Functional assessment of bioprosthetic mitral valves by cardiovascular magnetic resonance: An in vitro validation and comparison to Doppler echocardiography.

BACKGROUND: A comprehensive non-invasive evaluation of bioprosthetic mitral valve (BMV) function can be challenging. We describe a novel method to assess BMV effective orifice area (EOA) based on phase contrast (PC) cardiovascular magnetic resonance (CMR) data. We compare the performance of this new method to Doppler and in vitro reference standards. METHODS: Four sizes of normal BMVs (27, 29, 31, 33 mm) and 4 stenotic BMVs (27 mm and 29 mm, with mild or severe leaflet obstruction) were evaluated using a CMR- compatible flow loop. BMVs were evaluated with PC-CMR and Doppler methods under flow conditions of; 70 mL, 90 mL and 110 mL/beat (n = 24). PC-EOA was calculated as PC-CMR flow volume divided by the PC- time velocity integral (TVI). RESULTS: PC-CMR measurements of the diastolic peak velocity and TVI correlated strongly with Doppler values (r = 0.99, P < 0.001 and r = 0.99, P < 0.001, respectively). Across all conditions tested, the Doppler and PC-CMR measurement of EOA (1.4 ± 0.5 vs 1.5 ± 0.7 cm2, respectively) correlated highly (r = 0.99, P < 0.001), with a minimum bias of 0.13 cm2, and narrow limits of agreement (- 0.2 to 0.5 cm2). CONCLUSION: We describe a novel method to assess BMV function based on PC measures of transvalvular flow volume and velocity integration. PC-CMR methods can be used to accurately measure EOA for both normal and stenotic BMV's and may provide an important new parameter of BMV function when Doppler methods are unobtainable or unreliable.

The mystery of "missing" visits in an emergency cardiology department, in the era of COVID-19.; a time-series analysis in a tertiary Greek General Hospital.

BACKGROUND: In the era of the current COVID-19 health crisis, the aim of the present study was to explore population behavior as regards the visits in the Εmergency Cardiology department (ECD) of a tertiary General Hospital that does not hospitalize SARS-CoV-2 infected patients METHODS AND RESULTS: Daily number of visits at the EDC and admissions to Cardiology Wards and Intensive Care Unit of a tertiary General Hospital, in Athens, Greece, were retrieved from hospital's database (January 1st-April 30th 2018, 2019 and 2020). A highly significant reduction in the visits at ECD of the hospital during March and April 2020 was observed as compared with January and February of the same year (p for linear trend < ·001); in particular the number of visits was 41.1% lower in March 2020 and 32.7% lower in April 2020, as compared to January 2020. As the number of confirmed COVID-19 cases throughout the country increased (i.e., from February 26th to April 2nd) the number of visits at ECD decreased (p = 0.01), whereas, the opposite was observed in the period afterwards (p = 0.01).The number of acute Myocardial infarctions (MI) cases in March 2020 was the lowest compared to the entire three year period (p < 0·001); however, the number of acute MI cases in April 2020 was doubled as compared to March 2020, but still was lower than the preceding years (p < 0·001). CONCLUSIONS: It is hard to explain the mystery of the "missing" emergency hospital visits. However, if this decline in cardiovascular disease related hospital visits is "true", it is something that needs to be rigorously studied, to learn how to keep these rates down.

Assessment of arterial baroreflex sensitivity by different computational analyses of pressure wave signals alone.

BACKGROUND AND OBJECTIVE: Baroreflex sensitivity (BRS) is an important indicator of the functionality of the arterial baroreceptors, and its assessment may have major research and clinical implications. An important requirement for its quantification is the continuous recording of electrocardiography (ECG) signal, so as to extract the RR interval, in parallel with continuous beat-to-beat blood pressure recording. We aimed to accurately calculate the RR Interval from pressure wave recordings per se, namely, the Pulse Interval (PI) using various arterial pulse wave analysis algorithms and to evaluate the precision and accuracy of BRS values calculated with the PI compared to BRS values calculated with the RR Interval. METHODS: We analyzed the open access data of the Eurobavar study, which contains a set of ECG and arterial blood pressure (BP) wave signals recorded at 11 European centers. Pressure waveforms were continuously recorded by the Finapres apparatus which uses a finger cuff. The cuff pressure around the finger is dynamically adjusted by a servo-system to equal intra-arterial pressure, thus allowing the continuous recording of beat-to-beat BP waves. RR Interval was calculated from the ECG, whereas, PI was extracted from the arterial pulse waveforms, using 4 different methods (minimum, maximum, maximum 1st derivative and intersecting tangents method). BRS values were estimated by time domain and frequency domain methods. In order to compare agreement, accuracy, precision, variability, and the association between the reference BRS using the RR Interval and the BRS values using PI, standard statistical methods (i.e. intraclass correlation coefficients, RMSE, regression analysis) and Bland-Altman methods were performed. RESULTS: We found that analysis of pressure waves alone by frequency-based (i.e. spectral) methods, provides the most accurate results of BRS estimation compared to time-domain methods (ICC > 0.9, R > 0.9, RMSE > 0.8 ms/mmHg). Concerning the spectral method, any algorithm for PI calculation is sufficient, as all show excellent agreement with the respective RR-intervals determined by ECG time series. Only the intersecting tangents and the maximum 1st derivative methods for PI calculation produce the most accurate results in time domain BRS estimation. CONCLUSION: BRS estimation by proper analysis of pressure wave signals alone is feasible and accurate. Further studies are needed to investigate the clinical validity and relevance of the different BRS estimations in diagnostic, prognostic and therapeutic levels.

The role of ventricular-arterial coupling in cardiac disease and heart failure: assessment, clinical implications and therapeutic interventions. A consensus document of the European Society of Cardiology Working Group on Aorta & Peripheral Vascular Diseases, European Association of Cardiovascular Imaging, and Heart Failure Association.

Ventricular-arterial coupling (VAC) plays a major role in the physiology of cardiac and aortic mechanics, as well as in the pathophysiology of cardiac disease. VAC assessment possesses independent diagnostic and prognostic value and may be used to refine riskstratification and monitor therapeutic interventions. Traditionally, VAC is assessed by the non-invasive measurement of the ratio of arterial (Ea) to ventricular end-systolic elastance (Ees). With disease progression, both Ea and Ees may become abnormal and the Ea/Ees ratio may approximate its normal values. Therefore, the measurement of each component of this ratio or of novel more sensitive markers of myocardial (e.g. global longitudinal strain) and arterial function (e.g. pulse wave velocity) may better characterize VAC. In valvular heart disease, systemic arterial compliance and valvulo-arterial impedance have an established diagnostic and prognostic value and may monitor the effects of valve replacement on vascular and cardiac function. Treatment guided to improve VAC through improvement of both or each one of its components may delay incidence of heart failure and possibly improve prognosis in heart failure. In this consensus document, we describe the pathophysiology, the methods of assessment as well as the clinical implications of VAC in cardiac diseases and heart failure. Finally, we focus on interventions that may improve VAC and thus modify prognosis.

Personalized Assessment of the Coronary Atherosclerotic Arteries by Intravascular Ultrasound Imaging: Hunting the Vulnerable Plaque.

The term "vulnerable plaque" is commonly used to refer to an atherosclerotic plaque that is prone to rupture and the formation of thrombosis, which can lead to several cardiovascular and cerebrovascular events. Coronary artery atherosclerosis has a wide variety of different phenotypes among patients who may have a substantially variable risk for plaque rupture and cardiovascular events. Mounting evidence has proposed three distinctive histopathological mechanisms: plaque rupture, plaque erosion and calcified nodules. Studies have demonstrated the characteristics of plaques with high vulnerability such as the presence of a thin fibrous cap, a necrotic lipid-rich core, abundant infiltrating macrophages and neovascularization. However, traditional coronary angiographic imaging fails to determine plaque vulnerability features, and its ability to individualize treatment strategies is limited. In recent decades, catheter-based intravascular ultrasound imaging (IVUS) modalities have been developed to identify vulnerable plaques and ultimately vulnerable patients. The aim is to individualize prediction, prevention and treatment of acute coronary events based on the identification of specific features of high-risk atherosclerotic plaques, and to identify the most appropriate interventional procedures for their treatment. In this context, the aim of this review is to discuss how personalized assessment of coronary atherosclerotic arteries can be achieved by intravascular ultrasound imaging focusing on vulnerable plaque detection.

Echocardiography for prediction of 6-month and late response to cardiac resynchronization therapy: implementation of stress echocardiography and comparative assessment along with widely used dyssynchrony indices.

Non-response cardiac resynchronization therapy (CRT) remains an issue, despite the refinement of selection criteria. The purpose of this study was to investigate the role of stress echocardiography along with dyssynchrony parameters for identification of CRT responders or late responders. 106 symptomatic heart failure patients were examined before, 6 months and 2-4 years after CRT implementation. Inotropic contractile reserve (ICR) and inferolateral (IL) wall viability were studied by stress echocardiography. Dyssynchrony was assessed by: (1) Septal to posterior wall motion delay (SPWMD) by m-mode. (2) Septal to lateral wall delay (SLD) by TDI. (3) Interventricular mechanical delay (IVMD) by pulsed wave Doppler for (4) difference in time to peak circumferential strain (TmaxCS) by speckle tracking. (5) Apical rocking (ApR) and septal flash (SF) by visual assessment. At 6 months there were 54 responders, with 12 additional late responders. TmaxCS had the greatest predictive value with an area under curve (AUC) of 0.835, followed by the presence of both ICR and viability of IL wall (AUC 0.799), m-mode (AUC = 0.775) and presence of either ApR or SF (AUC = 0.772). Predictive ability of ApR and of ICR is augmented if late responders are also included. Performance of dyssynchrony parameters is enhanced, in patients with both ICR and IL wall viability. Stress echocardiography and dyssynchrony parameters are simple and reliable predictors of 6-month and late CRT response. A stepwise approach with an initial assessment of ICR and viability and, if positive, further dyssynchrony analysis, could assist decision making.

Gender-specific, Lifestyle-related Factors and 10-year Cardiovascular Disease Risk; the ATTICA and GREECS Cohort Studies.

BACKGROUND: Lifestyle remains a huge driving force of Cardiovascular Diseases (CVD) onset/ progression. Lifestyle-patterns are highly dependent on gender-related attitudes. OBJECTIVE: To evaluate the gender-specific association of lifestyle-related factors (adherence to Mediterranean diet (MedDiet), Physical Activity (PA), smoking) with 10-year first and recurrent CVD events. METHODS: Two prospective studies, the ATTICA (2002-2012, n=3,042 subjects free-of-CVD) and GREECS (2004-2014, n=2,172 subjects with Acute Coronary Syndrome (ACS)) were undertaken. Baseline adherence to MedDiet (MedDietScore <27/≥27, range 0-55), PA (sedentary/physically active) and smoking (current/never) was tested against 10-year first (ATTICA) and recurrent (GREECS) CVD events, in men and women. RESULTS: The "superiority" of men over women regarding overall CVD events was revealed in both first (ATTICA, 19.7% men vs. 11.7% women, p<0.001) and recurrent CVD events, but less significantly (GREECS, 38.8% men vs. 32.9% women, p=0.016). Gender-stratified analysis revealed that: lower adherence to MedDiet in women (Odds Ratio (OR)=1.22, 95% Confidence Interval (95%CI) 1.03, 1.51) and PA (OR=1.35, 95%CI 1.01, 1.85) and smoking (OR=1.28, 95%CI 1.04, 1.82) in men, were independent predictors of 10-year first CVD event; whereas, adherence to MedDiet (OR=1.28, 95%CI 1.01, 1.59), PA (OR=1.25, 95%CI 1.01, 2.50) and smoking (OR=1.15, 95%CI 1.01, 1.30) in women, yet only adherence to MedDiet (OR=1.27, 95%CI 1.01, 1.35) and PA (OR=1.27, 95%CI 1.02, 1.59) in men, were independent predictors of 10-year CVD recurrent events. CONCLUSION: Differences between men and women, in the effect-size measures of lifestyle-related factors, underline different paths for men and women, probably contributing to better designing strategies for primary and secondary CVD prevention.

Exploring the association between low socioeconomic status and cardiovascular disease risk in healthy Greeks, in the years of financial crisis (2002-2012): The ATTICA study.

BACKGROUND: Despite recent declines in mortality, cardiovascular disease (CVD) remains the leading cause of death in Europe today. Given the fact that many of the biological risk factors have already been identified, researchers still search for different modifiable factors that may influence CVD risk, among which SES gathers a great part of interest. AIMS: To explore the effect of low socioeconomic status (SES) on a 10-year cardiovascular disease (CVD) incidence, in the years of financial crisis. METHODS: This population-based study was carried out in the province of Attica, where Athens is a major metropolis. During 2001-2002, information from 1528 men (18-87years old) and 1514 women (18-89years old) was collected. Educational level and annual income were used to define their SES. After a 10-year of follow-up period (2002-2012), CVD incidence was recorded. RESULTS: Low compared to high SES class, at the ages above 45years, was independently associated with increased 10-year CVD incidence [adjusted odds ratio and 95% confidence interval: 2.7 (1.5, 4.9)] but not among the younger participants. SES was also negatively associated with psychological components (all p-values<0.001), diabetes mellitus (p=0.002), obesity (p=0.087) and physical activity (p=0.056). CONCLUSION: There is evidence for a consistent reverse relation between SES and the incidence of CVD and for higher CVD risk factors among less privileged individuals. The striking differences by SES underscore the critical need to improve screening, early detection, and treatment of CVD-related conditions for people of lower SES, emphasizing in the middle-aged groups.

Cardiac echo-lab productivity in times of economic austerity.

The present study attempts to offer insight into the volume, cost, and productivity of the operation of a cardiac echocardiographic laboratory (echo-lab) in a major public hospital of Greece and thus to contribute, on a practical level, to the widening of knowledge in the strategic field of secondary and tertiary healthcare management. The conducted research includes the basic step of the deployment of a primary data registry in the echo-lab and unfolds in three levels, i.e. the variability measurement of the quantity and cost of medical services provided to different patient populations, the assessment of operating costs and the development of productivity indexes. The results show that the mean costs of provision do change among distinct patient populations. The most important, from a financial standpoint, population cluster appears to be the one corresponding to outpatients. Productivity indices presented in this analysis constitute an essential piece of information which the public healthcare system is currently largely lacking, and which, combined with the pricing and the diagnosis-related group coding system of hospitals, can be used to improve efficiency in the management of secondary and tertiary care.

Assessment of health-related quality of life in a greek symptomatic population with atrial fibrillation: correlation with functional status and echocardiographic indices.

INTRODUCTION: Atrial fibrillation (AF) is known to have an unfavorable impact on quality of life. The purpose of this study was to assess the health-related quality of life (HRQOL) in a symptomatic population with AF seeking medical advice in a tertiary hospital, as well as to explore the relationship between HRQOL, functional status, and echocardiographic indices of left ventricular (LV) systolic and diastolic function. METHODS: The study sample consisted of 108 symptomatic patients suffering from AF who presented in the emergency department or were admitted to the cardiology department in an urban Greek tertiary hospital between January 1 and May 31, 2012. HRQOL was assessed using the SF-36 and EQ-5D instruments. RESULTS: In the study sample, AF was newly diagnosed in 16.5% of the patients, paroxysmal/persistent in 43.6% and permanent in 39.9%. The mean levels of physical and mental summary components of the SF-36 were 40.28 and 40.89, respectively. The EQ-VAS mean score was 59.63%, while the EQ-5D Europe VAS index and the York A1 Tariff index were 0.586 and 0.547, respectively. Reliability analysis found Cronbach's to be 0.890 for the SF-36 and 0.701 for the EQ-5D. Convergent validity was proved to be at satisfactory levels. Impaired HRQOL was associated with worse NYHA class and echocardiographic indices of impaired LV systolic and diastolic function. Apart from higher NYHA class, other predisposing factors for lower HRQOL were female sex, advanced age, low physical activity, and higher levels of brain natriuretic peptide. CONCLUSIONS: Symptomatic AF patients report impaired HRQOL. Functional status and echocardiographic indices of LV systolic and diastolic function appear to affect HRQOL significantly in these patients. The SF-36 and the EQ-5D are shown to be reliable and valid instruments in assessing HRQOL in patients with AF.

A new method for assessment of plaque vulnerability based on vasa vasorum imaging, by using contrast-enhanced intravascular ultrasound and differential image analysis.

BACKGROUND: Increased neovascularization in vasa vasorum and atherosclerotic plaques has recently been identified as a common feature of inflammation and plaque vulnerability. Microbubble contrast agents, which have been used for intravascular imaging, can be used to trace neovascularization. The aim of the study was to detect and evaluate the density of vasa vasorum in non-culprit coronary atherosclerotic plaques of patients with acute coronary syndrome. METHODS: We have studied intravascular ultrasound (IVUS) signals before, during, and after intracoronary injection of microbubbles, proximal to non-culprit atherosclerotic plaques in 16 patients with acute coronary syndrome. Analyses were accomplished using a computational algorithm for the detection of contrast perfusion in such contrast-enhanced sequences. Perfusion density was evaluated by the mean enhancement in the region of interest provided by this difference-imaging technique. RESULTS: Qualitative and quantitative analysis of the pre- and post-injection images showed a significant enhancement in the grey-scale intensity of intima-media and adventitia after injection (intima-media: from 6.0+/-2.5 to 7.9+/-3.3%, p=0.006 and adventitia: from 7.1+/-2.2 to 7.6+/-2.5%, p=0.035). CONCLUSIONS: Contrast-enhanced intravascular imaging is a novel, yet clinically available, technique that has the potential to enhance IVUS-based characterization of atherosclerotic plaques. The technique introduces a new perspective to the detection of vulnerable plaques and warrants further investigations.