Multimodality Cardiovascular Imaging for Totally Video-Guided Thorascopic Cardiac Surgery.

Totally video-guided thorascopic cardiac surgery (TVTCS) represents one of the most minimally invasive access routes to the heart. Its feasibility and safety can be guaranteed by an experienced surgeon with skilled operative techniques under the guidance of a video signal via thoracoscopy and the imaging from transesophageal echocardiography. At present, this surgical approach has been applied for atrioventricular valve disease, atrial septum defects plus and partial anomalous pulmonary venous drainage, cardiac tumors, hypertrophic obstructive cardiomyopathy, aortic valve disease, and atrial fibrillation. Multimodality cardiovascular imaging, including echocardiography, X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and cardiac catheterization, provides morphologic characteristics and function status of the cardiovascular system and a comprehensive view of the target anatomy. In this review, the benefits of multimodality cardiovascular imaging are summarized for the clinical practice of TVTCS, including the preoperative preparation, intraoperative guidance and postoperative supervision. The disease categories are also individually reviewed on the basis of multimodality cardiovascular imaging, to ensure the feasibility and safety for TVTCS. Cardiovascular imaging technologies not only confirm who is a candidate for this surgical technique, but also provide technical support during the procedure and for postop follow to assess the clinical outcomes. Multimodality cardiovascular imaging is instrumental to provide the requirements to solve the problems for conduction of TVTCS; and to provide individualized protocols with high-resolution and real-time dynamic imaging fusion.

Assessment the Predictive Value of Left Atrial Strain (LAS) on Exercise Tolerance in HCM Patients with E/e' between 8 and 14 by Two-Dimensional Speckle Tracking and Treadmill Stress Echocardiography.

Background: The aim of this study was to evaluate the reservoir, conduit, and contraction function of the left atrium and to evaluate the predictive value of left atrial strain (LAS) on exercise tolerance in hypertrophic cardiomyopathy (HCM) patients with an E/e' between 8 and 14 by two-dimensional speckle tracking using treadmill stress echocardiography. Methods: This was a retrospective study in which we analyzed a total of 70 patients with HCM between 2016 and 2017. According to the resting state E/e', patients were either assigned to an HCM-1 group (E/e' > 14) or an HCM-2 group (E/e' of 8 to 14). Thirty age-matched healthy controls were included in the normal group. Analysis involved the left atrial reservoir, conduit, contraction strain and reserve function. Results: The normal group had a higher left atrial reservoir and conduit strain than the HCM-2 group; the lowest values were in the HCM-1 group. The LAS reserve capacity of the HCM-1 and HCM-2 groups was lower than those of the normal group. The left atrial contraction strain reserve ( Δ LASct%) and global longitudinal strain reserve ( Δ GLS%) were lower in the HCM-2 and HCM-1 groups than in the normal group. We also found that the Δ LASct% and Δ GLS% in the HCM-2 group were higher than in the HCM-1 group. Furthermore, the metabolic equivalents (METS) in the HCM-2 group was greater than that in the HCM-1 group. Finally, the Rest-LASr indicated the highest differential diagnostic performance for METS < 6.0 (area under curve [AUC]: 0.759); the AUC of the composite model Rest-LASr+E/e'-rest was 0.8. Conclusions: Analysis showed that when the E/e' was between 8 and 14, the LAS and reserve capacity of HCM patients were significantly reduced. Our findings suggest that the routine assessment of LAS +E/e' can be a strategy with which to supplement current predictive models and facilitate clinical management strategies.

Assessment of fetal intraventricular diastolic fluid dynamics using ultrasound vector flow mapping.

OBJECTIVE: The purpose of this study was to investigate the feasibility of visualizing and quantifying the normal pattern of vortex formation in the left ventricle (LV) and right ventricle (RV) of the fetal heart during diastole using vector flow mapping (VFM). METHODS: A total of 36 healthy fetuses in the second trimester (mean gestational age: 23 weeks, 2 days; range: 22-24 weeks) were enrolled in the study. Color Doppler signals were recorded in the four-chamber view to observe the phase of the diastolic vortices in the LV and RV. The vortex area and circulation were measured, and parameters such as intraventricular pressure difference (IVPD), intraventricular pressure gradient (IVPG), and average energy loss (EL_AVG) were evaluated at different diastolic phases, including isovolumic relaxation (D1), early diastole (D2), and late diastole (D3). RESULTS: Healthy second-trimester fetal vortex formations were observed in both the LV and RV at the end of diastole, with the vortices rotating in a clockwise direction towards the outflow tract. There were no significant differences in vortex area and circulation between the two ventricles (p > 0.05). However, significant differences were found in IVPD, IVPG, and EL_AVG among the diastolic phases (D1, D2, and D3) (p < 0.05). Trends in IVPD, IVPG, and EL_AVG during diastole (D1-D2-D3) revealed increasing IVPD and EL_AVG values, as well as decreasing IVPG values. Furthermore, during D3, the RV exhibited significantly higher IVPD, IVPG, and EL_AVG compared to the LV (p > 0.05). CONCLUSION: VFM is a valuable technique for analyzing the formation of vortices in the left and right ventricles during fetal diastole. The application of VFM technology has the potential to enhance the assessment of fetal cardiac parameters.

Impact of Hemodialysis on Left Ventricular-Arterial Coupling in End-Stage Renal Disease Patients.

INTRODUCTION: As a key determinant of cardiovascular performance, vascular-arterial coupling (VAC) has been reported to be a predictor of clinical outcomes in various clinical scenarios. However, few studies have explored how acute fluid removal during hemodialysis (HD) impacts the interaction between cardiac function and the arterial system. METHODS: We recruited 317 HD patients from an established renal dialysis unit for this cross-sectional study and a total of 285 were included in the final analyses. We measured left ventricle end-systolic elastance (Ees), the effective arterial elastance (Ea), and VAC before and after HD using noninvasive echocardiographic measurements. We also compared echocardiographic and hemodynamic parameters in ventriculo-arterial coupling and ventriculo-arterial uncoupling patients. RESULTS: HD significantly altered partial ventricular and vascular function parameters such as blood pressure, left ventricular end-diastolic volume, stroke volume, left ventricular ejection fraction, and systemic vascular resistance index. Ea increased following HD from 3.5 ± 1.4 to 4.2 ± 1.8 mm Hg/mL (p < 0.0001), Ees increased following HD from 7.9 ± 5.5 to 9.2 ± 6.9 mm Hg/mL (p = 0.04), whereas VAC did not markedly alter as a result of HD. Ventriculo-arterial uncoupling was found to be related to abnormal cardiac structure and worse systolic function. CONCLUSIONS: VAC obtained from echocardiography is likely to be load-independent and useful as a reliable index for stratifying the risk of cardiovascular diseases in HD patients. Further investigations on larger patient cohorts are needed to further validate our findings.

Assessment of left ventricular energy loss in patients with mild coronary artery stenosis by using vector flow mapping combined with exercise stress echocardiography.

OBJECTIVES: To evaluate the left ventricular energy loss (EL), energy loss reserve (EL-r), and energy loss reserve rate in patients with mild coronary artery stenosis by using vector flow mapping (VFM) combined with exercise stress echocardiography. METHODS: A total of 34 patients (case group) with mild coronary artery stenosis and 36 sex and age matched patients (control group) without coronary artery stenosis according to coronary angiogram were prospectively enrolled. The total energy loss (ELt), basal segment energy loss (ELb), middle segment energy loss (ELm), apical segment energy loss (ELa), energy loss reserve (EL-r), and energy loss reserve rate were recorded in the isovolumic systolic period (S1), rapid ejection period (S2), slow ejection period (S3), isovolumic diastolic period (D1), rapid filling period (D2), slow filling period (D3), and atrial contraction period (D4). RESULTS: Compared with the control group, some of the EL in the resting case group were higher; some of the EL in the case group were lower after exercise, and those during D1 ELb and D3 ELb were higher. Compared with the resting state, the total EL and the EL within the time segment in the control group were higher after exercise, except during D2 ELb. In the case group, except for during D1 ELt, ELb and D2 ELb, the total and segmental EL of each phase was mostly higher after exercise (p < .05). Compared with the control group, most of the EL-r and EL reserve rates in the case group were lower (p < .05). CONCLUSION: The EL, EL-r, and energy loss reserve rate have a certain value in the evaluation of cardiac function in patients with mild coronary artery stenosis.

Sex Differences in Left Ventricular Wall Stress in Apparently Healthy Adults with Similar Cuff-Measured Blood Pressure.

Outcome-based evidence shows that women have a higher risk of heart failure than men at a similar level of blood pressure. Left ventricular wall stress (Ó) or afterload is an important determinant of myocardial performance. Thus, it might play a key role in determining the sex differences in heart failure.The Ó at the beginning of aortic valve opening (Ó-AVO), the systolic peak value of the Ó (Ó-peak), and the Ó at the end systole (Ó-ES) were determined using transthoracic echocardiography combined with cuff-measured brachial blood pressure in 990 age- and heart rate- and cuff-measured blood pressure-matched apparently healthy adults (495 men). The sex differences in the aortic pressure, the ratio of left ventricular wall volume to cavity volume (VW/VC), and Ó were analyzed.Compared with men, women demonstrated higher aortic systolic blood pressure (106.7 versus 101.7 mmHg), smaller VW/VC (1.12 versus 1.25 for the end-diastole VW/VC, 3.49 versus 3.82 for the end-systole VW/VC), and greater Ó (340.0 versus 315.6 for Ó-AVO, 471.9 versus 412.5 for Ó-peak, and 256.2 versus 230.3 kdynes/cm2 for Ó-ES) (all P < 0.001).At the same level of cuff-measured blood pressure, women have a greater Ó or afterload than men in consequence of the sex differences in left ventricular geometry and pulse pressure amplification. The evidence indicates that non-sex-specific categories of blood pressure factitiously impose a relatively higher afterload on the left ventricle in women and may therefore increase potential risk of heart failure in women.

Management strategies and outcomes of acute coronary syndrome (ACS) during Covid-19 pandemic.

BACKGROUND: The COVID-19 outbreak represents a significant challenge to international health. Several studies have reported a substantial decrease in the number of patients attending emergency departments with acute coronary syndromes (ACS) and there has been a concomitant rise in early mortality or complications during the COVID-19 pandemic. A modified management system that emphasizes nearby treatment, safety, and protection, alongside a closer and more effective multiple discipline collaborative team was developed by our Chest Pain Center at an early stage of the pandemic. It was therefore necessary to evaluate whether the newly adopted management strategies improved the clinical outcomes of ACS patients in the early stages of the COVID-19 pandemic. METHODS: Patients admitted to our Chest Pain Center from January 25th to April 30th, 2020 based on electronic data in the hospitals ACS registry, were included in the COVID-19 group. Patients admitted during the same period (25 January to 30 April) in 2019 were included in the pre-COVID-19 group. The characteristics and clinical outcomes of the ACS patients in the COVID-19 period group were compared with those of the ACS patients in the pre-COVID-19 group. Multivariate logistic regression analyses were used to identify the risk factors associated with clinical outcomes. RESULTS: The number of patients presenting to the Chest Pain Center was reduced by 45% (p = 0.01) in the COVID-19 group, a total of 223 ACS patients were included in the analysis. There was a longer average delay from the onset of symptom to first medical contact (FMC) (1176.9 min vs. 625.2 min, p = 0.001) in the COVID-19 period group compared to the pre-COVID-19 group. Moreover, immediate percutaneous coronary intervention (PCI) (80.1% vs. 92.3%, p = 0.008) was performed less frequently on ACS patients in the COVID-19 group compared to the pre-COVID-19 group. However, more ACS patients received thrombolytic therapy (5.8% vs. 0.6%, p = 0.0052) in the COVID-19 group than observed in the pre-COVID-19 group. Interestingly, clinical outcome did not worsen in the COVID-19 group when cardiogenic shock, sustained ventricular tachycardia, ventricular fibrillation or use of mechanical circulatory support (MCS) were compared against the pre-COVID-19 group (13.5% vs. 11.6%, p = 0.55). Only age was independently associated with composite clinical outcomes (HR = 1.3; 95% CI 1.12-1.50, p = 0.003). CONCLUSION: This retrospective study showed that the adverse outcomes were not different during the COVID-19 pandemic compared to historical control data, suggesting that newly adopted management strategies might provide optimal care for ACS patients. Larger sample sizes and longer follow-up periods on this issue are needed in the future.

Antithrombotic therapy and the risk of new-onset dementia in elderly patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is associated with an increased risk of dementia. Little is known about the relationship of antithrombotic therapy and the risk of dementia in patients with AF without clinical stroke. METHOD: This was an observational study based on a hospital AF registry. Patients aged 65-85 years at the time of AF diagnosis were identified via the computerised database of the clinical management system. Patients with prior stroke or known cognitive dysfunction were excluded. The primary outcome was newly diagnosed dementia during the follow-up period. RESULTS: 3284 patients (mean age 76.4±5.3 years, 51.6% male) were included for analysis. The mean CHA2DS2-VASc score was 3.94±1.44. 18.5% patients were prescribed warfarin, 39.8% were prescribed aspirin and 41.7% were prescribed no antithrombotic therapy. After a mean follow-up of 3.6 years, 71 patients (2.2%) developed dementia, giving rise to an incidence of 0.61%/year. The incidence of dementia were 1.04%/year, 0.69%/year and 0.14%/year for patients on no therapy, aspirin and warfarin, respectively. Both univariate and multivariate analyses showed that age ≥75 years, female gender and high CHA2DS2-VASc score were associated with significantly higher risk of dementia; warfarin use was associated with significantly lower risk of dementia (HR: 0.14%, 95% CI 0.05 to 0.36, p<0.001). Patients on warfarin with time in therapeutic range (TTR) ≥65% had a non-significant trend towards a lower risk of dementia compared with those with TTR <65%. CONCLUSION: In elderly AF patients, warfarin therapy was associated with a significantly lower risk of new-onset dementia compared those with no therapy or aspirin.

Body volume is the major determinant of worsening renal function in acutely decompensated heart failure with reduced left ventricular ejection fraction.

AIMS: Little is known about the relative importance of body volume and haemodynamic parameters in the development of worsening of renal function in acutely decompensated heart failure (ADHF). To study the relationship between haemodynamic parameters, body water content and worsening of renal function in patients with heart failure with reduced ejection fraction (HFrEF) hospitalised for ADHF. METHODS AND RESULTS: This prospective observational study involved 51 consecutive patients with HFrEF (age: 73±14 years, male: 60%, left ventricular ejection fraction: 33.3%±9.9%) hospitalised for ADHF. Echocardiographic-determined haemodynamic parameters and body volume determined using a bioelectric impedance analyser were serially obtained. All patients received intravenous furosemide 160 mg/day for 3 days. There was a mean weight loss of 3.95±2.82 kg (p<0.01), and brain natriuretic peptide (BNP) reduced from 1380±901 pg/mL to 797±738 pg/mL (p<0.01). Nonetheless serum creatinine (SCr) increased from 134±46 µmol/L to 151±53 µmol/L (p<0.01), and 35% of patients developed worsening of renal function. The change in SCr was positively correlated with age (r=0.34, p=0.017); and negatively with the ratio of extracellular water to total body water, a parameter of body volume status (r=-0.58, p<0.001); E:E' ratio (r=-0.36, p=0.01); right ventricular systolic pressure (r=-0.40, p=0.009); and BNP (r=-0.40, p=0.004). Counterintuitively, no correlation was observed between SCr and cardiac output, or total peripheral vascular resistance. Regression analysis revealed that normal body volume and lower BNP independently predicted worsening of renal function. CONCLUSIONS: Normal body volume and lower serum BNP on admission were associated with worsening of renal function in patients with HFrEF hospitalised for ADHF.

The hepato-cardiac disorders in Tibetan residents with hepatic echinococcosis: A case-control echocardiography study.

BACKGROUND: Clinical guidelines indicate that chronic highland exposure could induce pulmonary hypertension; chronic hepatic disease may affect cardiac structure and functions. However, the simultaneous impact of hepatic echinococcosis (HE) and chronic highland exposure on cardiac structure and function in Tibetan residents are under-investigated. METHODS: One hundred and twenty patients with HE, 23 healthy high-altitude migrants with a mean residence time of 7.15 ± 1.12 years, and 46 healthy Tibetan permanent residents were enrolled in this study. All participants received comprehensive transthoracic echocardiography. RESULTS: High-altitude migrants have a relatively lower pulmonary artery flow velocity (PV) and a slightly higher pulmonary artery mean pressure (PAMP) than the Tibetan permanent residents. Patients with HE presented relatively smaller dimensions of the main pulmonary artery and branches and a bigger right atrium and right ventricular cavity size than the two control groups. PV, PAMP and numbers of detectable tricuspid regurgitation jet velocity (TRJV), right ventricular fractional area change (RV_FAC), tricuspid annular plane systolic excursion (TAPSE), the ratio of tricuspid inflow velocities at early diastole to tricuspid annular early diastolic excursion velocity (RV_E/e') and right ventricular myocardial performance index (RV_MPI) were increased in patients with HE compared to the two control groups. Similarly, decreased LVEF and Impaired left ventricular diastolic function were identified in patients with HE compared to the two control groups. CONCLUSIONS: Patients with HE presented with impaired biventricular contractile performance and diastolic dysfunction.