The significant role of mitral regurgitation (MR) in development of pulmonary hypertension (PH) has been proved in previous studies. Experts suggest systolic pulmonary arterial pressure (SPAP) ⩾60 mmHg during exercise as a significant threshold of negative prognostic value in patients with MR.The aim of this study was to evaluate the changes of SPAP and to ascertain the determinants of exercise induced pulmonary hypertension (EIPH) in patients with asymptomatic primary MR.We performed a prospective study that included 50 patients with asymptomatic primary moderate to severe MR with preserved left ventricular ejection fraction (LV EF ⩾60%) at rest. They were divided into two groups according to the presence (PH group; n = 13) or absence (non-PH group; n = 37) of EIPH. Rest and stress (bicycle ergometry) echocardiography and speckle-tracking offline analysis were performed.An increment of SPAP from rest to peak stress was higher in PH group (p < 0.001). Multivariate regression analysis showed that MR effective regurgitation orifice area (EROA; p = 0.008) and regurgitant volume (RVol; p = 0.006) contributed significantly to SPAP at rest. Higher increment of MR EROA during stress and worse parameters of LV diastolic function at rest (E, A, E/e') correlated significantly with higher SPAP during peak stress and they had a major role in predicting EIPH according to univariate logistic regression analysis. In ROC analysis SPAP >33.1 mmHg at rest could predict EIPH with 84.6% sensitivity and 87.1% specificity (95%CI 0.849-1.000; p < 0.001).Parameters of MR severity (EROA and RVol) were significant determinants of SPAP at rest, while the increment of MR EROA during stress and parameters of resting LV diastolic function were the best predictors of significant EIPH.
Background The aim of this prospective study was to assess the usefulness of global longitudinal strain ( GLS ), regional diastolic and systolic strain, strain rate ( SR ) parameters at rest and during dobutamine stress echocardiography for detecting significant coronary artery stenosis in patients with a moderate or high probability of coronary artery disease ( CAD ). Methods Dobutamine stress echocardiography and adenosine magnetic resonance imaging ( AMRI ) were performed on 127 patients with a moderate and high probability of CAD and left ventricle ejection fraction ≥55%. CAD was defined as ≥70% diameter stenosis on coronary angiography validated as hemodynamically significant by AMRI . Patients were grouped according to coronary angiography and AMRI results: CAD (−) n=67 (52.8%) vs CAD (+) n=60 (47.2%). Results There were no significant differences of clinical characteristics, conventional echocardiography, and deformation parameters between the two groups at rest except that GLS was higher in the CAD (−) group (−21.5±2.4% vs −16.2±2.1%, P =.00). GLS at high dobutamine doses had the highest area under the ROC curve ( AUC ) ( AUC 0.955, sensitivity 94%, specificity 92%). Radial late diastolic SR at low doses performed best out of all diastolic parameters with an AUC of 0.789, sensitivity 76.7%, specificity 91.7%. Other deformation parameters including visual assessment were inferior. Conclusions Global longitudinal strain is highly sensitive and specific in detecting hemodynamically significant coronary artery stenosis in moderate‐ to high‐risk patients without known CAD . This is the first study showing that GLS is more sensitive and specific compared with early and late diastolic SR parameters or visual assessment in detecting CAD .
Abstract Background Evaluation of right ventricle (RV) function and pulmonary artery pressure (PAP) during stress, plays an important role in identifying worse prognosis for patients with chronic mitral regurgitation (MR) and may help to optimise the time of surgical interventions. Purpose The aim of the study was to evaluate changes of RV function and systolic PAP in patients with asymptomatic primary MR during stress echocardiography. Methods Resting and stress (veloergometry as per protocol 25 + 25 W every 3 minutes) echocardiography were performed in 63 asymptomatic patients (age 56.12 ± 13.97 years) with preserved left ventricle (LV) ejection fraction (EF) (>50%) at rest. 39 (61.9%) patients with moderate (grade 2-3) MR (MR group) and 24 (38.1%) patients without significant heart valves disease (control group) were included in the study. Statistical analyses were performed using the SPSS 20.0 software. The value of p < 0.05 was considered as statistically significant. Results Anthropometric and clinical characteristics, LV EF (64.96 ± 9.14% vs. 64.87 ± 6.46%, p = 0.97) and LV global longitudinal strain (GLS) (-19.24± 3.12% vs. -19.28 ± 3.36%, p = 0.055) at rest were not significantly different between MR and control groups. Diameter of RV was larger in MR group (36.07 ± 5.34 mm vs. 33.13 ± 3.48 mm) however difference was not significant (p = 0.971). Parameters of RV function (longitudinal myocardial velocity - S’, fractional area change (FAC) and tricuspid annular plane systolic excursion (TAPSE)) were similar in both groups at rest, during stress and at recovery phase (Picture 1). However TAPSE and S’ at rest (p = 0.037 and p = 0.205, respectively) and minimal stress (p = 0.006 and p = 0.035, respectively) were significantly lower in patients with MR who had highly increased (>60 mmHg) systolic PAP during stress. Also TAPSE (p = 0.002) and S’ (p = 0.017) during recovery phase were significantly lower in subjects with reduced LV contractile reserve (whom LV EF increased <4% or GLS <1.9% during stress). Systolic PAP during stress was growing much faster in patients with MR (Picture 1). Conclusions Patients with asymptomatic moderate primary mitral regurgitation had higher systolic PAP during stress even though at rest it was similar as in controls. Prominent severe pulmonary hypertension during stress was related to worsening parameters of RV function. Abstract P293 Figure. Parameters of RV during stress
Abstract Aims The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. Methods and results In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5–23.1%] vs. 15.7% (IQR 14.5–21.1%)}, diabetes [7.7% (IQR 7.1–10.1%) vs. 5.6% (IQR 4.8–7.0%)], and among males smoking [43.8% (IQR 37.4–48.0%) vs. 26.0% (IQR 20.9–31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0–10.8) vs. 16.7% (IQR 13.9–19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655–8115)] compared with high-income [2235 (IQR 1896–3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. Conclusion A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest.
Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Deep learning (DL) has been successfully applied in the automated assessment of some transthoracic echocardiography (TTE) parameters such as left-ventricular ejection fraction. Nevertheless, automation of the right-sided heart assessment has not been widely studied, partially due to the relative difficulty involved in some of the right-sided heart measurement evaluation and time constraints in routine practice. Here we have explored the feasibility of a DL-based system capable of performing different tasks involved in the right-sided heart functional and geometric evaluation. PURPOSE To develop a DL-based system assessing right atrium (RA) and right ventricle (RV) functional and geometric parameters and compare its accuracy to board-certified cardiologists. METHODS A total of 2,014 frames from 349 patients (with various indications for TTE) were used to train and validate four convolutional neural networks (CNNs) to perform either segmentation or landmark detection across four different TTE views: apical four-chamber (A4Ch), parasternal long-axis (PLAX), M-mode of tricuspid annulus and tissue Doppler imaging (TDI) of the right ventricular lateral wall. The CNNs were optimised to perform different right-sided heart measurements, namely, right atrial area in end-systole (RAA) and fractional area change (FAC) of RV in A4Ch view, proximal right ventricular outflow tract diameter (pRVOT) in PLAX view, tricuspid annular plane systolic excursion (TAPSE) in M-mode and S’ in TDI. Model performance was compared with two board-certified cardiologists using their average measurements on 20 test set patients. RESULTS CNN predicted pRVOT diameter with a mean absolute error (MAE) of 1.02 mm and root mean squared error (RMSE) of 3.08 mm. The intersection over union (IoU) for the segmentation of RV and RA was 0.89 and 0.87, respectively. We then used RV and RA segmentation predictions to calculate additional parameters which resulted in RMSE of 8.34% for FAC and 4.93cm2 for RAA. In the M-mode and TDI, the model achieved RMSE of 4.48 mm and 0.84 cm/s for the detection of TAPSE and S’, respectively. CONCLUSIONS We have demonstrated the feasibility of a DL-based system performing different measurements involved in right-sided heart evaluation. In a routine practice, where limited time resources might be available, such could assist in the thorough assessment of the right-sided heart geometry and function. Additional studies using cardiac magnetic resonance imaging to establish more precise accuracy of such systems is needed.
Abstract Introduction Patients with primary moderate or severe mitral regurgitation (MR) often remain asymptomatic for a long time due to mechanisms of compensation. Exercise stress could provoke symptoms, unmask subclinical changes of left and right ventricles and reveal decreased functional capacity. Reduced exercise capacity is related to worse outcomes. Purpose The aim of this study was to evaluate an exercise capacity and factors influencing it in patients with asymptomatic primary moderate to severe MR and preserved left ventricle (LV) ejection fraction (EF). Methods 60 patients with asymptomatic moderate or severe MR and LV EF >60% underwent resting and stress (bicycle–ergometry as per protocol 25 + 25W every 3 minutes) echocardiography. Their exercise capacity was evaluated in Watts (W) and metabolic units (MET). The blood sample for NT-proBNP evaluation was collected just before the stress test. Results Patients with primary MR achieved 84.74±35.16 W and 4.87±1.51 MET. According to univariate linear regression analysis exercise capacity in MET was significantly related to age (B=−0.066, p<0.001), systolic pulmonary artery pressure (SPAP) at rest (B=−0.048, p=0.034), resting E wave (B=−0.015, p=0.031) and NT-proBNP (B=−0.003, p=0.006). Predictors of exercise capacity in W also were age (B=−1.273, p=0.002), resting E wave (B=−0.318, p=0.041), NT-proBNP (B=−0.057, p=0.018). Higher concentration of NT-proBNP and bigger SPAP at rest correlated with lower exercise capacity (picture 1). In patients who had exercise induced pulmonary hypertension (EIPH; SPAP >60 mmHg during peak stress) ergometry was more frequently terminated prematurely (19 (95%) and 24 (60%), p=0.012). They also had significantly lower exercise capacity than subjects without EIPH ((W: p=0.015 and MET: p<0.001). Conclusions Age, NT-proBNP concentration, resting SPAP and E wave were predisposing factors of exercise capacity in patients with asymptomatic primary moderate to severe MR and preserved LV EF. EIPH and elevated NT-proBNP were related to premature exercise termination and lower exercise capacity. Funding Acknowledgement Type of funding sources: None. Picture 1
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