Artificial intelligence applied in cardiovascular disease: a bibliometric and visual analysis.

Background: With the rapid development of technology, artificial intelligence (AI) has been widely used in the diagnosis and prognosis prediction of a variety of diseases, including cardiovascular disease. Facts have proved that AI has broad application prospects in rapid and accurate diagnosis. Objective: This study mainly summarizes the research on the application of AI in the field of cardiovascular disease through bibliometric analysis and explores possible future research hotpots. Methods: The articles and reviews regarding application of AI in cardiovascular disease between 2000 and 2023 were selected from Web of Science Core Collection on 30 December 2023. Microsoft Excel 2019 was applied to analyze the targeted variables. VOSviewer (version 1.6.16), Citespace (version 6.2.R2), and a widely used online bibliometric platform were used to conduct co-authorship, co-citation, and co-occurrence analysis of countries, institutions, authors, references, and keywords in this field. Results: A total of 4,611 articles were selected in this study. AI-related research on cardiovascular disease increased exponentially in recent years, of which the USA was the most productive country with 1,360 publications, and had close cooperation with many countries. The most productive institutions and researchers were the Cedar sinai medical center and Acharya, Ur. However, the cooperation among most institutions or researchers was not close even if the high research outputs. Circulation is the journal with the largest number of publications in this field. The most important keywords are "classification", "diagnosis", and "risk". Meanwhile, the current research hotpots were "late gadolinium enhancement" and "carotid ultrasound". Conclusions: AI has broad application prospects in cardiovascular disease, and a growing number of scholars are devoted to AI-related research on cardiovascular disease. Cardiovascular imaging techniques and the selection of appropriate algorithms represent the most extensively studied areas, and a considerable boost in these areas is predicted in the coming years.

The D-SPECT SH reconstruction protocol: improved quantification of small left ventricle volumes.

BACKGROUND: Due to spatial resolution limitations, conventional NaI-SPECT typically overestimates the left ventricular (LV) ejection fraction (EF) in patients with small LV volumes. The purpose of this study was to explore the clinical application value of the small heart (SH) reconstruction protocol embedded in the postprocessing procedure of D-SPECT. METHODS: We retrospectively analyzed patients who undergo both D-SPECT and echocardiography (Echo) within one week. Patients with small LV volume were defined as those with a rest end-systolic volume (rESV) ≤ 25 mL and underwent reconstruction using the standard (SD) reconstruction protocol. The SH protocol was deemed successful in correcting the LVEF value if it decreased by 5% or more compared to the SD protocol. The ROC curve was used to calculate the optimal cutoff value of the SH protocol. LVEF, ESV and EDV were computed with SD and SH, respectively. Echo was performed as a reference, and Echo-LVEF, ESV, and EDV were calculated using the Teichholz formula. One-way ANOVA was used to compare these parameters among the three groups. RESULTS: The final study included 209 patients (73.21% female, age 67.34 ± 7.85 years). Compared with the SD protocol, the SH protocol significantly decreased LVEF (67.43 ± 7.38% vs. 71.30 ± 7.61%, p < 0.001). The optimal cutoff value for using the SH protocol was rESV > 17 mL (AUC = 0.651, sensitivity = 78.43%, specificity = 45.57%, p = 0.001). In the subgroup of rESV > 17 mL, there was no significant difference in LVEF (61.84 ± 4.67% vs. 62.83 ± 2.85%, p = 0.481) between the SH protocol and Echo, and no significant difference was observed in rESV (26.92 ± 3.25 mL vs. 27.94 ± 7.96 mL, p = 0.60) between the SH protocol and Echo. CONCLUSION: This pilot study demonstrated that the SH reconstruction protocol was able to effectively correct the overestimation of LVEF in patients with small LV volumes. Particularly, in the rESV > 17 mL subgroup, the time and computing power waste could be reduced while still ensuring the accuracy of the LVEF value and image quality.

High-definition blood flow imaging improves quantification of left ventricular volumes and ejection fraction.

AIMS: The accuracy and reproducibility of echocardiography to quantify left ventricular ejection fraction (LVEF) is limited due to image quality. High-definition blood flow imaging is a new technique which improves cavity delineation without the need for medication or intravenous access. We sought to examine the impact of high-definition blood flow imaging on accuracy and reproducibility of LV systolic function assessment. METHODS AND RESULTS: Prospective observational study of consecutive patients undergoing 2D and 3D transthoracic echocardiography (TTE), high-definition blood flow imaging, and cardiac magnetic resonance (CMR) within 1 h of each other. Left ventricular systolic function characterized by left ventricular end-systolic volumes and left ventricular end-diastolic volumes and LVEF were measured. Seventy-six patients were included. Correlation of 2D TTE with CMR was modest (r = 0.68) with a worse correlation in patients with three or more segments not visualized (r = 0.58). High-definition blood flow imaging was feasible in all patients, and the correlation of LVEF with CMR was excellent (r = 0.88). The differences between 2D, high-definition blood flow, and 3D TTE compared to CMR were 5 ± 9%, 2 ± 5%, and 1 ± 3%, respectively. The proportion of patients where the grade of LV function was correctly classified improved from 72.3% using 2D TTE to 92.8% using high-definition blood flow imaging. 3D TTE also had excellent correlation with CMR (r = 0.97) however was only feasible in 72.4% of patients. CONCLUSION: High-definition blood flow imaging is highly feasible and significantly improves the diagnostic accuracy and grading of LV function compared to 2D echocardiography.

Evaluation of the image quality and validity of handheld echocardiography for stroke volume and left ventricular ejection fraction quantification: a method comparison study.

Bedside quantification of stroke volume (SV) and left ventricular ejection fraction (LVEF) is valuable in hemodynamically compromised patients. Miniaturized handheld ultrasound (HAND) devices are now available for clinical use. However, the performance level of HAND devices for quantified cardiac assessment is yet unknown. The aim of this study was to compare the validity of HAND measurements with standard echocardiography (SE) and three-dimensional echocardiography (3DE). Thirty-six patients were scanned with HAND, SE and 3DE. LVEF and SV quantification was done with automated software for the HAND, SE and 3DE dataset. The image quality of HAND and SE was evaluated by scoring segmental endocardial border delineation (2 = good, 1 = poor, 0 = invisible). LVEF and SV of HAND was evaluated against SE and 3DE using correlation and Bland-Altman analysis. The correlation, bias, and limits of agreement (LOA) between HAND and SE were 0.68 [0.46:0.83], 1.60% [- 2.18:5.38], and 8.84% [- 9.79:12.99] for LVEF, and 0.91 [0.84:0.96], 1.32 ml [- 0.36:4.01], 15.54 ml [- 18.70:21.35] for SV, respectively. Correlation, bias, and LOA between HAND and 3DE were 0.55 [0.6:0.74], - 0.56% [- 2.27:1.1], and 9.88% [- 13.29:12.17] for LVEF, and 0.79 [0.62:0.89], 6.78 ml [2.34:11.21], 12.14 ml [- 26.32:39.87] for SV, respectively. The image quality scores were 9.42 ± 2.0 for the apical four chamber views of the HAND dataset and 10.49 ± 1.7 for the SE dataset and (P < 0.001). Clinically acceptable accuracy, precision, and image quality was demonstrated for HAND measurements compared to SE. In comparison to 3DE, HAND showed a clinically acceptable accuracy and precision for LVEF quantification.

Ejection Fraction Estimation from Echocardiograms Using Optimal Left Ventricle Feature Extraction Based on Clinical Methods.

Echocardiography is one of the imaging systems most often utilized for assessing heart anatomy and function. Left ventricle ejection fraction (LVEF) is an important clinical variable assessed from echocardiography via the measurement of left ventricle (LV) parameters. Significant inter-observer and intra-observer variability is seen when LVEF is quantified by cardiologists using huge echocardiography data. Machine learning algorithms have the capability to analyze such extensive datasets and identify intricate patterns of structure and function of the heart that highly skilled observers might overlook, hence paving the way for computer-assisted diagnostics in this field. In this study, LV segmentation is performed on echocardiogram data followed by feature extraction from the left ventricle based on clinical methods. The extracted features are then subjected to analysis using both neural networks and traditional machine learning algorithms to estimate the LVEF. The results indicate that employing machine learning techniques on the extracted features from the left ventricle leads to higher accuracy than the utilization of Simpson's method for estimating the LVEF. The evaluations are performed on a publicly available echocardiogram dataset, EchoNet-Dynamic. The best results are obtained when DeepLab, a convolutional neural network architecture, is used for LV segmentation along with Long Short-Term Memory Networks (LSTM) for the regression of LVEF, obtaining a dice similarity coefficient of 0.92 and a mean absolute error of 5.736%.

Screening left ventricular systolic dysfunction in children using intrinsic frequencies of carotid pressure waveforms measured by a novel smartphone-based device.

Objective.Children with heart failure have higher rates of emergency department utilization, health care expenditure, and hospitalization. Therefore, a need exists for a simple, non-invasive, and inexpensive method of screening for left ventricular (LV) dysfunction. We recently demonstrated the practicality and reliability of a wireless smartphone-based handheld device in capturing carotid pressure waveforms and deriving cardiovascular intrinsic frequencies (IFs) in children with normal LV function. Our goal in this study was to demonstrate that an IF-based machine learning method (IF-ML) applied to noninvasive carotid pressure waveforms can distinguish between normal and abnormal LV ejection fraction (LVEF) in pediatric patients.Approach. Fifty patients ages 0 to 21 years underwent LVEF measurement by echocardiogram or cardiac magnetic resonance imaging. On the same day, patients had carotid waveforms recorded using Vivio. The exclusion criterion was known vascular disease that would interfere with obtaining a carotid artery pulse. We adopted a hybrid IF- Machine Learning (IF-ML) method by applying physiologically relevant IF parameters as inputs to Decision Tree classifiers. The threshold for low LVEF was chosen as <50%.Main results.The proposed IF-ML method was able to detect an abnormal LVEF with an accuracy of 92% (sensitivity = 100%, specificity = 89%, area under the curve (AUC) = 0.95). Consistent with previous clinical studies, the IF parameterω1was elevated among patients with reduced LVEF.Significance.A hybrid IF-ML method applied on a carotid waveform recorded by a hand-held smartphone-based device can differentiate between normal and abnormal LV systolic function in children with normal cardiac anatomy.

Hypothermia as an Adjunctive Therapy to Percutaneous Intervention in ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Control Trials.

INTRODUCTION: In the setting of acute ST-elevation myocardial infarction (STEMI), several randomized control trials (RCTs) suggested a potential benefit with the use of therapeutic hypothermia (TH). However, results from previous studies are contradictory. METHOD: We performed a comprehensive literature search for studies that evaluated the efficacy and safety of adjunctive TH compared to the standard percutaneous coronary intervention (PCI) in awake patients with STEMI. The primary outcomes were the infarct size (IS) and microvascular obstruction (MVO) assessed by cardiac imaging at the end of follow-up. The secondary outcomes were major adverse cardiovascular events (MACE), procedure-related complications, and door-to-balloon time. Relative risk (RR) or the mean difference (MD) and corresponding 95 % confidence intervals (CIs) were calculated using the random-effects model. RESULTS: A total of 10 RCTs, including 706 patients were included. As compared to standard PCI, TH was not associated with a statistically significant improvement in the IS (MD: -0.87 %, 95%CI: -2.97, 1.23; P = 0.42) or in the MVO (MD: 0.11 %, 95%CI: -0.06, 0.27; P = 0.21). MACE and its components were comparable between the two groups. However, the TH approach was associated with an increased risk of infection and prolonged door-to-balloon time. Furthermore, there was a trend in the TH group toward an increased incidence of stent thrombosis and paroxysmal atrial fibrillation. CONCLUSIONS: According to our meta-analysis of published RCTs, TH is not beneficial in awake patients with STEMI and has a marginal safety profile with potential for care delays. Larger-scale RCTs are needed to further clarify our results.

Predictive value of myocardial strain on myocardial infarction size by cardiac magnetic resonance imaging in ST-segment elevation myocardial infarction with preserved left ventricular ejection fraction.

Background: The correlation between myocardial strain and infraction size by cardiac magnetic resonance imaging in ST-segment elevation myocardial infarction (STEMI) with preserved left ventricular ejection fraction (LVEF) is not clear. Objective: To investigate the correlation between myocardial strain and myocardial infarction size in patients of acute STEMI with preserved LVEF. Materials and Methods: A retrospective study was conducted to assess 31 patients with acute ST-segment elevation myocardial infarction (STEMI)after primary percutaneous coronary intervention (PCI) who received cardiac magnetic resonance (CMR) imaging during hospitalization at the Central Hospital of Shandong First Medical University from 2019 to 2022 and whose echocardiography indicated preserved LVEF (LVEF≥50%). The control group consisted of 21 healthy adults who underwent CMR during the same period. We compared the CMR characteristics, global and segmental strain between the two groups. Furthermore, the correlation between the global strain and the segmental strain of the left ventricle and late gadolinium enhancement (LGE) were evaluated. Results: Compared with healthy controls, the left ventricular ejection fraction (LVEF) of STEMI patients with preserved LVEF was significantly decreased (p < 0.05). Moreover, the global radial strain (GRS) (24.09% [IQR:17.88-29.60%] vs. 39.56% [IQR:29.19-42.20%], p < 0.05), global circumferential strain (GCS) [-14.66% (IQR: 17.91-11.56%) vs. -19.26% (IQR: 21.03-17.73%), p < 0.05], and global longitudinal strains (GLS) (-8.88 ± 2.25% vs. -13.46 ± 2.63%, p < 0.05) were damaged in patients. Furthermore, GCS and GLS were associated with LGE size (%left ventricle) (GCS: r = 0.58, p < 0.05; GLS: r = 0.37, p < 0.05). In the multivariate model, we found that LGE size was significantly associated with GCS (ß coefficient = 2.110, p = 0.016) but was not associated with GLS (ß coefficient = -0.102, p = 0.900) and LVEF (ß coefficient = 0.227, p = 0.354). The receiver operating characteristic (ROC) results showed that GCS emerged as the strongest LGE size (LGE >25%) prognosticator among strain parameters (AUC: 0.836 [95% CI, 0.692-0.981], sensitivity: 91%, specificity: 80%) and was significantly better (p = 0.001) than GLS [AUC: 0.761 (95% CI, 0.583-0.939), sensitivity: 64%, specificity: 85%] and LVEF [AUC: 0.673 (95% CI, 0.469-0.877), sensitivity: 73%, specificity: 70%]. Conclusion: Among STEMI patients with preserved LVEF after PCI, CMR-FT-derived GCS had superior diagnostic accuracy than GLS and LVEF in predicting myocardial infarction size.

The Reliability of Automated Three-Dimensional Echocardiography-HeartModelA.I. Versus 2D Echocardiography Simpson Methods in Evaluation of Left Ventricle Volumes and Ejection Fraction in Patients With Left Ventricular Dysfunction.

Background: Two-dimensional echocardiography (2DE) Simpson methods is the most frequently used imaging modality to assess Left ventricular ejection fraction (LVEF). LVEF is an important predictor of morbidity and mortality in a wide range of patients and clinical scenarios. Despite its importance in prognosis and clinical decision making, most echocardiography laboratories currently determine EF primarily by visual estimation, which is highly experience-dependent and sensitive to intra- and inter-observer variability and suboptimal accuracy and repeatability. Over the last decade, 3-dimensional echocardiography (3DE) has become increasingly implemented in clinical practice. The automated 3D HeartModelA.I. tracks every frame over the cardiac cycle using 3D speckle technology. HeartModelA.I. is a fully automated program that simultaneously detects LA and LV endocardial surfaces using an adaptive analytics algorithm that consists of knowledge-based identification of initial global shape and orientation followed by patient-specific adaptation. Objective: The objective of the study was to compare the automated 3D HeartModelA.I echocardiography and 2D Simpson methods echocardiography in evaluation of the left ventricular ejection fraction and left ventricular volumes in patients with left heart dysfunction. Methods: The study prospectively enrolled 165 patients with symptoms of LV dysfunction (ischemic or nonischemic) and New York Heart Association (NYHA) functional class I-III, referred for an echocardiographic study to evaluate the LV volumes and LV ejection fraction (LVEF) during the period from March 2020 to March 2022. Echocardiographic images were acquired by experienced echocardiographers using a commercially available Philips EPIQ machine (Koninklijke Philips Ultrasound, USA) equipped with X5-1 Matrix probe for 2DE and DHM 3DE acquisitions, respectively. Results: 2D Simpson methods echocardiography results for estimated LVEF were 38.43 ± 1.70 in patients with NYHA class I-II, 30.53 ± 1.60 in patients with NYHA class III. Using 3D Heart Model, LVEF were 38.23 ± 1.71 in patients with NYHA class I-II and 30.27 ± 1.50 in patients with NYHA class III. The results of 2D Simpson methods echocardiography for estimated LVEDVi in NYHA class I-II and NYHA class III were 99.06 ± 6.36 ml/m2, 121.96 ± 2.93 ml/m2 respectively, LVESVi were 60.91 ± 3.91 ml/m2, 84.74 ± 2.70 ml/m2 respectively, for 3D Heart Model, LVEDVi in NYHA class I-II and NYHA class III were 100.07 ± 6.72, 121.38 ± 3.01 ml/m2 respectively, LVESVi were 61.75 ± 3.94 ml/m2, 84.73 ± 2.33 ml/m2 respectively. 2DE measurement of LV volumes and EF was completed in 6.1 ± 0.8 min. per patient. 3DE HeartModelA.I acquisition and analysis in most patients was completed in <3.2 min., an average time of 2.9 ± 1.3 min. per patient. The result of our study shows that the 3D HeartModelA.I. is a reliable and robust method for LVEF and LV volume analysis, which has similar results to 2D echocardiography performed by experienced sonographers. In this study, we found that 3DE DHM fully automated tool is also significantly faster than 2DE analysis and thus can help overcome the time-consuming nature and its present a strong argument for its incorporation into the clinical workflow. In this study, we found that 3DE DHM fully automated tool is also significantly faster than 2DE analysis and thus can help overcome the time-consuming nature and its present a strong argument for its incorporation into the clinical workflow. Conclusion: 3D DHM provides fast and accurate LV volumes and LVEF quantitation, as it avoids geometric assumptions and left ventricular foreshortening, has better reproducibility and has incremental value to predict adverse outcomes in comparison with conventional 2DE. In the future major benefit of AI in echocardiography is expected from improvements in automated analysis and interpretation to reduce workload and improve clinical outcome.

The Reduction of Left Ventricle Ejection Fraction after Multi-Vessel PCI during Acute Myocardial Infarction as a Predictor of Major Adverse Cardiac Events in Long-Term Follow-Up.

BACKGROUND: Revascularisation strategy in patients with multi-vessel coronary disease and acute myocardial infarction (AMI) remains challenging. One of the potential treatment options is complete percutaneous revascularisation during index hospitalisation. This strategy could positively influence left ventricle ejection fraction (LVEF). AIM: To investigate the long-term changes in LVEF and clinical outcome among patients with AMI after complete coronary revascularisation (CCR). METHODS: Records of 171 patients with a diagnosis of AMI and multi-vessel coronary artery disease (CAD) on index angiography, in whom CCR was performed as a staged procedure during initial hospitalisation, were analysed. Clinical data were collected from in-hospital medical records and discharge letters. Cardiac ultrasound (CU), with particular assessment of LVEF, was performed one day before discharge. Follow-up (FU) CU was collected from the out-patient department at least six months ± one week after discharge. Follow-up data, including major adverse cardiac events (MACE), were collected during follow-up visits by telephone. Depending on the LVEF change during the follow-up period, patients were divided into two groups. Patients with a decrease in the LVEF (D-LVEF group) were compared with patients with no changes (preserved) or improvement regarding LVEF (P/I-LVEF). RESULTS: The median duration of the follow-up was 19 months (14-24 months). The median change in LVEF during observation was -5.0p% (IQR (-7.0)-(-2.75p.%)) in the D-LVEF group and +4.0% (IQR 1.0-5.0p%) in the P/I-LVEF group. Among patients in the P/I-LVEF group, there was a sub-group of patients with no change in LVEF (28 patients), and one demonstrating improvement in LVEF (104 patients). In the subgroup of patients with improved LVEF, the median change in LVEF was 4.5p% (IQR 2-6.25p%). Among patients with decreasing LVEF, there was a significantly higher risk of MACE (15 vs. 2.3%, p = 0.031), especially non-fatal AMI (10 vs. 0%, p = 0.017). We found the following among predictors concerning increased risk of MACE occurrence: urgent PCI (p = 0.004), hospitalisations regardless of cause (p = 0.028), EF worsening (p = 0.025), fasting glucose serum concentration (p = 0.024) and fasting triglyceride serum concentration (p = 0.027). CONCLUSIONS: Complete revascularisation (CR) at baseline (one stage) in patients with AMI and multi-vessel disease is associated with LVEF improvement and MACE rate reduction. Patients with worse LVEF have poor clinical outcome and a higher rate of MACE.

Mid-term results of surgical aortic valve replacement with bioprostheses in hemodialysis patients.

Background: Limited studies have assessed the factors affecting prognosis in hemodialysis (HD) patients who undergo surgical aortic valve replacement with a bioprostheses (SAVR-BP). This study aimed to evaluate the outcomes of HD patients who had undergone SAVR-BP for aortic stenosis (AS) and identify the risk factors for mortality. Methods: This retrospective study included 57 HD patients who had undergone SAVR-BP for AS between July 2009 and December 2020. Multivariate logistic regression was used to predict factors associated with mid-term outcomes and death or survival. Kaplan - Meier curves were also generated for mid-term survival. Results: The in-hospital mortality rate was 8.8%, and the 5-year mortality rate was 42.1%. The independent predictors of 5-year mortality were preoperative age (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.175-2.083, p = 0.002), hyperlipidemia (HR, 0.02; 95% CI, 0.002-0.297, p = 0.004), left ventricular diastolic diameter (HR, 1.74; 95% CI, 1.142-2.649, p = 0.010), left ventricular systolic diameter (HR, 0.61; 95% CI, 0.392-0.939, p = 0.025), and Japan SCORE (HR, 1.28; 95% CI, 1.052-1.563, p = 0.014). The postoperative predictors included intensive care unit stay (HR, 1.11; 95% CI, 1.035-1.194, p = 0.004) and albumin level (HR, 0.38; 95% CI, 0.196-0.725, p = 0.003). Conclusions: The 5-year prognosis of HD patients undergoing SAVR may be improved by early diagnosis (before the occurrence of LV hypertrophy/enlargement) and nutritional management with oral intake to alleviate postoperative hypoalbuminemia.Registration number of clinical studies: UMIN000047410.

Effect of Yoga Lifestyle in Patients with Heart Failure: A Randomized Control Trial.

Background: In spite of significant advances in the management of heart failure (HF), morbidity and mortality remain high. Therefore, there is a need for additional strategies. We did a randomized clinical trial to study effect of yoga in patients with HF in terms of quality of life (QOL), left ventricle ejection fraction (LVEF), C-reactive protein (CRP), and NTproBNP. Materials and Methods: 60 patients with stable HF New York Heart Association Class II with LVEF 30%-40% were randomized into control group (CG) and yoga group (YG). CG received the guideline-based therapy and YG in addition practiced the yoga, one hour daily for 3 months. All patients were assessed for QOL, CRP, NTProBNP, and LVEF at baseline and after 3 months. Results: A significant difference was observed in all four parameters in the YG as compared to the CG (P < 0.01) after 12 weeks. QOL as assessed by Minnesota living with heart failure questionnaire score improved significantly in YG as compared to CG (10 V/s 14, P < 0.001). There was a significant improvement within YG in terms of LVEF (33.4-36.8, P = 0.001), and the percentage change in LVEF was significant between the groups (10% V/s 5%, P = 0.001). NTproBNP also significantly reduced by 69.8% from 755 to 220 Pmol/l in YG as compared to 39.3% in CG (679-406 Pmol/l). CRP decreased by 49.3% (5.36-2.73 mg/L) in YG and 35.8% (5.39-3.45 mg/L) in CG. Conclusion: The result of this pilot study suggests that addition of yoga to guideline-based therapy for HF patients significantly improves QOL, LVEF, and NTProBNP and reduces CRP level. Larger studies are needed to confirm these findings.

Sleep-disordered breathing patterns in hospitalized patients with acute heart failure across the entire spectrum of ejection fraction.

BACKGROUND: Sleep-disordered breathing (SDB) is prevalent in heart failure (HF). Yet, scarce data exist on sleep-patterns in acute HF and differences in specific subgroups. Our goal was to assess SDB prevalence in hospitalized patients with decompensated HF across the entire spectrum of left ventricle ejection fraction (LVEF). METHODS: Single-center retrospective study enrolling patients admitted for acute HF between 2013 and 2018. All patients were screened for SDB with an ApneaLink™ Plus device before discharge while euvolemic and receiving oral therapy. Those with a sleep study time < 3 h were excluded. HF with reduced, moderately reduced, and preserved LVEF (HFrEF, HFmrEF, and HFpEF) was defined by a LVEF < 40%, 40-49%, and ≥ 50%, respectively. SDB was defined by an apnea-hypopnea index (AHI) ≥ 5/h. RESULTS: Overall, 221 patients were included (mean age 75 ± 11 years). Seventy-two (33%) had HFrEF, 26 (11%) HFmrEF, and 123 (56%) HFpEF. In total, 176 (80%) met the criteria for mild SDB, while 59% and 38% had an AHI ≥ 15/h or ≥ 30/h, respectively. SDB prevalence was high and similar between HFrEF, HFmrEF, and HFpEF. Yet, SDB was often more severe in HFrEF when compared to HFpEF. HFmrEF had intermediate characteristics, with an AHI closer to HFrEF. CONCLUSION: In a cohort of patients admitted for acute HF, SDB was highly prevalent in all subgroups, including HFmrEF. The pervasiveness and severity of SDB was particularly noted in HFrEF. These findings suggest that routine SDB screening may be warranted following acute HF.

Prognostic value of temporal patterns of global longitudinal strain in patients with chronic heart failure.

Background: We investigated whether repeatedly measured global longitudinal strain (GLS) has incremental prognostic value over repeatedly measured left ventricular ejection fraction (LVEF) and N-terminal pro B-type natriuretic peptide (NT-proBNP), and a single "baseline" GLS value, in chronic heart failure (HF) patients. Methods: In this prospective observational study, echocardiography was performed in 173 clinically stable chronic HF patients every six months during follow up. During a median follow-up of 2.7 years, a median of 3 (25th-75th percentile:2-4) echocardiograms were obtained per patient. The endpoint was a composite of HF hospitalization, left ventricular assist device, heart transplantation, cardiovascular death. We compared hazard ratios (HRs) for the endpoint from Cox models (used to analyze the first available GLS measurements) with HRs from joint models (which links repeated measurements to the time-to-event data). Results: Mean age was 58 ± 11 years, 76% were men, 81% were in New York Heart Association functional class I/II, and all had LVEF < 50% (mean ± SD: 27 ± 9%). The endpoint was reached by 53 patients. GLS was persistently decreased over time in patients with the endpoint. However, temporal GLS trajectories did not further diverge in patients with versus without the endpoint and remained stable during follow-up. Both single measurements and temporal trajectories of GLS were significantly associated with the endpoint [HR per SD change (95%CI): 2.15(1.34-3.46), 3.54 (2.01-6.20)]. In a multivariable model, repeatedly measured GLS maintained its prognostic value while repeatedly measured LVEF did not [HR per SD change (95%CI): GLS:4.38 (1.49-14.70), LVEF:1.14 (0.41-3.23)]. The association disappeared when correcting for repeatedly measured NT-proBNP. Conclusion: Temporal evolution of GLS was associated with adverse events, independent of LVEF but not independent of NT-proBNP. Since GLS showed decreased but stable values in patients with adverse prognosis, single measurements of GLS provide sufficient information for determining prognosis in clinical practice compared to repeated measurements, and temporal GLS patterns do not add prognostic information to NT-proBNP.

The Impact of Left Ventricle Ejection Fraction Reduction and Transient Ischemic Dilation in Patients With Normal Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging.

INTRODUCTION: Coronary artery disease (CAD) is a leading cause of death in developed countries. Non-invasive functional imaging modalities are currently recommended as initial diagnostic tests in patients with an intermediate-high pretest probability of CAD. Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) creates images of regional myocardial tracer uptake, reflecting relative myocardial blood flow. However, there are other non-perfusion predictors of CAD, such as transient ischemic dilatation (TID) and reduced post-stress left ventricle ejection fraction (LVEF). Available data regarding these parameters is controversial. The aim of our study was to evaluate the incidence of significant CAD in patients with non-perfusion high-risk markers of ischemia despite a normal SPECT-MPI. METHODS: Single-center, observational, retrospective, and longitudinal study. Inclusion criteria were age ≥18 years, normal SPECT-MPI, and availability of gated study for LVEF and volume analysis. Exclusion criteria were any known cardiomyopathy or congenital heart disease and known CAD. Non-perfusion high-risk markers: LVEF reduction ≥5% on post-stress images; TID (defined as a stress/rest left ventricle volume ratio ≥ 1.15), including end-systolic, end-diastolic, and mean volumes. The primary endpoint was the identification of significant CAD (stenosis >70% on an epicardial coronary artery or >50% on the left main artery) on invasive coronary angiography. RESULTS: A total of 197 patients met the inclusion criteria. Mean age was 64 ± 12.6 years and 59.4% (n = 117) of patients were male. Overall, 26% of patients had LVEF reduction ≥5% on stress study; 24.9% had a stress/rest end-systolic volume ratio ≥ 1.15; 7.1% had a stress/rest mean volume ratio ≥ 1.15; 7.1% had a stress/rest end-diastolic volume ratio ≥ 1.15. Time-to-primary endpoint was significantly lower in patients with LVEF reduction ≥5% on stress study (67.99 (95% CI 60.49-75.49) vs. 77.56 months (95% CI 75.14-79.99); p = 0.003) and in patients with stress/rest end-systolic volume ratio ≥ 1.15 (68.39 (95% CI 60.69-76.10) vs. 77.31 months (95% ICCI 74.68-79.76); p = 0.013). CONCLUSION: In patients with normal perfusion on SPECT-MPI, the incidence of significant CAD was significantly higher in those with LVEF reduction ≥ 5% on stress study and in those with a stress/rest end-systolic volume ratio ≥ 1.15, during a follow-up period of five years.

Clinical and Predictive Value of Computed Tomography Angiography in High-Altitude Pulmonary Hypertension.

Background: High-altitude pulmonary hypertension (HAPH), as the group 3 pulmonary hypertension, has been less studied so far. The limited medical conditions in the high-altitude plateau are responsible for the delay of the clinical management of HAPH. Objectives: This study aims to identify the imaging characteristics of HAPH and explore noninvasive assessment of mean pulmonary arterial pressure (mPAP) based on computed tomography angiography (CTA). Methods: Twenty-five patients with suspected HAPH were enrolled. Right heart catheterization (RHC) and pulmonary angiography were performed. Echocardiography and CTA image data were collected for analysis. A multivariable linear regression model was fit to estimate mPAP (mPAPpredicted). A Bland-Altman plot and pathological analysis were performed to assess the diagnostic accuracy of this model. Results: Patients with HAPH showed slow blood flow and coral signs in lower lobe pulmonary artery in pulmonary arteriography, and presented trend for dilated pulmonary vessels, enlarged right atrium, and compressed left atrium in CTA (P for trend <0.05). The left lower pulmonary artery-bronchus ratio (odds ratio: 1.13) and the ratio of right to left atrial diameter (odds ratio: 1.09) were significantly associated with HAPH, and showed strong correlation with mPAPRHC, respectively (r = 0.821 and r = 0.649, respectively; all P < 0.0001). The mPAPpredicted model using left lower artery-bronchus ratio and ratio of right to left atrial diameter as covariates showed high correlation with mPAPRHC (r = 0.907; P < 0.0001). Patients with predicted HAPH also had the typical pathological changes of pulmonary hypertension. Conclusions: Noninvasive mPAP estimation model based on CTA image data can accurately fit mPAPRHC and is beneficial for the early diagnosis of HAPH.

E-Point Septal Separation Accuracy for the Diagnosis of Mild and Severe Reduced Ejection Fraction in Emergency Department Patients.

Introduction: In the Emergency Department (ED), a thorough cardiovascular evaluation cannot be accomplished only with physical examination. E-Point Septal Separation (EPSS) measure through Point-of-Care Ultrasound (POCUS) has been used to evaluate systolic function in echocardiography. We analyzed EPSS for diagnosis of Left Ventricle Ejection Fraction <50% and ≤40% in ED patients. Methods: Retrospective analysis of a convenience sample of patients presenting to ED with chest pain or dyspnea who underwent admission POCUS evaluation by Internal Medicine Specialist unaware of Transthoracic Echocardiogram. Accuracy was assessed with sensitivity, specificity, likelihood ratios (LR) and Receiver operating characteristics (ROC) curve. The best cut off point was calculated using Youden Index. Results: Ninety-six patients were included. Median EPSS and LVEF were 10mm and 41% respectively. Area Under the ROC Curve (AUC-ROC) to diagnose a LVEF <50% was 0.90 (IC95% 0.84-0.97). Youden Index was 0.71 with cut off point EPSS at 9.5mm, performing with a sensitivity of 0.80, a specificity of 0.91, a positive LR of 9.8 and a negative LR of 0.2. AUC-ROC to diagnose a LVEF ≤40% was 0.91 (IC95% 0.85-0.97). Youden Index was 0.71 with a cut off point EPSS at 9.5mm, performing with a sensitivity of 0.91 and specificity of 0.80, a positive LR of 4.7 and a negative LR of 0.1. Conclusion: EPSS can reliably diagnose reduced LVEF in a set of ED patients with cardiovascular symptoms. A cut off point at 9.5 mm has good sensitivity, specificity and Likelihood ratios.

Variabilidad en el rendimiento neuropsicológico en pacientes con síndrome coronario agudo / Variability in the neuropsychological performance of patients with acute coronary syndrome

Introducción: Existe un interés creciente por el estudio de la relación entre las cardiopatías, incluido el síndrome coronario agudo (SCA) y el deterioro cognitivo, y, aunque no se conocen con concreción los factores que median entre el SCA y el deterioro cognitivo, en el centro de este debate se encuentra el papel de la fracción de eyección del ventrículo izquierdo (FEVI). Objetivos: Determinar la presencia de deterioro cognitivo en pacientes con SCA y explorar su asociación con diversos factores –sociodemográficos, consumo de fármacos, rendimiento en pruebas funcionales cardíacas (en particular, la FEVI)–. Pacientes y métodos: Se recogieron variables sociodemográficas, médicas y neuropsicológicas en 80 pacientes con SCA que participaban en un programa de rehabilitación cardíaca. Se compararon sus puntuaciones en la batería neuropsicológica con los datos normativos poblacionales para determinar qué sujetos mostraban un rendimiento deficitario. Se realizaron análisis de regresión para determinar qué factores se asocian con el rendimiento en las pruebas neuropsicológicas. Resultados: En comparación con su grupo normativo, el 37,5% de los sujetos presentó una baja puntuación en tres o más test neuropsicológicos. La edad, un bajo nivel educativo y una FEVI baja explicaron hasta el 51% de la variabilidad en los resultados de las pruebas neuropsicológicas. Conclusiones: Los pacientes con SCA tienen más posibilidades de presentar un deterioro de funciones cognitivas, como la atención, la memoria y las funciones ejecutivas, junto con un enlentecimiento en la velocidad de procesamiento de la información. Una FEVI inferior al 50% podría ser un factor explicativo destacado de dicho deterioro cognitivo.

Introduction: There is a growing interest in the study of the relationship between heart disease, including acute coronary syndrome (ACS) and cognitive impairment, and although the factors mediating ACS and cognitive impairment are not well understood, the debate revolves around the role of the left ventricular ejection fraction (LVEF). Aims: To determine the presence of cognitive impairment in patients with ACS and explore its association with various factors, including sociodemographic, medication use and performance on cardiac function tests (in particular LVEF). Patients and methods: Sociodemographic, medical and neuropsychological variables were collected in 80 patients with ACS participating in a cardiac rehabilitation programme. Their scores on the neuropsychological battery were compared with normative population data to determine which subjects showed deficient performance. Regression analyses were conducted to determine which factors are associated with performance on neuropsychological tests. Results: Compared to their normative group, 37.5% of the subjects had low scores on three or more neuropsychological tests. Age, low educational level and low LVEF explained up to 51% of the variability in neuropsychological test results. Conclusions. Patients with ACS are more likely to have impaired cognitive functions, such as attention, memory and executive functions, along with a slower information processing speed. An LVEF below 50% could be a major explanatory factor for such cognitive impairment.(AU)

Impact of Post-Procedural Change in Left Ventricle Systolic Function on Survival after Percutaneous Edge-to-Edge Mitral Valve Repair.

OBJECTIVES: To investigate how the changes of left ventricle ejection fraction (LVEF) between admission and discharge affected the long-term outcome in patients who underwent percutaneous edge-to-edge mitral valve repair for secondary mitral regurgitation. BACKGROUND: An acute impairment of LVEF after surgical repair of mitral regurgitation, known as afterload mismatch, has been associated with increased all-cause mortality. Afterload mismatch after percutaneous edge-to-edge mitral valve repair has been postulated to be a transient phenomenon. METHODS: This study is based on a single-center, retrospective, observational registry of patients who underwent percutaneous edge-to-edge mitral valve repair with the MitraClip (Abbot Vascular) system for the treatment of symptomatic, moderate-to-severe mitral regurgitation. We included data on 399 patients who underwent percutaneous edge-to-edge mitral valve repair for secondary mitral regurgitation. Expert echocardiographers assessed LVEF before the procedure and at discharge. The patients were divided into three groups according to the difference of periprocedural LVEF measurements: unchanged (n = 318), improved (n = 40), and decreased (n = 41) LVEF. RESULTS: The median follow-up time was 2.0 years. When adjusted for gender, NYHA class and estimated glomerular filtration rate, decreased postprocedural LVEF was associated with an increased risk of death (adjusted HR 2.05, 95% CI 1.26-3.34) and increased postprocedural LVEF with a reduced risk of death (adjusted HR 0.47, 95% CI 0.24-0.91) compared to unchanged LVEF. Conclusion: Among patients who underwent percutaneous edge-to-edge mitral valve repair, decreased postprocedural LVEF was associated with increased mortality, while improved LVEF was associated with lower mortality compared to unchanged LVEF.

Severe Heart Failure Associated With Tachycardia-Induced Cardiomyopathy Due to Incessant Atrioventricular Re-Entrant Tachycardia.

Short RP interval atrioventricular re-entrant tachycardias do not typically present as an incessant form. We present 2 cases of incessant atrioventricular re-entrant tachycardias leading to tachycardia-induced cardiomyopathy with severe heart failure presentation in middle-aged adults. Both underwent accessory pathway ablation and recovered normal left ventricle function before hospital discharge. (Level of Difficulty: Intermediate.).