4Dflow-VP-Net: A deep convolutional neural network for noninvasive estimation of relative pressures in stenotic flows from 4D flow MRI.

PURPOSE: To estimate relative transvalvular pressure gradient (TVPG) noninvasively from 4D flow MRI. METHODS: A novel deep learning-based approach is proposed to estimate pressure gradient across stenosis from four-dimensional flow MRI (4D flow MRI) velocities. A deep neural network 4D flow Velocity-to-Presure Network (4Dflow-VP-Net) was trained to learn the spatiotemporal relationship between velocities and pressure in stenotic vessels. Training data were simulated by computational fluid dynamics (CFD) for different pulsatile flow conditions under an aortic flow waveform. The network was tested to predict pressure from CFD-simulated velocity data, in vitro 4D flow MRI data, and in vivo 4D flow MRI data of patients with both moderate and severe aortic stenosis. TVPG derived from 4Dflow-VP-Net was compared to catheter-based pressure measurements for available flow rates, in vitro and Doppler echocardiography-based pressure measurement, in vivo. RESULTS: Relative pressures calculated by 4Dflow-VP-Net and in vitro pressure catheterization revealed strong correlation (r2 = 0.91). Correlations analysis of TVPG from reference CFD and 4Dflow-VP-Net for 450 simulated flow conditions showed strong correlation (r2 = 0.99). TVPG from in vitro MRI had a correlation coefficient of r2 = 0.98 with reference CFD. 4Dflow-VP-Net, applied to 4D flow MRI in 16 patients, showed comparable TVPG measurement with Doppler echocardiography (r2 = 0.85). Bland-Altman analysis of TVPG measurements showed mean bias and limits of agreement of -0.20 ± 2.07 mmHg and 0.19 ± 0.45 mmHg for CFD-simulated velocities and in vitro 4D flow velocities. In patients, overestimation of Doppler echocardiography relative to TVPG from 4Dflow-VP-Net (10.99 ± 6.77 mmHg) was observed. CONCLUSION: The proposed approach can predict relative pressure in both in vitro and in vivo 4D flow MRI of aortic stenotic patients with high fidelity.

The overestimation of concentric hypertrophy in patients with HFpEF as determined by 2D-echocardiography.

Background: Heart failure with preserved ejection fraction continues to pose multiple challenges in terms of accurate diagnosis, treatment, and associated morbidity. Accurate left ventricular (LV) mass calculation yields essential prognostic information relating to structural heart disease. Two-dimensional (2D) echocardiography-based calculations are solely limited to LV geometric assumptions of symmetry, whereas three-dimensional (3D) echocardiography could overcome these limitations. This study aims to compare the performance of 2D and 3D LV mass calculations. Methods: A prospective review of echocardiography findings at the University of Louisville, Kentucky, was conducted and assessed. Normal ejection fraction (EF) was defined as >=52% in males and >=54% in females. The following calculations were performed: relative wall thickness (RWT) = 2x posterior wall thickness/LV internal diastolic dimension (LVIDd) and 2D LV mass = 0.8{1.04([LVIDd + IVSd +PWd]3 - LVIDd3)} + 0.6. Concentric hypertrophy was RWT >0.42 and LV mass >95 kg/m2 in females or >115 kg/m2 in males. The same cut-offs were used for 2D and 3D echocardiography. Results: Echocardiographic findings for a total number of 154 patients in the study were investigated. There was a weak positive correlation between 2D and 3D LV mass indices (R = 0.534, r2 = 0.286, p = 0.001). Seventy patients had 3D EF >=45% with clinical heart failure (HFpEF). Among HFpEF patients, LV hypertrophy (LVH) was present in 74% of patients by 2D echocardiography and 30% by 3D echocardiography (McNemar test p = 0.001). Using 3D echocardiography as the reference, 68% of normal patients were misdiagnosed with LV hypertrophy by 2D echocardiography. Two-thirds of the patients with concentric remodeling by 3D echocardiography were misclassified as having concentric hypertrophy by 2D echocardiography (p = 0.001). Conclusion: Adapting necropsy-proven LV mass index cutoffs, 2D over-diagnosed LV hypertrophy through overestimation of the mass, compared to 3D echocardiography. In turn, the majority of HFpEF patients showed no structural hypertrophy of the LV on 3D imaging. This suggests that the majority of patients with HFpEF may qualify for pharmacological prevention to prevent further progression to LV remodeling or LVH.

FlowRAU-Net: Accelerated 4D Flow MRI of Aortic Valvular Flows With a Deep 2D Residual Attention Network.

In this work, we propose a novel deep learning reconstruction framework for rapid and accurate reconstruction of 4D flow MRI data. Reconstruction is performed on a slice-by-slice basis by reducing artifacts in zero-filled reconstructed complex images obtained from undersampled k-space. A deep residual attention network FlowRAU-Net is proposed, trained separately for each encoding direction with 2D complex image slices extracted from complex 4D images at each temporal frame and slice position. The network was trained and tested on 4D flow MRI data of aortic valvular flow in 18 human subjects. Performance of the reconstructions was measured in terms of image quality, 3-D velocity vector accuracy, and accuracy in hemodynamic parameters. Reconstruction performance was measured for three different k-space undersamplings and compared with one state of the art compressed sensing reconstruction method and three deep learning-based reconstruction methods. The proposed method outperforms state of the art methods in all performance measures for all three different k-space undersamplings. Hemodynamic parameters such as blood flow rate and peak velocity from the proposed technique show good agreement with reference flow parameters. Visualization of the reconstructed image and velocity magnitude also shows excellent agreement with the fully sampled reference dataset. Moreover, the proposed method is computationally fast. Total 4D flow data (including all slices in space and time) for a subject can be reconstructed in 69 seconds on a single GPU. Although the proposed method has been applied to 4D flow MRI of aortic valvular flows, given a sufficient number of training samples, it should be applicable to other arterial flows.

Calculation of Mitral Valve Area by Continuity Equation Using Velocity-Time Integral From Mitral Valve Orifices After Mitral Clip.

BACKGROUND: This study investigates the hemodynamics of a dual-orifice mitral valve after mitral valve clip closure (MVCC) in patients with functional and nonfunctional mitral regurgitation (MR). If inflow velocity-time integral (VTi) of both orifices is equal, then the standard continuity equation can be applied to calculate the total mitral valve area (MVA). METHODS AND RESULTS: Adults undergoing MVCC placement were prospectively enrolled. With transesophageal echocardiography (TEE), the vena contracta (VC) of the medial and lateral mitral valve (MV) orifices were determined using color-flow Doppler and dual MV orifice areas were calculated. Valve orifices were classified as large vs small based on VC diameters. Continuous-wave Doppler measurements from both orifices were obtained. Forty-nine patients with severe MR (functional, n = 18) were enrolled. The VTi, mean gradient, peak gradient, and mean velocity of the larger vs smaller orifice were not significantly different, irrespective of MR etiology (P=nonsignificant). There was no difference in these parameters between large and small orifice regardless of MR mechanism (P=nonsignificant). There were no differences in the means of MVA as derived from either large or small VTi-derived and VC-derived areas (P=nonsignificant). CONCLUSIONS: Mitral valve inflow hemodynamics were the same regardless of the size differences between the large and small orifices. Therefore, total MVA can be calculated using the continuity equation in patients irrespective of MR mechanism. This allows for a derivation of total MVA at the time of MVCC placement to evaluate for mitral stenosis.

Relative pressure estimation from 4D flow MRI using generalized Bernoulli equation in a phantom model of arterial stenosis.

OBJECTIVE: Arterial stenosis is a significant cardiovascular disease requiring accurate estimation of the pressure gradients for determining hemodynamic significance. In this paper, we propose Generalized Bernoulli Equation (GBE) utilizing interpolated-based method to estimate relative pressures using streamlines and pathlines from 4D Flow MRI. METHODS: 4D Flow MRI data in a stenotic phantom model and computational fluid dynamics simulated velocities generated under identical flow conditions were processed by Generalized Bernoulli Equation (GBE), Reduced Bernoulli Equations (RBE), as well as the Simple Bernoulli Equation (SBE) which is clinically prevalent. Pressures derived from 4D flow MRI and noise corrupted CFD velocities were compared with pressures generated directly with CFD as well as pressures obtained using Millar catheters under identical flow conditions. RESULTS: It was found that SBE and RBE methods underestimated the relative pressure for lower flow rates while overestimating the relative pressure at higher flow rates. Specifically, compared to the reference pressure, SBE underestimated the maximum relative pressure by 22[Formula: see text] for a pulsatile flow data with peak flow rate [Formula: see text] and overestimated by around 40[Formula: see text] when [Formula: see text]. In contrast, for GBE method the relative pressure values were overestimated by 15[Formula: see text] with [Formula: see text]and around 10[Formula: see text] with [Formula: see text]. CONCLUSION: GBE methods showed robust performance to additive image noise compared to other methods. Our findings indicate that GBE pressure estimation over pathlines attains the highest level of accuracy compared to GBE over streamlines, and the SBE and RBE methods.

Early Apixaban Use Following Stroke in Patients With Atrial Fibrillation: Results of the AREST Trial.

BACKGROUND AND PURPOSE: It is unknown when to start anticoagulation after acute ischemic stroke (AIS) from atrial fibrillation (AF). Early anticoagulation may prevent recurrent infarctions but may provoke hemorrhagic transformation as AF strokes are typically larger and hemorrhagic transformation-prone. Later anticoagulation may prevent hemorrhagic transformation but increases risk of secondary stroke in this time frame. Our aim was to compare early anticoagulation with apixaban in AF patients with stroke or transient ischemic attack (TIA) versus warfarin administration at later intervals. METHODS: AREST (Apixaban for Early Prevention of Recurrent Embolic Stroke and Hemorrhagic Transformation) was an open-label, randomized controlled trial comparing the safety of early use of apixaban at day 0 to 3 for TIA, day 3 to 5 for small-sized AIS (<1.5 cm), and day 7 to 9 for medium-sized AIS (≥1.5 cm, excluding full cortical territory), to warfarin, in a 1:1 ratio at 1 week post-TIA, or 2 weeks post-AIS. RESULTS: Although AREST ended prematurely after a national guideline focused update recommended direct oral anticoagulants over warfarin for AF, it revealed that apixaban had statistically similar yet generally numerically lower rates of recurrent strokes/TIA (14.6% versus 19.2%, P=0.78), death (4.9% versus 8.5%, P=0.68), fatal strokes (2.4% versus 8.5%, P=0.37), symptomatic hemorrhages (0% versus 2.1%), and the primary composite outcome of fatal stroke, recurrent ischemic stroke, or TIA (17.1% versus 25.5%, P=0.44). One symptomatic intracerebral hemorrhage occurred on warfarin, none on apixaban. Five asymptomatic hemorrhagic transformation occurred in each arm. CONCLUSIONS: Early initiation of anticoagulation after TIA, small-, or medium-sized AIS from AF does not appear to compromise patient safety. Potential efficacy of early initiation of anticoagulation remains to be determined from larger pivotal trials. Registration: URL: https://www.clinicaltrials.gov/; Unique identifier: NCT02283294.

Beneficial Cardiac Structural and Functional Adaptations After Lumbosacral Spinal Cord Epidural Stimulation and Task-Specific Interventions: A Pilot Study.

Cardiac myocyte atrophy and the resulting decreases to the left ventricular mass and dimensions are well documented in spinal cord injury. Therapeutic interventions that increase preload can increase the chamber size and improve the diastolic filling ratios; however, there are no data describing cardiac adaptation to chronic afterload increases. Research from our center has demonstrated that spinal cord epidural stimulation (scES) can normalize arterial blood pressure, so we decided to investigate the effects of scES on cardiac function using echocardiography. Four individuals with chronic, motor-complete cervical spinal cord injury were implanted with a stimulator over the lumbosacral enlargement. We assessed the cardiac structure and function at the following time points: (a) prior to implantation; (b) after scES targeted to increase systolic blood pressure; (c) after the addition of scES targeted to facilitate voluntary (i.e., with intent) movement of the trunk and lower extremities; and (d) after the addition of scES targeted to facilitate independent, overground standing. We found significant improvements to the cardiac structure (left ventricular mass = 10 ± 2 g, p < 0.001; internal dimension during diastole = 0.1 ± 0.04 cm, p < 0.05; internal dimension during systole = 0.06 ± 0.03 cm, p < 0.05; interventricular septum dimension = 0.04 ± 0.02 cm, p < 0.05), systolic function (ejection fraction = 1 ± 0.4%, p < 0.05; velocity time integral = 2 ± 0.4 cm, p < 0.001; stroke volume = 4.4 ± 1.5 ml, p < 0.01), and diastolic function (mitral valve deceleration time = -32 ± 11 ms, p < 0.05; mitral valve deceleration slope = 50 ± 25 cm s-1, p < 0.05; isovolumic relaxation time = -6 ± 1.9 ms, p < 0.05) with each subsequent scES intervention. Despite the pilot nature of this study, statistically significant improvements to the cardiac structure, systolic function, and diastolic function demonstrate that scES combined with task-specific interventions led to beneficial cardiac remodeling, which can reverse atrophic changes that result from spinal cord injury. Long-term improvements to cardiac function have implications for increased quality of life and improved cardiovascular health in individuals with spinal cord injury, decreasing the risk of cardiovascular morbidity and mortality.

Systolic and diastolic function in chronic spinal cord injury.

Individuals with spinal cord injury develop cardiovascular disease more than age-matched, non-injured cohorts. However, progression of systolic and diastolic dysfunction into cardiovascular disease after spinal cord injury is not well described. We sought to investigate the relationship between systolic and diastolic function in chronic spinal cord injury to describe how biological sex, level, severity, and duration of injury correlate with structural changes in the left ventricle. Individuals with chronic spinal cord injury participated in this study (n = 70). Registered diagnostic cardiac sonographers used cardiac ultrasound to measure dimensions, mass, and systolic and diastolic function of the left ventricle. We found no significant relationship to severity or duration of injury with left ventricle measurements, systolic function outcome, or diastolic function outcome. Moreover, nearly all outcomes measured were within the American Society of Echocardiography-defined healthy range. Similar to non-injured individuals, when indexed by body surface area (BSA) left ventricle mass [-14 (5) g/m2, p < .01], end diastolic volume [-6 (3) mL/m2, p < .05], and end systolic volume [-4 (1) mL/m2, p < .01] were significantly decreased in women compared with men. Likewise, diastolic function outcomes significantly worsened with age: E-wave velocity [-5 (2), p < .01], E/A ratio [-0.23 (0.08), p < .01], and e' velocity [lateral: -1.5 (0.3) cm/s, p < .001; septal: -0.9 (0.2), p < .001] decreased with age while A-wave velocity [5 (1) cm/s, p < .001] and isovolumic relaxation time [6 (3) ms, p < .05] increased with age. Women demonstrated significantly decreased cardiac size and volumes compared with men, but there was no biological relationship to dysfunction. Moreover, individuals were within the range of ASE-defined healthy values with no evidence of systolic or diastolic function and no meaningful relationship to level, severity, or duration of injury. Decreases to left ventricular dimensions and mass seen in spinal cord injury may result from adaptation rather than maladaptive myocardial remodeling, and increased incidence of cardiovascular disease may be related to modifiable risk factors.

Childhood cancer survivors: The integral role of the cardiologist and cardiovascular imaging.

IMPORTANCE: With 80% of childhood cancer survivors (CCS) alive 30 years after diagnosis, preventable causes of death, such as cardiovascular disease resulting from initial cancer therapy, becomes an important metric. This leads to a more pronounced role for cardiologists in the care of CCS. OBSERVATIONS: While routine cardiovascular screening has been traditionally performed by the hematologist/oncologist or primary care provider, our understanding of cardiovascular disease in CCS has advanced. The measurement of left ventricular ejection fraction (LVEF) can now be complemented with additional assessments of strain, LV mass, right ventricular function, diastolic function, valve function, the pericardium, coronary perfusion, and biomarkers. Risk factor modification, prophylaxis, and timing of treatment are also critical. CONCLUSIONS AND RELEVANCE: Early cardiovascular screening and treatment in asymptomatic CCS can be nuanced and complex. As a result, there is a renewed opportunity for the cardiologist to play an integral role in the care of CCS. KEY POINTS: Question/Purpose: Review cardiovascular disease and the role of the cardiologist in the care of asymptomatic childhood cancer survivors (CCS). FINDINGS: Cardiovascular care in CCS benefits from a multi-faceted approach that does not overly rely on LVEF. Meaning: Adequate screening and treatment of cardiovascular disease in asymptomatic CCS may often be optimized by the involvement of a cardiologist.

Dual-Venc acquisition for 4D flow MRI in aortic stenosis with spiral readouts.

BACKGROUND: Single Venc 4D flow MRI with Cartesian readout is hampered by poor velocity resolution and noise when imaging during diastole. Dual Venc acquisitions typically require the acquisition of two distinct datasets, which leads to longer scan times. PURPOSE/HYPOTHESIS: To design and develop a 4D Spiral Dual Venc sequence. The sequence allows for separate systolic and diastolic Venc s as part of a single acquisition with a prescribed switch time. The implemented sequence was hypothesized to be comparable to Cartesian 4D flow, but with increased velocity resolution in the diastolic phase and with better scan efficiency and reduced noise. STUDY TYPE: Prospective. POPULATION: The studied populations were two phantoms-a straight pipe with a stenotic narrowing and a phantom of the aortic arch which included a calcific polymeric valve-under both steady and pulsatile flows, six healthy volunteers, and eight patients with severe aortic stenosis (AS). FIELD STRENGTH/SEQUENCE: 1.5T, Dual Venc 4D flow with spiral readouts. ASSESSMENT: Data from the proposed sequence were compared with data from 4D Cartesian Dual Venc and Single Venc acquisitions. Noise was assessed from the acquired velocity data with the pump turned off and by varying Venc . Steady acquisitions were compared to the proximal slice of the lowest Single Venc acquisition. STATISTICAL TESTS: Steady flows were compared using relative-root-mean-squared-error (RRMSE). For in vivo flows and pulsatile in vitro flows, net flow for corresponding timepoints were compared with the Pearson correlation test (P < 0.01). RESULTS: For steady flows, RRMSEs for Single Venc s ranged from 17.6% to 19.4%, and 9.6% to 16.5% for Dual Venc s. The net flow correlation coefficient for the aortic arch phantom was 0.975, and 0.995 for the stenotic phantom. Normal volunteer and patient comparisons yielded a correlation of 0.970 and 0.952, respectively. in vitro and in vivo pulsatile flow waveforms closely matched. DATA CONCLUSION: The Dual Venc offers improved noise properties and velocity resolution, while the spiral trajectory offers a scan efficient acquisition with short echo time yielding reduced flow artifacts. LEVEL OF EVIDENCE: 2 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2020;52:117-128.

Two-dimensional strain echocardiography-derived left ventricular ejection fraction, volumes, and global systolic dyssynchrony index: Comparison with three-dimensional echocardiography.

BACKGROUND: Three-dimensional (3D) echocardiography is the most accurate echocardiographic method for ventricular chamber quantification. It is unclear how two-dimensional (2D) techniques perform against 3D technology and whether 2D methods can be extrapolated to obtain 3D data. METHODS: Retrospective review of transthoracic echocardiography was performed, with comparison of ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and 2D strain-derived global longitudinal strain (GLS) and synchrony index. RESULTS: One-hundred patients were identified. Using 3D echocardiography as reference standard, good correlation was noted with 2D strain-derived EF (r = 0.89, P < 0.01) and with 2D standard biplane EF (r = 0.90, P < 0.01) and similarly for EDV (r = 0.84 and r = 0.81, respectively, both P < 0.01). Two-dimensional strain-derived EDV by 8% and 2D biplane-derived EDV underestimated by 8% (P < 0.01). In relation to 3D EF, 2D strain underestimated by 2% and 2D standard biplane overestimated by 2% (P < 0.01). There was a negative correlation between GLS and 3D EF (r = 0.84, P = 0.001). On multivariate analysis, 3D EF could be derived from 2D strain [3D EF = 34.345 + (0.125 * EDV) + (-0.289 * ESV) + (-1.141 * GLS)]. Three-dimensional echocardiography-derived synchrony parameter (ie, standard deviation from mean time to minimum systolic volume from 16 subvolumes) did not correlate with 2D strain-derived synchrony index (r = 0.171). CONCLUSIONS: Two-dimensional standard biplane and 2D strain EF and EDV strongly correlate with 3D EF and EDV. Although 2D methods are predictive of 3D findings, over- and underestimations may occur. Three-dimensional echocardiography should be used when available.

The evolution of apical hypertrophic cardiomyopathy: Development of mid-ventricular obstruction and apical aneurysm 11 years after initial diagnosis.

Asian hypertrophic cardiomyopathy (AHCM) is a rare variant of hypertrophic cardiomyopathy (HCM) that is more prevalent in the Asian population. There is significant overlap between AHCM, mid-cavitary obstruction, and apical aneurysms. Although more benign compared to HCM, the course of AHCM is not clearly defined. We present an interesting case of an African American male with known AHCM who develops symptomatic mid-cavitary obstruction and apical aneurysm 11 years after initial diagnosis.

4D Dual-Venc Spiral Flow.

Dual-Venc flow acquisition sequences perform flow imaging with differing Vencs. The technique can be used to improve velocity to noise ratio and image quality for diastolic flow velocities as part of a single scan. In this paper, Dual-Venc was used in conjunction with spiral read-out trajectories, offering a faster coverage of k-space. The results illustrate that 4D Dual Venc Spiral Flow behaves similarly to 4D Dual-Venc Cartesian Flow but with the benefit of faster acquisition time and lower echo time (TE).

A curious case of an absent left atrial appendage.

The left atrial appendage (LAA) in the setting of non-valvular atrial fibrillation (NVAF) is the predominant location for intracardiac thrombus formation. An absent LAA is a very rare congenital cardiac anomaly. We present a case of a 79-year-old female with NVAF, high CHADS2VASC2 score, and high bleeding risk who presented for elective Watchman™ left atrial appendage closure device implant. A pre-procedural transesophageal echocardiography showed an absent LAA. This finding was confirmed with cardiac computed tomography and a left atrial angiogram. The patient was discharged on medical therapy with close outpatient follow-up.

Frequent premature atrial contractions impair left atrial contractile function and promote adverse left atrial remodeling.

OBJECTIVES: This study assessed if frequent premature atrial contractions (PACs) were associated with decreased left atrial (LA) strain and adverse remodeling. BACKGROUND: Left atrial dysfunction and enlargement increases risk of stroke. If frequent PACs cause LA dysfunction and remodeling, PAC suppressive therapy may be beneficial. METHODS: Inclusion criteria were age ≥18 years and sinus rhythm. Exclusion criteria were atrial fibrillation or any etiology for LA enlargement. Hundred and thirty-two patients with frequent PACs (≥100/24 hours) by Holter were matched to controls. Speckle tracking strain of the left atrium was performed from the 4-chamber view. Strain measurements were LA peak contractile, reservoir and conduit strain and strain rates. RESULTS: In the frequent PAC vs control group, PACs were more frequent (1959 ± 3796 vs 28 ± 25/24 hours, P < .0001). LA peak contractile strain was reduced in the group with frequent PACs vs controls (-7.85 ± 4.12% vs -9.33 ± 4.45%, P = .006). LA peak late negative contractile strain rate was less negative in the frequent PAC vs control group (-0.63 ± 0.27 s-1 vs -0.69 ± 0.32 s-1 , P = .051). LA reservoir and conduit strain and strain rates did not differ. LA volume index (LAVI) was larger in the frequent PAC vs control group (26.6 ± 7.8 vs 24.6 ± 8.8 mL/m2 , P < .05). Frequent PACs were an independent predictor of reduced LA peak contractile strain and reduced LA peak late negative contractile strain rate. CONCLUSIONS: Patients with frequent PACs have reduced LA peak contractile strain and strain rates and larger LAVI compared to controls. Frequent PACs are an independent predictor of reduced LA peak contractile strain and strain rate. These findings support the hypothesis that frequent PACs impair LA contractile function and promote adverse LA remodeling.

Echocardiographic Assessment of Cardiotoxic Effects of Cancer Therapy.

Patients with cancer can present with difficult management issues, as the medicine can sometimes cause sequelae destructive to healthy tissue. As this population lives longer, cardiotoxic effects are beginning to emerge, but the early recognition of this signal can prove difficult, with too late a recognition leading to lifelong cardiac impairment and dysfunction. Cardio-oncology can bridge this difficulty, and echocardiography and its newer imaging abilities are proving efficacious in this population. This article will address common sequelae of cardiotoxic treatment regimens and offer recommendations for echocardiographic surveillance. We recommend echocardiography, preferably three-dimensional and strain imaging, to monitor for cardiotoxic myocardial effects before, during, and after chemotherapy with cardiotoxic drug regimens, particularly anthracycline derivatives. A reduction in left ventricular (LV) global longitudinal strain in all patients, or reduction in LV global circumferential strain or global radial strain in patients at intermediate to high risk for cardiotoxicity, despite normal LV ejection fraction warrants a clinical assessment on the benefits of continuing cardiotoxic chemotherapeutic agents. Lifelong surveillance using echocardiography for cardiotoxicity and radiation-related valvular, pericardial, and coronary artery disease is prudent.

Risk of Recurrent Neurologic Stroke or Transient Ischemic Attack in Patients with Cryptogenic Stroke and Intrapulmonary Shunt.

BACKGROUND AND PURPOSE: Cardio-embolic phenomenon is believed to underlie a significant proportion of cryptogenic strokes. We recently showed that intrapulmonary shunt (IPS) was associated with cryptogenic stroke and transient ischemic attack (TIA). We hypothesized that patients with prior cryptogenic stroke or TIA that had an IPS were at a higher risk for recurrent ischemic events. METHODS: The population included subjects with cryptogenic cerebrovascular accident (CVA) or TIA. Inclusion criteria were age ≥18 years, sinus rhythm, and clinically indicated transesophageal echocardiography (TEE). Exclusion criteria were hemorrhagic CVA, septal defect, and patent foramen. Patients were followed from index TEE. RESULTS: Of 71 patients, 8 were lost to follow-up. A total of 23 patients had and 40 were without IPS. Average follow-up duration was 38.3 ± 19.2 months. Groups were similar at baseline. There was no significant difference in the recurrence of ischemic CVA or TIA in the IPS versus non-IPS groups (0% vs. 7.5%; P = NS). There was no difference between the incidence of hemorrhagic CVA in the IPS and non-IPS groups (4.3% vs. 5.0%; P = NS). The proportion of patients on warfarin in the IPS group was significantly higher compared to the non-IPS group (17.4% vs. 0%; P < 0.05). CONCLUSIONS: Patients with IPS and cryptogenic stroke or TIA did not have a higher recurrence of ischemic cerebral events. Warfarin was significantly higher at follow-up in the IPS compared to the non-IPS group, which may explain these findings. A study randomizing patients with IPS and cryptogenic stroke or TIA to warfarin or no warfarin would be of great interest.