramasso M, Duncan A, Lurz P, De Potter T, Zamorano Gómez JL, Bax JJ, von Bardeleben RS, Enriquez-Sarano M, Maisano F, Praz F, Sitges M. Atrial secondary tricuspid regurgitation: pathophysiology, definition, diagnosis, and treatment. Eur Heart J 2024; 45:895-911. [PMID: 38441886 PMCID: PMC11095052 DOI: 10.1093/eurheartj/ehae088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 01/03/2024] [Accepted: 01/30/2024] [Indexed: 03/16/2024] Open
Abstract
Atrial secondary tricuspid regurgitation (A-STR) is a distinct phenotype of secondary tricuspid regurgitation with predominant dilation of the right atrium and normal right and left ventricular function. Atrial secondary tricuspid regurgitation occurs most commonly in elderly women with atrial fibrillation and in heart failure with preserved ejection fraction in sinus rhythm. In A-STR, the main mechanism of leaflet malcoaptation is related to the presence of a significant dilation of the tricuspid annulus secondary to right atrial enlargement. In addition, there is an insufficient adaptive growth of tricuspid valve leaflets that become unable to cover the enlarged annular area. As opposed to the ventricular phenotype, in A-STR, the tricuspid valve leaflet tethering is typically trivial. The A-STR phenotype accounts for 10%-15% of clinically relevant tricuspid regurgitation and has better outcomes compared with the more prevalent ventricular phenotype. Recent data suggest that patients with A-STR may benefit from more aggressive rhythm control and timely valve interventions. However, little is mentioned in current guidelines on how to identify, evaluate, and manage these patients due to the lack of consistent evidence and variable definitions of this entity in recent investigations. This interdisciplinary expert opinion document focusing on A-STR is intended to help physicians understand this complex and rapidly evolving topic by reviewing its distinct pathophysiology, diagnosis, and multi-modality imaging characteristics. It first defines A-STR by proposing specific quantitative criteria for defining the atrial phenotype and for discriminating it from the ventricular phenotype, in order to facilitate standardization and consistency in research.
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Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, Milan 20126, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Rebecca T Hahn
- Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Roberto M Lang
- Department of Medicine, Section of Cardiology, University of Chicago Medical Center, Chicago, IL, USA
| | - Victoria Delgado
- Department of Cardiology, Hospital University Germans Trias I Pujol, Badalona, Spain
| | | | - Erwan Donal
- CHU Rennes, Inserm, University of Rennes 1, Rennes, France
| | - Maurizio Taramasso
- Department of Cardiac Surgery, HerzZentrum Hirslanden Zürich, Zürich, Switzerland
| | - Alison Duncan
- Heart Division, The Royal Brompton Hospital, London, UK
| | - Philipp Lurz
- Department of Cardiology, Heart Center Leipzig, Leipzig, Germany
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - José L Zamorano Gómez
- Department of Cardiology, University Hospital Ramón y Cajal, Ctra Colmenar Viejo Km 9.1, Madrid, Spain
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ralph Stephan von Bardeleben
- Department of Cardiology and Heart Valve Center, Universitätsmedizin Johannes Gutenberg-University, Langenbeckstr, Mainz 55131, Germany
| | | | - Francesco Maisano
- Valve Center IRCCS Ospedale San Raffaele, Cardiac Surgery, University Vita Salute, Milan, Italy
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Marta Sitges
- Cardiovascular Institute, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- CIBER, Centro de Investigación Biomédica en Red, Barcelona, Spain
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10
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Badano LP, Muraru D. Make Right Heart Remodeling in Secondary Tricuspid Regurgitation as Simple as Possible, But Not Simpler. JACC Cardiovasc Imaging 2024:S1936-878X(24)00058-5. [PMID: 38520426 DOI: 10.1016/j.jcmg.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/01/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Luigi P Badano
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy.
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Milan, Italy
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11
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Tomaselli M, Badano LP, Muraru D. Right atrial function, a mostly ignored but very valuable parameter in patients with secondary tricuspid regurgitation. Heart 2024; 110:389-390. [PMID: 37932022 DOI: 10.1136/heartjnl-2023-323426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2023] Open
Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
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12
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Russo G, Badano LP, Adamo M, Alessandrini H, Andreas M, Braun D, Connelly KA, Denti P, Estevez-Loureiro R, Fam N, Gavazzoni M, Hahn RT, Harr C, Hausleiter J, Himbert D, Kalbacher D, Ho E, Latib A, Lubos E, Ludwig S, Lurz P, Monivas V, Nickenig G, Pedicino D, Pedrazzini G, Pozzoli A, Pires Marafon D, Pastorino R, Praz F, Rodes-Cabau J, Besler C, Schofer J, Scotti A, Piayda K, Sievert H, Tang GHL, Thiele H, Schlotter F, von Bardeleben RS, Webb J, Windecker S, Leon M, Maisano F, Metra M, Taramasso M. Characteristics and outcomes of patients with atrial versus ventricular secondary tricuspid regurgitation undergoing tricuspid transcatheter edge-to-edge repair - Results from the TriValve registry. Eur J Heart Fail 2023; 25:2243-2251. [PMID: 37905381 DOI: 10.1002/ejhf.3075] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 09/19/2023] [Accepted: 10/24/2023] [Indexed: 11/02/2023] Open
Abstract
AIM Functional or secondary tricuspid regurgitation (STR) is the most common phenotype of tricuspid regurgitation (TR) with atrial STR (ASTR) and ventricular STR (VSTR) being recently identified as two distinct entities. Data on tricuspid transcatheter edge-to-edge repair (T-TEER) in patients with STR according to phenotype (i.e. ASTR vs. VSTR) are lacking. The aim of this study was to assess characteristics and outcomes of patients with ASTR versus VSTR undergoing T-TEER. METHODS AND RESULTS Patients with STR undergoing T-TEER were selected from the Transcatheter Tricuspid Valve Therapies (TriValve) registry. ASTR was defined by (i) left ventricular ejection fraction ≥50%, (ii) atrial fibrillation, and (iii) systolic pulmonary artery pressure <50 mmHg. Patients not matching these criteria were classified as VSTR. Patients with primary TR and cardiac implantable electronic device were excluded. Key endpoints included procedural success and survival at follow-up. A total of 298 patients were enrolled in the study: 65 (22%) with ASTR and 233 (78%) with VSTR. Procedural success was similar in the two groups (80% vs. 83% for ASTR vs. VSTR, p = 0.56) and TEER was effective in reducing TR in both groups (from 97% of patients with baseline TR ≥3+ to 23% in ASTR and to 15% in VSTR, all p = 0.001). At 12-month follow-up, survival was significantly higher in the ASTR versus VSTR cohort (91% vs. 72%, log-rank p = 0.02), with VSTR being an independent predictor of mortality at multivariable analysis (hazard ratio 4.75). CONCLUSIONS In a real-world, multicentre registry, T-TEER was effective in reducing TR grade in both ASTR and VSTR. At 12-month follow-up, ASTR showed better survival than VSTR.
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Affiliation(s)
- Giulio Russo
- Department of Biomedicine and Prevention, Cardiology Unit, Policlinico Tor Vergata, University of Rome, Rome, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy
- Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Marianna Adamo
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Braun
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | - Kim A Connelly
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, ON, Canada
| | - Paolo Denti
- Division of Cardiology and Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
| | | | - Neil Fam
- Division of Cardiology, Toronto Heart Center, St. Michael's Hospital, Toronto, ON, Canada
| | - Mara Gavazzoni
- Department of Medicine and Surgery, University Milano Bicocca, Milan, Italy
- Department of Cardiology, Auxologico IRCCS, Milan, Italy
| | - Rebecca T Hahn
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - Claudia Harr
- Department of Cardiology, Asklepios clinic Sankt Georg, Hamburg, Germany
| | - Joerg Hausleiter
- Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany
| | | | - Daniel Kalbacher
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Edwin Ho
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | - Edith Lubos
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Sebastian Ludwig
- Department of Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - Philipp Lurz
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Vanessa Monivas
- Division of Cardiology, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Daniela Pedicino
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Pedrazzini
- Division of Cardiology, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Biomedical Faculty, Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Alberto Pozzoli
- Division of Cardiac Surgery, Cardiocentro Ticino Institute EOC, Lugano, Switzerland
| | - Denise Pires Marafon
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, University Department of Life Sciences and Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Woman and Child Health and Public Health - Public Health Area, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabien Praz
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Joseph Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | | | - Joachim Schofer
- Department of Cardiology, Asklepios clinic Sankt Georg, Hamburg, Germany
| | - Andrea Scotti
- Division of Cardiology, Montefiore Medical Center, New York, NY, USA
| | | | - Horst Sievert
- CardioVascular Center Frankfurt CVC, Frankfurt, Germany
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | | | | | - John Webb
- St. Paul Hospital, Vancouver, BC, Canada
| | - Stephan Windecker
- Department of Cardiology, Cardiovascular Center, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Martin Leon
- Division of Cardiology, Columbia University Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - Francesco Maisano
- Division of Cardiology and Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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13
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Mor-Avi V, Blitz A, Schreckenberg M, Addetia K, Kebed K, Scalia G, Badano LP, Kirkpatrick JN, Gutierrez-Fajardo P, Tude Rodrigues AC, Sadeghpour A, Tucay ES, Prado AD, Tsang W, Ogunyankin KO, Rossmanith A, Schummers G, Laczik D, Asch FM, Lang RM. Deep learning assisted measurement of echocardiographic left heart parameters: improvement in interobserver variability and workflow efficiency. Int J Cardiovasc Imaging 2023; 39:2507-2516. [PMID: 37872467 DOI: 10.1007/s10554-023-02960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/16/2023] [Indexed: 10/25/2023]
Abstract
Machine learning techniques designed to recognize views and perform measurements are increasingly used to address the need for automation of the interpretation of echocardiographic images. The current study was designed to determine whether a recently developed and validated deep learning (DL) algorithm for automated measurements of echocardiographic parameters of left heart chamber size and function can improve the reproducibility and shorten the analysis time, compared to the conventional methodology. The DL algorithm trained to identify standard views and provide automated measurements of 20 standard parameters, was applied to images obtained in 12 randomly selected echocardiographic studies. The resultant measurements were reviewed and revised as necessary by 10 independent expert readers. The same readers also performed conventional manual measurements, which were averaged and used as the reference standard for the DL-assisted approach with and without the manual revisions. Inter-reader variability was quantified using coefficients of variation, which together with analysis times, were compared between the conventional reads and the DL-assisted approach. The fully automated DL measurements showed good agreement with the reference technique: Bland-Altman biases 0-14% of the measured values. Manual revisions resulted in only minor improvement in accuracy: biases 0-11%. This DL-assisted approach resulted in a 43% decrease in analysis time and less inter-reader variability than the conventional methodology: 2-3 times smaller coefficients of variation. In conclusion, DL-assisted approach to analysis of echocardiographic images can provide accurate left heart measurements with the added benefits of improved reproducibility and time savings, compared to conventional methodology.
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Affiliation(s)
- Victor Mor-Avi
- University of Chicago Medicine, 5758 S. Maryland Ave., MC 9067, DCAM 5509, Chicago, IL, 60637, USA
| | | | | | - Karima Addetia
- University of Chicago Medicine, 5758 S. Maryland Ave., MC 9067, DCAM 5509, Chicago, IL, 60637, USA
| | - Kalie Kebed
- Minneapolis Heart Institute - Allina Health at United Hospital, St. Paul, MN, USA
| | | | - Luigi P Badano
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
- University of Milano-Bicocca, Milan, Italy
| | | | | | | | - Anita Sadeghpour
- MedStar Heart and Vascular Institute/Health Research Institute, Washington, DC, USA
| | | | - Aldo D Prado
- Centro Privado de Cardiologia, Tucumán, Argentina
| | - Wendy Tsang
- Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Federico M Asch
- MedStar Heart and Vascular Institute/Health Research Institute, Washington, DC, USA
| | - Roberto M Lang
- University of Chicago Medicine, 5758 S. Maryland Ave., MC 9067, DCAM 5509, Chicago, IL, 60637, USA.
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14
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Gavazzoni M, Badano LP, Cascella A, Heilbron F, Tomaselli M, Caravita S, Baratto C, Perelli F, Radu N, Perger E, Parati G, Muraru D. Clinical Value of a Novel Three-Dimensional Echocardiography-Derived Index of Right Ventricle-Pulmonary Artery Coupling in Tricuspid Regurgitation. J Am Soc Echocardiogr 2023; 36:1154-1166.e3. [PMID: 37406715 DOI: 10.1016/j.echo.2023.06.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/06/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Echocardiographic surrogates of right ventricle-to-pulmonary artery (RV-PA) coupling have been reported to be associated with outcomes in patients with secondary tricuspid regurgitation (STR). However, pulmonary artery systolic pressure (PASP) is difficult to estimate using echocardiography in patients with severe STR. The aim of the present study was to evaluate the predictive power of a surrogate of RV-PA coupling obtained using right ventricular (RV) volumes measured on three-dimensional echocardiography. METHODS One hundred eight patients (mean age, 73 ± 13 years; 61% women) with moderate or severe STR were included. RESULTS At a median follow-up of 24 months (interquartile range, 2-48 months), 72 patients (40%) had reached the composite end point of death of any cause and heart failure hospitalization. RV-PA coupling was computed as the ratio between RV forward stroke volume (SV) (i.e., RV SV - regurgitant volume) and RV end-systolic volume (ESV). RV forward SV/ESV was significantly more related to the composite end point than RV ejection fraction (area under the curve, 0.85 [95% CI, 0.78-0.93] vs 0.73 [95% CI, 0.64-0.83], respectively; P = .03). A value of 0.40 was found to best correlate with outcome. On multivariate Cox regression, RV forward SV/ESV, tricuspid annular plane systolic excursion/PASP, and RV free wall longitudinal strain/PASP were all independently associated with the occurrence of the composite end point when added to a group of parameters including STR severity (severe vs moderate), atrial fibrillation, pulmonary arterial hypertension, right atrial volume, RV end-diastolic volume, and RV free wall longitudinal strain. RV forward SV/ESV < 0.40 (HR, 3.36; 95% CI, 1.49-7.56; P < .01) carried higher related risk than RV free wall longitudinal strain/PASP < -0.42%/mm Hg (HR, 3.1; 95% CI, 1.26-7.84; P = .01) and tricuspid annular plane systolic excursion/PASP < 0.36 mm/mm Hg (HR, 2.69; 95% CI, 1.29-5.58; P = .01). RV ejection fraction did not correlate independently with prognosis when added to the same group of variables. CONCLUSIONS RV forward SV/ESV is associated with the risk for death and heart failure hospitalization in patients with STR.
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Affiliation(s)
- Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Andrea Cascella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Perelli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Noela Radu
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Elisa Perger
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Caravita S, Baratto C, Filippo A, Soranna D, Dewachter C, Zambon A, Perego GB, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Fudim M. Shedding Light on Latent Pulmonary Vascular Disease in Heart Failure With Preserved Ejection Fraction. JACC Heart Fail 2023; 11:1427-1438. [PMID: 37115127 DOI: 10.1016/j.jchf.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Among patients with heart failure with preserved ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, ie, latent pulmonary vascular disease (HFpEF-latentPVD), defined by exercise pulmonary vascular resistance (PVR) >1.74 WU. OBJECTIVES This study aims to explore the pathophysiological significance of HFpEF-latentPVD. METHODS The authors analyzed a cohort of patients who had undergone supine exercise right heart catheterization with cardiac output (CO) measured by direct Fick method, between 2016 and 2021. HFpEF-latentPVD patients were compared with HFpEF control patients. RESULTS Out of 86 HFpEF patients, 21% qualified as having HFpEF-latentPVD, 78% of whom had PVR >2 WU at rest. Patients with HFpEF-latentPVD were older, with a higher pretest probability of HFpEF, and more frequently experienced atrial fibrillation and at least moderate tricuspid regurgitation (P < 0.05). PVR trajectories differed between HFpEF-latentPVD patients and HFpEF control patients (Pinteraction = 0.008), slightly increasing in the former and reducing in the latter. HFpEF-latentPVD patients displayed more frequent hemodynamically significant tricuspid regurgitation during exercise (P = 0.002) and had more impaired CO and stroke volume reserve (P < 0.05). Exercise PVR was correlated with mixed venous O2 tension (R2 = 0.33) and stroke volume (R2 = 0.31) in HFpEF-latentPVD patients. The HFpEF-latentPVD patients had had higher dead space ventilation during exercise and higher PaCO2 (P < 0.05), which correlated with resting PVR (R2 = 0.21). Event-free survival was reduced in HFpEF-latentPVD patients (P < 0.05). CONCLUSIONS The results suggest that when CO is measured by direct Fick, few HFpEF patients have isolated latent PVD (ie, normal PVR at rest, becoming abnormal during exercise). HFpEF-latentPVD patients present with CO limitation to exercise, associated with dynamic tricuspid regurgitation, altered ventilatory control, and pulmonary vascular hyperreactivity, portending a poor prognosis.
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Affiliation(s)
- Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy; Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.
| | - Aurora Filippo
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milano, Italy
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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16
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Baratto C, Caravita S, Dewachter C, Faini A, Perego GB, Bondue A, Senni M, Muraru D, Badano LP, Parati G, Vachiéry JL. Right Heart Adaptation to Exercise in Pulmonary Hypertension: An Invasive Hemodynamic Study. J Card Fail 2023; 29:1261-1272. [PMID: 37150503 DOI: 10.1016/j.cardfail.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Right heart failure (RHF) is associated with a dismal prognosis in patients with pulmonary hypertension (PH). Exercise right heart catheterization may unmask right heart maladaptation as a sign of RHF. We sought to (1) define the normal limits of right atrial pressure (RAP) increase during exercise; (2) describe the right heart adaptation to exercise in PH owing to heart failure with preserved ejection fraction (PH-HFpEF) and in pulmonary arterial hypertension (PAH); and (3) identify the factors associated with right heart maladaptation during exercise. METHODS AND RESULTS We analyzed rest and exercise right heart catheterization from patients with PH-HFpEF and PAH. Right heart adaptation was described by absolute or cardiac output (CO)-normalized changes of RAP during exercise. Individuals with noncardiac dyspnea (NCD) served to define abnormal RAP responses (>97.5th percentile). Thirty patients with PH-HFpEF, 30 patients with PAH, and 21 patients with NCD were included. PH-HFpEF were older than PAH, with more cardiovascular comorbidities, and a higher prevalence of severe tricuspid regurgitation (P < .05). The upper limit of normal for peak RAP and RAP/CO slope in NCD were >12 mm Hg and ≥1.30 mm Hg/L/min, respectively. PH-HFpEF had higher peak RAP and RAP/CO slope than PAH (20 mm Hg [16-24 mm Hg] vs 12 mm Hg [9-19 mm Hg] and 3.47 mm Hg/L/min [2.02-6.19 mm Hg/L/min] vs 1.90 mm Hg/L/min [1.01-4.29 mm Hg/L/min], P < .05). A higher proportion of PH-HFpEF had RAP/CO slope and peak RAP above normal (P < .001). Estimated stressed blood volume at peak exercise was higher in PH-HFpEF than PAH (P < .05). In the whole PH cohort, the RAP/CO slope was associated with age, the rate of increase in estimated stressed blood volume during exercise, severe tricuspid regurgitation, and right atrial dilation. CONCLUSIONS Patients with PH-HFpEF display a steeper increase of RAP during exercise than those with PAH. Preload-mediated mechanisms may play a role in the development of exercise-induced RHF.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy.
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | | | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
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17
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Karvandi M, Mohammadi Tofigh A, Ranjbar S, Badano LP. Changes in blood flow vortices inside the left ventricle in COVID-19 patients with intraventricular clot despite a normal coronary and myocardial motion. J Echocardiogr 2023; 21:122-130. [PMID: 37219722 PMCID: PMC10204037 DOI: 10.1007/s12574-023-00603-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 04/09/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE Our clinical observations showed clot formations in different regions of the left ventricle of the heart in some COVID-19 patients with normal myocardial motion and coronary artery. The aim of this study was to examine the changes caused by COVID-19 disease on blood flow inside the heart as a possible etiology of intracardiac clot formation. METHODS In a synergic convergence of mathematics, computer science, and cardio-vascular medicine, we evaluated patients hospitalized due to COVID-19 without cardiac symptoms who underwent two-dimensional echocardiography. Patients with normal myocardial motions on echocardiography, normal coronary findings on noninvasive cardio-vascular diagnostic tests, and normal cardiac biochemical examinations but who presented with a clot in their left ventricle were included. To display the velocity vectors of the blood in the left ventricle, motion and deformation echocardiographic data were imported into MATLAB software. RESULTS Analysis and output of the MATLAB program indicted anomalous blood flow vortices inside the left ventricular cavity, indicating irregular flow and turbulence of the blood inside the left ventricle in COVID-19 patients. CONCLUSION Our results suggest that in some COVID-19 patients, cardiac wall motion is not satisfactorily able to circulate the blood fluid in normal directions and that, despite normal myocardium, changes in the directions of blood flow inside the left ventricle might lead to clots in different zones. This phenomenon may be related to changes in blood properties, such as viscosity.
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Affiliation(s)
- Mersedeh Karvandi
- Department of Cardiovascular Diseases, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Mohammadi Tofigh
- Department of General Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Evin, Tehran, 1985717443 Iran
| | - Saeed Ranjbar
- Department of Cardiovascular Diseases, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, piazzale Brescia, 20, 20149 Milan, Italy
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18
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Tomaselli M, Badano LP, Cannone V, Radu N, Curti E, Perelli F, Heilbron F, Gavazzoni M, Rella V, Oliverio G, Caravita S, Baratto C, Perego GB, Parati G, Brasca F, Muraru D. Incremental Value of Right Atrial Strain Analysis to Predict Atrial Fibrillation Recurrence After Electrical Cardioversion. J Am Soc Echocardiogr 2023; 36:945-955. [PMID: 37302440 DOI: 10.1016/j.echo.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 05/17/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Although the assessment of left atrial (LA) mechanics has been reported to refine atrial fibrillation (AF) risk prediction, it doesn't completely predict AF recurrence. The potential added role of right atrial (RA) function in this setting is unknown. Accordingly, this study sought to evaluate the added value of RA longitudinal reservoir strain (RASr) for the prediction of AF recurrence after electrical cardioversion (ECV). METHODS We retrospectively studied 132 consecutive patients with persistent AF who underwent elective ECV. Complete two-dimensional and speckle-tracking echocardiography analyses of LA and RA size and function were obtained in all patients before ECV. The end point was AF recurrence. RESULTS During a 12-month follow-up, 63 patients (48%) showed AF recurrence. Both LASr and RASr were significantly lower in patients experiencing AF recurrence than in patients with persistent sinus rhythm (LASr, 10% ± 6% vs 13% ± 7%; RASr, 14% ± 10% vs 20% ± 9%, respectively; P < .001 for both). Right atrial longitudinal reservoir strain (area under the curve = 0.77; 95% CI, 0.69-0.84; P < .0001) was more strongly associated with the recurrence of AF after ECV than LASr (area under the curve = 0.69; 95% CI, 0.60-0.77; P < .0001). Kaplan-Meier curves showed that patients with both LASr ≤ 10% and RASr ≤ 15% had a significantly increased risk for AF recurrence (log-rank, P < .001). However, at multivariable Cox regression, RASr (hazard ratio, 3.26; 95% CI, 1.73-6.13; P < .001) was the only parameter independently associated with AF recurrence. Right atrial longitudinal reservoir strain was more strongly associated with the occurrence of AF relapse after ECV than LASr, and LA and RA volumes. CONCLUSION Right atrial longitudinal reservoir strain was independently and more strongly associated than LASr with AF recurrence after elective ECV. This study highlights the importance of assessing the functional remodeling of both the RA and LA in patients with persistent AF.
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Affiliation(s)
- Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.
| | - Vincenzo Cannone
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Noela Radu
- Carol Davila University of Medicine and Pharmacy, Prof. Dr. C. C. Iliescu Institute, Bucharest, Romania
| | - Emanuele Curti
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesco Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Valeria Rella
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giorgio Oliverio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Giovanni B Perego
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesco Brasca
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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19
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Baratto C, Faini A, Gallone GP, Dewachter C, Perego GB, Bondue A, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Caravita S. Pulmonary artery wedge pressure and left ventricular end-diastolic pressure during exercise in patients with dyspnoea. ERJ Open Res 2023; 9:00750-2022. [PMID: 37670852 PMCID: PMC10475984 DOI: 10.1183/23120541.00750-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/29/2023] [Indexed: 03/18/2023] Open
Abstract
Background Pulmonary artery wedge pressure (PAWP) during exercise, as a surrogate for left ventricular (LV) end-diastolic pressure (EDP), is used to diagnose heart failure with preserved ejection fraction (HFpEF). However, LVEDP is the gold standard to assess LV filling, end-diastolic PAWP (PAWPED) is supposed to coincide with LVEDP and mean PAWP throughout the cardiac cycle (PAWPM) better reflects the haemodynamic load imposed on the pulmonary circulation. The objective of the present study was to determine precision and accuracy of PAWP estimates for LVEDP during exercise, as well as the rate of agreement between these measures. Methods 46 individuals underwent simultaneous right and left heart catheterisation, at rest and during exercise, to confirm/exclude HFpEF. We evaluated: linear regression between LVEDP and PAWP, Bland-Altman graphs, and the rate of concordance of dichotomised LVEDP and PAWP ≥ or < diagnostic thresholds for HFpEF. Results At peak exercise, PAWPM and LVEDP, as well as PAWPED and LVEDP, were fairly correlated (R2>0.69, p<0.01), with minimal bias (+2 and 0 mmHg respectively) but large limits of agreement (±11 mmHg). 89% of individuals had concordant PAWP and LVEDP ≥ or <25 mmHg (Cohen's κ=0.64). Individuals with either LVEDP or PAWPM ≥25 mmHg showed a PAWPM increase relative to cardiac output (CO) changes (PAWPM/CO slope) >2 mmHg·L-1·min-1. Conclusions During exercise, PAWP is accurate but not precise for the estimation of LVEDP. Despite a good rate of concordance, these two measures might occasionally disagree.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Andrea Faini
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Gianluca P. Gallone
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Giovanni B. Perego
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
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20
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Lanzarone E, Baratto C, Vicenzi M, Villella F, Rota I, Dewachter C, Muraru D, Tomaselli M, Gavazzoni M, Badano LP, Senni M, Vachiéry JL, Parati G, Caravita S. Haemodynamic validation of the three-step HFA-PEFF algorithm to diagnose heart failure with preserved ejection fraction. ESC Heart Fail 2023. [PMID: 37321596 PMCID: PMC10375124 DOI: 10.1002/ehf2.14436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/09/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
AIMS The HFA-PEFF algorithm (Heart Failure Association-Pre-test assessment, Echocardiography and natriuretic peptide score, Functional testing in cases of uncertainty, Final aetiology) is a three-step algorithm to diagnose heart failure with preserved ejection fraction (HFpEF). It provides a three-level likelihood of HFpEF: low (score < 2), intermediate (score 2-4), or high (score > 4). HFpEF may be confirmed in individuals with a score > 4 (rule-in approach). The second step of the algorithm is based on echocardiographic features and natriuretic peptide levels. The third step implements diastolic stress echocardiography (DSE) for controversial diagnostic cases. We sought to validate the three-step HFA-PEFF algorithm against a haemodynamic diagnosis of HFpEF based on rest and exercise right heart catheterization (RHC). METHODS AND RESULTS Seventy-three individuals with exertional dyspnoea underwent a full diagnostic work-up following the HFA-PEFF algorithm, including DSE and rest/exercise RHC. The association between the HFA-PEFF score and a haemodynamic diagnosis of HFpEF, as well as the diagnostic performance of the HFA-PEFF algorithm vs. RHC, was assessed. The diagnostic performance of left atrial (LA) strain < 24.5% and LA strain/E/E' < 3% was also assessed. The probability of HFpEF was low/intermediate/high in 8%/52%/40% of individuals at the second step of the HFA-PEFF algorithm and 8%/49%/43% at the third step. After RHC, 89% of patients were diagnosed as HFpEF and 11% as non-cardiac dyspnoea. The HFA-PEFF score resulted associated with the invasive haemodynamic diagnosis of HFpEF (P < 0.001). Sensitivity and specificity of the HFA-PEFF score for the invasive haemodynamic diagnosis of HFpEF were 45% and 100% for the second step of the algorithm and 46% and 88% for the third step of the algorithm. Neither age, sex, body mass index, obesity, chronic obstructive pulmonary disease, or paroxysmal atrial fibrillation influenced the performance of the HFA-PEFF algorithm, as these characteristics were similarly distributed over the true positive, true negative, false positive, and false negative cases. Sensitivity of the second step of the HFA-PEFF score was non-significantly improved to 60% (P = 0.08) by lowering the rule-in threshold to >3. LA strain alone had a sensitivity and specificity of 39% and 14% for haemodynamic HFpEF, increasing to 55% and 22% when corrected for E/E'. CONCLUSIONS As compared with rest/exercise RHC, the HFA-PEFF score lacks sensitivity: Half of the patients were wrongly classified as non-cardiac dyspnoea after non-invasive tests, with a minimal impact of DSE in modifying HFpEF likelihood.
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Affiliation(s)
- Ettore Lanzarone
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
| | - Marco Vicenzi
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Villella
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Irene Rota
- UOC Cardiologia, Ospedale Civile di Legnano, ASST Ovest Milanese, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Piazzale Brescia 20, Milan, 20149, Italy
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Gavazzoni M, Heilbron F, Badano LP, Radu N, Cascella A, Tomaselli M, Perelli F, Caravita S, Baratto C, Parati G, Muraru D. Corrigendum: The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype. Front Cardiovasc Med 2023; 10:1169907. [PMID: 36993992 PMCID: PMC10041682 DOI: 10.3389/fcvm.2023.1169907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/21/2023] [Indexed: 03/16/2023] Open
Abstract
[This corrects the article DOI: 10.3389/fcvm.2022.1022755.].
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Affiliation(s)
- Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Correspondence: Luigi P. Badano
| | - Noela Radu
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- University of Medicine and Pharmacy Carol Davila Bucharest, Emergency University Hospital Bucharest, Bucharest, Romania
| | - Andrea Cascella
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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22
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Tondi L, Badano LP, Figliozzi S, Pica S, Torlasco C, Camporeale A, Florescu DR, Disabato G, Parati G, Lombardi M, Muraru D. The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and emptying fraction measured by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2023; 25:10. [PMID: 36793062 PMCID: PMC9933380 DOI: 10.1186/s12968-022-00905-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/29/2022] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND The use of apical views focused on the left atrium (LA) has improved the accuracy of LA volume evaluation by two-dimensional (2D) echocardiography. However, routine cardiovascular magnetic resonance (CMR) evaluation of LA volumes still uses standard 2- and 4-chamber cine images focused on the left ventricle (LV). To investigate the potential of LA-focused CMR cine images, we compared LA maximuml (LAVmax) and minimum (LAVmin) volumes, and emptying fraction (LAEF), calculated on both standard and LA-focused long-axis cine images, with LA volumes and LAEF obtained by short-axis cine stacks covering the LA. LA strain was also calculated and compared between standard and LA-focused images. METHODS LA volumes and LAEF were obtained from 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. In addition, LA strain reservoir (εs), conduit (εe) and booster pump (εa) were calculated using CMR feature-tracking. RESULTS Compared to the reference method, the standard approach significantly underestimated LA volumes (LAVmax: bias - 13 ml; LOA = + 11, - 37 ml; LAVmax i: bias - 7 ml/m2; LOA = + 7, - 21 ml/m2; LAVmin; bias - 10 ml, LOA: + 9, - 28 ml; LAVmin i: bias - 5 ml/m2, LOA: + 5, - 16 ml/m2), and overestimated LA-EF (bias 5%, LOA: + 23, - 14%). Conversely, LA volumes (LAVmax: bias 0 ml; LOA: + 10, - 10 ml; LAVmax i: bias 0 ml/m2; LOA: + 5, - 6 ml/m2; LAVmin: bias - 2 ml; LOA: + 7, - 10 ml; LAVmin i: bias - 1 ml/m2; LOA: + 3, - 5 ml/m2) and LAEF (bias 2%, LOA: + 11, - 7%) by LA-focused cine images were similar to those measured using the reference method. LA volumes by LA-focused images were obtained faster than using the reference method (1.2 vs 4.5 min, p < 0.001). LA strain (εs: bias 7%, LOA = 25, - 11%; εe: bias 4%, LOA = 15, - 8%; εa: bias 3%, LOA = 14, - 8%) was significantly higher in standard vs. LA-focused images (p < 0.001). CONCLUSION LA volumes and LAEF measured using dedicated LA-focused long-axis cine images are more accurate than using standard LV-focused cine images. Moreover, LA strain is significantly lower in LA-focused vs. standard images.
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Affiliation(s)
- Lara Tondi
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Stefano Figliozzi
- Clinical Echocardiography Diagnostic Service, Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Silvia Pica
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Camilla Torlasco
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Antonia Camporeale
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Diana R Florescu
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
- Department of Cardiology, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Giandomenico Disabato
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
- University of Pavia, Pavia, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
| | - Massimo Lombardi
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University Milano-Bicocca, Milan, Italy
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23
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Papetti DM, Van Abeelen K, Davies R, Menè R, Heilbron F, Perelli FP, Artico J, Seraphim A, Moon JC, Parati G, Xue H, Kellman P, Badano LP, Besozzi D, Nobile MS, Torlasco C. An accurate and time-efficient deep learning-based system for automated segmentation and reporting of cardiac magnetic resonance-detected ischemic scar. Comput Methods Programs Biomed 2023; 229:107321. [PMID: 36586175 PMCID: PMC10331164 DOI: 10.1016/j.cmpb.2022.107321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND OBJECTIVES Myocardial infarction scar (MIS) assessment by cardiac magnetic resonance provides prognostic information and guides patients' clinical management. However, MIS segmentation is time-consuming and not performed routinely. This study presents a deep-learning-based computational workflow for the segmentation of left ventricular (LV) MIS, for the first time performed on state-of-the-art dark-blood late gadolinium enhancement (DB-LGE) images, and the computation of MIS transmurality and extent. METHODS DB-LGE short-axis images of consecutive patients with myocardial infarction were acquired at 1.5T in two centres between Jan 1, 2019, and June 1, 2021. Two convolutional neural network (CNN) models based on the U-Net architecture were trained to sequentially segment the LV and MIS, by processing an incoming series of DB-LGE images. A 5-fold cross-validation was performed to assess the performance of the models. Model outputs were compared respectively with manual (LV endo- and epicardial border) and semi-automated (MIS, 4-Standard Deviation technique) ground truth to assess the accuracy of the segmentation. An automated post-processing and reporting tool was developed, computing MIS extent (expressed as relative infarcted mass) and transmurality. RESULTS The dataset included 1355 DB-LGE short-axis images from 144 patients (MIS in 942 images). High performance (> 0.85) as measured by the Intersection over Union metric was obtained for both the LV and MIS segmentations on the training sets. The performance for both LV and MIS segmentations was 0.83 on the test sets. Compared to the 4-Standard Deviation segmentation technique, our system was five times quicker (<1 min versus 7 ± 3 min), and required minimal user interaction. CONCLUSIONS Our solution successfully addresses different issues related to automatic MIS segmentation, including accuracy, time-effectiveness, and the automatic generation of a clinical report.
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Affiliation(s)
- Daniele M Papetti
- Department of Informatics, Systems and Communication, University of Milano-Bicocca, Viale Sarca 336, Milano 20126, Italy
| | - Kirsten Van Abeelen
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy
| | - Rhodri Davies
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK; MRC Unit for Lifelong Health and Ageing, University College London, London WC1E 6DD, UK
| | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy
| | - Francesca Heilbron
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy
| | - Francesco P Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy
| | - Jessica Artico
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Andreas Seraphim
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK; Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London EC1A 7BE, UK
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London WC1E 6DD, UK; Barts Heart Centre, St Bartholomew's Hospital, West Smithfield, London EC1A 7BE, UK
| | - Gianfranco Parati
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, MD, USA.
| | - Peter Kellman
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre (B4), University of Milano-Bicocca, Vedano al Lambro 20854, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan 20126, Italy; Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy
| | - Daniela Besozzi
- Department of Informatics, Systems and Communication, University of Milano-Bicocca, Viale Sarca 336, Milano 20126, Italy; Bicocca Bioinformatics Biostatistics and Bioimaging Centre (B4), University of Milano-Bicocca, Vedano al Lambro 20854, Italy.
| | - Marco S Nobile
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre (B4), University of Milano-Bicocca, Vedano al Lambro 20854, Italy; Department of Environmental Sciences, Informatics and Statistics, Ca' Foscari University of Venice, Via Torino 155, Mestre, Venice 30172, Italy.
| | - Camilla Torlasco
- Department of Cardiology, IRCCS Istituto Auxologico Italiano, Via Magnasco 2, Milan 20145, Italy.
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24
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Ciampi P, Badano LP, Florescu DR, Villella F, Tomaselli M, Torlasco C, Gavazzoni M, Parati G, Muraru D. Comparison of RA Volumes Obtained Using the Standard Apical 4-Chamber and the RV-Focused Views. JACC Cardiovasc Imaging 2023; 16:248-250. [PMID: 36648037 DOI: 10.1016/j.jcmg.2022.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 07/20/2022] [Accepted: 08/30/2022] [Indexed: 11/17/2022]
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25
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Genovese D, Badano LP, Perazzolo Marra M. Left atrial volume and left ventricular mass for pulmonary capillary wedge pressure assessment with cardiovascular magnetic resonance: accurate enough for clinical use? Eur Heart J 2023; 44:425-426. [PMID: 36514969 DOI: 10.1093/eurheartj/ehac739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Davide Genovese
- Cardiology Unit, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Azienda Ospedaliera di Padova, Via Giustiniani, 2, Padova 35128, Italy.,Cardiology Unit, Cardio-Neuro-Vascular Department, Ca Foncello Treviso Hospital, Piazzale Ospedale 1, Treviso 31100, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Piazza dellAteneo Nuovo 1, Milan 20126, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Piazzale Brescia 20, Milan 20149, Italy
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Azienda Ospedaliera di Padova, Via Giustiniani, 2, Padova 35128, Italy
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26
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Baratto C, Caravita S, Corbetta G, Soranna D, Zambon A, Dewachter C, Gavazzoni M, Heilbron F, Tomaselli M, Radu N, Perelli FP, Perego GB, Vachiéry JL, Parati G, Badano LP, Muraru D. Impact of severe secondary tricuspid regurgitation on rest and exercise hemodynamics of patients with heart failure and a preserved left ventricular ejection fraction. Front Cardiovasc Med 2023; 10:1061118. [PMID: 36937944 PMCID: PMC10014840 DOI: 10.3389/fcvm.2023.1061118] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/06/2023] [Indexed: 03/06/2023] Open
Abstract
Background Both secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problems in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified. Aim To explore the impact of STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF. Methods We analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age-, sex-, and body mass index (BMI)- matched HFpEF patients with mild or no STR (HFpEF-controls). Results Twelve HFpEF with atrial-STR (mean age 72 years, 92% females, BMI 28 Kg/m2) and 12 HFpEF-controls patients were analyzed. HFpEF-STR had higher (p < 0.01) right atrial pressure than HFpEF-controls both at rest (10 ± 1 vs. 5 ± 1 mmHg) and during exercise (23 ± 2 vs. 14 ± 2 mmHg). Despite higher pulmonary artery wedge pressure (PAWP) at rest in HFpEF-STR than in HFpEF-controls (17 ± 2 vs. 11 ± 2, p = 0.04), PAWP at peak exercise was no more different (28 ± 2 vs. 29 ± 2). Left ventricular transmural pressure and cardiac output (CO) increased less in HFpEF-STR than in HFpEF-controls (interaction p-value < 0.05). This latter was due to lower stroke volume (SV) values both at rest (48 ± 9 vs. 77 ± 9 mL, p < 0.05) and at peak exercise (54 ± 10 vs. 93 ± 10 mL, p < 0.05). Despite these differences, the two groups of patients laid on the same oxygen consumption isophlets because of the increased peripheral oxygen extraction in HFpEF-STR (p < 0.01). We found an inverse relationship between pulmonary vascular resistance and SV, both at rest and at peak exercise (R 2 = 0.12 and 0.19, respectively). Conclusions Severe STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, undermining the typical HFpEF pathophysiology.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Bergamo, Italy
- *Correspondence: Sergio Caravita
| | - Giorgia Corbetta
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milan, Italy
| | - Céline Dewachter
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Mara Gavazzoni
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Noela Radu
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Francesco Paolo Perelli
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Jean-Luc Vachiéry
- Department of Cardiology, Hôpital Académique Erasme, Cliniques Universitaires de Bruxelles, Brussels, Belgium
| | - Gianfranco Parati
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Ospedale San Luca, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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27
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Muraru D, Baldea SM, Genovese D, Tomaselli M, Heilbron F, Gavazzoni M, Radu N, Sergio C, Baratto C, Perelli F, Curti E, Parati G, Badano LP. Association of outcome with left ventricular volumes and ejection fraction measured with two- and three-dimensional echocardiography in patients referred for routine, clinically indicated studies. Front Cardiovasc Med 2022; 9:1065131. [PMID: 36620642 PMCID: PMC9815115 DOI: 10.3389/fcvm.2022.1065131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives We sought to analyze if left ventricular (LV) volumes and ejection fraction (EF) measured by three-dimensional echocardiography (3DE) have incremental prognostic value over measurements obtained from two-dimensional echocardiography (2DE) in patients referred to a high-volume echocardiography laboratory for routine, clinically-indicated studies. Methods We measured LV volumes and EF using both 2DE and 3DE in 725 consecutive patients (67% men; 59 ± 18 years) with various clinical indications referred for a routine clinical study. Results LV volumes were significantly larger, and EF was lower when measured by 3DE than 2DE. During follow-up (3.6 ± 1.2 years), 111 (15.3%) all-cause deaths and 248 (34.2%) cardiac hospitalizations occurred. Larger LV volumes and lower EF were associated with worse outcome independent of age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart diseases). In stepwise Cox regression analyses, the associations of both death and cardiac hospitalization with clinical data (CD: age, creatinine, hemoglobin, atrial fibrillation, and ischemic heart disease) whose Harrel's C-index (HC) was 0.775, were augmented more by the LV volumes and EF obtained by 3DE than by 2DE parameters. The association of CD with death was not affected by LV end-diastolic volume (EDV) either measured by 2DE or 3DE. Conversely, it was incremented by 3DE LVEF (HC = 0.84, p < 0.001) more than 2DE LVEF (HC = 0.814, p < 0.001). The association of CD with the composite endpoint (HC = 0.64, p = 0.002) was augmented more by 3DE LV EDV (HC = 0.786, p < 0.001), end-systolic volume (HC = 0.801, p < 0.001), and EF (HC = 0.84, p < 0.001) than by the correspondent 2DE parameters (HC = 0.786, HC = 0.796, and 0.84, all p < 0.001) In addition, partition values for mild, moderate and severe reduction of the LVEF measured by 3DE showed a higher discriminative power than those measured by 2DE for cardiac death (Log-Rank: χ2 = 98.3 vs. χ2 = 77.1; p < 0.001). Finally, LV dilation defined according to the 3DE threshold values showed higher discriminatory power and prognostic value for death than when using 2DE reference values (3DE LVEDV: χ2 = 15.9, p < 0.001 vs. χ2 = 10.8, p = 0.001; 3DE LVESV: χ2 = 24.4, p < 0.001 vs. χ2 = 17.4, p = 0.001). Conclusion In patients who underwent routine, clinically-indicated echocardiography, 3DE LVEF and ESV showed stronger association with outcome than the corresponding 2DE parameters.
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Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Sorina Mihaila Baldea
- Department of Cardiology, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Davide Genovese
- Cardiology Unit, Cardio-Neuro-Vascular Department, Ca’ Foncello Hospital, Treviso, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Noela Radu
- Department of Cardiology, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Caravita Sergio
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Emanuele Curti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P. Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy,*Correspondence: Luigi P. Badano,
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28
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Torlasco C, Papetti DM, Sabatini M, Muscogiuri G, Castelletti S, Xue H, Kellman P, Parati G, Badano LP, Nobile MS, Besozzi D. 506 TECHNIQUES OF ARTIFICIAL INTELLIGENCE FOR THE DETERMINATION OF THE OPTIMAL INVERSION TIME: THE THAITI PROJECT. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Introduction
Identifying the optimal Inversion Time (TI) is pivotal to null the myocardium and obtain high quality cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Setting the optimal TI can be challenging in some diseases and for less experienced operators. We propose an Artificial Intelligence (AI) tool to automatically predict the optimal TI in CMR-LGE imaging.
Methods
The AI tool, named THAITI, consists of a Random Forest regression model whose hyperparametrs were optimized by means of evolutionary computation. The model considers as input parameters patient-specific TI determinants, such as age, gender, weight, height, kidney function, heart rate, contrast dose, and time from injection to image acquisition. THAITI was trained on 155 patients (2588 CMR-LGE images) with mixed cardiac conditions who underwent CMR (1.5T Siemens AvantoFit; Gadovist; averaged, motion-corrected, free-breathing true-FISP IR). Clinical testing was performed on 55 matched patients, randomized to experimental (THAITI-set TI) vs control (experienced operator-set TI) group. A user interface was developed for clinical testing. Image quality was assessed blindly by 2 independent experienced operators.
Results
THAITI Mean Squared Error (MSE) in the validation set was 4.7 and percentage of mispredicted TI of 4.5%. During clinical testing, LGE quality did not differ between the experimental vs control group: quality was “optimal” or “good” in 96% vs 93%, “poor” in 4% vs 7%. The average number of LGE images acquired and LGE imaging duration were similar (experimental vs control group: 17 ± 3 vs 16 ± 3 LGE images per patient; 12:14 vs 12:20 mm:ss, respectively).
Conclusion
THAITI efficiently predicts optimal TI for CMR-LGE imaging. Further development is needed to increase generalizability (multi-vendor, multi-sequence, multi-contrast) and to test its potential to improve LGE image quality and reduce the need for repeated imaging for inexperienced operators. Figure 1. Top panel: THAITI interface. Bottom panel: examples of experimental group LGE imaging. Table 1. Control vs experimental group. Data expressed as absolute number (%), mean ±SD
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Affiliation(s)
| | | | - Maria Sabatini
- IRCCS Istituto Auxologico Italiano
- Università Politecnica Delle Marche
| | | | | | - Hui Xue
- National Institutes Of Health
| | | | - Gianfranco Parati
- IRCCS Istituto Auxologico Italiano
- Università Degli Studi Di Milano-Bicocca
| | - Luigi P Badano
- IRCCS Istituto Auxologico Italiano
- Università Degli Studi Di Milano-Bicocca
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Caravita S, Baratto C, Filippo A, Soranna D, Battista Perego G, Muraru D, Badano LP, Parati G. 1017 CLINICAL AND HEMODYNAMIC CHARACTERISTICS ASSOCIATED WITH LATENT PULMONARY VASCULAR DISEASE IN HEART FAILURE WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Among patients with heart failure and a preserved left ventricular ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, with potential clinical implication, i.e. latent pulmonary vascular disease (PVD). HFpEF patients with latent PVD have been shown to have worse outcome after creation of an interatrial septal shunt. However, the pathophysiological significance of latent PVD in HFpEF has not been thoroughly investigated.
Methods
We retrospectively analyzed our cohort of consecutive patients with HFpEF who have undergone a right heart catheterization at rest and during exercise between 2016 and 2020. HFpEF was defined based on a resting and/or exercise hemodynamics: pulmonary artery wedge pressure (PAWP) > 15 mmHg at rest; PAWP during exercise >= 25 mmHg; PAWP/cardiac output (CO) slope > 2 mmHg/L/min. Latent PVD was defined based on exercise pulmonary vascular resistance (PVR) > 1.74 WU.
Results
Out of 199 exercise right heart catheterization, 86 patients had a hemodynamic diagnosis of HFpEF. Of these, 68 (79%) qualified as HFpEF without PVD (HFpEF-PVR-) and 16 (21%) qualified as latent PVD (HFpEF-PVR+). HFpEF-PVR+ were older, presented more frequently with diabetes mellitus or glucose intolerance, had higher H2FPEF and HFA-PEFF scores, slightly lower LVEF, had more frequently a history of atrial fibrillation and had more frequently at tricuspid regurgitation ≥ moderate (p<0.05). HFpEF-PVR+ had more frequently high PVR (> 2 WU) also at rest (72% vs 10%, p<0.001). At rest and only in HFpEF-PVR+, PVR was directly associated with PaCO2 (R2=0.21), while at peak exercise PVR was inversely associated with PvO2 as well as with stroke volume index (R2=0.32 and 0.31, respectively). HFpEF-PVR+ presented with a lack of decrease in PVR during exercise, higher mPAP both at rest and during exercise (p<0.05) in spite of non-different mean PAWP, and lower CO increase during exercise (p<0.05) in spite of similar CO at rest (Figure). HFpEF-PVD presented more frequently with exercise-induced tall V waves in the right atrium (50% vs 16%, p=0.002), indicating severe tricuspid regurgitation.
Conclusions
HFpEF-PVR+ is associated with peculiar clinical and hemodynamic characteristics, reflecting a more advanced and polycomorbid HFpEF profile, characterized by heightened pulmonary vascular reactivity and overt cardiac limitation to exercise.
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Affiliation(s)
- Sergio Caravita
- Istituto Auxologico Italiano Irccs Ospedale San Luca
- Università Degli Studi Di Bergamo
| | | | - Aurora Filippo
- Istituto Auxologico Italiano Irccs Ospedale San Luca
- Università Degli Studi Di Milano-Bicocca
| | | | | | - Denisa Muraru
- Istituto Auxologico Italiano Irccs Ospedale San Luca
- Università Degli Studi Di Milano-Bicocca
| | - Luigi P Badano
- Istituto Auxologico Italiano Irccs Ospedale San Luca
- Università Degli Studi Di Milano-Bicocca
| | - Gianfranco Parati
- Istituto Auxologico Italiano Irccs Ospedale San Luca
- Università Degli Studi Di Milano-Bicocca
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Baratto C, Caravita S, Corbetta G, Soranna D, Zambon A, Parati G, Badano LP, Muraru D. 588 EXPLORING THE IMPACT OF SEVERE SECONDARY TRICUSPID REGURGITATION ON REST AND EXERCISE HEMODYNAMICS OF PATIENTS WITH HEART FAILURE AND A PRESERVED LEFT VENTRICULAR EJECTION FRACTION. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Both secondary tricuspid regurgitation (STR) and heart failure with preserved ejection fraction (HFpEF) are relevant public health problem in the elderly population, presenting with potential overlaps and sharing similar risk factors. However, the impact of severe STR on hemodynamics and cardiorespiratory adaptation to exercise in HFpEF remains to be clarified.
Aim
To explore the impact of severe STR on exercise hemodynamics and cardiorespiratory adaptation in HFpEF.
Methods
We analyzed invasive hemodynamics and gas-exchange data obtained at rest and during exercise from HFpEF patients with severe STR (HFpEF-STR), compared with 1:1 age, sex and body mass index matched HFpEF patients with mild or no STR (HFpEF-controls).
Results
13 HFpEF-STR (mean age 72 years, 85% females, BMI 28 Kg/m2) and 13 age-, sex-, and BMI-matched HFpEF-controls patients were included. HFpEF-STR had higher (p<0.01) right atrial pressure than HFpEF-controls both at rest (10±1 vs 5±1 mmHg) and during exercise (23±2 vs 14±2). During exercise, pulmonary artery wedge pressure as well as left ventricular transmural pressure increased less in HFpEF-STR than in HFpEF-controls (interaction p-value<0.05). Similarly, cardiac output (CO) increased less in HFpEF-STR than in HFpEF-controls (interaction p-value<0.05) during exercise, due to the lower stroke volume (SV) values both at rest (49±8 vs 78±8, p<0.05) and at peak exercise (55±9 vs 92±9 mL, p<0.05). Despite these differences, the two groups of patients laid on the same oxygen consumption isophlets because of the increased peripheral oxygen extraction in HFpEF-STR (p<0.01). An inverse relationship was found between pulmonary vascular resistance and SV, both at rest and at peak exercise (R2=0.12 and 0.19, respectively).
Conclusions
Severe STR complicating HFpEF impairs SV and CO reserve, leading to pulmonary vascular de-recruitment and relative left heart underfilling, mining the typical HFpEF pathophysiology.
Exercise pathophysiology of secondary tricuspid regurgitation (STR) in heart failure with preserved ejection fraction (HFpEF).
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Affiliation(s)
- Claudia Baratto
- Dipartimento Di Cardiologia, IRCCS Istituto Auxologico Italiano , Milano
| | - Sergio Caravita
- Dipartimento Di Cardiologia, IRCCS Istituto Auxologico Italiano , Milano
- Dipartimento Di Ingegneria, Università Di Bergamo , Dalmine
| | - Giorgia Corbetta
- Dipartimento Di Medicina E Chirurgia, Università Degli Studi Milano-Bicocca , Milano
| | - Davide Soranna
- Unità Di Biostatistica, IRCCS Istituto Auxologico Italiano , Milano
| | - Antonella Zambon
- Unità Di Biostatistica, IRCCS Istituto Auxologico Italiano , Milano
| | - Gianfranco Parati
- Dipartimento Di Cardiologia, IRCCS Istituto Auxologico Italiano , Milano
- Dipartimento Di Medicina E Chirurgia, Università Degli Studi Milano-Bicocca , Milano
| | - Luigi P Badano
- Dipartimento Di Cardiologia, IRCCS Istituto Auxologico Italiano , Milano
- Dipartimento Di Medicina E Chirurgia, Università Degli Studi Milano-Bicocca , Milano
| | - Denisa Muraru
- Dipartimento Di Cardiologia, IRCCS Istituto Auxologico Italiano , Milano
- Dipartimento Di Medicina E Chirurgia, Università Degli Studi Milano-Bicocca , Milano
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Gavazzoni M, Heilbron F, Badano LP, Radu N, Cascella A, Tomaselli M, Perelli F, Caravita S, Baratto C, Parati G, Muraru D. The atrial secondary tricuspid regurgitation is associated to more favorable outcome than the ventricular phenotype. Front Cardiovasc Med 2022; 9:1022755. [PMID: 36523369 PMCID: PMC9744784 DOI: 10.3389/fcvm.2022.1022755] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
AimWe sought to evaluate the differences in prognosis between the atrial (A-STR) and the ventricular (V-STR) phenotypes of secondary tricuspid regurgitation.Materials and methodsConsecutive patients with moderate or severe STR referred for echocardiography were enrolled. A-STR and V-STR were defined according to the last ACC/AHA guidelines criteria. The primary endpoint was the composite of all-cause death and heart failure (HF) hospitalizations.ResultsA total of 211 patients were enrolled. The prevalence of A-STR in our cohort was 26%. Patients with A- STR were significantly older and with lower NYHA functional class than V-STR patients. The prevalence of severe STR was similar (28% in A-STR vs. 37% in V-STR, p = 0.291). A-STR patients had smaller tenting height (TH) (10 ± 4 mm vs. 12 ± 7 mm, p = 0.023), larger end-diastolic tricuspid annulus area (9 ± 2 cm2 vs. 7 ± 6 cm2/m2, p = 0.007), smaller right ventricular (RV) end-diastolic volumes (72 ± 27 ml/m2 vs. 92 ± 38 ml/m2; p = 0.001), and better RV longitudinal function (18 ± 7 mm vs. 16 ± 6 mm; p = 0.126 for TAPSE, and −21 ± 5% vs. −18 ± 5%; p = 0.006, for RV free-wall longitudinal strain, RVFWLS) than V-STR patients. Conversely, RV ejection fraction (RVEF, 48 ± 10% vs. 46 ± 11%, p = 0.257) and maximal right atrial volumes (64 ± 38 ml/m2 vs. 55 ± 23 ml/m2, p = 0.327) were similar between the two groups. After a median follow-up of 10 months, patients with V-STR had a 2.7-fold higher risk (HR: 2.7, 95% CI 95% = 1.3–5.7) of experiencing the combined endpoint than A-STR patients. The factors related to outcomes resulted different between the two STR phenotypes: TR-severity (HR: 5.8, CI 95% = 1, 4–25, P = 0.019) in A-STR patients; TR severity (HR 2.9, 95% CI 1.4–6.3, p = 0.005), RVEF (HR: 0.97, 95% CI 0.94–0.99, p = 0.044), and RVFWLS (HR: 0.93, 95% CI 0.85–0.98, p = 0.009) in V-STR.ConclusionAlmost one-third of patients referred to the echocardiography laboratory for significant STR have A-STR. A-STR patients had a lower incidence of the combined endpoint than V-STR patients. Moreover, while TR severity was the only independent factor associated to outcome in A-STR patients, TR severity and RV function were independently associated with outcome in V-STR patients.
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Affiliation(s)
- Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P. Badano
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- *Correspondence: Luigi P. Badano,
| | - Noela Radu
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Emergency University Hospital Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Bucharest, Romania
| | - Andrea Cascella
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Francesco Perelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Management, Information, and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Soliman-Aboumarie H, Joshi SS, Cameli M, Michalski B, Manka R, Haugaa K, Demirkiran A, Podlesnikar T, Jurcut R, Muraru D, Badano LP, Dweck MR. EACVI survey on the multi-modality imaging assessment of the right heart. Eur Heart J Cardiovasc Imaging 2022; 23:1417-1422. [PMID: 36093580 DOI: 10.1093/ehjci/jeac183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the use of different cardiac imaging modalities for the evaluation of the right heart. METHODS AND RESULTS Delegates from 250 EACVI registered centres were invited to participate in a survey which was also advertised on the EACVI bulletin and on social media. One hundred and thirty-eight respondents from 46 countries across the world responded to the survey. Most respondents worked in tertiary centres (79%) and echocardiography was reported as the commonest imaging modality used to assess the right ventricle (RV). The majority of survey participants (78%) included RV size and function in >90% of their echocardiographic reports. The RV basal diameter obtained from the apical four-chamber view and the tricuspid annular plane systolic excursion were the commonest parameters used for the echocardiographic assessment of RV size and function as reported by 82 and 97% respondents, respectively. Survey participants reported arrhythmogenic cardiomyopathy as the commonest condition (88%) where cardiac magentic resonance (CMR) imaging was used for right heart assessment. Only 52% respondents included RV volumetric and ejection fraction assessments routinely in their CMR reports, while 30% of respondents included these parameters only when RV pathology was suspected. Finally, 73% of the respondents reported pulmonary hypertension as the commonest condition where right heart catheterization was performed. CONCLUSION Echocardiography remains the most frequently used imaging modality for the evaluation of the right heart, while the use of other imaging techniques, most notably CMR, is increasing.
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Affiliation(s)
- Hatem Soliman-Aboumarie
- Department of Anaesthetics and Critical Care, Harefield Hospital, Royal Brompton and Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK
- School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Shruti S Joshi
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - Matteo Cameli
- Division of Cardiology, University of Siena, Siena, Italy
| | - Blazej Michalski
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Robert Manka
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Institute for Biomedical Engineering, University and ETH Zurich, Zurich, Switzerland
| | - Kristina Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Norway and Faculty of Medicine, Huddinge Karolinska Institute and Cardiovascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Ahmet Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Tomaz Podlesnikar
- Department of Cardiac Surgery, University Medical Centre Maribor, Maribor, Slovenia
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ruxandra Jurcut
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases, 'Carol Davila' University of Medicine and Pharmacy, Bucharest, Romania
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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Muscogiuri G, Volpato V, Cau R, Chiesa M, Saba L, Guglielmo M, Senatieri A, Chierchia G, Pontone G, Dell’Aversana S, Schoepf UJ, Andrews MG, Basile P, Guaricci AI, Marra P, Muraru D, Badano LP, Sironi S. Application of AI in cardiovascular multimodality imaging. Heliyon 2022; 8:e10872. [PMID: 36267381 PMCID: PMC9576885 DOI: 10.1016/j.heliyon.2022.e10872] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/23/2022] [Accepted: 09/27/2022] [Indexed: 12/16/2022] Open
Abstract
Technical advances in artificial intelligence (AI) in cardiac imaging are rapidly improving the reproducibility of this approach and the possibility to reduce time necessary to generate a report. In cardiac computed tomography angiography (CCTA) the main application of AI in clinical practice is focused on detection of stenosis, characterization of coronary plaques, and detection of myocardial ischemia. In cardiac magnetic resonance (CMR) the application of AI is focused on post-processing and particularly on the segmentation of cardiac chambers during late gadolinium enhancement. In echocardiography, the application of AI is focused on segmentation of cardiac chambers and is helpful for valvular function and wall motion abnormalities. The common thread represented by all of these techniques aims to shorten the time of interpretation without loss of information compared to the standard approach. In this review we provide an overview of AI applications in multimodality cardiac imaging.
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Affiliation(s)
- Giuseppe Muscogiuri
- Department of Radiology, Istituto Auxologico Italiano IRCCS, San Luca Hospital, Italy,School of Medicine, University of Milano-Bicocca, Milan, Italy,Corresponding author.
| | - Valentina Volpato
- Department of Cardiac, Neurological and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano IRCCS, Milan, Italy,IRCCS Ospedale Galeazzi - Sant'Ambrogio, University Cardiology Department, Milan, Italy
| | - Riccardo Cau
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari, Polo di Monserrato, Cagliari, Italy
| | | | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari, Polo di Monserrato, Cagliari, Italy
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht University Medical Center, Utrecht, the Netherlands
| | | | | | | | - Serena Dell’Aversana
- Department of Radiology, Ospedale S. Maria Delle Grazie - ASL Napoli 2 Nord, Pozzuoli, Italy
| | - U. Joseph Schoepf
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr., Charleston, SC, USA
| | - Mason G. Andrews
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, 25 Courtenay Dr., Charleston, SC, USA
| | - Paolo Basile
- University Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Paolo Marra
- Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Denisa Muraru
- School of Medicine, University of Milano-Bicocca, Milan, Italy,Department of Cardiac, Neurological and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Luigi P. Badano
- School of Medicine, University of Milano-Bicocca, Milan, Italy,Department of Cardiac, Neurological and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Sandro Sironi
- School of Medicine, University of Milano-Bicocca, Milan, Italy,Department of Radiology, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
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Caravita S, Baratto C, Gallone GP, Faini A, Dewachter C, Senni M, Badano LP, Vachiery JL, Parati G. Is pulmonary artery wedge pressure a reliable surrogate of left ventricular end-diastolic pressure during exercise for diagnosing HFpEF in patients with unexplained dyspnea? Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Left ventricular end-diastolic pressure (LVEDP) is the gold-standard for the assessment of LV filling pressure. For practical reasons, pulmonary artery wedge pressure (PAWP) is used as a surrogate for LVEDP. However, the interposition of the left atrium (LA) may account discrepancies between LVEDP and PAWP. The imprecision of both end-diastolic (or mid-A) and mean PAWP estimates for LVEDP has been widely described for cardiac catheterization at rest. PAWP measurement during exercise has been advocated to discriminate heart failure with preserved ejection fraction (HFpEF) from non-cardiac dyspnea, with an end-expiratory pathologic threshold ≥25 mmHg. However, a formal comparison of PAWP (either mid-A or mean PAWP) vs LVEDP during exercise has never been performed.
Aim
To compare LVEDP and PAWP during exercise.
Methods
We retrospectively analyzed consecutive patients with unexplained dyspnea and a normal LV ejection fraction, who had a clinical indication of right and left heart catheterization at rest and during exercise to assess unexplained dyspnea. Patients with mitral regurgitation ≥ moderate were excluded. Hemodynamic measurements were always taken at end-expiration.
Results
Forty-six consecutive patients were included in the analysis (80% with a peak mean PAWP ≥25 mmHg). We found a good correlation between both mid-A and mean PAWP on one side, and LVEDP on the other side (R2>0.55). At peak exercise, mid-A PAWP had no bias as compared with LVEDP, while mean PAWP slightly overestimated LVEDP by 1–2 mmHg. However, confidence intervals were quite large (Figure 1), suggesting imprecision of PAWP estimates for LVEDP in the individual patient. A disagreement between mean PAWP and LVEDP, using a threshold of ≥25 mmHg for both variables at peak exercise, was found in 11% of patients. In 4% of them, mean PAWP was ≥25 but LVEDP <25 mmHg, due to the appearance of tall V waves in the PAWP position (LA stiffness), increasing PAWP above LVEDP. In the remaining 7%, LVEDP was ≥25 but PAWP <25 mmHg. The latter patients, in whom HFpEF would have not been diagnosed based on peak PAWP alone, showed a PAWP increase during exercise relative to cardiac output changes (PAWP/CO slope) >2 mmHg/L/min, as an alternative parameter suggesting HFpEF.
Conclusions
In patients with unexplained exertional breathlessness, both mid-A and mean PAWP showed good correlation with LVEDP during exercise with minimal average bias, but their ability to estimate LVEDP was burdened by a relevant imprecision. Therefore, when in these patients peak PAWP is <25 mmHg, its assessment might need to be complemented by additional measurements (including LVEDP or PAWP/CO slope) to maximize the diagnostic power of exercise cardiac catheterization in identifying HFpEF.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
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Affiliation(s)
- S Caravita
- University of Bergamo and Istituto Auxologico Italiano , Bergamo , Italy
| | - C Baratto
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G P Gallone
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - A Faini
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | | | - M Senni
- ASST Papa Giovanni XXIII Bergamo , Bergamo , Italy
| | - L P Badano
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | | | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Tondi L, Figliozzi S, Badano LP, Torlasco C, Disabato G, Pica S, Camporeale A, Muraru D, Lombardi M. Cardiac magnetic resonance feature-tracking analysis of left atrial volumes and function in standard vs left-atrial focused images. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Left atrial (LA) volume and function have shown prognostic value in several cardiac conditions. Routine cardiac magnetic resonance (CMR) evaluation of the LA is obtained from standard 2- and 4-chamber long-axis cine images focused on the left ventricle. Previous echocardiographic data showed that LA-focused apical views provide a more accurate estimation of LA maximum volume, as compared to standard apical images. CMR LA-focused imaging could improve the accuracy of LA morpho-functional analysis. CMR feature-tracking (CMR-FT) analysis is emerging as a feasible semi-automatic tool for the evaluation of LA volumes and function.
Purpose
To investigate the potential of LA-focused CMR cine images using LA CMR-FT analysis.
Methods
100 consecutive patients clinically referred to CMR were included in this prospective, observational, multicenter study. LA volumes (LAVmax, LAVmin), emptying fraction (EF), atrial strain reservoir (ɛs), conduit (ɛe), booster (ɛa) and strain rate reservoir (SRɛs) were calculated by CMR-FT analysis on both standard and LA-focused 2- and 4-chamber long-axis cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method (RefMeth) for LA volumes and EF.
Results
In comparison to the RefMeth, the standard acquisitions underestimated LA volumes (LAVmax: bias = −8ml, LOA = +20, −35ml; LAVmin: bias = −6 ml, LOA = +15, −27ml) and slightly overestimated EF (bias = +3%, LOA = +17, −11%). Conversely, LA-focused images provided a more accurate estimation (LAV max bias = −1ml, LOA = +11, −9ml; LAV min bias = −2ml, LOA = +12, −7ml) and EF (bias = −2%, LOA = +9, −12%). All three LA strain (εs: bias 7%, LOA = 25, −11%; εe: bias 4%, LOA = 15, −8%; εa: bias 3%, LOA = 14, −8%) and SRεs (bias 0.2 s–1, LOA = 1.13, −0.7 s–1) were significantly higher in standard vs LA-focused images (all p<0.001).
Conclusions
Assessment of LA volumes using CMR-FT applied to dedicated LA-focused long-axis cine images is more accurate than the use of standard acquisitions. LA strain and SRɛs obtained from LA-focused images are significantly lower than those obtained from standard LA acquisitions, possibly due to the inclusion in LA-focused images of LA posterior wall, where pulmonary veins convey and atrial deformation is blunted.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- L Tondi
- IRCCS San Donato Polyclinic, Multimodality Cardiac Imaging Section , Milan , Italy
| | - S Figliozzi
- Humanitas Research Hospital, Cardiology , Milan , Italy
| | - L P Badano
- IRCCS Istituto Auxologico Italiano, Cardiology , Milan , Italy
| | - C Torlasco
- IRCCS Istituto Auxologico Italiano, Cardiology , Milan , Italy
| | - G Disabato
- Policlinic Foundation San Matteo IRCCS , Pavia , Italy
| | - S Pica
- IRCCS San Donato Polyclinic, Multimodality Cardiac Imaging Section , Milan , Italy
| | - A Camporeale
- IRCCS San Donato Polyclinic, Multimodality Cardiac Imaging Section , Milan , Italy
| | - D Muraru
- IRCCS Istituto Auxologico Italiano, Cardiology , Milan , Italy
| | - M Lombardi
- IRCCS San Donato Polyclinic, Multimodality Cardiac Imaging Section , Milan , Italy
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Baratto C, Caravita S, Dewachter C, Faini A, Perego GB, Senni M, Muraru D, Badano LP, Parati G, Vachiery JL. Right heart adaptation during exercise in pulmonary arterial hypertension and in pulmonary hypertension due to heart failure with preserved ejection fraction. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Right heart failure (RHF) represents the final step of distinct diseases, such as pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF). RHF may be defined by the inability of the heart to maintain a normal cardiac output (CO) or to do so at the expense of high right atrial pressure (RAP), at rest or during exercise.
However, exercise hemodynamic features suggestive of RHF, as well as their determinants, have still not been defined.
Aim
We sought to i. define the limits of normal of RAP increase during exercise; ii. describe the behavior of RAP during exercise in PAH and in PH-HFpEF, and its relation to right heart afterload and preload.
Methods
We retrospectively analyzed data from consecutive patients referred for suspicion of PH, who underwent both a resting and exercise right heart catheterization at two centers with identical methodology. We included patients with PH-HFpEF or PAH. Right heart adaptation to exercise was described either using absolute or CO-normalized RAP increase during exercise (RAP/CO slope), this latter representing the inverse of the Frank-Starling reserve. A control cohort of subjects with normal hemodynamics at rest and during exercise served to define abnormal increase in RAP, i.e. values of RAP and RAP/CO slope > mean ± 2 standard deviation of controls.
Estimated stressed blood volume (eSBV), as a measure of effective preload, was computed using a commercially-available software.
Results
80 patients were included in the analysis, of which 29 were PH-HFpEF, 30 PAH and 21 controls.
HFpEF patients were older than PAH patients and with a higher burden of cardiovascular comorbidities (p<0.05). Sex representation, BMI, and NTproBNP values were similar in the two groups.
Mean pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR) and total vascular resistance (TPR) were higher in PAH than in PH-HFpEF both at rest and during exercise (p<0.01), in spite of similar CO (Table 1). At rest, eSBV did not differ between HFpEF and PAH, but it was higher in HFpEF at peak exercise.
On average, PH-HFpEF had higher resting and peak RAP than PAH, as well as higher RAP/CO slope (Figure 1).
The upper limit of normal of exercise RAP and of RAP/CO slope, as determined in control subject, was 12 mmHg and 1.55 mmHg/L/min. A higher rate of HFpEF patients, compared with PAH, had a RAP/CO slope and a peak RAP above normal limits (78% and 91% of PH-HFpEF vs 47% and 44% of PAH, respectively, p<0.001).
RAP/CO slope in the whole cohort was associated with eSBV but not with right ventricular afterload measures (PAP, TPR, PVR).
Conclusions
PH-HFpEF display more frequently a steeper increase of RAP during exercise than PAH patients in spite of similar CO, suggesting a more exhausted Frank-Starling reserve. The steep RAP increase during exercise seems to reflect a dysfunctional preload rather than an afterload-mismatch.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
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Affiliation(s)
- C Baratto
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - S Caravita
- University of Bergamo and Istituto Auxologico Italiano , Bergamo , Italy
| | | | - A Faini
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G B Perego
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - M Senni
- ASST Papa Giovanni XXIII Bergamo , Bergamo , Italy
| | - D Muraru
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - L P Badano
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Caravita S, Baratto C, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G. An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pulmonary hypertension (PH) is associated with a poor prognosis in patients with left heart disease (LHD). Several hemodynamic variables have been shown to predict outcome, including pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and the diastolic pressure gradient (DPG). We sought to provide an updated analysis on the association of these variables with prognosis in PH-LHD.
Methods
We performed a systematic literature review including studies reporting association measurements between DPG and/or PVR and/or PAC and death in PH-LHD patients. These hemodynamic variables were extracted to estimate the pooled hazard ratio (HR) of adverse outcome for each one, and cumulative meta-analysis was performed to investigate temporal trends in the effects reported in the literature as well as the impact of sample size.
Results
17 articles were identified, including 9716 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, we found that PVR (HR, 1.09; 95% CI: 1.06–1.12), DPG (HR, 1.02; 95% CI: 1.01–1.02) and PAC (HR, 0.73; 95% CI: 0.76–0.81) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG (Figure 1). Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD (either heart failure with preserved or reduced left ventricular ejection fraction, or valvular heart disease). Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018 (Figure 2).
Conclusions
Despite the heterogeneity of PH-LHD group and the intrinsic limitations of each variable, PVR, DPG, and PAC have an established prognostic value in PH-LHD. The strongest correlation with PVR and PAC supports their use in defining disease severity and identifying a subgroup of patients at higher risk of adverse outcome. We believe that these results are consistent through the years and unlikely to change with the addition of further studies.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
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Affiliation(s)
- S Caravita
- University of Bergamo and Istituto Auxologico Italiano , Bergamo , Italy
| | - C Baratto
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - D Soranna
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | | | - A Bondue
- CUB Hopital Erasme , Bruxelles , Belgium
| | - A Zambon
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - L P Badano
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Cascella A, Gavazzoni M, Muraru D, Heilbron F, Caravita S, Tomaselli M, Parati G, Badano LP. Prognostic power of a new index of right ventricle-pulmonary artery coupling based on right ventricular volumes in patients with secondary tricuspid regurgitation. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Although echocardiographic surrogates of right ventricular -arterial coupling (RVAC) have been reported to be associated with outcome in patients with moderate or severe secondary tricuspid regurgitation (STR), pulmonary artery systolic pressure (SPAP) is difficult to be estimated using echocardiography in patients with severe STR.
Purpose
Accordingly, we evaluated the predictive power of indexes of RVAC obtained using RV volumes measured using three-dimensional echocardiography (3DE).
Methods
We prospectively enrolled 180 patients with moderate or severe STR and complete two-dimensional, Doppler and 3DE data. The composite endpoint of death for any cause and heart failure hospitalization was used as primary outcome.
Results
After a median follow up of 24 months (IQR: 2–48), 72 patients (40%) reached the primary endpoint. Most of the echocardiographic parameters of RV function were associated with outcomes. Among the different parameters of RVAC, the receiver operating curve (ROC) analysis selected the ratio between (RV stroke volume [SV]-RegVol)/ RV End-systolic volume (ESV) (i.e. the RV forward SV/ESV) as the best predictor of the combined endpoint (AUC 0.80 [IC 95% 0.73–087]), with a threshold value of 0.49.
Event-free survival of patients with RV forward SV/ESV higher and lower 0.49 has been performed (Figure 1).
Multivariable Cox proportional hazards models were constructed (Figure 2). Adding sequentially the 3D-RVEF, TAPSE/SPAP and the forward RV SV/RV ESV on top of a basal model made of TR severity, New York Heart Association (NYHA) functional class and tricuspid anulus plane systolic excursion (TAPSE), the χ2 of the model increased from 40 to 43 (p=0.13) by adding 3D RVEF, from 43 to 46 (p=0.04) by adding TAPSE/SPAP, and from 46 to 51 (p=0.02) by adding RV forward SV/ESV. Severe TR (HR 3.53 [CI 95%: 1.84–6.78], p<0.001) and RV forward SV/ESV <0.49 (HR 2.45 [CI 95% 1.16–5.18], p=0.02) were the only parameters independently associated with outcome.
Conclusions
The RV forward SV/ESV is an index of RVAC obtained by 3DE which is independent from SPAP and it is strongly associated with the occurrence of death or heart failure hospitalization in patients with STR.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- A Cascella
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - M Gavazzoni
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - D Muraru
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - F Heilbron
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - S Caravita
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - M Tomaselli
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - L P Badano
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiery JL. A meta-analysis of exercise hemodynamics in heart failure with preserved ejection fraction: the relevance of PAWP/CO slope. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current hemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise hemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects.
Methods
We performed a systematic literature review following the PRISMA statement until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all hemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP / cardiac output (CO) slope during exercise was extrapolated.
Results
Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, HfpEF cohorts showed a summary estimate of PAWP at peak which was twice as high as compared with control cohorts (30; 95% CI: 29–31 mmHg and 16; 95% CI: 15–17 mmHg, respectively), as well as of delta PAWP (15; 95% CI: 14–16 mmHg and 7; 95% CI: 6–8 mmHg, respectively), and of right atrial pressure (18; 95% CI: 16–19 mmHg and 8; 95% CI: 8–9 mmHg, respectively). These differences persisted after adjustment for age, sex, body mass index, body position. Additionally, summary estimates of PAWP at peak performed during supine exercise was slightly higher than that obtained in upright position only for HFpEF cohorts (supine position: 31; 95% CI: 30–32 mmHg vs upright position; 26; 95% CI: 25–27 mmHg, respectively, p-value<0.01). However, peak PAWP values were highly heterogeneous among the cohorts (I2=93%), with a relative overlap with controls (Figure 1). HFpEF had a significantly larger impairment in the hemodynamic response to exercise, witnessed by a steeper summary PAWP/CO slope than controls (3.75; 95% CI: 3.20–4.28 mmHg/L/min and 0.95; 95% CI: 0.30–1.59 mmHg/L/min, p-value <0.0001), even after adjustment for covariates (p=0.007) (Figure 2). Finally, summary estimates of PAWP/CO slope were higher in HFpEF cohorts performing exercise in the supine position compared with those in upright position (p<0.0001 and p=0.0002 at non-adjusted and adjusted analysis, respectively), but not in control cohorts (p=0.135 and p=0.966 at non-adjusted and adjusted analysis, respectively).
Conclusions
Despite methodological heterogeneity across centers, the hemodynamic profile of HFpEF patients is consistent across studies and characterized by a higher left and right filling pressure at rest compared with controls, enhanced by physical exercise. A PAWP/CO slope cut-off >2 mmHg/L/min seems to retain validity also for studies conducted in the supine position, potentially overcoming the need of different supine and upright PAWP cut-offs.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
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Affiliation(s)
- C Baratto
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - S Caravita
- University of Bergamo and Istituto Auxologico Italiano , Bergamo , Italy
| | - D Soranna
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | | | - A Bondue
- CUB Hopital Erasme , Bruxelles , Belgium
| | - A Zambon
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - L P Badano
- Italian Auxological Institute San Luca Hospital , Milan , Italy
| | - G Parati
- Italian Auxological Institute San Luca Hospital , Milan , Italy
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. An updated meta-analysis of hemodynamics markers of prognosis in patients with pulmonary hypertension due to left heart disease. Pulm Circ 2022; 12:e12145. [PMID: 36568693 PMCID: PMC9768568 DOI: 10.1002/pul2.12145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/20/2022] [Accepted: 07/14/2022] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension (PH) is associated with a poor prognosis in left heart disease (LHD). We sought to provide an updated analysis on the association of hemodynamic variables, such as pulmonary vascular resistance (PVR), pulmonary artery compliance (PAC), and diastolic pressure gradient (DPG), with prognosis in PH-LHD, through a systematic literature review. Sixteen articles were identified, including 9600 patients with LHD, heterogeneous in terms of age, sex, and etiology of cardiac disease. In this large population, PVR (hazard ratio [HR], 1.07; 95% confidence interval [CI]: 1.05-1.0), DPG (HR, 1.02; 95% CI: 1.01-1.02) and PAC (HR, 0.76; 95% CI: 0.69-0.84) were associated with an increased risk of adverse outcome, albeit with a less solid performance of DPG. Similar results were found when hemodynamic variables were analyzed according to the thresholds commonly applied in clinical practice, or subdividing cohorts according to the underlying LHD. Furthermore, cumulative metanalysis indicated that these results are consistently stable since 2018. Thus, PVR, DPG and PAC have an established prognostic value in PH-LHD. These results are consistent through the years and unlikely to change with further studies.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Management, Information and Production EngineeringUniversity of BergamoDalmine (BG)Italy
| | - Davide Soranna
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antoine Bondue
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
| | - Antonella Zambon
- IRCCS Istituto Auxologico ItalianoBiostatistics UnitMilanItaly,Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano IRCCSOspedale San LucaMilanoItaly,Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanoItaly
| | - Jean‐Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de BruxellesHôpital Académique ErasmeBruxellesBelgium
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Baratto C, Caravita S, Soranna D, Dewachter C, Bondue A, Zambon A, Badano LP, Parati G, Vachiéry J. Exercise haemodynamics in heart failure with preserved ejection fraction: a systematic review and meta-analysis. ESC Heart Fail 2022; 9:3079-3091. [PMID: 35748109 PMCID: PMC9715813 DOI: 10.1002/ehf2.13979] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/08/2022] [Accepted: 05/08/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Exercise right heart catheterization (RHC) is considered the gold-standard test to diagnose heart failure with preserved ejection fraction (HFpEF). However, exercise RHC is an insufficiently standardized technique, and current haemodynamic thresholds to define HFpEF are not universally accepted. We sought to describe the exercise haemodynamics profile of HFpEF cohorts reported in literature, as compared with control subjects. METHODS AND RESULTS We performed a systematic literature review until December 2020. Studies reporting pulmonary artery wedge pressure (PAWP) at rest and peak exercise were extracted. Summary estimates of all haemodynamic variables were evaluated, stratified according to body position (supine/upright exercise). The PAWP/cardiac output (CO) slope during exercise was extrapolated. Twenty-seven studies were identified, providing data for 2180 HFpEF patients and 682 controls. At peak exercise, patients with HFpEF achieved higher PAWP (30 [29-31] vs. 16 [15-17] mmHg, P < 0.001) and mean right atrial pressure (P < 0.001) than controls. These differences persisted after adjustment for age, sex, body mass index, and body position. However, peak PAWP values were highly heterogeneous among the cohorts (I2 = 93%), with a relative overlap with controls. PAWP/CO slope was steeper in HFpEF than in controls (3.75 [3.20-4.28] vs. 0.95 [0.30-1.59] mmHg/L/min, P value < 0.0001), even after adjustment for covariates (P = 0.007). CONCLUSIONS Despite methodological heterogeneity, as well as heterogeneity of pooled haemodynamic estimates, the exercise haemodynamic profile of HFpEF patients is consistent across studies and characterized by a steep PAWP rise during exercise. More standardization of exercise haemodynamics may be advisable for a wider application in clinical practice.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Management, Information and Production EngineeringUniversity of BergamoDalmineItaly
| | - Davide Soranna
- Biostatistics UnitIRCCS Istituto Auxologico ItalianoMilanItaly
| | - Céline Dewachter
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Antoine Bondue
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
| | - Antonella Zambon
- Biostatistics UnitIRCCS Istituto Auxologico ItalianoMilanItaly
- Department of Statistic and Quantitative MethodsUniversity of Milano‐BicoccaMilanItaly
| | - Luigi P. Badano
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic SciencesIstituto Auxologico Italiano IRCCS, Ospedale San LucaMilanItaly
- Department of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | - Jean‐Luc Vachiéry
- Department of CardiologyHopital Universitaire de Bruxelles, Hôpital Académique Erasme808 Route de Lennik1070BruxellesBelgium
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Muraru D, Gavazzoni M, Heilbron F, Mihalcea DJ, Guta AC, Radu N, Muscogiuri G, Tomaselli M, Sironi S, Parati G, Badano LP. Reference ranges of tricuspid annulus geometry in healthy adults using a dedicated three-dimensional echocardiography software package. Front Cardiovasc Med 2022; 9:1011931. [PMID: 36176994 PMCID: PMC9513148 DOI: 10.3389/fcvm.2022.1011931] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundTricuspid annulus (TA) sizing is essential for planning percutaneous or surgical tricuspid procedures. According to current guidelines, TA linear dimension should be assessed using two-dimensional echocardiography (2DE). However, TA is a complex three-dimensional (3D) structure.AimIdentify the reference values for TA geometry and dynamics and its physiological determinants using a commercially available three-dimensional echocardiography (3DE) software package dedicated to the tricuspid valve (4D AutoTVQ, GE).MethodsA total of 254 healthy volunteers (113 men, 47 ± 11 years) were evaluated using 2DE and 3DE. TA 3D area, perimeter, diameters, and sphericity index were assessed at mid-systole, early- and end-diastole. Right atrial (RA) and ventricular (RV) end-diastolic and end-systolic volumes were also measured by 3DE.ResultsThe feasibility of the 3DE analysis of TA was 90%. TA 3D area, perimeter, and diameters were largest at end-diastole and smallest at mid-systole. Reference values of TA at end-diastole were 9.6 ± 2.1 cm2 for the area, 11.2 ± 1.2 cm for perimeter, and 38 ± 4 mm, 31 ± 4 mm, 33 ± 4 mm, and 34 ± 5 mm for major, minor, 4-chamber and 2-chamber diameters, respectively. TA end-diastolic sphericity index was 81 ± 11%. All TA parameters were correlated with body surface area (BSA) (r from 0.42 to 0.58, p < 0.001). TA 3D area and 4-chamber diameter were significantly larger in men than in women, independent of BSA (p < 0.0001). There was no significant relationship between TA metrics with age, except for the TA minor diameter (r = −0.17, p < 0.05). When measured by 2DE in 4-chamber (29 ± 5 mm) and RV-focused (30 ± 5 mm) views, both TA diameters resulted significantly smaller than the 4-chamber (33 ± 4 mm; p < 0.0001), and the major TA diameters (38 ± 4 mm; p < 0.0001) measured by 3DE. At multivariable linear regression analysis, RA maximal volume was independently associated with both TA 3D area at mid-systole (R2 = 0.511, p < 0.0001) and end-diastole (R2 = 0.506, p < 0.0001), whereas BSA (R2 = 0.526, p < 0.0001) was associated only to mid-systolic TA 3D area.ConclusionsReference values for TA metrics should be sex-specific and indexed to BSA. 2DE underestimates actual 3DE TA dimensions. RA maximum volume was the only independent echocardiographic parameter associated with TA 3D area in healthy subjects.
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Affiliation(s)
- Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Mara Gavazzoni
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- *Correspondence: Mara Gavazzoni
| | - Francesca Heilbron
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Diana J. Mihalcea
- University of Medicine and Pharmacy Carol Davila Bucharest, Emergency University Hospital Bucharest, Bucharest, Romania
| | - Andrada C. Guta
- Department of Cardiology, Methodist DeBakey Heart Center, Houston Methodist Hospital, Houston, TX, United States
| | - Noela Radu
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- University of Medicine and Pharmacy Carol Davila Bucharest, Emergency University Hospital Bucharest, Bucharest, Romania
| | - Giuseppe Muscogiuri
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Michele Tomaselli
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Sandro Sironi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Radiology Department, Azienda Socio Sanitaria Territoriale (ASST) Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Luigi P. Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Department of Cardiology, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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43
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Badano LP, Surkova E, Muraru D. Letter to the editor regarding 'Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study: prognostic value of cardiac magnetic resonance-derived right ventricular parameters substudy'. Eur Heart J Cardiovasc Imaging 2022; 23:e477-e478. [PMID: 35946058 DOI: 10.1093/ehjci/jeac159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luigi P Badano
- Department of Medicine and Surgery, University Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, MI, Italy.,Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Elena Surkova
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Part of Guy's and St. Thomas NHS Foundation Trust, London UB9 6JH, UK
| | - Denisa Muraru
- Department of Medicine and Surgery, University Milano-Bicocca, Piazza dell'Ateneo Nuovo, 1, 20126 Milan, MI, Italy.,Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
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44
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Kong WKF, Salsano A, Giacobbe DR, Popescu BA, Laroche C, Duval X, Schueler R, Moreo A, Colonna P, Piper C, Calvo-Iglesias F, Badano LP, Srdanovic I, Boutoille D, Huttin O, Stöhr E, Timóteo AT, Vaskelyte JJ, Sadeghpour A, Tornos P, Abid L, Poh KK, Habib G, Lancellotti P. Outcomes of culture-negative vs. culture-positive infective endocarditis: the ESC-EORP EURO-ENDO registry. Eur Heart J 2022; 43:2770-2780. [PMID: 35695691 PMCID: PMC9459867 DOI: 10.1093/eurheartj/ehac307] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/21/2022] [Accepted: 05/25/2022] [Indexed: 12/13/2022] Open
Abstract
AIM Fatality of infective endocarditis (IE) is high worldwide, and its diagnosis remains a challenge. The objective of the present study was to compare the clinical characteristics and outcomes of patients with culture-positive (CPIE) vs. culture-negative IE (CNIE). METHODS AND RESULTS This was an ancillary analysis of the ESC-EORP EURO-ENDO registry. Overall, 3113 patients who were diagnosed with IE during the study period were included in the present study. Of these, 2590 (83.2%) had CPIE, whereas 523 (16.8%) had CNIE. As many as 1488 (48.1%) patients underwent cardiac surgery during the index hospitalization, 1259 (48.8%) with CPIE and 229 (44.5%) with CNIE. The CNIE was a predictor of 1-year mortality [hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.04-1.56], whereas surgery was significantly associated with survival (HR 0.49, 95% CI 0.41-0.58). The 1-year mortality was significantly higher in CNIE than CPIE patients in the medical subgroup, but it was not significantly different in CNIE vs. CPIE patients who underwent surgery. CONCLUSION The present analysis of the EURO-ENDO registry confirms a higher long-term mortality in patients with CNIE compared with patients with CPIE. This difference was present in patients receiving medical therapy alone and not in those who underwent surgery, with surgery being associated with reduced mortality. Additional efforts are required both to improve the aetiological diagnosis of IE and identify CNIE cases early before progressive disease potentially contraindicates surgery.
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Affiliation(s)
- William K F Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Antonio Salsano
- Department of Integrated Surgical and Diagnostic Sciences (DISC), University of Genoa, Genoa, Italy
- Division of Cardiac Surgery, Ospedale Policlinico San Martino—IRCCS, Largo Rosanna Benzi, 10, Genoa, Italy
| | - Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- Infectious Diseases Unit, Ospedale Policlinico San Martino—IRCCS, Genoa, Italy
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy ‘Carol Davila’ Euroecolab, Emergency Institute for Cardiovascular Diseases ‘Prof. Dr. C. C. Iliescu’, Bucharest, Romania
| | - Cécile Laroche
- EORP, European Society of Cardiology, Sophia-Antipolis, France
| | - Xavier Duval
- INSERM Clinical Investigation Center 1425, Université Paris Diderot, Sorbonne Paris-Cité, IAME 1138, Paris, France
- AEPEI Service de Maladies Infectieuses et Tropicales, APHP, Hôpital Bichat, Paris, France
| | | | - Antonella Moreo
- Dipartimento CardioToracoVascolare ‘De Gasperis’, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Colonna
- Cardiology Hospital, Policlinico University Hospital of Bari, Bari, Italy
| | - Cornelia Piper
- Clinic for General and Interventional Cardiology/Angiology, Herz-und Diabeteszentrum Nordrhein-Westfalen, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | - Luigi P Badano
- University of Milano-Bicocca, Milano, Italy
- Department of Cardiovascular, Neural and Metabolic Sciences; Istituto Auxologico Italiano, IRCCS—San Luca Hospital, Milano, Italy
| | - Ilija Srdanovic
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Institute of Cardiovascular Diseases Vojvodina, Sremska Kamenica, Serbia
| | - David Boutoille
- Department of Infectious Diseases, CIC UIC 1413 INSERM, University Hospital, Nantes, France
| | - Olivier Huttin
- Service de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, CHU de Nancy, Nancy, France
- CIC-Plurithématique 1433, Inserm U1116, CHRU Nancy, Université de Lorraine, CIC-IT, U1433, CHRU de Nancy, France
- INSERM U1254, IADI, Université de Lorraine, Nancy, France
| | | | - Ana Teresa Timóteo
- Secretária-Geral Sociedade Portuguesa Cardiologia, Lisbon, Portugal
- Assistente Hospitalar Graduada Cardiologia, Hospital Santa Marta, Centro Hospitalar Universitário Lisbon Central, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | | | - Anita Sadeghpour
- Rajaie Cardiovascular Medical & Research Center, Tehran, Iran
- Duke Cardiovascular MR Center, Durham, NC, USA
| | - Pilar Tornos
- Cardiology Service, Hospital Quiron, Barcelona, Spain
| | | | - Kian Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gilbert Habib
- Department of Cardiology, APHM, La Timone Hospital, Marseille, France
- University Hospital of Liege (CHU), Liege, Belgium
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45
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Tomaselli M, Badano LP, Menè R, Gavazzoni M, Heilbron F, Radu N, Caravita S, Baratto C, Oliverio G, Florescu DR, Parati G, Muraru D. Impact of correcting the 2D PISA method on the quantification of functional tricuspid regurgitation severity. Eur Heart J Cardiovasc Imaging 2022; 23:1459-1470. [PMID: 35734964 DOI: 10.1093/ehjci/jeac104] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS In functional tricuspid regurgitation (FTR) patients, tricuspid leaflet tethering and relatively low jet velocity could result in proximal flow geometry distortions that lead to underestimation of TR. Application of correction factors on two-dimensional (2D) proximal isovelocity surface area (PISA) equation may increase its reliability. This study sought to evaluate the impact of the corrected 2D PISA method in quantifying FTR severity. METHODS AND RESULTS In 102 patients with FTR, we compared both conventional and corrected 2D PISA measurements of effective regurgitant orifice area [EROA vs. corrected (EROAc)] and regurgitant volume (RegVol vs. RegVolc) with those obtained by volumetric method (VM) using three-dimensional echocardiography (3DE), as reference. Both EROAc and RegVolc were larger than EROA (0.29 ± 0.26 vs. 0.22 ± 0.21 cm2; P < 0.001) and RegVol (24.5 ± 20 vs. 18.5 ± 14.25 mL; P < 0.001), respectively. Compared with VM, both EROAc and RegVolc resulted more accurate than EROA [bias = -0.04 cm2, limits of agreement (LOA) ± 0.02 cm2 vs. bias = -0.15 cm2, LOA ± 0.31 cm2] and RegVol (bias = -3.29 mL, LOA ± 2.19 mL vs. bias = -10.9 mL, LOA ± 13.5 mL). Using EROAc and RegVolc, 37% of patients were reclassified in higher grades of FTR severity. Corrected 2D PISA method led to a higher concordance of TR severity grade with the VM method (ĸ = 0.84 vs. ĸ = 0.33 for uncorrected PISA, P < 0.001). CONCLUSION Compared with VM by 3DE, the conventional PISA underestimated FTR severity in about 50% of patients. Correction for TV leaflets tethering angle and lower velocity of FTR jet improved 2D PISA accuracy and reclassified more than one-third of the patients.
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Affiliation(s)
- Michele Tomaselli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Roberto Menè
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Mara Gavazzoni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Francesca Heilbron
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Noela Radu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy.,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Giorgio Oliverio
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Diana R Florescu
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy.,University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
| | - Denisa Muraru
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, P.le Brescia 20, 20149 Milan, Italy
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46
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Fratianni G, Malfatto G, Perger E, Facchetti L, Pini L, Bosco M, Cernigliaro F, Perego GB, Facchini M, Badano LP, Parati G. Lung Ultrasound in Patients With SARS-COV-2 Pneumonia: Correlations With Chest Computed Tomography, Respiratory Impairment, and Inflammatory Cascade. J Ultrasound Med 2022; 41:1465-1473. [PMID: 34533859 PMCID: PMC8662157 DOI: 10.1002/jum.15831] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/13/2021] [Accepted: 08/20/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Lung ultrasound (LUS) might be comparable to chest computed tomography (CT) in detecting parenchymal and pleural pathology, and in monitoring interstitial lung disease. We aimed to describe LUS characteristics of patients during the hospitalization for COVID-19 pneumonia, and to compare the extent of lung involvement at LUS and chest-CT with inflammatory response and the severity of respiration impairment. METHODS During a 2-week period, we performed LUS and chest CT in hospitalized patients affected by COVID-19 pneumonia. Dosages of high sensitivity C-reactive protein (HS-CRP), d-dimer, and interleukin-6 (IL-6) were also obtained. The index of lung function (P/F ratio) was calculated from the blood gas test. LUS and CT scoring were assessed using previously validated scores. RESULTS Twenty-six consecutive patients (3 women) underwent LUS 34 ± 14 days from the early symptoms. Among them, 21 underwent CT on the same day of LUS. A fair association was found between LUS and CT scores (R = 0.45, P = .049), which became stronger if the B-lines score on LUS was not considered (R = 0.57, P = .024). LUS B-lines score correlated with IL-6 levels (R = 0.75, P = .011), and the number of involved lung segments detected by LUS correlated with the P/F ratio (R = 0.60, P = .019) but not with HS-CRP and d-Dimer levels. No correlations were found between CT scores and inflammations markers or P/F. CONCLUSION In patients with COVID-19 pneumonia, LUS was correlated with both the extent of the inflammatory response and the P/F ratio.
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Affiliation(s)
- Gerardina Fratianni
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Gabriella Malfatto
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Elisa Perger
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
- Dipartimento di Medicina e Chirurgia, Università di Milano‐BicoccaMilan
| | - Luca Facchetti
- Department of Radiology, ASST Spedali Civili di BresciaBresciaItaly
| | - Laura Pini
- Respiratory Medicine Unit, ASST Spedali Civili di BresciaBresciaItaly
- Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Miriam Bosco
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Franco Cernigliaro
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Giovanni B. Perego
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Mario Facchini
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
| | - Luigi P. Badano
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
- Dipartimento di Medicina e Chirurgia, Università di Milano‐BicoccaMilan
| | - Gianfranco Parati
- Department of CardiologyIstituto Auxologico Italiano IRCCS, Ospedale S. LucaMilan
- Dipartimento di Medicina e Chirurgia, Università di Milano‐BicoccaMilan
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47
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Senage T, Paul A, Le Tourneau T, Fellah-Hebia I, Vadori M, Bashir S, Galiñanes M, Bottio T, Gerosa G, Evangelista A, Badano LP, Nassi A, Costa C, Cesare G, Manji RA, Cueff de Monchy C, Piriou N, Capoulade R, Serfaty JM, Guimbretière G, Dantan E, Ruiz-Majoral A, Coste du Fou G, Leviatan Ben-Arye S, Govani L, Yehuda S, Bachar Abramovitch S, Amon R, Reuven EM, Atiya-Nasagi Y, Yu H, Iop L, Casós K, Kuguel SG, Blasco-Lucas A, Permanyer E, Sbraga F, Llatjós R, Moreno-Gonzalez G, Sánchez-Martínez M, Breimer ME, Holgersson J, Teneberg S, Pascual-Gilabert M, Nonell-Canals A, Takeuchi Y, Chen X, Mañez R, Roussel JC, Soulillou JP, Cozzi E, Padler-Karavani V. The role of antibody responses against glycans in bioprosthetic heart valve calcification and deterioration. Nat Med 2022; 28:283-294. [PMID: 35177855 PMCID: PMC8863575 DOI: 10.1038/s41591-022-01682-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 01/06/2022] [Indexed: 12/11/2022]
Abstract
Bioprosthetic heart valves (BHVs) are commonly used to replace severely diseased heart valves but their susceptibility to structural valve degeneration (SVD) limits their use in young patients. We hypothesized that antibodies against immunogenic glycans present on BHVs, particularly antibodies against the xenoantigens galactose-α1,3-galactose (αGal) and N-glycolylneuraminic acid (Neu5Gc), could mediate their deterioration through calcification. We established a large longitudinal prospective international cohort of patients (n = 1668, 34 ± 43 months of follow-up (0.1–182); 4,998 blood samples) to investigate the hemodynamics and immune responses associated with BHVs up to 15 years after aortic valve replacement. Early signs of SVD appeared in <5% of BHV recipients within 2 years. The levels of both anti-αGal and anti-Neu5Gc IgGs significantly increased one month after BHV implantation. The levels of these IgGs declined thereafter but anti-αGal IgG levels declined significantly faster in control patients compared to BHV recipients. Neu5Gc, anti-Neu5Gc IgG and complement deposition were found in calcified BHVs at much higher levels than in calcified native aortic valves. Moreover, in mice, anti-Neu5Gc antibodies were unable to promote calcium deposition on subcutaneously implanted BHV tissue engineered to lack αGal and Neu5Gc antigens. These results indicate that BHVs manufactured using donor tissues deficient in αGal and Neu5Gc could be less prone to immune-mediated deterioration and have improved durability. In a large cohort of patients who underwent aortic valve replacement, antibody responses to glycans present in bioprosthetic heart valves, notably galactose-α1,3-galactose and N-glycolylneuraminic acid, were implicated in valve calcification and deterioration.
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Affiliation(s)
- Thomas Senage
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France.,Institut National de la Santé et de la Recherche Médicale UMR 1246-SPHERE, Nantes University, Tours University, Nantes, France
| | - Anu Paul
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thierry Le Tourneau
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Imen Fellah-Hebia
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Marta Vadori
- Consortium for Research in Organ Transplantation, Ospedale Giustinianeo, Padova, Italy
| | - Salam Bashir
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Manuel Galiñanes
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Tomaso Bottio
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Surgery, University of Padova, Padova, Italy
| | - Gino Gerosa
- Department of Cardiac, Vascular and Thoracic Sciences and Public Health University of Padova, L.I.F.E.L.A.B. Program Veneto Region, Padova, Italy
| | - Arturo Evangelista
- Department of Cardiology, Vall d'Hebron Research Institut, Hospital Vall d'Hebron, Barcelona, Spain
| | - Luigi P Badano
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Neural and Metabolic Sciences, Istituto Auxologico Italiano, Istituto di Ricovero e Cura a Carattere Scientifico, San Luca Hospital, Milan, Italy
| | - Alberto Nassi
- Transplantation Immunology Unit, Padova University Hospital, Padova, Italy
| | - Cristina Costa
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Rizwan A Manji
- Department of Surgery, Max Rady College of Medicine, University of Manitoba Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Caroline Cueff de Monchy
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Nicolas Piriou
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Romain Capoulade
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Jean-Michel Serfaty
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Guillaume Guimbretière
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Etienne Dantan
- Institut National de la Santé et de la Recherche Médicale UMR 1246-SPHERE, Nantes University, Tours University, Nantes, France
| | - Alejandro Ruiz-Majoral
- Department of Cardiology, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Guénola Coste du Fou
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France
| | - Shani Leviatan Ben-Arye
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Liana Govani
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Yehuda
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shirley Bachar Abramovitch
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ron Amon
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Eliran Moshe Reuven
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yafit Atiya-Nasagi
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.,Israel Institute for Biological Research, Ness Ziona, Israel
| | - Hai Yu
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Laura Iop
- Cardiovascular Regenerative Medicine Group, Department of Cardiac, Thoracic and Vascular Surgery, University of Padova, Padova, Italy.,Department of Cardiac, Vascular and Thoracic Sciences and Public Health University of Padova, L.I.F.E.L.A.B. Program Veneto Region, Padova, Italy.,Department of Cardiac Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Kelly Casós
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Cardiovascular Disease at the Vall d'Hebron Institut Research, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sebastián G Kuguel
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Arnau Blasco-Lucas
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Cardiac Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Eduard Permanyer
- Department of Cardiac Surgery and Reparative Therapy of the Heart, Vall d'Hebron Research Institute, University Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Cardiac Surgery, Quironsalud Teknon Heart Institute, Barcelona, Spain
| | - Fabrizio Sbraga
- Cardiac Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Roger Llatjós
- Pathology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Gabriel Moreno-Gonzalez
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Intensive Care Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Michael E Breimer
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Jan Holgersson
- Institute of Biomedicine, Department of Laboratory Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Susann Teneberg
- Institute of Biomedicine, Department of Medical Biochemistry and Cell Biology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | | | | | - Yasuhiro Takeuchi
- Division of Infection and Immunity, University College London, London, UK
| | - Xi Chen
- Department of Chemistry, University of California, Davis, Davis, CA, USA
| | - Rafael Mañez
- Infectious Diseases and Transplantation Division, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain. .,Intensive Care Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Jean-Christian Roussel
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale UMR1087, University Hospital, Nantes, France.
| | - Jean-Paul Soulillou
- Institut de Transplantation-Urologie-Néphrologie, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1064, Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Emanuele Cozzi
- Transplantation Immunology Unit, Padova University Hospital, Padova, Italy.
| | - Vered Padler-Karavani
- Department of Cell Research and Immunology, Shmunis School of Biomedicine and Cancer Research, George S. Wise Faculty of Life Sciences, Tel Aviv University, Tel Aviv, Israel.
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Volpato V, Ciampi P, Johnson R, Hipke K, Tomaselli M, Oliverio G, Muraru D, Lang RM, Badano LP. Routine use of automated strain analysis and 3D echocardiography provides a more comprehensive assessment of cardiac chambers than conventional 2D echocardiography and is time-saving. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background. In most laboratories three-dimensional echocardiography (3DE) and longitudinal strain (Lstrain) analysis are not part of the routine studies. Although these modalities have been shown to provide additional clinical information and prognostic value compared to conventional two-dimensional echocardiography (2DE), their acquisition and analysis are perceived as being time-consuming. Recently, new automated tools have been developed to perform accurate, fast and reproducible analyses of heart chambers’ geometry and function. However, their cost-effectiveness when compared to conventional 2DE remains to be demonstrated.
Aim. We designed a prospective, multicenter, observational study aimed to compare the time required for the acquisition and analysis of conventional transthoracic 2DE vs advanced echocardiography (AEcho, i.e. 3DE+ Lstrain) for the assessment of cardiac chambers and myocardial mechanics.
Methods. According to current guidelines, 196 consecutive patients referred for clinically indicated echocardiography underwent complete 2DE and Doppler echocardiography. In addition, 3DE datasets of the left atrium (LA), left and right ventricle (LV, RV) were acquired using automated 3DE software package (Heart Model). Acquisition time for both 2DE and 3DE images were recorded. Conventional 2DE analyses of LA (biplane volume), LV (biplane volumes and mass) and RV (both linear dimensions, areas, and longitudinal function) were performed following current guidelines, and the time required for acquisition and analysis was recorded. The time spent for AEcho analysis (both 3DE volumetric analysis and Lstrain of LA, LV and RV) was also recorded.
Results. Feasibility of AEcho was 86% (169 patients). The additional time for 3D dataset acquisition over conventional 2DE was 38 ± 0.16 sec. Quantitative analysis of the cardiac chambers by 2DE required an average of 5.55 ± 1.51 min vs 4.25 ± 1.23 min using AEcho (p < 0.001). Total time for both 3D dataset acquisition and AEcho assessment was 5.03 ± 1.28 min vs 5.55 ± 1.51 min of 2DE analysis alone (p < 0.001). Globally, AEcho provided a more comprehensive assessment of heart chambers than 2DE (Table). Moreover, the time spent for 3DE dataset acquisition and AEcho analysis on top of standard 2DE acquisition was significantly shorter compared to the 2DE acquisition and analysis (18:50 ± 4.23 vs 19:42 ± 4.24 min, p < 0.001) (Table).
Conclusions. Our data showed that the use of new AEcho automated tools are highly feasible resulting in significant time-savings compared to standard 2DE evaluation, while providing significant additional information. Abstract Table
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Affiliation(s)
- V Volpato
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - P Ciampi
- Catholic University of the Sacred Heart - Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - R Johnson
- University of Chicago Medicine, Chicago, United States of America
| | - K Hipke
- University of Chicago Medicine, Chicago, United States of America
| | - M Tomaselli
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - G Oliverio
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - D Muraru
- University of Milan Bicocca, San Luca Hospital, Milan, Italy
| | - RM Lang
- University of Chicago Medicine, Chicago, United States of America
| | - LP Badano
- University of Milan Bicocca, San Luca Hospital, Milan, Italy
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Tomaselli M, Gavazzoni M, Muraru D, Caravita S, Volpato V, Oliverio G, Ciambellotti F, Mene" R, Florescu DR, Ciampi P, Heilbron F, Rella V, Parati G, Badano LP. Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, assessment of TR severity is pivotal. Calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are still the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations.
Purpose: The aims of our study were
(1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC.
Methods
Forty-one patients with functional TR (73.5 ± 11.8 years,51% men,36% sinus rhythm,17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RVSV) – left ventricular forward SV (LVSV), where RVSV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI) (Fig. 1). TR RVol by PISA was calculated as EROA x VTITR. Uncorrected EROA was calculated using the formula: 6.28 r2 xVa/ PeakVTR (r - PISA radius, Va, aliasing velocity, PeakVTR – TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 x Va (α/180)/ PeakV TR (PISAac), where α was measured using a protractor generated by dedicated software.
Results
Application of AC to PISA method resulted in larger EROA and RVol (0.34± 0.38 cm2 vs 0.24± 0.24cm2 and, 25.2± 19.3 mL vs 18.6 ± 13.1mL, respectively). The percentage change in EROAac was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias -3.95mL, LOA ± 6.41 mL, r= .987; p< .001) than the conventional PISA without AC (bias -10.5 mL, LOA ± 15 mL, r= .975). Angle correction resulted in a change of TR severity in 32% of cases (Fig. 2) and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs 52%, 22/41 without AC).
Conclusions
Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to 1/3 of patients with functional TR. Abstract Figure. Representation of study method Abstract Figure. Reclassification of TR severity
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Affiliation(s)
- M Tomaselli
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - M Gavazzoni
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - D Muraru
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - S Caravita
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - V Volpato
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - G Oliverio
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - F Ciambellotti
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - R Mene"
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - DR Florescu
- University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - P Ciampi
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - F Heilbron
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - V Rella
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - G Parati
- Italian Auxological Institute San Luca Hospital, Milan, Italy
| | - LP Badano
- Italian Auxological Institute San Luca Hospital, Milan, Italy
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Florescu D, Badano LP, Tomaselli M, Torlasco C, Florescu C, Tartea GC, Balseanu TA, Volpato V, Parati G, Muraru D. Automated left atrial volume measurement by two-dimensional speckle-tracking echocardiography: feasibility, accuracy and reproducibility. Eur Heart J Cardiovasc Imaging 2022. [DOI: 10.1093/ehjci/jeab289.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Introduction - A by-product of left atrial (LA) strain analysis is the automated measurement of LA maximal volume (LAVmax), which may decrease the time of echocardiography reporting, and increase the reproducibility of the LAVmax measurement. However, the automated measurement of LAVmax by two-dimensional speckle-tracking analysis (2DSTE) has never been validated.
Purpose – Accordingly, we sought to: i. assess the feasibility of automated LAVmax measurement by 2DSTE; ii. compare the automated LAVmax by 2DSTE with conventional two-dimensional (2DE) biplane and three-dimensional echocardiography (3DE) measurements; and iii. evaluate the accuracy and reproducibility of the three echocardiography techniques.
Methods – LAVmax (34-197 mL) were prospectively obtained from 198/210 (feasibility 94%) consecutive patients with various cardiac diseases (median age 67 years, 126 men) by 2DSTE, 2DE and 3DE.
Results – 2DE and 2DSTE measurements resulted in similar LAVmax values (bias = 1.5 mL, limits of agreement, LOA ± 7.5 mL), and slightly underestimated 3DE LAVmax (biases=-5 mL, LOA ± 17 mL, and -6 mL, LOA ± 16 mL, respectively). LAVmax by 2DSTE and 2DE were strongly correlated to those obtained by cardiac magnetic resonance (CMR) (r=.946, and r=.935, respectively; p<.001). However, LAVmax obtained by 2DSTE (bias=-9.5 mL, LOA ± 16 mL), and 2DE (bias=-8 mL, LOA ± 17 mL) were significantly smaller than those measured by CMR. Conversely, 3DE LAVmax were similar to CMR (bias=-2 ml, LOA ± 10 mL). Excellent intra- and inter-observer intraclass correlation coefficients were found for 3DE (0.995 and 0.995), 2DE (0.990 and 0.988), and 2DSTE (0.990 and 0.989).
Conclusion – Automated LAVmax measurement by 2DSTE is highly feasible, highly reproducible, and provided similar values to conventional 2DE calculations in consecutive patients with a wide range of LAVmax. Abstract Figure. Echocardiography and CMR correlations Abstract Figure. Echocardiography techniques correlations
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Affiliation(s)
- D Florescu
- University of Medicine and Pharmacy of Craiova, Department of Cardiology, Craiova, Romania
| | - LP Badano
- University of Milan-Bicocca, Department of Medicine and Surgery, Milan, Italy
| | - M Tomaselli
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Department of Cardiac, Neural and Metabolic Sciences , Milan, Italy
| | - C Torlasco
- Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Department of Cardiac, Neural and Metabolic Sciences , Milan, Italy
| | - C Florescu
- University of Medicine and Pharmacy of Craiova, Department of Cardiology, Craiova, Romania
| | - GC Tartea
- University of Medicine and Pharmacy of Craiova, Department of Cardiology, Craiova, Romania
| | - TA Balseanu
- University of Medicine and Pharmacy of Craiova, Department of Physiology, Craiova, Romania
| | - V Volpato
- University of Milan-Bicocca, Department of Medicine and Surgery, Milan, Italy
| | - G Parati
- University of Milan-Bicocca, Department of Medicine and Surgery, Milan, Italy
| | - D Muraru
- University of Milan-Bicocca, Department of Medicine and Surgery, Milan, Italy
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