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Background Atrioventricular (AV) delay in cardiac resynchronisation therapy (CRT) recipients are typically optimised at rest. However, there are limited data on the impact of exercise-induced changes in heart rate on the optimal AV delay and left ventricular function. Methods and results The authors serially programmed AV delays in 41 CRT patients with intrinsic sinus rhythm at rest and during two stages of supine bicycle exercise with heart rates at 20 bpm (stage I) and 40 bpm (stage II) above baseline. The optimal AV delay during exercise was determined by the iterative method to maximise cardiac output using Doppler echocardiography. Results were compared to physiological change in PR intervals in 56 normal controls during treadmill exercise. The optimal AV delay was progressively shortened (p<0.05) with escalating exercise level (baseline: 123±26 ms vs stage I: 102±24 ms vs stage II: 70±22 ms, p<0.05). AV delay optimisation led to a significantly higher cardiac output than without optimisation did during stage I (6.2±1.2 l/min vs 5.2±1.2 l/min, p<0.001) and stage II (6.8±1.6 l/min vs 5.9±1.3 l/min, p<0.001) exercise. A linear inverse relationship existed between optimal AV delays and heart rates in CRT patients (AV delay=241-1.61xheart rate, R(2)=0.639, p<0.001) and healthy controls (R(2)=0.646, p<0.001), but the slope of regression was significantly steeper in CRT patients (p<0.001). Conclusions Haemodynamically optimal AV delay shortened progressively with increasing heart rate during exercise, which suggests the need for programming of rate-adaptive AV delay in CRT recipients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify subgroups of heart failure patients who might benefit from biventricular pacing. BACKGROUND: Cardiac resynchronization therapy (CRT) improves the quality of life, New York Heart Association (NYHA) functional class, and exercise capacity and decreases hospitalizations for heart failure for patients who have severe heart failure and a wide QRS. It is unclear if other populations of heart failure patients would benefit from CRT. METHODS: One hundred forty-four consecutive heart failure patients who underwent CRT and completed 3 months of follow-up were reviewed. Demographic, echocardiographic, electrocardiographic, and clinical outcome data were analyzed to assess the relationship of functional class and QRS duration before device implantation to postimplant outcomes. RESULTS: There were 20, 88, and 36 patients in NYHA functional class II, III, and IV, respectively. Thirty-four patients had right ventricular pacing and another 29 patients had a QRS duration < or = 150 ms. Patients who were in NYHA functional class II at baseline had significant improvement in left ventricular ejection fraction and indices of left ventricular remodeling after CRT. Similar significant findings were seen in the subgroup with right ventricular pacing at baseline after CRT. However, in the subgroup with a narrow QRS duration, there were no significant changes in the indices of left ventricular remodeling or in the NYHA functional class and there was a significant increase in the QRS duration. For the study cohort as a whole, an improvement in NYHA functional class after CRT correlated with a significant decrease in adverse clinical outcomes. CONCLUSIONS: Heart failure patients who were in NYHA functional class II and those with right ventricular pacing appeared to benefit from CRT. [ABSTRACT FROM AUTHOR]

Background: Heart failure patients who are candidates for CRT frequently display longitudinal rotation (LR) - a swinging motion of the heart when imaged in a horizontal long-axis plane. Objectives: To identify the magnitude and predictors of LR in patients with ischaemic (ICM) and idiopathic dilated (DCM) cardiomyopathy, and to assess predictive value of LR in patients undergoing cardiac resynchronisation therapy (CRT). Design and Setting: A retrospective study in a tertiary heart care setting. Methods: Echocardiography was performed in 45 ICM and 41 DCM patients who were CRT candidates and 16 control subjects. Global LR, segmental strains and segmental LR were assessed from echocardiograms using speckle tracking. Repeat echocardiography >40 days after the beginning of CRT was performed in 64 patients. Results: While DCM patients with QRS duration of both <130 ms and > or =130 ms displayed significant clockwise LR (p<0.001 for both vs 0), ICM patients and control subjects had LR that did not differ from 0. The most significant LR predictor was end-diastolic volume (p<0.001) followed by the absence of ischaemia (p<0.001) and QRS duration (p = 0.05). DCM patients with prominent clockwise LR had lower septal but higher lateral strains than DCM patients with minimal LR, or ICM patients with counterclockwise LR. LR correlated with decrease of end-systolic volume in DCM (r = 0.49, p = 0.004), while no relationship was observed in ICM. Conclusion: Clockwise LR is linked to presence of DCM, with the small impact of QRS duration. LR is a moderately strong predictor of end-systolic volume decrease during CRT in DCM. [ABSTRACT FROM AUTHOR]

In a multicenter randomized trial, we studied a transesophageal echocardiography (TEE) guided strategy with short-term anticoagulation compared with a conventional strategy for patients with atrial fibrillation >2 days' duration and undergoing cardioversion. Composite major and minor bleeding was a predetermined secondary end point of the study. The objective of the study was to assess the incidence, location, and predictors of bleeding in the 2 treatment groups. A total of 1,222 patients were assigned to a TEE guided or conventional strategy and followed over 8 weeks. We present data on major and minor adjudicated bleeding complications for the 2 study groups during the 8-week study period. Composite major and minor bleeding complications occurred in 51 of 1,222 patients (4.2%) and were significantly lower in the TEE guided group compared with the conventional group (2.9 vs 5.5%, p = 0.025). The TEE group had fewer cancellations of cardioversion as a result of bleeding (0% vs 0.7%, p = 0.003). Major (n = 14) and minor (n = 38) bleeding complications were predominantly gastrointestinal (71.4% and 31.6%, respectively) and were associated with warfarin use. Predictors of bleeding included patient age, conventional group assignment, inpatient status, and functional status. Thus, composite major and minor bleeding complications occurred in 4.2% of the 1,222 patients and were significantly lower in the TEE guided group compared with the conventional group. Treatment variables affecting length of anticoagulant therapy in the conventional arm combined with advancing age and functional status are important concerns in patients who undergo cardioversion of atrial fibrillation. [ABSTRACT FROM AUTHOR]

Doppler assessments of pulmonary venous (PV) and left atrial appendage flows are useful surrogates of left atrial (LA) function, but it is unknown if these can predict atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation. We compared Doppler surrogates of LA function immediately after pulmonary vein antrum isolation in patients with AF recurrence versus matched patients without recurrence. Patients with a 6-month recurrence had significantly lower LA appendage peak emptying velocity (19 +/- 10 vs 29 +/- 11 cm/s) and lower peak PV systolic wave velocity (36 +/- 17 vs 46 +/- 22 cm/s) compared with those without, suggesting that intracardiac Doppler assessment of LA function after AF ablation predicts AF recurrence. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to compare the relative cost of a transesophageal echocardiography (TEE)-guided strategy versus conventional strategy for patients with atrial fibrillation (AF) >2 days duration undergoing electrical cardioversion over an eight-week period. Background: The Assessment of Cardioversion Using Transesophageal Echocardiography (ACUTE) trial found no difference in embolic rates between the two approaches. However, the TEE-guided strategy had a shorter time to cardioversion and a lower rate of composite bleeding. While similar clinical efficacy was concluded, the relative cost of these two strategies has not been explored. Methods: Two economic approaches were employed in the ACUTE trial. The first approach was based on hospital charge data from complete hospital Universal Billing Code of 1992 forms, a detailed hospital charge questionnaire, or imputation. Regression analysis was used to investigate the added cost of adverse events. The second economic approach involved the development of an independent analytic model simulating treatment and actual ACUTE outcome costs as a validation of clinically derived data. Sensitivity analysis was performed on the analytic model to investigate the potential range in cost differences between the strategies. Results: A total of 833 of the 1,222 patients were enrolled from 53 U.S. sites; TEE-guided (n = 420) and conventional (n = 413). At eight-week follow-up, total mean costs did not significantly differ between the two groups, respectively (6,508 dollars vs. 6,239 dollars; difference of 269 dollars; p = 0.50). Cumulative costs were 24% higher in the conventional group, primarily due to increased incidence of bleeding and hospital costs associated with bleeding. A separate analytic model showed that treatment costs were higher for the TEE-guided strategy, but outcome costs were higher for the conventional strategy. Sensitivity analysis of the analytic model illustrated that varying the incidence and cost of major bleeding and the cost of TEE had the greatest impact on cost differences between the two groups. Conclusions: In patients with AF >2 days duration undergoing electrical cardioversion, the TEE-guided group showed little difference in patient costs compared with the conventional group. The TEE strategy had higher initial treatment costs but lower outcome-associated costs. Cumulative costs were 24% higher in the conventional group, primarily due to bleeding. The TEE-guided strategy is an economically feasible approach compared with the conventional strategy. [ABSTRACT FROM AUTHOR]

Transesophageal echocardiographic (TEE)-guided cardioversion of patients in atrial fibrillation (AF) of >2 days' duration is used as an alternative to conventional therapy. The purpose of this study was to investigate practice patterns employed for stroke prophylaxis in patients with AF who underwent cardioversion, and to determine the relative use of conventional and TEE-guided management strategies. We forwarded regionally stratified survey questionnaires to 947 clinical practices within the United States. The 10-question questionnaire queried demographic and clinical practice volumes and practices for managing patients with AF who underwent cardioversion. In addition, we used historical data to determine longitudinal use patterns of the TEE-guided approach for a large institution over 7 years. The 197 completed and returned surveys yielded a return rate of 20.8%. The TEE-guided approach was employed in approximately 12% of total cardioversions, but 75% of practices indicated that they employed transesophageal echocardiography only occasionally. The TEE-guided approach was associated with community size (r = 0.19; p<0.008), type of practice (r = 0.26; p = 0.001), total use of transesophageal echocardiography (r = 0.48; p<0.001), and volume of cardioversions (r = 0.28; p<0.001). Importantly, there was little consensus on the most appropriate clinical indications for TEE-guided cardioversions, and the proportions of TEE-guided cardioversion to total number of electrical cardioversions remained stable over 7 years. Practice volume and physician training may be the most important variables in the adoption of the TEE approach. [ABSTRACT FROM AUTHOR]

Background: Left ventricular end-diastolic pressure (LVEDP) is a key indicator of cardiac health. The gold-standard method of measuring LVEDP is invasive intra-cardiac catheterization. Echocardiography is used for non-invasive estimation of left ventricular (LV) filling pressures; however, correlation with invasive LVEDP is variable. We sought to use machine learning (ML) algorithms to predict elevated LVEDP (>20 mmHg) using clinical, echocardiographic, and biomarker parameters., Methods: We identified a cohort of 460 consecutive patients from the Cleveland Clinic, without atrial fibrillation or significant mitral valve disease who underwent transthoracic echocardiography within 24 hours of elective heart catheterization between January 2008 and October 2010. We included patients' clinical (e.g., heart rate), echocardiographic (e.g., E/e'), and biomarker [e.g., N-terminal brain natriuretic peptide (NT-proBNP)] profiles. We fit logistic regression (LR), random forest (RF), gradient boosting (GB), support vector machine (SVM), and K-nearest neighbors (KNN) algorithms in a 20-iteration train-validate-test workflow and measured performance using average area under the receiver operating characteristic curve (AUROC). We also predicted elevated tau (>45 ms), the gold-standard parameter for LV diastolic dysfunction, and performed multi-class classification of the patients' cardiac conditions. For each outcome, LR weights were used to identify clinically relevant variables., Results: ML algorithms predicted elevated LVEDP (>20 mmHg) with good performance [AUROC =0.761, 95% confidence interval (CI): 0.725-0.796]. ML models showed excellent performance predicting elevated tau (>45 ms) (AUROC =0.832, 95% CI: 0.700-0.964) and classifying cardiac conditions (AUROC =0.757-0.975). We identified several clinical variables [e.g., diastolic blood pressure, body mass index (BMI), heart rate, left atrial volume, mitral valve deceleration time, and NT-proBNP] relevant for LVEDP prediction., Conclusions: Our study shows ML approaches can robustly predict elevated LVEDP and tau. ML may assist in the clinical interpretation of echocardiographic data., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (https://cdt.amegroups.com/article/view/10.21037/cdt-24-128/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Background: There are significant sex and age differences in left ventricular (LV) remodeling that may lead to disparity in outcomes when used to inform the timing of aortic regurgitation (AR) intervention., Objectives: The aim of this study was to examine whether left atrial (LA) parameters might represent better criteria than LV parameters to inform the timing of AR intervention., Methods: Using data on patients with moderate to severe or severe AR with serial echocardiography (2010-2016), the longitudinal trends in left atrial volume index (LAVI) and left atrial reservoir strain (LAr) were evaluated by sex and age. The incremental utility of these parameters in predicting adverse events over LV parameters was also determined., Results: In 525 patients (25.7% women) with 1,687 echocardiograms over a median follow-up period of 2.0 years (Q1-Q3: 1.0-3.6 years), there was significant increase in LAVI (1.0 mL/m 2 per year [95% CI: 0.76-1.2 mL/m 2 per year]) and decrease in LAr (-1.3% per year [95% CI: -1.6% to -0.92%]), without a significant interaction by sex or age category (P for interaction ≥ 0.17). In addition, both LAVI and LAr were significant predictors of adverse events independent of LV parameters. The optimal discriminatory thresholds were 37 mL/m 2 for LAVI and 35% for LAr. These thresholds were similar across categories of sex and age. Within the relatively short-term follow-up, surgery was associated with survival benefit among patients with LAVI ≥37 mL/m 2 (HR: 0.33 [95% CI: 0.15-0.72]; P = 0.006) but was not statistically significant among patients with LAVI <37 mL/m 2 (HR: 0.46 [95% CI: 0.18-1.17]; P = 0.09). Similarly, surgery was associated with survival for the subgroup with LAr ≤35% but not among those with LAr >35%., Conclusions: Unlike LV remodeling, LA remodeling demonstrates a similar rate of progression between categories of sex and age among patients with AR. In addition, LA parameters provide incremental prognostic value over LV parameters., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Significant controversy continues to confound patient selection and referral for revascularization and mitral valve intervention in patients with ischemic cardiomyopathy (ICM). Cardiac magnetic resonance (CMR) enables comprehensive phenotyping with gold-standard tissue characterization and volumetric/functional measures. Therefore, we sought to determine the impact of CMR-enriched phenomapping patients with ICM to identify differential outcomes following surgical revascularization and surgical mitral valve intervention (sMVi)., Methods: Consecutive patients with ICM referred for CMR between 2002 and 2017 were evaluated. Latent class analysis was performed to identify phenotypes enriched by comprehensive CMR assessment. The primary end point was death, heart transplant, or left ventricular assist device implantation. A multivariable Cox survival model was developed to determine the association of phenogroups with overall survival. Subgroup analysis was performed to assess the presence of differential response to post-magnetic resonance imaging procedural interventions., Results: A total of 787 patients were evaluated (63.0±11.2 years, 24.8% women), with 464 primary events. Subsequent surgical revascularization and sMVi occurred in 380 (48.3%) and 157 (19.9%) patients, respectively. Latent class analysis identified 3 distinct clusters of patients, which demonstrated significant differences in overall outcome ( P <0.001). Latent class analysis identified differential survival benefit of revascularization in patients as well as patients who underwent revascularization with sMVi, based on phenogroup classification, with phenogroup 3 deriving the most survival benefit from revascularization and revascularization with sMVi (hazard ratio, 0.61 [0.43-0.88]; P =0.0081)., Conclusions: CMR-enriched unsupervised phenomapping identified distinct phenogroups, which were associated with significant differential survival benefit following surgical revascularization and sMVi in patients with ICM. Phenomapping provides a novel approach for patient selection, which may enable personalized therapeutic decision-making for patients with ICM., Competing Interests: Disclosures Dr W.H. Wilson Tang is a consultant for Sequana Medical, Cardiol Therapeutics, Genomics plc, Zehna Therapeutics, Boston Scientific, WhiteSwell, Inc, Kiniksa Pharmaceuticals, CardiaTec Biosciences, Intellia Therapeutics, and has received honoraria from Springer Nature, Belvoir Media Group, and American Board of Internal Medicine. Dr Deborah Kwon is funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health under 1R01HL170090-01. Dr Kwon also had a research agreement with Circle cvi42. Dr Xiaofeng Wang is funded by the National Institute of General Medical Sciences of the National Institutes of Health under 1R01GM152717.

Infective endocarditis (IE) is common in patients with liver disease. Outcomes of IE in patients with liver disease are limited. We aimed to investigate IE outcomes in patients with variables associated with liver disease in the USA. We used the 2017 National Readmission Database to identify index admission of adults with IE, based on the International Classification of Disease, 10 th revision codes. The primary outcome was 30-day readmission. Secondary outcomes were mortality and predictors of hospital readmission. We identified 40,413 IE admissions. Patients who were readmitted were more likely to have a history of HCV (19.4 vs 12.3%, P < .001), hyponatremia (25 vs 21%, P < .001), and thrombocytopenia (20.3 vs 16.3%, P < .001). After adjusting for age, hypertension, heart failure, diabetes mellitus, and end stage renal disease, hyponatremia (odds ratio (OR) 1.25; 95% confidence intervals [CI]: 1.17-1.35; P < .001) and thrombocytopenia (OR 1.16; 95% CI: 1.08-1.24; P < .001) correlated with higher odds of 30-day readmission. Mortality was higher among patients with hyponatremia (29 vs 22%, P < .001), thrombocytopenia (29 vs 17%, P < .001), coagulopathy (12 vs 5%, P < .001), cirrhosis (6 vs 4%, P < .001), ascites (7 vs 3%, P < .001), liver failure (18 vs 3%, P < .001), and portal hypertension (3 vs 1.5%, P < .001)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Obesity leads to an increased risk of cardiovascular disease morbidity and death, including heart failure. Bariatric surgery has been proven to be the most effective long-term weight management treatment. This study investigated the changes in cardiac structure and function after bariatric surgery, including left ventricular global longitudinal strain., Methods and Results: There were 398 consecutive patients who underwent bariatric surgery with pre- and postoperative transthoracic echocardiographic imaging at a US health system between 2004 and 2019. We compared cardiovascular risk factors and echocardiographic parameters between baseline and follow-up at least 6 months postoperatively. Along with decreases in weight postoperatively, there were significant improvements in cardiovascular risk factors, including reduction in systolic blood pressure levels from 132 mm Hg (25th-75th percentile: 120-148 mm Hg) to 127 mm Hg (115-140 mm Hg; P =0.003), glycated hemoglobin levels from 6.5% (5.9%-7.6%) to 5.7% (5.4%-6.3%; P <0.001), and low-density lipoprotein levels from 97 mg/dL (74-121 mg/dL) to 86 mg/dL (63-106 mg/dL; P <0.001). Left ventricular mass decreased from 205 g (165-261 g) to 190 g (151-236 g; P <0.001), left ventricular ejection fraction increased from 58% (55%-61%) to 60% (55%-64%; P <0.001), and left ventricular global longitudinal strain improved from -15.7% (-14.3% to -17.5%) to -18.6% (-16.0% to -20.3%; P <0.001) postoperatively., Conclusions: This study has shown the long-term impact of bariatric surgery on cardiac structure and function, with reductions in left ventricular mass and improvement in left ventricular global longitudinal strain. These findings support the cardiovascular benefits of bariatric surgery.

The current guidelines for the management and treatment of acute coronary syndromes do not fully consider the role of age in guiding medical or invasive management. We investigated the characteristics, management strategies, and clinical outcomes of patients aged 80 years and older presenting with non-ST elevation myocardial infarction (NSTEMI). A cohort study using the nationwide inpatient sample database of patients aged 80 years and older presenting with NSTEMI in the United States between 2012 to 2018 was performed. About 24.2% (151,472/625,916) of NSTEMI patients were 80 years and older. Older patients (≥80 years) had higher in-hospital mortality and cardiovascular complications compared to younger patients (odds ratio (OR) 1.79, 95% confidence intervals (CI) 1.71-1.88, P < 0.001). Among older patients, conservative medical management was associated with higher inpatient mortality compared to percutaneous coronary intervention (PCI) (OR 2.3, 95% CI 2.18-2.41, P < 0.001) or coronary artery bypass graft (CABG) (OR 1.9, 95% CI 1.76-2.09, P < 0.001). The highest mortality rate was observed in older patients who underwent both PCI and CABG, followed by those treated conservatively and those undergoing coronary angiography without revascularization. This study provides valuable insights into the clinical characteristics and outcomes of elderly patients presenting with NSTEMI in the United States. The results emphasize the importance of a tailored approach to the management of ACS in elderly patients and the need for improved revascularization strategies to reduce in-hospital mortality and adverse cardiovascular outcomes. Therefore, the clinician should tailor the management of older patients presenting with NSTEMI., Competing Interests: Declaration of Competing Interest Dr. Kapadia receives fees of $5,000 or more per year (or, in rare cases, equity or stock options) as a paid consultant, speaker, or as member of an advisory committee for Anteris Technologies. Dr. Kapadia receives or has the right to receive royalty payments for inventions or discoveries commercialized through Bavaria Medizin Technologie GmbH. Dr. Kapadia may receive future financial benefits from the Cleveland Clinic for inventions or discoveries commercialized through Mitria Medical, LLC, Bavaria Medizin Technologie GmbH. All other authors have no disclosures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Infective endocarditis (IE) describes the infection of native and prosthetic cardiac valves as well as cardiac implantable electronic devices. Echocardiography is the most widely used imaging technique for evaluation of IE. Due to its reduced sensitivity in detection of prosthetic valve IE and cardiac implantable electronic device related IE and related complications, complementary techniques such as cardiac computed tomography (CT) and 18-flurodeoxyglucose positron emission tomography/CT play an emerging role. Therefore, multiple guidelines recommend the use of multimodality imaging in the diagnosis and management of IE. In this review, we aim to compare the various guidelines and to discuss the role of imaging in the diagnosis, detection of complications, monitoring of treatment response, and prognostication of IE., Competing Interests: Declaration of Competing Interest None., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response., Methods: This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%., Results: Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference  -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e [0.81-0.1*t] ; at t = 0, HR 2.24; 95% CI 1.08-4.64)., Conclusions: Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders., Competing Interests: Declaration of Competing Interest PC disclosed he received consulting and speaking fees from Philips. All other authors have disclosed that they do not have any conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Current guidelines for aortic regurgitation (AR) recommend the same linear left ventricular (LV) dimension for intervention regardless of age and sex., Objectives: The purpose of this study was to evaluate the impact of age and sex on the degree of LV remodeling and outcomes., Methods: We included consecutive patients with severe AR who were serially monitored by echocardiogram between 2010 and 2016. The 2 main endpoints were as follows: 1) LV end-systolic volume indexed to body surface area (LVESVi) and LV end-diastolic volume indexed to body surface area; and 2) adverse events (AE). We evaluated the longitudinal rate of LV remodeling and determined the association between LV volume and AE by age and sex., Results: A total of 525 adult patients (26% women) with a median echocardiogram follow-up of 2.0 years (IQR: 1.0-3.6 years) were included. At baseline, older patients (age ≥60 years) had smaller LV volumes compared with younger patients (age <60 years), eg, the mean LVESVi was 27.3 mL/m 2 vs 32.3 mL/m 2 , respectively. Similarly, women had smaller LV volumes compared with men (mean LVESVi was 23.3 mL/m 2 vs 32.4 mL/m 2 ). On serial evaluation, older patients and women maintained smaller LV volumes compared with younger patients and men, respectively. There were 210 (40%) AE during follow-up. The optimal discriminatory threshold for AE varies by age and sex, eg, the LVESVi threshold was highest for young men (50 mL/m 2 ), intermediate for older men (35 mL/m 2 ), and lowest for women (27 mL/m 2 )., Conclusions: On serial evaluation, older patients and women with chronic AR maintained smaller LV volumes than younger patients and men, respectively, and develop AE at lower LV volumes., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Data regarding mitral regurgitation (MR) in extremely elderly patients are limited. The aim of the present study was to assess symptomatic status, frailty, etiology and outcomes for nonagenarians with severe MR., Methods: Single-center cohort study of patients ≥90 years of age with at least 3+ MR on echocardiography between September 2010 and August 2018. Out of a total of 11,998 patients with at least 3+ MR, 267 patients were included in the present study., Results: The average age was 93.5 ± 2.6 years, and 57% were female. At baseline, 88% were symptomatic, with mean Charlson co-morbidity index of 6 ± 2 points, and mean frailty score of 2.9 ± 1.4 points. Primary MR was present in 50%, secondary in 47%, and prosthetic valve dysfunction in 3%. Among patients with primary MR, the most common etiology was mitral annular calcification (58%). In comparison, the most common etiology of secondary MR was atrial functional MR (52%). Of all, 95% were treated conservatively, and 5% underwent interventional management. Among 253 patients who had follow-up data with a median follow-up of 14 months (25th-75th interquartile range: 3-31 months), 191 patients (75%) died. Mortality trended higher in the conservative group versus the interventional group (60% vs. 22%, log-rank P = 0.063)., Conclusions: Most nonagenarians with significant MR were symptomatic at presentation, had elevated Charlson co-morbidity index and frailty scores. Etiologies of MR were almost equally distributed between primary and secondary causes. The vast majority of nonagenarians with significant MR were conservatively managed., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The implications of left ventricular remodeling and dysfunction before and after aortic valve replacement (AVR) for mixed aortic valve disease (MAVD) are not well understood. This study aims to evaluate the impact of AVR on left ventricular (LV) systolic function in MAVD, and determine the prognostic value of postoperative LV global longitudinal strain (LV-GLS) and LV ejection fraction (LVEF)., Methods: We retrospectively assessed 489 consecutive patients with MAVD (defined as at least moderate aortic stenosis and at least moderate aortic regurgitation) and baseline LVEF ≥50%, who underwent AVR between February 2003 and August 2018. All patients had baseline echocardiography, whereas 192 patients underwent postoperative echocardiography between 3 and 18 months after AVR. The primary endpoint was all-cause mortality., Results: Mean age was 65 ± 15 years, and 65% were male. AVR in MAVD patients has a neutral effect on LV systolic function quantitated by LVEF and LV-GLS. During a median follow-up period of 5.8 years, 65 patients (34%) of 192 patients with follow-up echocardiography died. The patients with postoperative LVEF ≥50% had better survival than those with postoperative LVEF <50% (P < .001). Furthermore, among patients with postoperative LVEF ≥50%, mortality differed between patients with postoperative LV-GLS worse than -15% and those with postoperative LV-GLS better than -15% (P < .001)., Conclusions: In patients with MAVD who underwent AVR, the mean postoperative LV-GLS and LVEF remain at a similar value to baseline. However, worse postoperative LV-GLS and LVEF were both independently associated with higher mortality in this population., (© 2023 Wiley Periodicals LLC.)

Background: Infective endocarditis (IE) is associated with high morbidity and mortality. Following an initial negative transesophageal echocardiogram (TEE), high clinical suspicion warrants repeat examination. We evaluated the diagnostic performance of contemporary TEE imaging for IE., Methods: This retrospective cohort study included patients ≥18 years old undergoing ≥2 TEEs within 6 months, with confirmed diagnosis of IE based on Duke criteria, 70 in 2011 and 172 in 2019, were included. We compared the diagnostic performance of TEE for IE in 2019 versus 2011. The primary endpoint was the sensitivity of initial TEE to detect IE., Results: Sensitivity of the initial TEE to detect endocarditis was 85.7% versus 95.3%, in 2011 and 2019, respectively (P=0.01). On multivariable analysis, initial TEE more frequently detected IE in 2019, compared to 2011 [odds ratio (OR): 4.06, 95% confidence intervals (CIs): 1.41-11.71, P=0.01]. Improved diagnostic performance was driven by improved detection of prosthetic valve infective endocarditis (PVIE), sensitivity 70.8% in 2011 versus 93.7% (P=0.009) in 2019. In 2019, TEEs more frequently utilized probes with higher frame rates/resolution, than 2011 (P<0.001). Three dimensional (3D) technology was utilized in 97.2% of initial TEEs in 2019, compared to 70.5% in 2011 (P<0.001)., Conclusions: Contemporary TEE was associated with improved diagnostic performance for endocarditis, driven by improved sensitivity for PVIE., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-22-431/coif). BM received Education grant $5000 from Healthcare Delivery and Implementation Science Center (separate project) and was supported by the National Center for Advancing Translational Sciences of the NIH under Award Number TL1TR002344. This grant contributed to drafting the manuscript, data analysis, manuscript submission, and manuscript revision. The other authors have no conflicts of interest to declare., (2023 Cardiovascular Diagnosis and Therapy. All rights reserved.)

The objective of the study was to construct a multi-parametric mitral annular calcification (MAC) score using computed tomography (CT) features for prediction of outcomes in patients undergoing mitral valve surgery. We constructed a multi-parametric MAC score, which ranges between 2 and 12, and consists of Agatston calcium score (1 point: <1000 Agatston units (AU); 2 points: 1000-<3000 AU; 3 points: 3000-5000 AU; 4 points: >5000 AU), quantitative MAC circumferential angle (1 point: <90°; 2 points: 90-<180°; 3 points: 180-<270°; 4 points: 270-360°), involvement of trigones (1 point: 1 trigone; 2 points: both trigones), and 1 point each for myocardial infiltration and left ventricular outflow tract extension/involvement of aorto-mitral curtain. The association between MAC score and clinical outcomes was evaluated. The study cohort consisted of 334 patients undergoing mitral valve surgery (128 mitral valve repairs, 206 mitral valve replacements) between January 2011 and September 2019, who had both non-contrast gated CT scan and evidence of MAC. The mean age was 72 ± 11 years, with 58% of subjects being female. MAC score was a statistically significant predictor of total operation time (P<0.001), cross-clamp time (P = 0.001) and in-hospital complications (P = 0.003). Additionally, MAC score was a significant predictor of time to all-cause death (P = 0.046). A novel multi-parametric score based on CT features allowed systematic assessment of MAC, and predicted clinical outcomes in patients with mitral valve dysfunction undergoing mitral valve surgery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Infective endocarditis (IE) is associated with marked morbidity and mortality in the United States and parallels the opioid pandemic. Few studies explore this interaction and its effect on clinical outcomes. We analyzed contemporary patients admitted with IE to determine predictors of readmission in the United States. The 2017 National Readmission Database was used to identify index admissions in adults with the diagnosis of IE, based on the International Classification of Disease, 10th Revision codes. The primary outcome of interest was 30-day readmission. Secondary outcomes were mortality, hospital charges, and predictors of hospitalization readmission. Of 40,413 index admissions for IE, 5,558 patients (13.8%) were readmitted within 30 days. Patients who were readmitted were younger (55 ± 20 vs 61 ± 19 years, p <0.001) and more likely to have end-stage renal disease (12.2% vs 10.5%, p <0.001), hepatitis C virus (19.4% vs 12.6%, p <0.001), HIV (1.8% vs 1.2%, p = 0.001), opioid abuse (23.9% vs 15%, p <0.001), cocaine use (7.3% vs 4.4%, p <0.001), and other substance abuse (8.5 vs 5.6, p <0.001). Patients readmitted were less likely to have diabetes mellitus (27.8% vs 29.4%, p = 0.01), hypertension (56.9% vs 64%, p <0.001), heart failure (37.7% vs 40%, p <0.001), chronic kidney disease (31.2% vs 32%, p <0.001), and peripheral vascular disease (3.6% vs 4.6%, p = 0.001). The median cost of index admission for the total cohort was $84,325 (39,922 to 190,492). After adjusting for age, diabetes mellitus, heart failure, hypertension, and end-stage renal disease, opioid abuse (odds ratio [OR] 1.34; 95% confidence interval [CI] 1.23 to 1.46; p <0.001), cocaine use (OR 1.32; 95% CI 1.17 to 1.48; p <0.001), other substance abuse (OR 1.16; 95% CI 1.04 to 1.30; p = 0.008), and hepatitis C virus (OR 1.32; 95% CI 1.21 to 1.43; p <0.001) correlated with higher odds of 30-day readmission. These factors may present targets for future intervention., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Systemic lupus erythematosus (SLE) is a challenging autoimmune and multi-system condition. With advances in cardiovascular screening and therapies for SLE patients, we evaluated the cardiovascular characteristics, multi-modality imaging, and outcomes of SLE at our tertiary referral center over an 8 year period. Consecutive patients from our SLE registry from April 2012 to March 2020 were retrospectively analyzed. Data pertaining to cardiovascular manifestations, investigations, management, and outcomes were assessed. We studied 258 SLE patients (mean age 42.2 ± 14.7 years); 233 (90.3%) were female. The main cardiac manifestations at index SLE clinic were pericardial disease in 33.3%, valve disease in 18%, cardiomyopathy in 9.6%, and stroke in 7.4%. During a mean follow-up of 3.0 ± 2.2 years after index SLE clinic, there were 5 (1.9%) deaths, 24 (9.3%) cardiovascular events, and 44 (17.1%) SLE-related hospitalizations. A history of stroke and hypertension were independently associated with cardiovascular events, hazard ratio (HR) (95% confidence intervals (CI)) of 5.38 (1.41-20.6) and 3.31 (1.02-10.7), respectively, while younger age and lower albumin predicted SLE-related hospitalizations. Cardiovascular manifestations are prevalent in SLE, especially for pericardial, valvular, and atherosclerotic diseases. With contemporary SLE and cardiovascular management, subsequent adverse cardiovascular events were infrequent in this study.

Background: Post-systolic shortening index (PSI) is defined as myocardial shortening that occurs after aortic valve closure, and is an emerging measure of regional LV contractile dysfunction. PSI measurement variability amongst software vendor and its relationship with mechanical dyssynchrony and mechanical dispersion index (MDI) remains unknown. We evaluated PSI by speckle-tracking echocardiography from several vendors in patients with increased left ventricular wall thickness, and associations with MDI., Methods: This is a prospective cross-sectional study of 70 patients (36 hypertrophic cardiomyopathy [HCM], 18 cardiac amyloidosis and 16 healthy controls) undergoing clinically indicated echocardiography. PSI was measured using QLAB/aCMQ (Philips), QLAB/LV auto-trace (Philips), EchoPAC (GE), Velocity Vector Imaging (Siemens), and EchoInsight (EPSILON) software packages, and calculated as 100%×(post systolic strain-end-systole strain)/post systolic strain., Results: There was a significant difference in mean PSI among controls 2.1±0.6%, HCM 6.1±2.6% and cardiac amyloidosis 6.8±2.7% (p <0.001). Variations between software vendors were significant in patients with pathologic increases in LV wall thickness (for HCM p = 0.03, for amyloidosis p = 0.008), but not in controls (p = 0.11). Furthermore, there were moderate correlations between PSI and both MDI (r = 0.77) and left ventricular global longitudinal strain (r = 0.69)., Conclusion: PSI was greater in HCM and cardiac amyloidosis patients than controls, and a valuable tool for dyssynchrony evaluation, with moderate correlations to MDI and strain. However, there were significant variations in PSI measurements by software vendor especially in patients with pathological increase in LV wall thickness, suggesting that separate vendor-specific thresholds for abnormal PSI are required., Competing Interests: The authors have declared that no competing interests exist.

Background: The incremental utility of right ventricular (RV) strain on predicting right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation, beyond clinical and haemodynamic indices, is not clear., Methods: Two hundred and forty-six (246) patients undergoing LVAD implantation, who had transthoracic echocardiograms pre and post LVAD, pulmonary artery pulsatility index (PAPI) measurements and Michigan risk score, were included. We analysed RV global longitudinal strain (GLS) using speckle tracking echocardiography. RVF following LVAD implantation was defined as the need for medical support for >14 days, or unplanned RV assist device insertion after LVAD implantation., Results: Mean preoperative RV-GLS was -7.8±2.8%. Among all, 27% developed postoperative RVF. A classification and regression tree analysis identified preoperative Michigan risk score, PAPI and RV-GLS as important parameters in predicting postoperative RVF. Eighty per cent (80%) of patients with PAPI <2.1 developed postoperative RVF, while only 4% of patients with PAPI >6.8 developed RVF. For patients with a PAPI of 2.1-3.2, having baseline Michigan risk score >2 points conferred an 81% probability of subsequent RVF. For patients with a PAPI of 3.3-6.8, having baseline RV-GLS of -4.9% or better conferred an 86% probability of no subsequent RVF. The sensitivity and specificity of this algorithm for predicting postoperative RVF were 67% and 93%, respectively, with an area under the curve of 0.87., Conclusion: RV-GLS has an incremental role in predicting the development of RVF post-LVAD implantation, even after controlling for clinical and haemodynamic parameters., (Copyright © 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Aims: We sought to assess the relationship between left atrial (LA) strain mechanics and exercise intolerance, and to evaluate the prognostic impact of LA strain mechanics on clinical deterioration necessitating septal reduction therapy in hypertrophic cardiomyopathy (HCM)., Methods and Results: Consecutive HCM patients who underwent exercise stress echocardiography and cardiopulmonary exercise testing on the same day between October 2015 and April 2019 were enrolled prospectively. LA strain mechanics were analysed using speckle tracking echocardiography. LA stiffness was calculated as the ratio of E/e' ratio to LA reservoir strain. The study cohort was divided into four groups based on the quartile of percent-predicted peak VO2, and exercise intolerance was defined as the lowest quartile (≤51%). Of 532 patients studied (mean age: 51 ± 15 years, 42% female), 138 patients demonstrated exercise intolerance. As exercise capacity worsened, LA strain mechanics worsened along a continuum (P < 0.001). LA contractile strain with a cut-off of -13.9% was optimal at identifying exercise intolerance. On multivariable analysis, worse LA contractile strain was an independent predictor for exercise intolerance (P = 0.002). Of patients with left ventricular outflow tract obstruction, patients with LA stiffness worse than the median value (≥0.41) were significantly more likely to require septal reduction therapy than those with better LA stiffness (P = 0.026)., Conclusion: Worse LA contractile strain was an independent predictor for exercise intolerance in HCM. Patients with worse LA stiffness had a higher probability of clinical deterioration necessitating septal reduction therapy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Dobutamine stress echocardiography (DSE) is a useful tool for assessing low-gradient significant aortic stenosis (AS) and contractile reserve (CR), but its prognostic utility has become controversial in recent studies. We evaluated the impact of DSE on aortic valve physiological, structural, and left ventricular parameters in low-gradient AS. Consecutive patients undergoing DSE for low-gradient AS evaluation from September 2010 to July 2016 were retrospectively studied, and DSE findings were divided into four groups: with and without severe AS and/or CR. Relationships between left ventricular chamber quantification, CR, aortic valve Doppler during DSE, and calcium score [by computerized tomography (CT)] were analyzed. There were 258 DSE studies performed on 243 patients, mean age 77.6 ± 10.8 yr and 183 (70.1%) were males. With increasing dobutamine dose, apart from systolic blood pressure, left ventricular ejection fraction, flow, cardiac power output, and longitudinal strain magnitude, along with aortic valve area and mean aortic gradient were all significantly increased ( P < 0.05). Flow and mean gradient increased in both the presence and absence of CR, whereas stroke volume and aortic valve area increased mainly in those with CR only. The aortic valve area increased in both patients with low and high calcium scores; however, the baseline area was lower in those with a higher calcium score. During DSE, aortic valve area increases with increase in aortic valve gradient. Higher calcium score is associated with lower baseline aortic valve area, but the aortic valve area still increases with dobutamine even in presence of a high calcium score. NEW & NOTEWORTHY We show that even in most severe aortic stenosis, there is some residual valve pliability. This suggests that a complete loss of pliability is not compatible with survival.

Objective: To conduct a comprehensive systematic review and meta-analysis to compare mortality and other clinical outcomes associated with chili pepper (CP) consumption versus no/rare consumption of CP., Methods: A comprehensive search was performed using Ovid, Cochrane, Medline, EMBASE, and Scopus from inception till January 16, 2020. Observational studies and randomized controlled trials were included, while pediatric/animal studies, letters/case reports, reviews, abstracts, and book chapters were excluded. All-cause mortality was studied as the primary outcome. Cardiovascular mortality, cancer-related deaths and cerebrovascular accidents were studied as secondary outcomes., Results: From 4729 studies, four studies met the inclusion criteria. Random effects pooled analysis showed that all-cause mortality among CP consumers was lower, compared to rare/non-consumers, with a hazard ratio (HR) of 0.87 [95% CI: 0.85-0.90; p <0.0001; I 2 =1%]. HR for cardiovascular mortality was 0.83 [95% CI: 0.74-0.95; p  = 0.005, I 2 =66%] and for cancer-related mortality as 0.92 [95% CI: 0.87-0.97; p  = 0.001; I 2 =0%]. However, the HR for CVA was 0.78 [95% CI: 0.56-1.09; p  = 0.26; I 2 =60%]. The mode and amount of CP consumption varied across the studies, and data were insufficient to design an optimal strategy guiding its intake., Conclusion: Regular CP consumption was associated with significantly lower all-cause, cardiovascular, and cancer-related mortalities. However, based on current literature, it is difficult to derive a standardized approach to guide the optimal mode and amount of CP consumption. This warrants well-designed prospective studies to further investigate the potential health benefits of CP consumption., (© 2021 The Author(s).)

We sought to evaluate the outcomes of patients with severe mitral stenosis (MS) resulting from mitral annular calcification and assessed the prognostic impact of co-morbidities and frailty in guiding management. Among 6,915 patients with calcific MS who underwent echocardiography between January 2011 and March 2020, a total of 283 patients with severe calcific MS were retrospectively enrolled. We calculated the Charlson co-morbidity index (CCI). Frailty was scored from 0 to 3 points, with 1 point each assigned for reduced hemoglobin, reduced albumin, and inactivity. The primary end point was all-cause death. The mean age was 72 ± 11 years. The mean mitral valve (MV) area was 1.1 ± 0.4 cm 2 , and the mean transmitral gradient was 12 ± 4 mm Hg. Although 33% of the patients underwent MV intervention, 67% were conservatively managed. During a median follow-up of 360 days, 35% died. Patients who underwent MV intervention had an improved prognosis compared with those who were treated conservatively, even after propensity score matching. On multivariate Cox regression analysis, higher CCI (hazard ratio [HR] 1.20, 95% confidence interval [CI] 1.04 to 1.38, p = 0.011) and frailty score (HR 1.58, 95% CI 1.12 to 2.23, p = 0.01) were predictors of all-cause mortality, and MV intervention (HR 0.45, 95% CI 0.25 to 0.83, p = 0.011) and angiotensin converting enzyme inhibitor/angiotensin receptor blocker use (HR 0.39, 95% CI 0.20 to 0.79, p = 0.009) were associated with an improved prognosis. In conclusion, patients with severe calcific MS were often frail with multiple co-morbidities and were often managed conservatively. Higher CCI and worse frailty were associated with worse prognosis, regardless of the treatment strategy. MV intervention for select patients was associated with improved prognosis., Competing Interests: Disclosures Dr. Gillinov receives fees of ≥$5,000 per year as a paid consultant, speaker, or member of an advisory committee for Clear Catheter Systems, Inc., AtriCure, Inc., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the diagnostic and prognostic performance of the aortic valve calcium score (AVCS) with the Agatston method using CT in aortic stenosis (AS) and to assess mean AVCS according to AS severity., Materials and Methods: In this meta-analysis, PubMed, Embase, and Cochrane were searched from January 1, 1980, to December 31, 2020, for studies reporting sensitivity and specificity of AVCS using CT for severe AS, mean AVCS in severe and nonsevere AS, and/or hazard ratios for all-cause mortality in AS. Data were pooled using random effect models and meta-analysis software., Results: Twelve studies (six diagnostic, three prognostic, and 10 reporting mean AVCS by AS severity) were included for analysis. A total of 4101 patients (2255 with severe AS) were described in these 12 studies. Pooled sensitivity and specificity were 82% (95% CI: 80, 84) and 78% (95% CI: 75, 81), respectively. Pooled mean AVCS were 3219 (95% CI: 2795, 3643) for severe AS, compared with 1252 (95% CI: 863, 1640) for nonsevere AS, 1808 (95% CI: 1163, 2452) for moderate AS, and 584 (95% CI: 309, 859) for mild AS. Pooled hazard ratio for AVCS as a binary threshold to predict mortality was 2.11 (95% CI: 1.11, 4.12)., Conclusion: AVCS had moderate to high sensitivity and specificity for identifying severe AS and was also a useful prognostic imaging marker in AS. Mean AVCS categorized by AS severity may help guide clinical management. Keywords CT, Aortic Valve, Valves, Meta-Analysis© RSNA, 2021., Competing Interests: Disclosures of Conflicts of Interest: T.K.M.W. disclosed no relevant relationships. S.D.F. disclosed no relevant relationships. P.S. disclosed no relevant relationships. B.P.G. disclosed no relevant relationships. L.L.R. disclosed no relevant relationships. R.A.G. disclosed no relevant relationships. B.X. disclosed no relevant relationships., (2021 by the Radiological Society of North America, Inc.)

Background: Right ventricular (RV) systolic strain has recently demonstrated prognostic value in various cardiovascular diseases. Despite this, the reference range including the lower limit of normal (LLN) and factors associated with RV strain measurements are not well-established. This meta-analysis aimed to determine the mean and LLN of two- (2D) and three-dimensional (3D) right ventricular global (RVGLS), free wall (RVFWLS) and interventricular septal wall (IVSLS) longitudinal strains in healthy individuals and factors that affect strain measurements., Methods: In this meta-analysis, Pubmed, Embase and Cochrane databases were searched until 31 July 2020 for eligible studies reporting RVGLS, RVFWLS and/or IVSLS in at least 30 healthy subjects. We pooled the means and LLNs of RV strains by two- (2D) and three- (3D) dimensional echocardiography, and performed meta-regression analyses., Results: From 788 articles screened, 45 eligible studies totaling 4439 healthy subjects were eligible for analysis. Pooled means and LLNs with 95% confidence intervals for 2D- RV strains were RVGLS -23.4% (-24.2%, -22.6%) and -16.4% (-17.3%, -15.5%) in 27 studies; RVFWLS -26.9% (-28.0%, -25.9%) and -18.0% (-19.2%, -16.9%) in 32 studies; and IVSLS -20.4% (-22.0%, -18.9%) and -11.5% (-13.6%, -9.6%) in 10 studies, and similar results for 3D- RV strains. Right ventricular fractional area change and vendor software were associated with 2D-RVGLS and RVFWLS means and LLNs., Conclusion: We reported the pooled means and LLNs of RV systolic strains in healthy subjects, to define thresholds for abnormal, borderline and normal strains. Important factors associated with RV systolic strains include right ventricular fractional area change and vendor software., Competing Interests: The authors have declared that no competing interests exist.

Objectives: The aims of this study were to characterize the interplay between mixed aortic valve disease (MAVD) phenotypes (defined by concomitant severities of aortic stenosis and aortic regurgitation) and left ventricular global longitudinal strain (LV-GLS), and to assess the prognostic utility of LV-GLS in MAVD., Background: Little is known about the way LV-GLS separates MAVD phenotypes and if it is associated with their outcomes., Methods: This observational cohort study evaluated 783 consecutive adult patients with left ventricular ejection fraction ≥50% and MAVD, which was defined as coexisting with at least moderate aortic stenosis and at least moderate aortic regurgitation. We measured the conventional echocardiographic variables and average LV-GLS from apical long, 2- and 4-chamber views. The primary endpoint was all-cause mortality., Results: Mean age of patients was 69 ± 15 years, and 58% were male. Mean LV-GLS was -14.7 ± 2.9%. In total, 458 patients (59%) underwent aortic valve replacement at a median period of 50 days (25th to 75th percentile range: 6 to 560 days). During a median follow-up period of 5.6 years (25th to 75th percentile range: 1.8 to 9.4 years), 391 patients (50%) died. When stratified patients into tertiles according to LV-GLS values, patients with worse LV-GLS had worse outcomes (p < 0.001). LV-GLS was independently associated with mortality (hazard ratio: 1.09; 95% confidential intervals: 1.04 to 1.14; p < 0.001), with the relationship between LV-GLS and mortality being linear., Conclusions: LV-GLS is associated with all-cause mortality. LV-GLS may be useful for risk stratification in patients with MAVD., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

To evaluate the temporal relations of cardiovascular disease in oncology patients referred to cardio-oncology and describe the impact of cardiovascular disease and cardiovascular risk factors on outcomes. All adult oncology patients referred to the cardio-oncology service at the Cleveland Clinic from January 2011 to June 2018 were included in the study. Comprehensive clinical information were collected. The impact on survival of temporal trends of cardiovascular disease in oncology patients were assessed with a Cox proportional hazards model and time-varying covariate adjustment for confounders. In total, 6,754 patients were included in the study (median age, 57 years; [interquartile range, 47 to 65 years]; 3,898 women [58%]; oncology history [60% - breast cancer, lymphoma, and leukemia]). Mortality and diagnosis of clinical cardiac disease peaked around the time of chemotherapy. 2,293 patients (34%) were diagnosed with a new cardiovascular risk factor after chemotherapy, over half of which were identified in the first year after cancer diagnosis. Patients with preexisting and post-chemotherapy cardiovascular disease had significantly worse outcomes than patients that did not develop any cardiovascular disease (p < 0.0001). The highest 1-year hazard ratios (HR) of post-chemotherapy cardiovascular disease were significantly associated with male (HR 1.81; 95% confidence interval 1.55 to 2.11; p < 0.001] and diabetes [HR 1.51; 95% confidence interval 1.26 to 1.81; p < 0.001]. In conclusion, patients referred to cardio-oncology, first diagnosis of cardiac events peaked around the time of chemotherapy. Those with preexisting or post-chemotherapy cardiovascular disease had worse survival. In addition to a high rate of cardiovascular risk factors at baseline, risk factor profile worsened over course of follow-up., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Left ventricular global longitudinal strain (LVGLS), circumferential strain (LVGCS) and radial strain (LVGRS) are echocardiographic parameters with wide clinical applicability. However, the thresholds for abnormal left ventricular (LV) strains, particularly the lower limits of normal (LLN), are not well established. This meta-analysis determined the mean and LLN of two- (2D) and three-dimensional (3D) LV strain in healthy subjects and factors that influence strain measurements., Methods: We searched PubMed, Embase and Cochrane databases until 31 December 2019 for studies reporting left ventricular (LV) global strain in at least 50 healthy subjects. We pooled means and LLNs of 2D and 3D LV strain using random-effects models, and performed subgroup and meta-regression analysis for LVGLS., Results: Forty-four studies were eligible totaling 8,910 subjects. The pooled means and LLNs (95% confidence intervals) were -20.1% (-20.7%, -19.6%) and -15.4% (-16.0%, -14.7%) respectively for 2D-LVGLS; -21.9% (-23.4%, -20.3%) and -15.3% (-16.9%, -13.8%) respectively for 2D-LVGCS; and 48.4% (43.8%, 53.0%) and 25.5% (17.8%, 33.1%) respectively for 2D-LVGRS. All pooled analyses demonstrated significant heterogeneity, and means and LLNs of and 3D-LV strains differed marginally from 2D. Only vendor software was associated with differences in pooled means and LLN of 2D-LVGLS., Conclusions: In conclusion, pooled means and LLNs of 2D- and 3D-LV global strain parameters in healthy subjects were reported. Based on the pooled LLNs, thresholds for abnormal, borderline and normal strains can be defined, such as less negative than -14.7%, between -14.7% and -16.0% and more negative than -16.0% respectively for 2D-LVGLS, and 2D-LVGLS values are only affected by vendor software., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/cdt-20-711). TKMW received a clinical and research fellowship grant from the National Heart Foundation of New Zealand (number 1775). The other authors have no conflicts of interest to declare., (2020 Cardiovascular Diagnosis and Therapy. All rights reserved.)

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery., Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II)., Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76-7.59), P =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25-11.7), P <0.001 and 9.84 (1.89-51.0), P =0.007, respectively., Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

Background: Cardiac resynchronization therapy (CRT) improves heart failure outcomes but has significant nonresponse rates, highlighting limitations in ECG selection criteria: QRS duration (QRSd) ≥150 ms and subjective labeling of left bundle branch block (LBBB). We explored unsupervised machine learning of ECG waveforms to identify CRT subgroups that may differentiate outcomes beyond QRSd and LBBB., Methods: We retrospectively analyzed 946 CRT patients with conduction delay. Principal component analysis (PCA) dimensionality reduction obtained a 2-dimensional representation of preCRT 12-lead QRS waveforms. k -means clustering of the 2-dimensional PCA representation of 12-lead QRS waveforms identified 2 patient subgroups (QRS PCA groups). Vectorcardiographic QRS area was also calculated. We examined following 2 primary outcomes: (1) composite end point of death, left ventricular assist device, or heart transplant, and (2) degree of echocardiographic left ventricular ejection fraction (LVEF) change after CRT., Results: Compared with QRS PCA Group 2 ( n =425), Group 1 ( n =521) had lower risk for reaching the composite end point (HR, 0.44 [95% CI, 0.38-0.53]; P <0.001) and experienced greater mean LVEF improvement (11.1±11.7% versus 4.8±9.7%; P <0.001), even among patients with LBBB with QRSd ≥150 ms (HR, 0.42 [95% CI, 0.30-0.57]; P <0.001; mean LVEF change 12.5±11.8% versus 7.3±8.1%; P =0.001). QRS area also stratified outcomes but had significant differences from QRS PCA groups. A stratification scheme combining QRS area and QRS PCA group identified patients with LBBB with similar outcomes to non-LBBB patients (HR, 1.32 [95% CI, 0.93-1.62]; difference in mean LVEF change: 0.8% [95% CI, -2.1% to 3.7%]). The stratification scheme also identified patients with LBBB with QRSd <150 ms with comparable outcomes to patients with LBBB with QRSd ≥150 ms (HR, 0.93 [95% CI, 0.67-1.29]; difference in mean LVEF change: -0.2% [95% CI, -2.7% to 3.0%])., Conclusions: Unsupervised machine learning of ECG waveforms identified CRT subgroups with relevance beyond LBBB and QRSd. This method may assist in objective classification of bundle branch block morphology in CRT.

COVID-19 infection is associated with several cardiac complications with high rates of adverse outcomes. Cardiac imaging has different utility in different clinical scenarios, and the importance of minimizing healthcare worker exposure should be considered. Cardiac imaging should only be ordered if its benefits outweigh its risks, with anticipated changes in acute treatment and outcomes, and no suitable alternative of sufficient adequacy is available. Indications for advanced cardiac imaging for COVID-19 patients in the acute phase are limited, although follow-up imaging in the convalescent stage may provide prognostic importance in recovered COVID-19 patients with positive troponin or decompensated heart failure., (Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.)