Echocardiographic probability of pulmonary hypertension: a validation study

BackgroundAccording to current guidelines, the diagnosis of pulmonary hypertension (PH) relies on echocardiographic probability followed by right heart catheterization. How echocardiography predicts PH recently re-defined by a mean pulmonary artery pressure (mPAP) >20 mmHg instead of ≥25 mmHg and pulmonary vascular disease defined by a pulmonary vascular resistance (PVR) >3 or >2 Wood units has not been established.MethodsA total of 278 patients referred for PH underwent a comprehensive echocardiography followed by a right heart catheterization. Fifteen patients (5.4%) were excluded because of insufficient quality echocardiography.ResultsWith PH defined by a mPAP >20 mmHg, 23 patients had no PH, 146 had pre-capillary and 94 post-capillary PH. At univariate analysis, maximum velocity of tricuspid regurgitation (TRV) ≥2.9 and ≤3.4 m s−1, left ventricle (LV) eccentricity index >1.1, right ventricle (RV) outflow tract (OT) notching or acceleration time <105 ms, RV-LV basal diameter >1 and PA diameter predicted PH, whereas inferior vena cava diameter and right atrial area did not. At multivariable analysis, only TRV ≥2.9 m s−1 independently predicted PH. Additional independent prediction of PVR >3 Wood units was offered by LV eccentricity index >1.1 and RVOT acceleration time <105 ms and/or notching, but with no improvement of optimal combination of specificity and sensibility or positive prediction.ConclusionsEchocardiography as recommended in current guidelines can be used to assess the probability of re-defined PH in a referral center. However, the added value of indirect signs is modest and sufficient quality echocardiographic signals may not be recovered in some patients.

Effect of interventional edge-to-edge repair in tricuspid regurgitation on ring dimensions

Background The concept of percutaneous tricuspid valve edge-to-edge repair (pTVR) is based on the connection of leaflets in the area of insufficiency using a coaptation device. By closing the coaptation device a considerable tractive force is applied on the leaflets, which might have an effect on the valve ring. Aim of the study was to examine the impact of device implantation on tricuspid ring dimensions. Methods During pTVR 3D zoom loops of tricuspid valve were acquired before and after clip placement using transoesophageal echocardiography. Measurements of TV ring dimensions included the following parameters: ring area (TV area), maximal diameter, minimal diameter, eccentricity index (Figure 1). Tenting area was derived from a four-chamber view of the valve. In addition, regurgitation severity was graded from 1+ to 5+ by measuring vena contracta area (VCA3D) in 3D full volume colour Doppler loop using multiplanar reconstruction. Right atrial (RA) and ventricular volumes (RVVd3D, RVVs3D) and function (RVEF3D) were assessed in a 3D full volume loop. Results The study population comprised 97 patients (age 78±6 years, 47 male), who underwent pTVR at our hospital. As expected cavity dimension correlated with TV area size (for RVVd3D r=0.51, p&lt;0.001 and for RA volume r=0.71, p&lt;0.001). The mean TV ring area was significantly reduced (ring area 8.53±2.23 cm2/m2BSA vs. 7.55±2.18 cm2/m2BSA, p&lt;0.001) and the ring shape became more oval (Eccentricity index 1.2±0.15 vs. 1.29±0.17, p&lt;0.001) after pTVR. The reduction of ring area (12±7%, range 0.7–28%) showed an only modest correlation to the number of implanted coaptation devices (r=0.30, p&lt;0.001) and percentage reduction of VCA3D (r=0.36, p&lt;0.001). In the patient group with a ring area change ≥12% a reduction to TR grade ≤2+ by pTVR was achieved in 83% of cases, whereas only 62% of patients reached moderate TR when area change was below 12%. Conclusion pTVR using coaptation devices reduces the ring area. This effect is related to the number of devices implanted. FUNDunding Acknowledgement Type of funding sources: None.

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort. One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured. P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m2; 79±16 vs 80±14mL/m2, respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p&lt;0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p&lt;0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p&lt;0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p&lt;0.001). In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m2, p&lt;0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m2). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p&lt;0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p&lt;0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p&lt;0.01). Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings. FUNDunding Acknowledgement Type of funding sources: None. Post-Covid athlete with SF

Echocardiographic, Biochemical, and Electrocardiographic Correlates Associated With Progressive Pulmonary Arterial Hypertension

Background: Pulmonary arterial hypertension (PAH) is a progressive proliferative vasculopathy associated with mechanical and electrical changes, culminating in increased vascular resistance, right ventricular (RV) failure, and death. With a main focus on invasive tools, there has been an underutilization of echocardiography, electrocardiography, and biomarkers to non-invasively assess the changes in myocardial and pulmonary vascular structure and function during the course of PAH.Methods: A SU5416-hypoxia rat model was used for inducing PAH. Biventricular functions were measured using transthoracic two-dimensional (2D) echocardiography/Doppler (echo/Doppler) at disease onset (0 week), during progression (3 weeks), and establishment (5 weeks). Similarly, electrocardiography was performed at 0, 3, and 5 weeks. Invasive hemodynamic measurements and markers of cardiac injury in plasma were assessed at 0, 3, and 5 weeks.Results: Increased RV systolic pressure (RVSP) and rate of isovolumic pressure rise and decline were observed at 0, 3, and 5 weeks in PAH animals. EKG showed a steady increase in QT-interval with progression of PAH, whereas P-wave height and RS width were increased only during the initial stages of PAH progression. Echocardiographic markers of PAH progression and severity were also identified. Three echocardiographic patterns were observed: a steady pattern (0–5 weeks) in which echo parameter changed progressively with severity [inferior vena cava (IVC) expiratory diameter and pulmonary artery acceleration time (PAAT)], an early pattern (0–3 weeks) where there is an early change in parameters [RV fractional area change (RV-FAC), transmitral flow, left ventricle (LV) output, estimated mean PA pressure, RV performance index, and LV systolic eccentricity index], and a late pattern (3–5 weeks) in which there is only a late rise at advanced stages of PAH (LV diastolic eccentricity index). RVSP correlated with PAAT, PAAT/PA ejection times, IVC diameters, RV-FAC, tricuspid systolic excursion, LV systolic eccentricity and output, and transmitral flow. Plasma myosin light chain (Myl-3) and cardiac troponin I (cTnI) increased progressively across the three time points. Cardiac troponin T (cTnT) and fatty acid-binding protein-3 (FABP-3) were significantly elevated only at the 5-week time point.Conclusion: Distinct electrocardiographic and echocardiographic patterns along with plasma biomarkers were identified as useful non-invasive tools for monitoring PAH progression.

Changes In Left Atrial Appendage Orifice Following Percutaneous Left Atrial Appendage Closure Using Three-Dimensional Echocardiography

Purpose: Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics.Methods: We included 50 consecutive patients who underwent percutaneous LAA occlusion with the Watchman device. Three-dimensional images of LAA pre- and post-device placement were analyzed offline. We measured the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured.Results: Patients were elderly (mean age 76±8 years years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1±3.2 vs. post-device 21.5±3.4 mm, p<0.001), diameter 2 (20.6±3.9 vs. 22.1±3.6 mm, p<0.001), minimum diameter (17.6±3.1 vs. 21.3±3.4 mm, p<0.001), maximum diameter (21.5±3.9 vs. 22.4±3.6 mm, p=0.022), circumference (63.6±10.7 vs. 69.6±10.5 mm, p<0.001), and area (3.1±1.1 vs. 3.9±1.2 cm2, p<0.001). Eccentricity index decreased after procedure (1.23±0.16 vs. 1.06±0.06, p<0.001). LUPV peak S and D velocities did not show a significant difference (0.29±0.15 vs. 0.30±0.14 cm/s, p=0.637; and 0.47±0.19 vs. 0.48±0.20 cm/s, p=0.549; respectively).Conclusion: LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.

Acute Mechanical Performance of Magmaris vs. DESolve Bioresorbable Scaffolds in a Real-World Scenario

Background: After the bioresorbable PLLA-based vascular scaffold (Absorb BVS) was taken from the market due to its high adverse event rates, a magnesium-based scaffold (Magmaris) was introduced.Objective: To compare the acute performance of the sirolimus-eluting magnesium alloy Magmaris scaffold with that of the novolimus-eluting PLLA-based DESolve scaffold in terms of appropriate scaffold deployment using optical coherence tomography (OCT).Methods and Results: Data from the final OCT pullback of 98 patients were included (19 Magmaris, 79 DESolve) and analyzed at 1-mm intervals. The following indices were calculated: mean and minimal area, residual area stenosis, incomplete strut apposition, tissue prolapse, eccentricity index, symmetry index, strut fracture, and edge dissection. OCT showed a minimum lumen area for Magmaris vs. DESolve of 6.6 ± 1.6 vs. 6.0 ± 1.9 (p = 0.06). Scaffolds with residual area stenosis &gt;20% were predominantly seen in the DESolve group (15.8 vs. 46.8%; p = 0.01). The mean eccentricity index did differ significantly (0.74 ± 0.06 vs. 0.63 ± 0.09; p &lt; 0.001). No fractures were observed for Magmaris scaffolds, but 15.2% were documented for DESolve BRS (p &lt; 0.001). Incomplete scaffold apposition area was significantly higher in the DESolve group (0.01 ± 0.02 vs. 1.05 ± 2.32 mm2; p &lt; 0.001).Conclusion: This is the first study to compare the acute mechanical performance between Magmaris and DESolve in a real-world setting. The acute mechanical performance of Magmaris BRS seems to be superior to that of DESolve BRS, whereas OCT showed a good acute mechanical performance for both BRS in terms of generally accepted imaging criteria.

Ethnic Differences of Corneal Parameters: A Cross-Sectional Study

Purpose: To investigate the ethnic differences of corneal parameters in Arabs and other ethnicities. Methods: This study recruited 250 Saudi Arabian participants, 18–45 years of age. The McMonnies questionnaire was used to exclude participants with dry eye. The KR8800 auto refractometer (Topcon, Japan) was used to measure the refractive error. Oculus Keratograph 4 topography was used to assess 16 corneal parameters, including the k-readings, horizontal visible iris diameter, mean eccentricity index, asphericity, corneal shape factor, corneal flattening factor, sagittal height, sagittal curvature, and vertical palpebral aperture. Results: A statistically significant difference was found between male and female participants. Corneal parameters were compared to other ethnicities, including Caucasians and Asians, and those of Mongoloid origin. The horizontal visible iris diameter was wider in Saudi Arabians than in Asians but similar to Caucasians. The sagittal height was deeper and the corneal shape factor was higher than in the other ethnicities, and the eccentricity index was lower than that in Caucasians and Asians of Mongoloid origin. Conclusion: Our data provided normative corneal parameters of Saudi Arabians that may be useful for ophthalmic clinicians and designers of contact lenses. Furthermore, the parameters suggest that the corneal characteristics of Arabians are distinct from those of major ethnicities.

Quantification of regurgitation in mitral valve prolapse with automated real time echocardiographic 3D proximal isovelocity surface area: multimodality consistency and role of eccentricity index

Three-dimensional transthoracic echocardiography (3D-TTE) provides a semi-automated proximal isovelocity surface area method (3D-PISA) to obtain quantitative parameters. Data assessing regurgitation severity in mitral valve prolapse (MVP) are scarce, so we assessed the 3D-PISA method compared with 2D-PISA and cardiovascular magnetic resonance (CMR) and the role of an eccentricity index. We evaluated the 3D-PISA method for assessing MR in 54 patients with MVP (57 ± 14 years; 42 men; 12 mild/mild-moderate; 12 moderate-severe; and 30 severe MR). Role of an asymmetric (i.e. eccentricity index ≥ 1.25) flow convergence region (FCR) and inter-modality consistency were then assessed. 3D-PISA derived regurgitant volume (RVol) showed a good correlation with 2D-PISA and CMR derived parameters (r = 0.86 and r = 0.81, respectively). The small mean differences with 2D-PISA derived RVol did not reach statistical significance in overall population (5.7 ± 23 ml, 95% CI − 0.6 to 12; p = 0.08) but differed in those with asymmetric 3D-FCR (n = 21; 2D-PISA: 72 ± 36 ml vs. 3D-PISA: 93 ± 47 ml; p = 0.001). RVol mean values were higher using PISA methods (CMR 57 ± 33 ml; 2D-PISA 73 ± 39 ml; and 3D-PISA 79 ± 45 ml) and an overestimation was observed when CMR was used as reference (2D-PISA vs. CMR: mean difference: 15.8 ml [95% CI 10–22, p < 0.001]; and 3D-PISA vs. CMR: 21.5 ml [95% CI 14–29, p < 0.001]). Intra- and inter-observer reliability was excellent (ICC 0.91–0.99), but with numerically lower coefficient of variation for 3D-PISA (8%–10% vs. 2D-PISA: 12%–16%). 3D-PISA method for assessing regurgitation in MVP may enable analogous evaluation compared to standard 2D-PISA, but with overestimation in case of asymmetric FCR or when CMR is used as reference method.