Surface Models of the Four Chambers in Young Adult Hearts with Average Volumes Measured by Artificial Intelligence Tools / Modelos de Superficie de las Cuatro Cámaras en Corazones de Adultos Jóvenes con Volúmenes Promedio Medidos Mediante Herramientas de Inteligencia Artificial

SUMMARY: The average volumes of normal heart chambers in computed tomography (CT) are used not only as clinical criterions for heart disease diagnosis, but also as references in cardiology. With the development of artificial intelligence (AI), numerous CT data can be analyzed and segmented automatically. This study aimed to determine the average volumes of the four chambers in healthy adult hearts and present surface models with the average volume. Coronary CT angiographs of 508 Korean individuals (330 men and 178 women, 20 - 39 years old) were obtained. An automatic segmentation module for 3D Slicer was developed using machine learning in Anatomage KoreaTM. Using the module, the four chambers and heart valves in the CT were segmented and reconstructed into surface models. Surface models of the four chambers of identical hearts in the CT were produced using SimplewareTM. The volumes of structures were measured using Sim4life Light and statistically analyzed. After determining the average volumes of the four chambers, surface models of the average volumes were constructed. In both software measurements, the atrial volumes of females increased with age, and the ventricular volumes of males decreased significantly with age. The atrial and ventricular volumes of Simpleware were larger and smaller than those of Anatomage, respectively, because of errors in the Simpleware. Regarding the volume measurement, our module developed in this study was more accurate than the Simpleware. The average volume and three-dimensional models used in this study can be used not only for clinical purposes, but also for educational or industrial purposes.

Los volúmenes medios de las cámaras cardíacas normales en la tomografía computarizada (TC) se utilizan no sólo como criterios clínicos para el diagnóstico de enfermedades cardíacas, sino también como referencia en cardiología. Con el desarrollo de la inteligencia artificial (IA), numerosos datos de TC se pueden analizar y segmentar automáticamente. Este estudio tuvo como objetivo determinar los volúmenes promedio de las cuatro cámaras en corazones adultos sanos y presentar modelos de superficie con el volumen promedio. Se obtuvieron angiografías coronarias por TC de 508 individuos coreanos (330 hombres y 178 mujeres, de 20 a 39 años). Se desarrolló un módulo de segmentación automática para 3D Slicer utilizando aprendizaje automático en Anatomage KoreaTM. Utilizando el módulo, las cuatro cámaras y valvas cardíacas de la TC se segmentaron y reconstruyeron en modelos de superficie. Se produjeron modelos de superficie de las cuatro cámaras de corazones idénticos en la TC utilizando SimplewareTM. Los volúmenes de las estructuras se midieron utilizando Sim4life Light y se analizaron estadísticamente. Después de determinar los volúmenes promedio de las cuatro cámaras, se construyeron modelos de superficie de los volúmenes promedio. En ambas mediciones de software, los volúmenes atriales de las mujeres aumentaron con la edad y los volúmenes ventriculares de los hombres disminuyeron significativamente con la edad. Los volúmenes atrial y ventricular de Simpleware eran mayores y menores que los de Anatomage, respectivamente, debido a errores en Simpleware. En cuanto a la medición de volumen, nuestro módulo desarrollado en este estudio fue más preciso que el Simpleware. Los modelos tridimensionales y de volumen medio utilizados en este estudio se pueden utilizar no solo con fines clínicos, sino también con fines educativos o industriales.

Impact of breath hold on regional nodal irradiation and heart volume in field in left breast cancer adjuvant irradiation.

PURPOSE: Compared to the free-breathing technique, adjuvant left breast irradiation after breast-conserving surgery or mastectomy using the breath-hold method significantly reduces the heart mean dose, Left anterior descending artery, and ipsilateral lung doses. Movement with deep inspiration may also reduce heart volume in the field and regional node doses. MATERIALS AND METHODS: Pre-radiotherapy planning CT was performed in the free-breathing, and breath-hold techniques using RPM, demographic information, clinicopathological data, heart volume in the field, heart mean dose, LAD mean dose, and regional nodal doses were calculated in both free breathing and DIBH. Fifty patients with left breast cancer receiving left breast adjuvant radiation were enrolled. RESULTS: There was no significant difference in axillary LN coverage between the two techniques, except for SCL maximum dose, Axilla I node maximum dose, and Axilla II minimum dose in favor of the breath hold technique. The mean age was 47.54 years, 78% had GII IDC, 66% had positive LVSI results, and 74% of patients had T2. The breath hold strategy resulted in considerably decreased mean heart dose (p = 0.000), LAD dose (p = 0.000), ipsilateral lung mean dose (p = 0.012), and heart volume if the field (p = 0.013). The mean cardiac dosage and the dose of the LAD were significantly correlated (p = 0.000, R = 0.673). Heart volume in the field and heart mean dosage was not significantly correlated (p = 0.285, r = - 0.108). CONCLUSION: When compared to free breathing scans, DIBH procedures result in considerably reduced dosage to the OAR and no appreciable changes in dose exposure to regional lymph node stations in patients with left-sided breast cancer.

Surgically Induced Cardiac Volume Overload by Aortic Regurgitation in Mouse.

Aortic regurgitation (AR) is a common valvular heart disease that exerts volume overload on the heart and represents a global public health problem. Although mice are widely applied to shed light on the mechanisms of cardiovascular disease, mouse models of AR, especially those induced by surgery, are still paucity. Here, a mouse model of AR was described in detail which is surgically induced by disruption of the aortic valves under high-resolution echocardiography. In accordance with regurgitated blood flow, AR mouse hearts present a distinctive and clinically relevant volume overload phenotype, which is characterized by eccentric hypertrophy and cardiac dysfunction, as evidenced by echocardiographic and invasive hemodynamic evaluation. Our proposal, in a reliable and reproducible manner, provides a practical guide on the establishment and assessment of a mouse model of AR for future studies on molecular mechanisms and therapeutic targets of volume overload cardiomyopathy.

Initial estimates of continuous positive airway pressure (CPAP) on heart volume, position and motion in patients receiving chest radiation.

To evaluate effects of Continuous Positive Airway Pressure (CPAP) on cardiac position, volume, and motion in a cohort of patients receiving thoracic radiation therapy (RT). Patients underwent 3-dimensional (3D) and 4D-computerized tomography (CT) imaging with free-breathing (FB) and CPAP for RT planning. All scans were co-registered on the treatment planning system for contouring, identification of the center of heart volume and comparative measurements of cardiac displacement, volume and motion. Heart volume (HV) was created from 3D-CT contours. Range of heart motion was estimated by creating an internal heart volume (IHV) from 4D-CT contours. Magnitude of cardiac motion (cardiac excursion) was recorded as the difference in volume between IHV and HV. Wilcoxon signed rank test and Spearmen's rank correlation coefficient were used to assess differences between variables and correlations between lung volume and heart parameters. Results from 9 patient data sets were available for this report. Compared to FB, CPAP use was associated with caudal displacement of the HV (1 cm, p < 0.008) and IHV (1.1 cm, p < 0.008). CPAP use decreased HV 6% (p < 0.008) and IHV 13% (p < 0.008). Cardiac excursion was 49% (p < 0.01) less with CPAP than with FB. CPAP use increased mean lung volume by 30% (p < 0.008) which correlated with caudal displacement of the HV (r = 0.83, p < 0.008) and IHV (r = 0.98, p < 0.001). The use of CPAP reduced cardiac motion and volume although the reduction in volume was minimal. The increase in lung volume correlated with caudal displacement of the heart. These results suggest the mechanism for achieving dosimetric benefit was obtained by cardiac displacement and decreased lung and heart motion rather than reduction of HV. Further evaluation of CPAP as a novel technique to reduce heart exposure when offering RT is warranted.

Small Cavity of Left Ventricle Does Not Affect Short-term Outcome in Patients with Rheumatic Mitral Valve Stenosis Undergoing Mitral Valve Replacement.

BACKGROUND: Small cavity left ventricle (SCLV) may affect the clinical outcomes of patients undergoing mitral valve replacement (MVR). This study aims to investigate the incidence of SCLV in patients with rheumatic mitral valve stenosis undergoing MVR and analyze its effect on short-term patient outcomes. METHODS: We retrospectively examined all consecutive patients with isolated or concomitant MVR for rheumatic mitral valve stenosis in our center from 2013 to 2018. SCLV was defined as end-diastolic volume index ≤ 50 ml/m2. After inclusion and exclusion, a total of 1,437 patients were analyzed. The baseline information was collected and compared between SCLV and non-SCLV patients. Multivariate logistic regression analysis was conducted to determine the effect of SCLV on early mortality. RESULTS: A total of 1,437 patients were included in the study. SCLV was detected in 13.57% of the patients. Compared with the non-SCLV group, patients with SCLV were smaller-sized and primarily female. There were no significant differences between SCLV and non-SCLV patients regarding major postoperative complications, nor were there incidence of prosthesis-patient mismatch. Logistic regression analysis showed that SCLV was not a risk factor for short-term mortality (P = 0.998). CONCLUSIONS: Our results demonstrated that SCLV was not associated with poorer early outcomes after MVR surgery in patients with rheumatic mitral valve stenosis.

Cardiac Computed Tomography-Derived Left Atrial Volume Index as a Predictor of Long-Term Success of Cryo-Ablation in Patients With Atrial Fibrillation.

Patients with symptomatic, drug-refractory atrial fibrillation (AF) are frequently treated with catheter ablation. Cryo-ablation has been established as an alternative to radiofrequency ablation but long-term outcome data are still limited. This study aimed at elucidating the influence of the left atrial volume index (LAVI), derived from cardiac computed tomography (cCT) data, on the long-term outcome of ablation-naïve AF patients, after their first cryo-ablation. 415 patients (n = 290 [69.90%] male, 60.00 [IQR: 53.00 to 68.00] years old) who underwent a cCT and subsequent cryo-ablation index procedure were included in this single centre retrospective data analysis. A composite end point was defined (AF on electrocardiogram and/or electric cardioversion and/or re-do). Patients were closely followed for a year and then contacted for long-term follow-up after a median of 53.00 months (IQR: 34.50 to 73.00). Statistical analyses of the outcome and predictors of AF recurrence were conducted. In 224 patients (53.98%) no evidence of AF recurrence could be found. LAVI differed significantly between the positive and adverse (AF recurrence) outcome group (49.96 vs 56.07 ml/m2, p < 0.001). Cox regression analyses revealed cCT LAVI (HR: 1.022, 95% CI: 1.013 to 1.031, p < 0.001), BMI (HR: 1.044, 95% CI: 1.005 to 1.084, p < 0.05) and the type of AF (HR: 1.838 for nonparoxysmal AF, 95% CI: 1.214 to 2.781, p < 0.01) to be effective predictors of AF recurrence. A prognostic cCT LAVI cut-off value of 51.99 ml/m2 was calculated and must be validated in future prospective studies. In conclusion, LAVI is an accurate, yet underutilized predictor of AF recurrence after pulmonary vein isolation with cryo-energy and scores for calculating AF recurrence or progression risks might underemphasize the importance of CT-derived LAVI as a predictive factor.

Heart dose linked with cardiac events and overall survival in lung cancer radiotherapy: A meta-analysis.

BACKGROUND: The aim of this study was to investigate the link between heart dose and overall survival, the link between heart dose and cardiac events and whether radiation-induced heart diseases were associated with overall survival in lung cancer radiotherapy. METHODS: We performed a literature search by using Pubmed, Embase, China National Knowledge Infrastructure (CNKI) databases. Pairs of reviewers independently screened literature according to the inclusion criteria, extracted data, assessed methodological quality, and publication bias. The primary end points included overall survival and cardiac events. I was calculated in a heterogeneity assessment. Publication bias was evaluated by using Begg funnel plot and Egger test. RESULTS: Ten studies including 1 randomized controlled trial, 3 post hoc analysis of prospective trials, and 6 cohort studies were identified. The meta-analysis showed that heart volume receiving ≥5 Gy (HV5) (hazard ratio [HR] = 1.01; 95% confidence interval [CI]: 1.00-1.01), heart volume receiving ≥30 Gy (HV30) (HR = 1.01; 95% CI: 1.00-1.02), heart volume receiving ≥50 Gy (HV50) (HR = 1.05; 95%CI: 1.00-1.10), and mean heart dose (MHD) (HR = 1.01; 95%CI:1.00-1.02) all were associated with worse overall survival. In addition, the MHD (HR = 1.03; 95% CI: 1.02-1.05), HV5 (HR = 1.02; 95% CI: 1.01-1.03), and HV30 (HR = 1.02; 95% CI: 1.01-1.03) were significantly associated with all grade cardiac events. Meanwhile, compared with those who did not receive radiotherapy, the radiotherapy group experienced a significantly increased risk for cardiac-specific mortality (HR = 1.297; 95% CI: 1.213-1.387). However, the results did not show that cardiac events were associated with overall survival in lung cancer radiotherapy (HR = 1.472; 95% CI: 0.988-2.193). CONCLUSION: Exposure of the heart to radiation increased the risk of cardiac events during radiotherapy for lung cancer. Meanwhile, heart dose including HV5 and HV30 were predictors of overall survival in lung cancer radiotherapy. It is necessary to constrain the heart dose when perform thoracic radiation therapy to decrease the incidence of cardiac events and improve the overall survival.

Continuous Heart Volume Monitoring by Fully Implantable Soft Strain Sensor.

Cardiothoracic open-heart surgery has revolutionized the treatment of cardiovascular disease, the leading cause of death worldwide. After the surgery, hemodynamic and volume management can be complicated, for example in case of vasoplegia after endocarditis. Timely treatment is crucial for outcomes. Currently, treatment decisions are made based on heart volume, which needs to be measured manually by the clinician each time using ultrasound. Alternatively, implantable sensors offer a real-time window into the dynamic function of our body. Here it is shown that a soft flexible sensor, made with biocompatible materials, implanted on the surface of the heart, can provide continuous information of the heart volume after surgery. The sensor works robustly for a period of two days on a tensile machine. The accuracy of measuring heart volume is improved compared to the clinical gold standard in vivo, with an error of 7.1 mL for the strain sensor versus impedance and 14.0 mL versus ultrasound. Implanting such a sensor would provide essential, continuous information on heart volume in the critical time following the surgery, allowing early identification of complications, facilitating treatment, and hence potentially improving patient outcome.

Fetal Cardiac Function and Ventricular Volumes Determined by Three-Dimensional Ultrasound Using STIC and VOCAL Methods in Fetuses from Pre-gestational Diabetic Women.

To assess the fetal cardiac function and ventricular volumes by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) methods in fetuses from pre-gestational diabetic women. This was a prospective and cross-sectional study that evaluated 53 fetuses from pre-gestational diabetic women and 53 fetuses from healthy mothers between 20 and 34 weeks of gestation. Only fetuses with no structural or genetic abnormalities and singleton pregnant women were included in this study. The fetal cardiac volumes were assessed by STIC and VOCAL methods. The ejection fraction, stroke volume, and cardiac output were calculated from these measurements to evaluate fetal cardiac function. The Mann-Whitney U test was performed to compare the two groups. For calculation of intra- and interobserver reproducibility's, we used concordance correlation coefficients. The mean differences in the right atrial volumes between the diabetic and normal groups ranged from 0.05 mL to 0.1 mL (p = 0.917 and 0.355, respectively). The median of left atrium (LA) volume measurement in pre-gestational diabetic group was significantly lower than healthy mothers (LA: 0.62 vs. 0.68 mL; p < 0.001). The fetal right and left ventricular volumes were similar in both groups. No significant differences in ejection fraction, stroke volume and cardiac output were observed (p value range 0.086-0.815). The majority of fetal atrial/ventricular volumes showed good intra- and interobserver reliabilities. Conversely, the majority cardiac function parameters showed poor intra- and interobserver agreements. STIC and VOCAL methods gave reproducible quantitative results for fetal atrial and ventricular volumes. Significant differences in fetal left atrial volumes were observed between the two groups, which be related to LA atrial dysfunction and /or left ventricle (LV) compliance, reflecting earlier stages of cardiac dysfunction.

Commercial 4-dimensional echocardiography for murine heart volumetric evaluation after myocardial infarction.

BACKGROUND: Traditional preclinical echocardiography (ECHO) modalities, including 1-dimensional motion-mode (M-Mode) and 2-dimensional long axis (2D-US), rely on geometric and temporal assumptions about the heart for volumetric measurements. Surgical animal models, such as the mouse coronary artery ligation (CAL) model of myocardial infarction, result in morphologic changes that do not fit these geometric assumptions. New ECHO technology, including 4-dimensional ultrasound (4D-US), improves on these traditional models. This paper aims to compare commercially available 4D-US to M-mode and 2D-US in a mouse model of CAL. METHODS: 37 mice underwent CAL surgery, of which 32 survived to a 4 week post-operative time point. ECHO was completed at baseline, 1 week, and 4 weeks after CAL. M-mode, 2D-US, and 4D-US were taken at each time point and evaluated by two separate echocardiographers. At 4 weeks, a subset (n = 12) of mice underwent cardiac magnetic resonance (CMR) imaging to serve as a reference standard. End systolic volume (ESV), end diastolic volume (EDV), and ejection fraction (EF) were compared among imaging modalities. Hearts were also collected for histologic evaluation of scar size (n = 16) and compared to ECHO-derived wall motion severity index (WMSI) and global longitudinal strain as well as gadolinium-enhanced CMR to compare scar assessment modalities. RESULTS: 4D-US provides close agreement of ESV (Bias: -2.55%, LOA: - 61.55 to 66.66) and EF (US Bias: 11.23%, LOA - 43.10 to 102.8) 4 weeks after CAL when compared to CMR, outperforming 2D-US and M-mode estimations. 4D-US has lower inter-user variability as measured by intraclass correlation (ICC) in the evaluation of EDV (0.91) and ESV (0.93) when compared to other modalities. 4D-US also allows for rapid assessment of WMSI, which correlates strongly with infarct size by histology (r = 0.77). CONCLUSION: 4D-US outperforms M-Mode and 2D-US for volumetric analysis 4 weeks after CAL and has higher inter-user reliability. 4D-US allows for rapid calculation of WMSI, which correlates well with histologic scar size.

Standard echocardiography versus very-low mechanical index contrast-imaging: left ventricle volumes and ejection fraction multi-reader variability and reference values in a subgroup with no risk factors or cardiac disease.

We retrospectively assessed the rest-phase images of 300 contrast stress- echocardiograms, during which very-low mechanical index (VLMI) imaging with ultrasound enhancing agents (UEAs) was routinely acquired in addition to greyscale echocardiography; intra- and inter-reader variability for left ventricle (LV) volumes and ejection fraction (LVEF) at rest was established in the overall cohort and normal values were calculated in the subset of subjects with no cardiac risk factors or cardiac disease and a normal stress-echocardiogram. Current recommendations for chamber quantification using echocardiography advise the use of UEAs in case of insufficient quality of endocardial visualization, but normal values for LV volumes and LVEF using UEAs have never been published using currently recommended VLMI method. Single-centre retrospective study, enrolling subjects referred to contrast stress- echocardiography for suspect coronary artery disease, including the acquisition of both standard 2D greyscale and bolus UEAs with VLMI, regardless of the image quality. This enables offline measurement of the LV volumes and LVEF for both greyscale and UEAs-VLMI images at rest in all subjects. Images were allocated to 3 readers in random order. Normal range for LV volumes and LVEF was also derived in a subset of apparently healthy subjects. In the 298 exams finally assessed, measurement variability among the three readers was lower with UEAs-VLMI, in particular for end-systolic volumes (intra-class correlation coefficient for concordance improved from 0.855 to 0.916, for LVEF from 0.68 to 0.783, p < 0.01), intra- observer variability reduced (Lin's correlation coefficient for LVEF from 0.747 to 0.857, p < 0.01). Normal mean indexed LV end-diastolic volume with UEAs-VLMI, compared to greyscale imaging, was + 14 ml/m2, while LVEF was + 5 to + 6% points. This is the largest study specifically addressing UEAs-VLMI imaging and comparing data with standard greyscale imaging; it demonstrates a reduction in measurement variability of LV volumes and LVEF. Normal reference values for VLMI ultrasound are reported for the first time in comparison with greyscale values.

Clinical significance of right atrial volume in patients with repaired tetralogy of Fallot.

OBJECTIVES: Atrial arrhythmia and right ventricular (RV) diastolic dysfunction are associated with increased morbidity and mortality in patients with repaired tetralogy of Fallot (TOF). This study was performed to determine whether the preoperative right atrial (RA) volume can predict the development of atrial arrhythmia after pulmonary valve replacement (PVR) in patients with TOF. METHODS: Forty-seven consecutive adult patients with repaired TOF underwent PVR from 2003 to 2018. Seventeen patients showed preoperative atrial arrhythmia and underwent the Maze procedure concomitantly. The preoperative RA volume was evaluated with computed tomography and image analysis software. RESULTS: The median follow-up period after PVR was 6.8 years. Among 17 patients who underwent the Maze procedure, recurrent atrial arrhythmia developed in 8 patients. Among 30 patients without preoperative atrial arrhythmia, novel atrial arrhythmia developed in 2 patients. The RA volume index was a significant predictor according to the multivariate analysis (P = 0.003). The RA volume index showed a significant positive correlation with the RV end-diastolic pressure (P < 0.001). CONCLUSIONS: The RA volume predicts the development of atrial arrhythmia after PVR in patients with repaired TOF. RA volume measurement is strongly recommended in the management of this patient population.

Reproducibility of LVEF, LV volumes, and LV mass between Rubidium-82 PET/CT scans in young healthy volunteers using two commercially available software packages.

BACKGROUND: Global functional parameters are available from electrocardiographic gated Rubidium-82 positron emission tomography/computed tomography (82Rb-PET/CT). However, the reproducibility of these data is not clarified. We aimed to investigate reproducibility of left ventricular ejection fraction (LVEF), endsystolic volume (ESV), enddiastolic volume (EDV), and left ventricular (LV) mass between two scans and between two commercially available software packages. METHODS AND RESULTS: Forty healthy young volunteers underwent two 82Rb-PET/CT rest and adenosine stress scans obtaining global functional parameters. Corridor4DM (4DM) and Quantitative Gated SPECT (QGS) were used for analyses. Mean (± SD) age was 24 ± 4 years and 50% were men. High reproducibility of all parameters was found between scans and this was true for both software packages. LVEF at rest with 4DM: mean difference (95% CI) - 1.1 (- 3.0 to 0.8), P = .25, limits of agreement: - 12.8 to 10.6. Significant differences were found between software packages on all functional parameters (P < .0001). CONCLUSION: High reproducibility was found between scans when measuring LVEF, ESV, EDV, and LV mass from 82Rb-PET/CT. However, concordance between parameter measures was poor when comparing the two software packages. Thus, global functional parameter measures are reliable, but the same software package should be used within a study and when comparing absolute values.

Exercise Rehabilitation Improves Cardiac Volumes and Functional Capacity in Patients With Endomyocardial Fibrosis: A RANDOMIZED CONTROLLED TRIAL.

PURPOSE: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy associated with low functional capacity and high mortality rates. Exercise training has been proved to be a nonpharmacological treatment of cardiovascular diseases. Therefore, the purpose of this study was to determine the effects of exercise rehabilitation in EMF patients. METHODS: Twenty-two EMF patients, functional classes II and III (New York Heart Association [NYHA]), were randomized to the control (C-EMF) or exercise rehabilitation (Rehab-EMF) group. Patients in the Rehab-EMF group underwent 4 mo of exercise rehabilitation, whereas patients in the C-EMF group were instructed to maintain their usual daily routine. Peak oxygen uptake ((Equation is included in full-text article.)O2), cardiac function, and quality of life were evaluated. All assessments were performed at baseline and after 4 mo. RESULTS: After 4 mo of rehabilitation, peak (Equation is included in full-text article.)O2 increased in the Rehab-EMF group (17.4 ± 3.0 to 19.7 ± 4.4 mL/kg/min, P < .001), whereas the C-EMF group showed no difference (15.3 ± 3.0 to 15.0 ± 2.0 mL/kg/min, P = .87). Also, post-intervention, peak (Equation is included in full-text article.)O2 in the Rehab-EMF group was greater than that in the C-EMF group (P < .001). Furthermore, the Rehab-EMF group, when compared to the C-EMF group, showed an increase in left ventricular end-diastolic volume (102.1 ± 64.6 to 136.2 ± 75.8 mL vs 114.4 ± 55.0 to 100.4 ± 49.9 mL, P < .001, respectively) and decrease in left atrial diastolic volume (69.0 ± 33.0 to 34.9 ± 15.0 mL vs 44.6 ± 21.0 to 45.6 ± 23.0 mL, P < .001, respectively). Quality-of-life scores also improved in the Rehab-EMF group, whereas the C-EMF group showed no change (45 ± 23 to 27 ± 15 vs 47 ± 15 to 45 ± 17, P < .001, respectively). CONCLUSION: Exercise rehabilitation is a nonpharmacological intervention that improves functional capacity, cardiac volumes, and quality of life in EMF patients after endocardial resection surgery. In addition, exercise rehabilitation should be prescribed to EMF patients to improve their clinical condition.

Relationship of Aortic Stiffness to Exercise and Ventricular Volumes in Single Ventricles.

BACKGROUND: Patients with single ventricle (SV) may often undergo aortic reconstruction that creates a stiff large vessel, increasing afterload and affecting exercise performance. The objective of this study was to determine the relationship of pulse wave velocity (PWV) and distensibility in reconstructed and normal aortic arches after Fontan with exercise variables. METHODS: PWV and distensibility of the descending aorta at the level of the diaphragm (DAo) were calculated with real-time exercise cardiac magnetic resonance in 48 patients with SV after Fontan (18 after aortic reconstruction; 30 without aortic reconstruction) and compared with metabolic exercise stress test variables. RESULTS: PWV was greater in the reconstructed group than in the non-reconstructed group (median 4.4 m/s [range: 2.3 to 9.8 m/s] versus 3.6 [range: 2.6 to 6.3 m/s], respectively, p = 0.003). Statistically significant inverse correlations were found between PWV and end-diastolic, end-systolic, and stroke volumes at rest and at exercise in the reconstructed group. In addition, inverse correlations also existed in the reconstructed group between distensibility of the DAo and the exercise variables such as peak oxygen pulse (R = 0.56, p = 0.02), peak oxygen consumption (R = 0.63, p = 0.008), oxygen consumption at ventilatory anaerobic threshold (R = 0.48, p = 0.04), and peak work (R = 0.54, p = 0.02). Similar correlations were not seen in patients with non-reconstructed aortas. CONCLUSIONS: Patients with SV with reconstructed aortas have increased aortic stiffness, increasing afterload on the ventricle. Native DAo stiffness distal to the reconstruction is inversely correlated with exercise performance, presumably to decrease impedance mismatch to maintain homogeneity of the aortic wall. This information suggests a possible mechanism for decreased exercise performance in patients with SV with aortic reconstructions.

Tricuspid annular diameter and right ventricular volume on preoperative cardiac CT can predict postoperative right ventricular dysfunction in patients who undergo tricuspid valve surgery.

BACKGROUND: We investigated the predictive value of preoperative computed tomography (CT)-derived tricuspid annular and right ventricular (RV) parameters for postoperative RV dysfunction in patients undergoing tricuspid valve (TV) surgery. METHODS: We retrospectively reviewed clinical, transthoracic echocardiography (TTE), and CT data of 100 consecutive patients who underwent cardiac CT and subsequently received TV surgery. Preoperative cardiac CT and TTE parameters were analyzed, including TV annulus diameter and RV size. Univariate and multivariate logistic regression analyses were performed to identify significant predictors for postoperative RV dysfunction, both in the entire study population and in the subgroup of patients without preoperative RV dysfunction. RESULTS: Postoperative RV dysfunction occurred in 46% of all patients. In the multivariate logistic regression analysis, longer TV annulus diameter (>29.3 mm/m2 on four-chamber view; (odds ratio [OR] 3.56, 95% confidence interval [CI] 1.13-11.24), larger RV volume (RV end-diastolic volume/body surface area > 128.8 ml/m2) on CT (OR 3.85, 95% CI 1.24-11.98) and presence of preoperative RV dysfunction on TTE (OR 11.96, 95% CI 2.8-50.99) were independent predictors for postoperative RV dysfunction in the entire study population (P < 0.05). Among patients without preoperative RV dysfunction, longer TV annulus diameter (OR 4.02, 95% CI 1.20-13.41) and larger RV volume on CT (OR 6.09, 95% CI 1.87-19.80) were independent predictors for postoperative RV dysfunction (P < 0.05). CONCLUSIONS: Preoperative assessment of cardiac CT imaging-based TV annular diameter and RV volume can provide independent information for predicting postoperative RV dysfunction in patients undergoing TV surgery.

Regional Right Ventricular Volume and Function Analysis Using Intraoperative 3-Dimensional Echocardiography-Derived Mesh Models.

OBJECTIVES: In daily echocardiographic practice, the right ventricle (RV) is assessed using mostly 2-dimensional (2D) echocardiography. Parameters measuring longitudinal shortening (eg, tricuspid annular plane systolic excursion) or changes in areas (eg, fractional area change) are used as surrogates for right ventricular function. Three-dimensional (3D) echocardiography-based techniques allow for cardiac magnetic resonance imaging-validated assessment of the RV. Depiction of regional right ventricular function is of increasing clinical interest. This study aimed to calculate regional volumetric changes in the right ventricular inlet, apical section, and outflow tract. Correlations between traditional parameters and regional right ventricular function were studied. DESIGN: Retrospective cohort study on patients scheduled for cardiac surgery. SETTING: Tertiary care university hospital. PARTICIPANTS: The study comprised 80 patients scheduled for cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Based on 3D echocardiographic datasets, mesh models of the RV were generated on a vendor-independent platform. The meshes were further cut into the following 3 regions: the inlet part, the apical section, and the outflow tract. The regional volumes and ejection fractions were compared with the global right ventricular and left ventricular functions. Regional volumes were correlated linearly with the global end-diastolic volume. The right ventricular outflow tract demonstrated a significantly lower ejection fraction than the inlet part (34% ± 11% v 28% ± 11%; p = 0.0054). The function in the right ventricular outflow tract was reduced significantly compared with the global right ventricular function in patients with severely reduced left ventricular ejection fraction (<20%). CONCLUSION: The different parts of the RV seem to have different ejection fractions. Different regions of the RV are affected differently by reduced left ventricular ejection fraction. Regional right ventricular analyses could help clinicians better understand pathologic states of the RV.

Assessment of Left Ventricular Reverse Remodeling by Cardiac MRI in Patients Undergoing Repair Surgery for Severe Aortic or Mitral Regurgitation.

OBJECTIVE: To evaluate left ventricular (LV) reverse remodeling after repair surgery for mitral regurgitation (MR) or aortic regurgitation (AR), aiming at determining optimal preoperative thresholds for normalization of LV volumes and function after surgery. DESIGN: Observational prospective cohort study. SETTING: Single-center, academic, tertiary care cardiovascular center. PARTICIPANTS: Patients and volunteers. INTERVENTIONS: Cardiac magnetic resonance with measurement of indexed LV end-diastolic volume (LVEDVi) and end-systolic volume (LVESVi), mass (LVmassi), and ejection fraction (LVEF) was performed preoperatively and postoperatively. MEASUREMENTS AND MAIN RESULTS: The authors included 29 patients with AR and 59 patients with MR (46 ± 12 and 56 ± 12 years, follow-up 222 ± 57 days). Both AR and MR repair resulted in a significant reduction of LV volumes and mass (respectively, delta change in LVEDVi -55 mL/m² and -43 mL/m²; in LVESVi -26 mL/m² and -10 mL/m²; and in LVmassi -24 g/m² and -12 g/m²; p < 0.001 for all). Yet despite the absence of perioperative necrosis, 7 (24%) patients with AR had persistent LV dilatation (LVEDVi >106 mL/m²) relative to controls and 16 (27%) patients with MR developed systolic LV dysfunction (LVEF <50%) postoperatively. Binary logistic regression analysis indicated preoperative LV volumes as the most accurate parameter for predicting both incomplete LV reverse remodeling in AR and LV dysfunction in MR. Receiver operating characteristic-determined thresholds were LVEDVi >155 mL/m² for AR and >129 mL/m² for MR. CONCLUSION: Although both AR and MR repair allow significant reverse postoperative LV remodeling, persistent LV dilatation after AR correction and systolic LV dysfunction after MR repair are common and best predicted by increased preoperative LV volumes. This highlights the importance of considering LV volumes in the decision-making process.

The role of irradiated heart and left ventricular volumes in heart failure occurrence after childhood cancer.

BACKGROUND: Paediatric cancer survivors have a high risk of developing cardiac diseases, and the most frequent cardiac disease is heart failure (HF). The radiation dose-volume effects in the heart and cardiac substructures have not been explored in childhood cancer survivors (CCS). Therefore, the role of irradiated heart volume in the occurrence of HF among this population remains unclear. The aims of this study were to determine the doses and irradiated volumes of the heart and left ventricle (LV) related to the risk of HF in CCS and to investigate the impact of anthracycline exposure on this risk. METHODS AND RESULTS: A case-control study nested in the French Childhood Cancer Survivors Study cohort. The mean heart and left ventricular doses and volumes indicators were estimated by reconstruction of individual treatments. A total of 239 HF cases and 1042 matched controls were included. The median age of HF diagnosis was 25.1 years. The median volume of the heart that received ≥ 30 Gy was 61.1% for cases and 16.9% for controls. In patients who did not receive anthracycline, the risk of HF was increased 3.6-fold when less than 10% of the LV received ≥ 30 Gy when compared to patients who were not exposed to any cardiac radiation and anthracycline. CONCLUSIONS: Small irradiated volumes of the heart or LV were significantly associated with HF risk. To the author's knowledge, this is the first study to report a dose-response relationship based on dose-volume indicators in CCS, which can be translated efficiently into current clinical practice.

Intraoperative 3-Dimensional Echocardiography-Derived Right Ventricular Volumetric Analysis in Chronic Thromboembolic Pulmonary Hypertension Patients Before and After Pulmonary Thromboendarterectomy.

OBJECTIVES: To assess the change in 3-dimensional (3D) echocardiography-derived right ventricular volumes before and after pulmonary thromboendarterectomy (PTE) and to evaluate the correlation of these variables with right heart catheterization-calculated pulmonary vascular resistance (PVR). SETTING: Single university hospitals. PARTICIPANTS: Patients undergoing elective PTE surgery between November 2016 and February 2018. METHODS: All patients received a pulmonary artery catheter and arterial line, and transesophageal echocardiographic monitoring was performed. Transesophageal echocardiographic monitoring before surgery (pre-PTE) and postsurgery (post-PTE) included comprehensive 2D examinations and 3D right ventricular data set acquisition for offline volumetric analysis. Right ventricular fractional area of change (RVFAC) was measured from a right ventricular-focused midesophageal 4-chamber view. TomTec-Arena 4D RV-Function 2.0 offline software (TomTec Imaging Systems GmbH, Unterschlessheim, Germany) was used to measure right ventricular end diastolic volume (RVEDV), right ventricular end systolic volume (RVESV), and right ventricular ejection fraction (RVEF). Paired t tests were used to evaluate for differences before and after surgery, and echocardiographic variables versus PVR were analyzed with linear regression. RESULTS: Forty patients were scheduled for elective PTE surgery; 35 patients had complete hemodynamic profiles and echocardiographic data sets and were included in the evaluation. Mean pulmonary artery pressure decreased from 40 ± 11 to 28 ± 7 mmHg, and PVR decreased from 708 ± 432 to 285 ± 136 dynes*s/cm5 after PTE. RVEDV decreased from 106 ± 43 to 79 ± 35 cm3 (p < 0.001), and RVESV decreased from 77 ± 36 to 59 ± 31 cm3 (p < 0.001). A statistically significant change was not identified in RVEF or RVFAC post-PTE compared with pre-PTE values. All volumetric analyses and RVFAC correlated poorly with PVR (pre-PTE RVEDV correlation to PVR [R2 = 0.004]; post-PTE RVEDV correlation to PVR [R2 = 0.024]). CONCLUSION: Even though RVEDV and RVESV displayed a statistically significant change after PTE, this study did not identify a correlation between those variables and PVR. In addition, markers of right ventricular systolic function (eg, RVFAC and RVEF) did not correlate with PVR. Therefore, the authors conclude that even though these echocardiographic measurements quantified a statistically significant change after PVR reduction, they cannot be reliably used as a surrogate marker of success immediately after PTE.