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PurposeTo evaluate the safety, efficacy, and outcomes of outpatient intravenous diuresis in a rural setting and compare it to urban outcomes.MethodsA single-center study was conducted on 60 patients (131 visits) at the Dartmouth-Hitchcock Medical Center (DHMC) from 1/2021–12/2022. Demographics, visit data, and outcomes were collected and compared to urban outpatient IV centers, and inpatient HF hospitalizations from DHMC FY21 and national means. Descriptive statistics, T-tests and chi-squares were used.ResultsThe mean age was 70 ± 13 years, 58% were male, and 83% were NYHA III-IV. Post-diuresis, 5% had mild-moderate hypokalemia, 16% had mild worsening of renal function, and 3% had severe worsening of renal function. No hospitalizations occurred due to adverse events. The mean infusion-visit urine output was 761 ± 521 ml, and post-visit weight loss was −3.9 ± 5.0 kg. No significant differences were observed between HFpEF and HFrEF groups. 30-day readmissions were similar to urban outpatient IV centers, DHMC FY21, and the national mean (23.3% vs. 23.5% vs. 22.2% vs. 22.6%, respectively; p = 0.949). 30-day mortality was similar to urban outpatient IV centers but lower than DHMC FY21 and the national means (1.7% vs. 2.5% vs. 12.3% vs. 10.7%, respectively; p ConclusionOP IV diuresis appears safe and effective for rural HF patients, potentially decreasing mortality rates and healthcare expenses while mitigating rural-urban disparities.

Graphical abstract, Highlights • Congenital heart disease may be first diagnosed during pregnancy. • PDA with significant left-to-right shunting can cause peripartum cardiac decompensation. • Multidisciplinary management of congenital heart disease in pregnancy is recommended.

Introduction: Left ventricular (LV) global longitudinal strain (GLS) is a robust LV systolic function measure used to detect subtle chemotherapy cardiotoxicity. However, inter-reader and inter-vendor variabilities compromise the clinical value of longitudinal follow-up of GLS. Artificial intelligence (AI)-based, fully automated measurement of longitudinal strain may be more reliable compared with human interpretation. Methods: We studied 52 transthoracic echocardiographic examinations randomly selected from a Cardio-oncology registry. All subjects received anthracycline-based chemotherapy in 2016-2019. AI-based longitudinal strain was assessed by EchoGo Core using standard 2- and 4-chamber apical views. Two readers verified the myocardium tracing by AI and found no errors. Longitudinal strain results by EchoGo were compared to GLS measured by conventional software (TomTec and Philips QLAB) using standard 3-, 2- and 4-chamber apical views. Results: AI-based longitudinal strain analysis was feasible in 51/52 (98%) transthoracic echocardiographic studies. The mean longitudinal strain was -17.3±3.3% for EchoGo, -16.9±2.4% for TomTec and -17.5±3.1% for QLAB. Bland-Altman analysis showed a bias of -0.4 ± 2.7% and 95% limits of -5.7 to 4.9% between EchoGo longitudinal strain and TomTec GLS (Figure 1A). A bias of 0.2 ± 3.3% and 95% limits of -6.2 to 6.6% between EchoGo longitudinal strain and QLAB GLS (Figure 1B) were seen. The bias between TomTec GLS and QLAB GLS was 0.6 ±2.2% (Figure 1C). The inter-reader correlation coefficients of TomTec GLS and QLAB GLS were 0.57 and 0.71, respectively. Conclusions: This novel AI-based longitudinal strain analysis was feasible in the majority of echocardiograms without any operator input. The bias between EchoGo longitudinal strain and conventional software appears small. AI-based myocardial strain analysis may reduce variabilities and facilitate longitudinal follow-up of GLS in Cardio-oncology patients.

Introduction: Poor outcomes have been reported in Pregnant patients with WHO Group I Pulmonary Hypertension (PH) before the advent of PH targeted therapies. We performed a systematic review and meta-analysis with the goal of evaluating the association between mortality rates and PH targeted therapies in pregnant women with WHO group 1 PH. Methods: PubMed Database was searched with keywords “pulmonary hypertension”, “pregnancy” from inception to December 2020. Inclusion criteria: >10 pregnancies, maternal mortality reported and WHO Classification available. A meta-analysis was performed to evaluate the association between maternal death and treatment with PH targeted therapies in patients with WHO group 1 PH. All other WHO groups were excluded. Results: Seven studies, published between 1992 and 2016, including 91 patients with WHO group 1 PH met inclusion criteria and were analyzed. (Table 1) Most common etiologies were Idiopathic PH and Congenital Heart Disease. Mortality ranged from 8.3% to 36.3%. Use of PH targeted therapies ranged from 25% to 100%. There was a trend towards survival benefit with PH targeted therapies compared with no therapy. This trend was not statistically significant. Of all deaths reported (n=18), thirteen (72.2%) occurred postpartum. Conclusions: Mortality in pregnant patients with WHO group I PH remains high; most deaths were due to PH crisis and occurred postpartum. Increased monitoring in the postpartum period is likely warranted. Studies were retrospective with small sample sizes. Larger and higher quality studies are needed to determine if PH targeted therapies improve mortality in pregnant patients with WHO group I PH.

In the strictest sense, do-not-resuscitate (DNR) status means that cardiopulmonary resuscitation should not be performed after death has occurred, all other medical interventions in line with a patient’s goals of care should be implemented. The use of transthoracic echocardiography (TTE) in patients with DNR status is unknown. Therefore, we aim to evaluate the utilization of TTE among patients with DNR status using this retrospective data analysis. A total of 16,546 patient admissions were included in the final study. A total of 4370 (26.4%) of the patients had a TTE during hospitalization, among full code patients, 3976 (25.7%) underwent TTE, whereas TTEs were performed in 394 (37.4%) of DNR patients. On univariate logistic regression analysis, full code status had OR (95% confidence interval, CI) 0.57 (0.51–0.66), p &lt, 0.01 compared with DNR status for the performance of inpatient TTE. In the final multivariate model adjusted for age, sex, race, and clinical comorbidities, the full code patients had OR (95% CI) 0.91 (0.79–1.05), p = 0.22 compared with DNR patients for the performance of inpatient TTE. DNR status is not associated with a decrease in inpatient transthoracic echocardiography performance.

Limited evidence-based therapies exist for the management of heart failure with preserved ejection fraction (HFpEF). Sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in patients with systolic heart failure (HFrEF) and type-2-diabetes mellitus (T2DM) is associated with improved cardiovascular (CV) and renal outcomes. We sought to examine whether there is an association of SGLT2i use with improved CV outcomes in patients with HFpEF. We conducted a single-center, retrospective review of patients with HFpEF and T2DM. The cohort was divided into two groups based on prescription of a SGLT2i or sitagliptin. The primary outcome was heart failure hospitalization (HFH); secondary outcomes were all-cause hospitalization and acute kidney injury (AKI). After propensity score matching, there were 250 patients (89 in the SGLT2i group, 161 in the sitagliptin group), with a mean follow-up of 295 days. Univariate Cox regression analysis showed that the SGLT2i group had a reduced risk of HFH versus the sitagliptin group (hazard ratio (HR) 0.13; 95% confidence interval (CI) (0.05–0.36); p < 0.001). The SGLT2i group had a decreased risk of all-cause hospitalization (HR 0.48; 95% CI (0.33–0.70); p

Background Whether the combination of ventricular strain with high‐sensitivity troponin I (hs‐TNI) has an incremental prognostic value in coronavirus disease 2019 (COVID‐19) patients has not been evaluated. The study aimed to evaluate the prognostic value of biventricular longitudinal strain and its combination with hs‐TNI in COVID‐19 patients. Methods A total of 160 COVID‐19 patients who underwent both echocardiography and hs‐TNI testing were enrolled in our study. COVID‐19 patients were divided into two groups (critical and non‐critical) according to severity‐of‐illness. The clinical characteristics, cardiac structure and function were compared between the two groups. The prognostic value of biventricular longitudinal strain and its combination with hs‐TNI were evaluated by logistic regression analyses and receiver operating characteristic curves. Left ventricular longitudinal strain (LV LS) and right ventricular free wall longitudinal strain (RVFWLS) were determined by 2D speckle‐tracking echocardiography. Results The LV LS and RVFWLS both were significantly lower in critical patients than non‐critical patients (LV LS: ‐16.6±2.4 vs ‐17.9±3.0, P = .003; RVFWLS :‐18.8±3.6 vs ‐23.9±4.4, P

Background: The accuracy of speckle-tracking echocardiography (STE) depends on temporal resolution. The goal of this study was to demonstrate the feasibility of relatively high frame rate (rHi-FR) (~200 fps) for STE. Methods: In this prospective study, echocardiographic images were acquired using clinical scanners on patients with normal left ventricular systolic function using rHi-FR and conventional frame rate (Reg-FR) (~50 FPS). GLS values were evaluated on apical 4-, 2- and 3-chamber images acquired in both rHi-FR and Reg-FR. Inter-observer and intra-observer variabilities were assessed in rHi-FR and Reg-FR. Results: There were 143 echocardiograms evaluated in this study. The frame rate of rHi-FR was 190 ± 25 and Reg-FR was 50 ± 3, and the heart rate was 71 ± 13. Absolute strain values measured in rHi-FR were significantly higher than those measured in Reg-FR (all p &lt, 0.001). Inter-observer and intra-observer correlations were strong in both rHi-FR and Reg-FR. Conclusions: We demonstrated that absolute strain values were significantly higher using rHi-FR when compared with Reg-FR. It is plausible that higher temporal resolution enabled the measurement of myocardial strain at desired time point. Further investigations are necessary to evaluate the value of rHi-FR to assess myocardial strain in the setting of tachycardia.

Objectives Data regarding the longitudinal relationship of global longitudinal strain (GLS) and echocardiographic parameters are lacking in peripartum cardiomyopathy (PPCM). We evaluated GLS and its correlation with change (∆) in left ventricular ejection fraction (LVEF). Methods We retrospectively identified women age ≥16 years hospitalized at Montefiore Medical Center in Bronx, NY from 1999-2015 with International Statistical Classification of Diseases and Related Health Problems, 9th revision codes for PPCM or an occurrence of unexplained heart failure during or up to 5 months postpartum. N = 195 charts were reviewed for inclusion/exclusion criteria, n = 53 patients met criteria for PPCM, and of those, n = 13 had a baseline and follow-up echocardiogram suitable for GLS analysis. Results Of those eligible for strain analysis, the mean age was 30 ± 6 years, 46.2% identified as Black and 38.5% as Hispanic/Latina. Baseline LVEF was 30 (25, 35)%, GLS was -13.2 (-14, -7.6)%. At a mean follow-up time of 1.2 ± 0.7 years, 11/13 had persistently mild -15.6 (-16.3, -12.7)%, and 2/13 severely abnormal GLS -7.05 (-7.1, -7.0)%. There was no correlation between baseline GLS and ∆LVEF (r = .014, P = .965). Conclusions Global longitudinal strain is a sensitive method to identify subclinical myocardial dysfunction. In this series of women with PPCM, GLS remained persistently abnormal over time, even if LVEF improved. Future studies should examine the implication of persistently abnormal GLS in PPCM.

Background: global longitudinal strain (GLS) measures myocardial deformation and is a sensitive modality for detecting subclinical myocardial dysfunction and predicting cardiac outcomes. The accuracy of speckle-tracking echocardiography (STE) is dependent on temporal resolution. A novel software enables relatively high frame rate (Hi-FR) (~200 fps) echocardiographic images acquisition which empowers us to investigate the impact of Hi-FR imaging on GLS analysis. The goal of this pilot study was to demonstrate the feasibility of Hi-FR for STE. Methods: In this prospective study, we acquired echocardiographic images using clinical scanners on patients with normal left ventricular systolic function using Hi-FR and conventional frame rate (Reg-FR) (~50 FPS). GLS values were evaluated on apical 4-, 2- and 3-chamber images acquired in both Hi-FR and Reg-FR. Inter-observer and intra-observer variabilities were assessed in Hi-FR and Reg-FR. Results: There were 143 resting echocardiograms with normal LVEF included in this study. The frame rate of Hi-FR was 190 ± 25 and Reg-FR was 50 ± 3, and the heart rate was 71 ± 13. Strain values measured in Hi-FR were significantly higher than those measured in Reg-FR (all p < 0.001). Inter-observer and intra-observer correlations were strong in both Hi-FR and Reg-FR. Conclusions: We demonstrated that strain values were significantly higher using Hi-FR when compared with Reg-FR in patients with normal LVEF. It is plausible that higher temporal resolution enabled the measurement of myocardial strain at desired time point. The result of this study may inform clinical adoption of the novel technology. Further investigations are necessary to evaluate the value of Hi-FR to assess myocardial strain in stress echocardiography in the setting of tachycardia.

Background: Myocardial strain derived from two-dimensional speckle-tracking echocardiography (2D-STE) has been shown to be more sensitive to detect early ventricular dysfunction than conventional echocardiography. However, the study about the prognostic value of biventricular longitudinal strain in coronavirus disease 2019 (COVID-19) is still scarce. Aims: We aimed to evaluate the prognostic value of biventricular longitudinal strain and its combination with high-sensitivity troponin I (hs-TNI) in COVID-19 patients. Methods: We enrolled a total of 160 COVID-19 patients who underwent both echocardiogram and hs-TNI testing. The cardiac structure, function and myocardial strain were compared between patients with and without elevated hs-TNI levels. Left ventricular longitudinal strain (LV LS) and right ventricular free wall longitudinal strain (RVFWLS) were determined by 2D-STE. Results: Compared with patients with normal hs-TNI levels, patients with elevated hs-TNI levels had diminished LV diastolic function, larger right-heart chamber, higher proportion of pulmonary hypertension, lower LV LS and RVFWLS. During a median follow-up of 60 days, 23 patients died. The multivariant analysis revealed LV LS and RVFWLS [Odd ratio (confidence interval): 1.533 (1.131-2.079); P =0.006; 1.267 (1.101-1.794), P =0.021, respectively] both were the independent predictors of higher mortality. Further, receiver-operating characteristic analysis revealed that the accuracy for predicting death was greater for the combination of hs-TNI levels with LV LS than separate LV LS (AUC: 0.93 vs 0.77, P =0.001), and for the combination of hs-TNI levels with RVFWLS than RVFWLS alone (AUC: 0.92 vs 0.83, P =0.041). Conclusion: Our study highlights that the combination of ventricular longitudinal strain with hs-TNI can provide a higher accuracy for predicting mortality in COVID-19 patients, which may enhance risk stratification in COVID-19 patients.

Background Pulmonary embolism (PE) is a significant cause of morbidity and hospitalization worldwide with Right Ventricular (RV) dysfunction identified in association with morality. Two-dimensional speckle tracking echocardiography is an imaging modality used to calculate cardiac strain which can be used to identify early mechanical stress in the RV. Purpose Combining imaging techniques with patient demographics, comorbidities, and clinical parameters, we aim to create a supervised machine learning model to predict mortality within one year after PE and identify important variables. Methods A retrospective cohort of 74 patients who presented with acute PE, confirmed by contrast CT or V/Q scanning, to our hospital system in 2017 who had a transthoracic echocardiogram within 48 hours after the event. STE was used to calculate Endocardial Global Longitudinal Strain (Endo-GLS), End-Diastolic Area (EDA), End-Systolic Area (ESA), and Fractional Area Change (FAC). These parameters were taken along with Size/location of PE, RV size, RV Function, RV Systolic Pressure (RVSP), and TR Velocity. A supervised machine learning model was created using logistic regression and random forest classifier algorithm 100 trees with bootstrapping using Python version 3.7.2. The data was randomly sampled and run through our classifier 50 times which our outcome measurements averaged. Results We identified Endo-GLS as the parameter with the highest weight (30.9%) followed by, FAC (14.0%), and ESA (10.8%). Non-echocardiographic variables that had high importance were patients BMI and Intervention at time of event. We found an Accuracy of 84.3%, Sensitivity of 57.1%, and Specificity of 91.5%. The AUC for our model was 0.87. Conclusion The use of novel imaging methods and supervised machine learning can help identify important variables such as Endo-GLS and help predict mortality in patients with PE. Extrapolated, strain patterns can be sensitively measured in the acute setting of diseases and be used to help predict clinical outcomes. Our next steps are to obtain larger sample size in to create a more robust classifier and to prospectively validate our model. Random Forest Model Funding Acknowledgement Type of funding source: None

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days postdischarge (ie, 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However, the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.

A substantial proportion of patients with acute myocardial infarction develop clinical heart failure, which remains a common and major healthcare burden. It has been shown that in patients with chronic coronary artery disease, ischemic episodes lead to a global pattern of cardiomyocyte remodeling and dedifferentiation, hallmarked by myolysis, glycogen accumulation, and alteration of structural proteins. These changes, in conjunction with an impaired global coronary reserve, may eventually become irreversible and result in ischemic cardiomyopathy. Moreover, noninvasive imaging of myocardial scar and hibernation can inform the risk of sudden cardiac death. Therefore, it would be intuitive that imaging of myocardial viability is an essential tool for the proper use of invasive treatment strategies and patient prognostication. However, this notion has been challenged by large-scale clinical trials demonstrating that, in the modern era of improved guideline-directed medical therapies, imaging of myocardial viability failed to deliver effective guidance of coronary bypass surgery to a reduction of adverse cardiac outcomes. In addition, current available imaging technologies in this regard are numerous, and they target diverse surrogates of structural or tissue substrates of myocardial viability. In this document, we examine these issues in the current clinical context, collect current evidence of imaging technology by modality, and inform future directions.

We present a late presentation of saddle pulmonary embolism and thrombus-in-transit straddle the patent foramen on patient who successfully recovered from severe acute respiratory syndrome coronavirus-2 (COVID-19) pneumonia. Seven days post-discharge (i.e. 28 days after initial COVID-19 symptom onset), she was readmitted to hospital for severe dyspnea. Computer tomography angiogram and echocardiography confirmed the diagnosis. Severe pro-inflammatory and pro-thrombotic states with endothelial involvement have been reported associated with severe COVID-19 infection. However the duration of hypercoagulable state has not yet known. This case highlights the risk of thromboembolic phenomena for prolonged periods of times after recovering from COVID-19 pneumonia.

• ASE guidance for patient and provider protection during echo exams in the COVID-19 pandemic. • Triaging approach for prioritizing echo exams during the COVID-19 pandemic. • Recommended imaging approach and appropriate PPE use during echo exams.

Objectives This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head. Background Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation. Methods The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure. Results Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p Conclusions The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).

Aims Pregnancy in patients with Marfan's syndrome (MFS) carries an increased risk of cardiovascular complications, resulting in increased maternal and fetal mortality and morbidity. Literature on MFS pregnant patients is relatively sparse, and there has yet to be a concrete consensus on the management of this unique patient population. The purpose of our paper is to provide a literature review of case reports and studies on MFS during pregnancy (published between 2005 and 2015) and to explore cardiovascular outcomes of patients with MFS. Methods and Results Of the 852 women in our review, there were 1112 pregnancies, with an aortic dissection rate of 7.9% and mortality of 1.2%. Data demonstrated a trend that patients whose aortic diameter ≥40 mm had a greater rate of dissection than MFS patients whose aortic diameter

Background Preclinical diastolic dysfunction PDD is a well-known but poorly understood risk factor for clinical heart failure CHF. Preclinical diastolic dysfunction and predictors of progression of PDD to CHF in patients with malignancy has never been studied. Purpose The purpose of our study was to determine the incidence of CHF in cancer patients who have preexisting preclinical diastolic dysfunction, with a particular focus on identifying the risk factors contributing to progression of PDD to CHF. Study design We retrospectively sought all the patients who underwent echocardiography from 2003 to 2008 and were found to have preclinical diastolic dysfunction at our institution. PDD was defined as presence of grade I diastolic dysfunction, LVEF ≥50%, and free of clinical diagnosis of heart failure. Of these, only the patients who had a confirmed histopathological diagnosis of malignancy were included in the study. The end point was incidence of clinical heart failure, HFrEF and HFpEF. Multivariable adjusted Cox proportional hazards regression were performed to study the predictors of CHF. Results Out of 1086 patients with PDD and a histopathological diagnosis of malignancy, 208 patients were diagnosed with new onset CHF during the 10 years follow-up. Incidence of CHF, HFpEF and HFrEF was found to be 32.1 per 1,000 person-year, 13.9 per 1,000 person-year and 2.93 per 1,000 person-year respectively. Patients who developed clinical heart failure were found to have more hypertension, diabetes, myocardial infarction, peripheral vascular disease, pulmonary disease, renal disease, hematological malignancies and metastatic disease when compared to patients who did not develop heart failure. In multivariable adjusted Cox regression analysis, age at index date (HR 1.02, 95% CI 1.01–1.04, p=0.001), diabetes (HR 1.74, 95% CI 1.28–2.35, p Conclusion This is the first study ever to report the incidence of CHF, HFrEF and HFpEF and identify a distinct set of predictors of heart failure in patients with PDD and malignancy. We estimated a much higher incidence of CHF (19%) in our study population, when compared to the general population with malignancy. Our study also depicted a significantly high incidence of HFpEF compared to HFrEF (8.3% vs 1.75%). Our study shows that patients with malignancy are at a significantly higher risk of developing heart failure if they have preexisting diastolic dysfunction. This emphasizes the importance of identifying patients with diastolic dysfunction and a more rigorous cardiovascular surveillance to prevent them from potential heart failure. Acknowledgement/Funding None

Background: Information on the clinical and echocardiographic characteristics of young patients with heart failure with reduced ejection fraction is scant, especially among racially diverse populations. Methods: Patients admitted to Montefiore Medical Center between 2000 and 2016 with heart failure and ejection fraction of

ObjectivesWe aimed to study the racial differences in clinical presentations, survival outcomes and outcome predictors among patients with heart failure (HF) with midrange ejection fraction (HFmrEF, EF 40%–49%).DesignThis is a retrospective study.SettingAdults with HF diagnosis at Montefiore Medical Center, Bronx, New York between 2008 and 2012, with an inpatient echocardiogram showing left ventricular ejection fraction of 40%–49% were included as HFmrEF population.Participants1,852 HFmrEF patients are included in the study (56% male, mean age 67 years). There were 493 (26.5%) non-Hispanic whites, 541 (29.2%) non-Hispanic black, 489 (26.4%) Hispanics and 329 (17.8%) other racial populations.Outcome measuresCumulative probabilities of all-cause mortality among different racial groups were estimated and multivariable adjusted Cox proportional regressions were performed to assess predictors of mortality.ResultsAmong the HFmrEF patients, white patients were older and were less likely to be on guideline-directed medications. Blacks had a lower prevalence of prior myocardial infarction comparing to other groups. Hispanics had more chronic diseases and yet better survival comparing to whites and blacks after adjustment for age, sex and comorbidities. Distinct sets of survival predictors were revealed in individual racial groups. Baseline use of mineralocorticoid receptor antagonist (MRA) was associated with lower mortality among HFmrEF patients in general (HR 0.61, 95% CI 0.37 to 0.99).ConclusionsThere are significant racial/ethnic differences in clinical phenotypes, survival outcomes and mortality predictors of HFmrEF. Furthermore, the use of MRA predicted a reduced mortality in HFmrEF patients.

(1) Background: This study sought to explore how the novel coronavirus (COVID-19) pandemic affected the echocardiography (TTE) laboratory operations at a high volume medical center in New York City. Changes in cardiac imaging study volume, turn-around time, and abnormal findings were analyzed and compared to a pre-pandemic period. (2) Methods: Volume of all cardiac imaging studies and TTE reports between 11 March 2020 to 5 May 2020 and the same calendar period in 2019 were retrospectively identified and compared. (3) Results: During the pandemic, our center experienced a 46.72% reduction in TTEs, 82.47% reduction in transesophageal echocardiograms, 83.16% reduction in stress echo, 70.32% reduction in nuclear tests, 46.25% reduction in calcium score, 73.91% reduction in coronary computed tomography angiography, and 87.23% reduction in cardiac magnetic resonance imaging. TTE findings were overall similar between 2020 and 2019 (all p &ge, 0.05), except for a significantly higher right ventricular systolic pressure in 2020 (39.8 &plusmn, 14.2 vs. 34.6 &plusmn, 11.2 mmHg, p = 0.012). (4) Conclusions: Despite encountering an influx of critically ill patients, our hospital center experienced a reduction in the number of cardiac imaging studies, which likely represents a change in both patient mindset and physician management approach.

Background:Hydroxychloroquine (HCQ) cardiotoxicity remains an underrecognized condition. Diagnosis ultimately relies on invasive endomyocardial biopsy (EMB) and non-invasive screening methods are warranted. Strain imaging is a novel tool to detect early subclinical left ventricular (LV) dysfunction and may have a role in screening for HCQ cardiotoxicity (1). Strain measures systolic deformation indices that when decreased can predict cardiovascular outcomes more accurately than LV ejection fraction (2).Objectives:We assessed whether high HCQ cardiotoxicity risk is associated with a specific strain pattern in a group of patients with SLE and end-stage renal disease (ESRD).Methods:This was a retrospective study in a tertiary care center in New York on a group of patients with an established diagnosis of SLE, ESRD and cardiomyopathy on the index echocardiogram followed between years 2003 and 2019. The patients were stratified into two groups: high risk HCQ toxicity group was defined as either cumulative HCQ dose ≥1000g and/or an endomyocardial biopsy confirming HCQ toxicity. Low/moderate risk group was defined as a cumulative dose of HCQ Results:A total of 16 patients were included. Two patients had EMB consistent with HCQ induced toxicity and 3 patients had cumulative HCQ doses ≥1000g. There were no significant differences in the baseline demographic characteristics between the two groups. Compared to patients with low/moderate risk, patients in the high risk group had a lower heart rate at the time of the echocardiogram (69 vs 87 beats per minute, p=0.08) and a higher frequency of LV hypertrophy (40% vs 9.1%, p=0.2). Strain analysis showed that both groups had compromised LV global longitudinal strain (GLS) and global cross-sectional strain (GCS). However, compared to the low/moderate risk group, the high risk group had a weaker LV GLS (-12.3% vs -14.9%, p=0.27).Characteristics overall and stratified by HCQ risk groupCharacteristicOverall (n=16)Low/Moderate HCQ Risk(n=11)High HCQ Risk and/or Positive EMB (n=5)P valueDemographicsAge, years47.5 (36.5,60.7)50.0 (33.9,60.5)42.5 (42.7,61.0)0.95Female, n(%)14 (87.5)9 (90)5 (83.3)0.99Clinical FeaturesSLE duration, years7.4 (4.3,17.5)5.5 (3.5,13.2)15.6 (11.6,19.3)0.15HCQ cumulative dose, g422.8 (224.2,422.8)285.4 (110.8,523.6)1140 (1006,1625.4)0.005HCQ therapy duration, years3.4 (2.5, 8.9)3.2 (1.5,5.1)7.8 (6.8,11.6)0.06HCQ daily dose, mg/d226 (200,394.9)200 (179.4,253.7)400 (389.8,400)0.007Hypertension, n (%)14 (87.5)10 (90.9)4 (80.0)0.99Diabetes, n (%)3 (18.8)2 (18.8)1 (20.0)0.99CAD, n (%)3 (18.8)2 (18.8)1 (20)0.99EchocardiogramEF, %55 (42.5,60)55 (40,60)55 (55,70)0.45LA size, cm3.8 (3.4,4.3)3.8 (3.4,4.2)4.3 (3.4,4.9)0.30LVEDD, cm4.9 (4.4, 5.5)4.8 (4.2,5.5)5.0 (4.9,5.4)0.43E/E’12.3 (8.8,16.3)12 (8.8,14.9)16.9 (4.9,21.8)0.43Moderate-severe LV hypertrophy, n(%)3 (18.7)1 (9.1)2 (40.0)0.20Strain echocardiographyGLS, %-13.9 (-16.7,-12.3)-14.9 (-16.7,-12.9)-12.3 (-15.4,-12.2)0.27Base/Apex Ratio0.8 (0.7,0.9)0.76 (0.68,0.86)0.76 (0.66,0.83)0.95GCS, %-20.2 (-21.7,-17)-19.7 (-20.5,18.0)-21.7 (-23.9,-20.9)0.16RV GLS, %-20.19 (-22.1,-17.5)-20.2 (-22.3,-17.1)-19.8 (-22.1,-17.5)0.99Conclusion:We report an association of higher HCQ cardiotoxicity risk and impaired strain in a set of SLE ESRD patients. Standard echo measures did not differentiate between high and low/moderate risk patients. Although the findings did not reach statistical significance, given the small sample size, results are still suggestive of a possible utility of strain echocardiography for detection of early HCQ toxicity.References:[1]Buss SJ, et al. J Rheumatol. 2010;37(1):79-86[2]Kalam K, et al. Heart. 2014;100(21):1673-80Disclosure of Interests: None declared

Aortitis is a recognized complication of tertiary syphilis. Pathogen invades the aortic wall causing inflammation, lead to severe complications such as aortic aneurysm and valvular insufficiency. A 56-year-old man with a medical history of hypertension was evaluated for new-onset dyspnea, fatigue

Background Left ventricular diastolic dysfunction has been shown to associate with increased risk of atrial fibrillation (AF). We aimed to examine the predictors of AF in individuals with preclinical diastolic dysfunction (PDD) - diastolic dysfunction without clinical heart failure – and develop a risk score in this population. Methods Patients underwent echocardiogram from December 2009 to December 2015 showing left ventricular ejection fraction (LVEF) ≥ 50% and grade 1 diastolic dysfunction, without clinical heart failure, valvular heart disease or AF were included. Outcome was defined as new onset AF. Cumulative probabilities were estimated and multivariable adjusted competing-risks regression analysis was performed to examine predictors of incident AF. A predictive score model was constructed. Results A total of 9591 PDD patients (mean age 66, 41% men) of racial/ethnical diversity were included in the study. During a median follow-up of 54 months, 455 (4.7%) patients developed AF. Independent predictors of AF included advanced age, male sex, race, hypertension, diabetes, and peripheral artery disease. A risk score including these factors showed a Wolber’s concordance index of 0.65 (0.63–0.68, p

Background— A significant proportion of patients requiring aortic valve replacement (AVR) have undergone prior coronary artery bypass grafting (CABG). Reoperative heart surgery is associated with increased risk. Data on relative utilization and comparative outcomes of transcatheter (TAVR) versus surgical AVR (SAVR) in patients with prior CABG are limited. Methods and Results— We queried the 2012 to 2014 National Inpatient Sample databases to identify isolated AVR hospitalizations in adults with prior CABG. In-hospital outcomes of TAVR versus SAVR were compared using propensity-matched analysis. Of 147 395 AVRs, 15 055 (10.2%) were in patients with prior CABG. The number of TAVRs in patients with prior CABG increased from 1615 in 2012 to 4400 in 2014, whereas the number of SAVRs decreased from 2285 to 1895 ( P trend P =0.71) but lower incidence of myocardial infarction (1.5% versus 3.4%; P P P P Conclusions— TAVR is being increasingly used as the preferred modality of AVR in patients with prior CABG. Compared with SAVR, TAVR is associated with similar in-hospital mortality but lower rates of in-hospital complications in this important subset of patients.

This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head.Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation.The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure.Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p 0.001).The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).

> It’s not that I’m so smart, it’s just that I stay with problems longer > > —Albert Einstein The impact of severe organic mitral regurgitation (MR) on left atrium (LA) size and function has been studied; however, changes in LA function after mitral valve (MV) interventions remain unclear. In this issue of Circulation: Cardiovascular Imaging , Gucuk Ipek et al1 retrospectively studied LA and left ventricle (LV) strain by speckle-tracking echocardiography (STE) at baseline and at 12-month follow-up in 87 subjects with severe organic MR enrolled in the EVERST II trial (Endovascular Valve Edge-to-Edge Repair Study), including 49 patients who underwent MitraClip placement and 38 patients who underwent surgical MV repair (MVr). Their findings suggest that LA strain post-MV interventions is complicated and may be affected by multiple factors (Figure), including patient demographics, baseline LA size/function, treatment modalities and MR reduction, among others. Figure. Left atrium (LA) strain post-mitral valve (MV) interventions is affected by multiple factors. LV indicates left ventricle. See Article by Gucuk Ipek et al Organic MR can lead to chronic volume overload on LA and consequent remodeling, which is manifested as LA dilatation and LA dysfunction. LA becomes less compliant because of chronic inflammation, LA myocyte hypertrophy, interstitial fibrosis, and decreased matrix metalloproteinase expression.2 LA volume index ≥40 mL/m2 is an independent predictor of atrial fibrillation and combined end point of death or need for mitral surgery in patients with organic MR.3 Baseline LA volume index and its progressive increase can predict the development of symptoms and LV dysfunction in asymptomatic patients with moderate and severe organic MR.4 Baseline LA volume index was also shown to strongly predict survival independent of MR severity and other known risk factors, and mitral surgery was shown to markedly improve outcomes and restore life expectancy.5 LA function …

Sarcoidosis is a multisystem granulomatous disease of unknown cause that can affect the heart. Cardiac sarcoidosis may be present in as many as 25% of patients with systemic sarcoidosis, and it is frequently underdiagnosed. The early and accurate diagnosis of myocardial involvement is challenging. Advanced imaging techniques play important roles in the diagnosis and management of patients with cardiac sarcoidosis.

Objectives This study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR). Background CKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis. Methods The authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes. Results Of 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period. Conclusions Patients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years.

Highlights • ASE guidance for patient and provider protection during echo exams in the COVID-19 pandemic. • Triaging approach for prioritizing echo exams during the COVID-19 pandemic. • Recommended...

Purpose: Real-time three-dimensional transesophageal echocardiography (3D TEE) is useful in a variety of clinical scenarios. However, the pattern of its clinical utilization in an urban academic center is unknown. The objective of this study is to evaluate the practical use of 3D TEE and to explore factors that may affect its applications. Methods: We conducted a retrospective study by reviewing 2,734 consecutive TEEs performed at Montefiore Medical Center in Bronx, NY, between January 2009 and August 2011. Types of 3D modes (biplane, live, 3D zoom, full volume, and 3D quantifi cations) and indications were reviewed. Linear regression was performed to examine the association between echocardiographers & rsquo; characteristics and 3D TEE utilization. Results: 3D modalities were utilized in 1,655 studies (61%) during the study period. The use of 3D technology increased from 44% at 4 months to 79% at 32 months. Biplane, 3D zoom, and full volume acquisition showed a steady increase, but quantification remained very low throughout the study period. Level 3 training was significantly associated with 66.6% (95% CI 13.0%, 120.1%, P = 0.029) higher rate of 3D TEE utilization compared to level 2, after adjusting for age, sex, years of practice, and total TEE volume. Level 3 echocardiographers utilized more zoom 3D and full volume, whereas level 2 echocardiographers used biplane more frequently. Conclusion: There has been a growing use of 3D TEE over time, but not all 3D modes were equally employed. The association between advanced training and increased 3D utilization is likely due to interest and self-motivation. Key words: Echocardiographer, echocardiography, real-time three-dimensional transesophageal echocardiography.

Background: Cardiovascular changes of pregnancy are well-known; however, parameters for accurately assessing these changes have not been refined as measurement tools have advanced. We sought to examine the range of echocardiographic parameters during normal pregnancy using current echocardiographic imaging modalities. Methods: We performed a retrospective analysis of normal echocardiograms in 121 women (97 pregnant, 24 non-pregnant) without evidence of cardiovascular disease. Linear, area, and Doppler fl ow measurements were made of commonly reviewed cardiac structures. Height-indexed measurements were compared between pregnant women and controls and between trimesters of pregnancy. Results: Compared to non-pregnant patients, all four cardiac chambers showed significant enlargement in the pregnant patients. The left atrium was the first chamber to enlarge. LV mass also increased in the third trimester (134.5 ± 31 vs. 112.3 ± 28.2 g, P & lt; 0.01), with preservation of LV mass to volume ratio. LV ejection fraction was significantly larger (68% vs. 63%, P Conclusion: This study provides data on echocardiographic parameters during normal pregnancy and is one of the largest sample sizes in the literature. The results will contribute to the current literature by helping to distinguish between normal and abnormal echocardiograms during pregnancy. Key words: Chamber quantifi cations, echocardiography, pregnancy.

The evaluation of chest pain (CP) in the emergency department (ED) frequently employs a non-invasive strategy, which includes coronary computed tomography angiography (CCTA), stress echocardiography (SE) or myocardial perfusion imaging (MPI). We sought to report the real-world experience and

Background: Acute flail mitral valve frequently results in severe mitral regurgitation. However, its clinical presentation can be similar to other disease processes, potentially leading to initial misdiagnosis and a morbid outcome. We sought to analyze baseline characteristics, clinical presentations, time to diagnosis, and in-hospital mortalities of patients with the acute flail mitral valve. Methods: Two hundred and sixty two consecutive echocardiograms with severe mitral regurgitation performed between February 2005 and October 2010 at the Jack D. Weiler Hospital (Bronx, New York, USA) were reviewed. Adult patients who had presented with new onset flail mitral valves were selected for this retrospective study. Results: Fifteen patients were found to have acute flail mitral valve. The majority was elderly male. Over half presented to the emergency room with a sudden onset of dyspnea. A mitral regurgitant murmur was appreciated in only a third of the patients. The chest X-ray of five patients had no acute pulmonary findings, whereas, two were found to have gross unilateral pulmonary edema. Clinically, 60% were misdiagnosed on admission. Using echocardiogram, the correct diagnosis of flail mitral valve was made in all cases, however, only 40% on the day of presentation. The maximum time to echocardiographic diagnosis was 4 days. The main cause of acute flail mitral valve was degenerative disease. Seven patients were managed surgically. Overall, there was only one mortality (7%) during incident hospitalization. Conclusions: Initial misdiagnosis of acute flail mitral valve happens frequently. Early echocardiographic exam is essential in the timely diagnosis and management of acute flail mitral valve. Key words: Acute flail mitral valve, Echocardiography, Misdiagnosis, Severe mitral valve regurgitation.

Complete dehiscence of a composite aortic valve graft with pseudoaneurysm formation is a rare complication following aortic root replacement. This complication often takes place in the setting of acute graft infection and accompanies symptoms of heart failure, valve insufficiency or sepsis. We present a delayed, asymptomatic presentation of this complication in a young man with distant history of aortic root replacement and medically treated prosthetic valve endocarditis a year postoperatively. He had been non-adherent to warfarin over 10 years, but otherwise maintained a healthy life. After being lost to follow-up, he re-presented 12 years after the initial operation with new-onset seizures. Echocardiogram revealed complete dehiscence of a composite valved conduit at the proximal anastomosis site with a resultant large pseudoaneurysm. The patient underwent an urgent re-operation with resection of the pseudoaneurysm and insertion of a tissue valved conduit. He had an uncomplicated postoperative recovery and promised close follow-up on discharge.

Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR.Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR.After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01).SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.