Left atrial remodeling and the prognostic value of feature tracking derived left atrial strain in patients with light-chain amyloidosis: a cardiovascular magnetic resonance study.

Systemic light-chain (AL) amyloidosis is characterized by the aggregation of misfolded immunoglobulin light chain, predominantly infiltrating in the heart, including left atrium (LA). LA remodeling, such as increased interatrial septal thickness and enlarged size, has been observed. However, LA strain assessed by cardiac magnetic resonance feature tracking (CMR-FT) and its prognostic role remains to be further determined. Using CMR, the current study sought to investigate the characteristic of LA remodeling and the prognostic value of LA strain in patients with AL. Eighty-seven consecutive patients who underwent CMR with histologically confirmed systemic light-chain amyloidosis were retrospectively enrolled. LA strain parameters were analyzed based on CMR-FT algorithm. Amyloid infiltration and burden loads were assessed with CMR late gadolinium enhancement (LGE) and extracellular volume (ECV). Patients were categorized according to the extent of amyloid infiltration in cardiac myocardium. The primary endpoint was defined as all-cause mortality. The prognosis value of LA strain indices was evaluated using Cox proportional hazards regression and Kaplan-Meier curves. Interatrial septal thickness (3 [2-5] vs. 4 [3-5] mm, p = 0.007) and indexed LA volume (34.6 [26.9-44.6] vs. 50.5 [36.1-58.5] ml/m2, p = 0.001) were significantly higher in patients with atrial involvement (LA-LGE). Compared with patients with low amyloid burden loads (ECV group I), those at moderate and high (ECV group II and III) show progressive impairment in LA reservoir, conduit, and booster strains and strain rates. A total of 44 patients died during a median follow-up of 12 months. In multivariate analysis, LA reservoir strain, New York Heart Association (NYHA), and ECV remained independently associated with survival. On Kaplan-Meier analyses, low LA reservoir strain (< 8.6%) increased the risk of mortality. In moderate amyloid burden loads patients, low LA reservoir strain provides additive prognosis value. Progress left atrial remodeling and dysfunction are common findings in AL cardiac amyloidosis. The CMR-FT-derived LA reservoir strain provides independent and additive prognostic value for all-cause mortality in patients with AL cardiac amyloidosis.

ECG-gated CT in Aortic Perivalvular Abscess: Comparison with Transesophageal Echocardiography and Intraoperative Findings.

Background The 2015 European Society of Cardiology guidelines acknowledged similar diagnostic performance of electrocardiography (ECG)-gated CT on perivalvular abscesses compared with transesophageal echocardiography (TEE), but data on ECG-gated CT remain insufficient. Purpose To determine the diagnostic performance of ECG-gated CT for assessing aortic root perivalvular abscesses and to compare it with TEE. Materials and Methods Between January 2008 and June 2019, the imaging records of surgically confirmed infective endocarditis were retrospectively reviewed for presence of aortic perivalvular abscesses, their extension, fistulization, vegetations, and valvular destruction. The diagnostic performance of ECG-gated CT was analyzed in all patients (part A) and in an noninferiority analysis (part B; δ = -10%) in patients undergoing TEE. Results A total of 178 patients (median age, 54 years [interquartile range, 15 years]; 147 men) were evaluated (CT, n = 178; TEE, n = 35). In part A, the sensitivity and specificity of CT were 70 of 71 (99% [95% confidence interval (CI): 96%, 100%]) and 102 of 107 (95% [95% CI: 91%, 99%]) for abscess; 65 of 68 (96% [95% CI: 91%, 100%]) and 107 of 110 (97% [95% CI: 94%, 100%]) for extension, 36 of 36 (100% [95% CI: 100%, 100%]) and 139 of 142 (98% [95% CI: 96%, 100%]) for fistulization, 153 of 160 (96% [95% CI: 93%, 99%]) and five of 18 (28% [95% CI: 7%, 49%]) for vegetations, and 90 of 90 (100% [95% CI: 100%, 100%]) and 24 of 88 (27% [95% CI: 18%, 37%]) for valvular destruction. In part B, ECG-gated CT had noninferior sensitivity compared with TEE for detecting abscess (difference, 14 percentage points [lower one-sided 95% CI: -4 percentage points]), extension (difference, 0 percentage points [lower one-sided 95% CI: 0 percentage points]), fistulization (difference, 0 percentage points [lower one-sided 95% CI: 0 percentage points]), and valvular destruction (difference, 5 percentage points [lower one-sided 95% CI: -4 percentage points]). Specificity of CT was inferior for demonstrating perivalvular abscess (difference, 5 percentage points [lower one-sided 95% CI: -11 percentage points]) and valvular destruction (difference, -62 percentage points [lower one-sided 95% CI: -92 percentage points]). ECG-gated CT had inferior sensitivity in detecting vegetations (difference, -6 percentage points [lower one-sided 95% CI: -14 percentage points]). Conclusion Electrocardiography-gated CT had noninferior sensitivity compared with transesophageal echocardiography for identification of aortic perivalvular abscesses, extension of these abscesses, fistulization, and valvular destruction but had inferior sensitivity in detection of vegetations. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Sakuma in this issue.

Using machine learning to predict one-year cardiovascular events in patients with severe dilated cardiomyopathy.

PURPOSE: Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy and it is associated with poor outcomes. A poor prognosis of DCM patients with low ejection fraction has been noted in the short-term follow-up. Machine learning (ML) could aid clinicians in risk stratification and patient management after considering the correlation between numerous features and the outcomes. The present study aimed to predict the 1-year cardiovascular events in patients with severe DCM using ML, and aid clinicians in risk stratification and patient management. MATERIALS AND METHODS: The dataset used to establish the ML model was obtained from 98 patients with severe DCM (LVEF < 35%) from two centres. Totally 32 features from clinical data were input to the ML algorithm, and the significant features highly relevant to the cardiovascular events were selected by Information gain (IG). A naive Bayes classifier was built, and its predictive performance was evaluated using the area under the curve (AUC) of the receiver operating characteristics by 10-fold cross-validation. RESULTS: During the 1-year follow-up, a total of 22 patients met the criterion of the study end-point. The top features with IG > 0.01 were selected for ML model, including left atrial size (IG = 0.240), QRS duration (IG = 0.200), and systolic blood pressure (IG = 0.151). ML performed well in predicting cardiovascular events in patients with severe DCM (AUC, 0.887 [95% confidence interval, 0.813-0.961]). CONCLUSIONS: ML effectively predicted risk in patients with severe DCM in 1-year follow-up, and this may direct risk stratification and patient management in the future.

Left atrial strain reproducibility using vendor-dependent and vendor-independent software.

BACKGROUND: Two-dimensional speckle-tracking echocardiography (2D-STE) enables objective assessment of left atrial (LA) deformation through the analysis of myocardial strain, which can be measured by different speckle-tracking software. The aim of this study was to compare the consistency of 3 different commercially available software, which include vendor-specific software for measuring left ventricle (VSSLV), vendor-independent software packages for measuring LV strain (VISLV) and vendor-independent software packages for measuring LA strain (VISLA). METHODS: Sixty-four subjects (mean age: 44 ± 16 years, 50% males) underwent conventional echocardiograms using a GE Vivid 9 (GE Ultrasound, Horten, Norway) cardiac ultrasound system. Standard apical 4 and 2 chamber views of the left atrium were obtained in each subject with a frame-rate range of 40-71 frames/s. LA strain during the contraction phase (Sct), conduit phase (Scd), reservoir phase (Sr = Sct + Scd) were analyzed by 2 independent observers and 3 different software. RESULTS: Sct, Scd, Sr were, respectively, - 11.26 ± 2.45%, - 16.77 ± 7.06%, and 28.03 ± 7.58% with VSSLV, - 14.77 ± 3.59%, - 23.17 ± 10.33%, and 38.23 ± 10.99% with VISLV, and - 14.80 ± 3.88%, - 23.94 ± 10.48%, and 38.73 ± 11.56% when VISLA was used. A comparison of strain measurements between VSSLV and VIS (VISLV and VISLA) showed VIS had significantly smaller mean differences and narrower limits of agreement. Similar results were observed in the coefficient of variation (CV) for measurements between VSSLV and VIS (VISLV and VISLA). Comparison of the intra-class correlation coefficients (ICCs) indicated that measurement reliability was weaker with VSSLV (ICC < 0.6) than with VIS (VISLV and VISLA) (ICC > 0.9). For intra-observer ICCs, VISLA > VSSLV = VISLV. For inter-observer ICCs, VSSLV > VISLA > VISLV. CONCLUSIONS: Software measurement results of LA strain vary considerably. We recommended not measuring LA strain across vendor platforms.

Association of Thromboembolic Risk Score with Left Atrial Thrombus and Spontaneous Echocardiographic Contrast in Non-Anticoagulated Nonvalvular Atrial Fibrillation Patients.

OBJECTIVES: The aim of the study was to examine the association of CHADS2/CHA2DS2-VASc scores with left atrial thrombus (LAT) and spontaneous echocardiographic contrast (SEC) in non-anticoagulated nonvalvular atrial fibrillation (NVAF) spontaneous patients, and to develop a new scoring system for LAT/SEC prediction. METHODS: Consecutive non-anticoagulated NVAF patients with or without LAT/SEC by transesophageal echocardiography were identified in the Guangdong General Hospital. RESULTS: Among 2,173 patients, the prevalence of LAT/SEC was 4.9%. Both predictive values of CHADS2 and CHA2DS2-VASc scores for the presence of LAT/SEC were low-to-moderate (receiver operating characteristic [ROC] = 0.591 and 0.608, respectively, p = 0.90). By multivariate analysis, non-paroxysmal AF, decreased left ventricular ejection fraction, and left atrial enlargement were positively associated with LAT/SEC, while CHADS2/CHA2DS2VASc scores were not. A new scoring system based on these 3 factors above significantly improved the discrimination for LAT/SEC (ROC = 0.792). CONCLUSIONS: CHADS2/CHA2DS2-VASc scores had limited value in predicting LAT/SEC; a new scoring system that combines AF type and echocardiographic parameters may better predict LAT/SEC as a surrogate for cardioembolic risk in NVAF patients.

Echocardiography in the diagnosis of patients with absent pulmonary valve syndrome: a review study of 12 years.

Absent pulmonary valve syndrome (APVS) is a rare congenital heart disease that is easily misdiagnosed as tetralogy of Fallot (TOF). We herein discuss the echocardiographic features of APVS, compare its two subtypes, and clarify some differences between APVS and TOF. From July 1998 to October 2011, 31 patients diagnosed with APVS at Fuwai Hospital underwent echocardiography, computed tomography, or cardiac angiography. APVS was clinically categorized as either infant-type or child-type. We compared the echocardiographic similarities and differences between APVS and TOF and between the two subtypes of APVS. Although enlargement or aneurysmal dilatation was present in the main pulmonary artery (PA) and its branch in most patients, pulmonary dysplasia or even an absent left PA was found in a few patients. Four important echocardiographic features of APVS useful for distinguishing this syndrome from TOF were (1) absence of the pulmonary valve or presence of pulmonary valve dysplasia, (2) concurrent stenosis and regurgitation at the pulmonary annulus, (3) significant aneurysmal dilatation in the areas of the PAs, and (4) increased rather than decreased PA pressure. 10 patients had infant-type APVS and 21 had child-type APVS. Compared with child-type APVS, infant-type APVS was usually characterized by a lower oxygen saturation, more dilated main PA and right PA, lower aorta-PA ratio, higher diastolic PA pressure, and lower incidence of an absent left PA. Echocardiography is important for diagnosing APVS and distinguishing it from TOF. There are minimal differences in the echocardiographic features between infant-type and child-type APVS.

Assessment of left ventricular twist mechanics by speckle tracking echocardiography reveals association between LV twist and myocardial fibrosis in patients with hypertrophic cardiomyopathy.

We aimed to investigate whether left ventricular (LV) twist analysis can detect the extent of myocardial fibrosis in patients with hypertrophic cardiomyopathy (HCM). This prospective case-control study recruited 81 consecutive patients with HCM examined between January 2012 and April 2013. Data of 76 patients were analyzed after excluding 5 patients whose echocardiographic images were of poor quality. Healthy volunteers (n = 46) served as controls. Both groups underwent comprehensive echocardiographic examination (i.e., Bas-Rotation, AP-Rotation, LVEF, LADs, IVST, LAVi, E/Em, LVMI, advanced LV-twist analysis by speckle tracking echocardiography) and magnetic resonance imaging. Between-group differences were analyzed by independent t test; logistic regression analysis was performed to identify effect factors. No significant differences were found between baseline characteristics of HCM and control groups (all p > 0.05). HCM patients had significantly higher Bas-Rotation, AP-Rotation, LV Twist, LVEF, LADs, IVST, LAVi, E/Em and LVMI than controls (all p < 0.0001) and significantly lower LVDd and E/A (both p < 0.001). Bas-Rotation, AP-Rotation, LV-Twist, LADs, IVST, LAVi, E/Em and LVMI were significantly higher in HCM patients with fibrosis than in those without fibrosis (p < 0.001), but no significant differences in other echocardiographic parameters were found between those with and without fibrosis. Age, Bas-Rotation, AP-Rotation, LV twist, LADs, IVST, LAVi, E/A, E/Em, and LVMI were significant effect factors for fibrosis. AUROC analysis showed that LV twist had high discriminatory power to detect extent of myocardial fibrosis (AUC 0.996, 95 % CI 0.989-1.004, p < 0.001). Left ventricular twist mechanics are associated with the extent of myocardial fibrosis. LV-twist assessment by STE may be clinically useful.

Quantification of mitral regurgitation by general imaging three-dimensional quantification: feasibility and accuracy.

BACKGROUND: Mitral regurgitant volume (MRvol) is an important index of the severity of mitral regurgitation (MR), but MRvol measurement remains challenging. With the development of probe technology and software, General Imaging 3D Quantification (GI 3DQ) allows the direct measurement of MR jet volume. The aim of this study was to evaluate the feasibility and accuracy of MRvol by quantification of MR jet volume using GI 3DQ. METHODS: Ninety-three patients were included, 61 with functional MR and 32 with mitral valve prolapse. Patients with MR were also divided into those with central MR (n = 41) and those with eccentric MR (n = 52). MRvol was assessed using GI 3DQ and the proximal isovelocity surface area (PISA) method. MRvol using effective regurgitant orifice area by real-time three-dimensional echocardiography multiplied by the MR time-velocity integral was used as the reference method. RESULTS: MRvol measured by GI 3DQ and the PISA method had good correlation with MRvol by the reference method. A significant underestimation of MRvol using GI 3DQ and the PISA method was observed in the assessment of eccentric MR, but without a significant difference in the assessment of central MR. CONCLUSIONS: Quantification of MRvol with GI 3DQ was feasible. Quantification of central MRvol using this methodology is accurate compared with the reference method. Quantification of MRvol with GI 3DQ has no significant difference from the currently recommended PISA method.

Left atrial minimum volume by real-time three-dimensional echocardiography as an indicator of diastolic dysfunction.

BACKGROUND: Left atrial (LA) maximum volume is becoming a prognostic biomarker for left ventricular (LV) diastolic dysfunction. However, we assessed LV diastolic function by measuring LA phasic volumes using real-time threedimensional echocardiography (RT3DE) in patients with stable coronary artery disease (CAD). METHODS: Sixty-five stable CAD patients with normal LV ejection fraction (LVEF) were divided into three groups according to degree of coronary stenosis: control (n = 15) with <50% stenosis as control group, mildS (n = 25) with mild stenosis (50%-70%) and severeS (n = 25) with >70% stenosis. LA phasic volumes and function were evaluated and compared using RT3DE and two dimensional echocardiography (2DE). N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were examined. The correlations of RT3DE-derived parameters with other conventional indices were analyzed. RESULTS: Significant correlations between RT3DE and 2DE for LA volume measurements were: control, r = 0.93; mildS, r = 0.94; severeS, r = 0.90 (all P < 0.05). Patients with severe coronary stenosis presented higher NT-proBNP level, indices of LA minimum volume and volume before atrial contraction, but lower LA total emptying fraction (LAEF) and LAEFpassive. Significant correlations of RT3DE derived LA volume indices with E/E' (r = 0.695) and NF-proBNP (r = 0.630) level were found. CONCLUSIONS: RT3DE derived, LA indices correlate well with NT-proBNP level and may be superior to 2DE measurements for the evaluation of LV diastolic dysfunction. Enlargement of LA minimum volume in stable CAD patients without systolic dysfunction appears earlier and may be better correlated with LV diastolic function than that of LA maximum volume.

Transthoracic echocardiography for diagnosis of right pulmonary artery to left atrial fistula.

Right pulmonary artery to left atrial fistula (RPA-LAF) is a rare cardiovascular anomaly. There were no systematic and detail represent by echocardiography. We chose the patients who diagnosed with RPA-LAF at Fuwai Hospital from 2000 to 2010. All patients underwent clinical examination, chest roentgenogram, laboratory testing, electrocardiography, transthoracic echocardiography (TTE), contrast echocardiography, and cardiac catheterization. In this article, we summarize the characteristics of the TTE for diagnosing the rare cardiovascular anomaly of RPA-LAF. We undertook a detailed review of their TTE and contrast echocardiography findings to determine the characteristic findings of this condition.

Th17 cells contribute to viral replication in coxsackievirus B3-induced acute viral myocarditis.

Acute viral myocarditis (AVMC) is characterized by virus-triggered myocardial inflammation, and Coxsackievirus B3 (CVB3) is the primary pathogen. We previously proved that Th17 cells, besides having proinflammatory effects, were involved in AVMC by enhancing humoral response. However, the relationship between Th17 cells and CVB3 replication remains unknown. In this experiment, we infected BALB/c mice with CVB3 for establishing AVMC models and then found that, with the increase of viral replication, the expressions of splenic Th17 cells, serum IL-17, and cardiac IL-17 mRNA were elevated significantly, accompanied by the progressive cardiac injuries of AVMC. Furthermore, on day 5, the peak time for viral replication, correlation was positive between cardiac IL-17 mRNA and CVB3 RNA (correlation index = 0.835; p < 0.01). Although the expressions of Th1 and CD8(+) T cells, which could secrete the antiviral cytokine IFN-γ and damage the heart, were also elevated, along with Th17 cells, in AVMC, the neutralization of IL-17 further upregulated the percentages of splenic Th1 and CD8(+) T cells and the levels of cardiac IFN-γ mRNA. The cardiac pathological changes were obviously improved after neutralization, with reduced viral replication followed by decreases in the cardiac inflammatory cytokines IL-17, TNF-α, and IL-1ß. These data suggest that Th17 cells contribute to CVB3 replication in AVMC, and that IL-17 might be an important target for regulating the balance of antiviral immunities.

Th17 cells facilitate the humoral immune response in patients with acute viral myocarditis.

BACKGROUND: Recently, the Th17 cell, a newly determined CD4+Th subset, was reported to participate in the inflammation of myocarditis combined with Th1 cells, and this study aimed to explore whether it was involved in the Th2 cell-mediated humoral immunity in viral myocarditis. METHODS: A total of 34 patients, including 16 acute viral myocarditis (AVMC) and 18 dilated cardiomyopathy (DCM) having a history of AVMC, were enrolled for this study besides 18 healthy volunteers. RESULTS: The frequencies of Th17 and Th1 cells, especially Th17 cells in AVMC patients, while those of Th1 and Th2 cells, especially Th2 cells in DCM group, were all increased significantly compared with those in healthy volunteers (P < 0.01), with no changes of Th2 cells in AVMC and Th17 cells in DCM groups. The similar results were also observed in Th cell cytokines (IL-17, INF-gamma, and IL-4) and key transcript factors (RORgammat, T-bet, and GATA-3). Meanwhile, antiheart antibodies (AHA) of IgG type were found in 15 (93.8%) patients with AVMC and ten (55.6%) cases with DCM, accompanied by the higher expression of IL-17R on B cells and the frequencies of B cells than those in healthy controls (P < 0.01 in AVMC and P < 0.05 in DCM, respectively) who had no AHA. Furthermore, both of the B cell activities in AVMC and DCM groups were elevated and positively correlated to serum IL-17 (R = 0.66, P < 0.01) and IL-4 (R = 0.47, P < 0.05) respectively, with no correlation to INF-gamma. CONCLUSIONS: It was Th17 cells but not Th2 cells that helped the B cells to produce AHA in AVMC and not until at the late phase of viral myocarditis could Th2 cells play the important role in mediating humoral response.

Neutralization of IL-17 inhibits the production of anti-ANT autoantibodies in CVB3-induced acute viral myocarditis.

Anti-adenine nucleotide translocator (ANT) autoantibodies are related to the development of Coxsackievirus B3 (CVB3)-triggered acute viral myocarditis (AVMC). Recently, studies suggested that IL-17 especially produced by a novel CD4(+) Th-cell subset Th17 cells contributed to the production of pathogenic autoantibodies in some autoimmune diseases. However, the pathogenic role of IL-17 in AVMC remains largely unknown. In this study, we investigated whether IL-17 was associated with the disease progression and the production of anti-ANT autoantibodies in AVMC mouse model. The results showed that IL-17 monoclonal antibody (mAb)-treated AVMC mice had decreased HW/BW, reduced serum CK-MB activity and improved pathological score of heart sections along with the reduction of circulating IL-17 level and serum anti-ANT autoantibodies. The correlation index of serum IL-17 concentration and anti-ANT-autoantibody level was 0.874, p<0.01. In addition, the experimental results in vitro further proved that IL-17mAb could inhibit the proliferation of CD19(+) B lymphocytes and the secretion of anti-ANT autoantibodies. Our data suggested that IL-17 was related to the disease progression in AVMC mouse model by regulating the production of autoantibodies and blocking IL-17 might represent a promising novel therapeutic approach.