Comparison between Automatic and Semiautomatic System for the 3D Echocardiographic Multiparametric Evaluation of RV Function and Dimension.

BACKGROUND: The right ventricle (RV) plays a pivotal role in cardiovascular diseases and 3-dimensional echocardiography (3DE) has gained acceptance for the evaluation of RV volumes and function. Recently, a new artificial intelligence (AI)-based automated 3DE software for RV evaluation has been proposed and validated against cardiac magnetic resonance. The aims of this study were three-fold: (i) feasibility of the AI-based 3DE RV quantification, (ii) comparison with the semi-automatic 3DE method and (iii) assessment of 2-dimensional echocardiography (2DE) and strain measurements obtained automatically. METHODS: A total of 203 subject (122 normal and 81 patients) underwent a 2DE and both the semi-automatic and automatic 3DE methods for Doppler standard, RV volumes and ejection fraction (RVEF) measurements. RESULTS: The automatic 3DE method was highly feasible, faster than 2DE and semi-automatic 3DE and data obtained were comparable with traditional measurements. Both in normal subjects and patients, the RVEF was similar to the two 3DE methods and 2DE and strain measurements obtained by the automated system correlated very well with the standard 2DE and strain ones. CONCLUSIONS: results showed that rapid analysis and excellent reproducibility of AI-based 3DE RV analysis supported the routine adoption of this automated method in the daily clinical workflow.

Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study.

Background: Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR). Methods: We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment. Results: The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival. Conclusions: In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Predicting Long-Term Mortality in TAVI Patients Using Machine Learning Techniques.

BACKGROUND: Whereas transcatheter aortic valve implantation (TAVI) has become the gold standard for aortic valve stenosis treatment in high-risk patients, it has recently been extended to include intermediate risk patients. However, the mortality rate at 5 years is still elevated. The aim of the present study was to develop a novel machine learning (ML) approach able to identify the best predictors of 5-year mortality after TAVI among several clinical and echocardiographic variables, which may improve the long-term prognosis. METHODS: We retrospectively enrolled 471 patients undergoing TAVI. More than 80 pre-TAVI variables were collected and analyzed through different feature selection processes, which allowed for the identification of several variables with the highest predictive value of mortality. Different ML models were compared. RESULTS: Multilayer perceptron resulted in the best performance in predicting mortality at 5 years after TAVI, with an area under the curve, positive predictive value, and sensitivity of 0.79, 0.73, and 0.71, respectively. CONCLUSIONS: We presented an ML approach for the assessment of risk factors for long-term mortality after TAVI to improve clinical prognosis. Fourteen potential predictors were identified with the organic mitral regurgitation (myxomatous or calcific degeneration of the leaflets and/or annulus) which showed the highest impact on 5 years mortality.

Predictive Value of Pre-Operative 2D and 3D Transthoracic Echocardiography in Patients Undergoing Mitral Valve Repair: Long Term Follow Up of Mitral Valve Regurgitation Recurrence and Heart Chamber Remodeling.

The "ideal" management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP) is still debated. The aims of this study were to identify pre-operatory parameters predictive of residual MR and of early and long-term favorable remodeling after MVP repair. We included 295 patients who underwent MV repair for MVP with pre-operatory two- and three-dimensional transthoracic echocardiography (2DTTE and 3DTTE) and 6-months (6M) and 3-years (3Y) follow-up 2DTTE. MVP was classified by 3DTTE as simple or complex and surgical procedures as simple or complex. Pre-operative echo parameters were compared to post-operative values at 6M and 3Y. Patients were divided into Group 1 (6M-MR < 2) and Group 2 (6M-MR ≥ 2), and predictors of MR 2 were investigated. MVP was simple in 178/295 pts, and 94% underwent simple procedures, while in only 42/117 (36%) of complex MVP a simple procedure was performed. A significant relation among prolapse anatomy, surgical procedures and residual MR was found. Post-operative MR ≥ 2 was present in 9.8%: complex MVP undergoing complex procedures had twice the percentage of MR ≥ 2 vs. simple MVP and simple procedures. MVP complexity resulted independent predictor of 6M-MR ≥ 2. Favorable cardiac remodeling, initially found in all cases, was maintained only in MR < 2 at 3Y. Pre-operative 3DTTE MVP morphology identifies pts undergoing simple or complex procedures predicting MR recurrence and favorable cardiac remodeling.

Transthoracic echocardiography in patients undergoing mitral valve repair: comparison of new transthoracic 3D techniques to 2D transoesophageal echocardiography in the localization of mitral valve prolapse.

Successful mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is mainly related to surgical expertise and MV anatomy. Although 2D echocardiography, specifically transoesophageal (TOE), provides precise information regarding MV anatomy, recent advancements in matrix technology meant a decisive step forward to the point where segmental MV analysis can be accurately performed from a noninvasive 3D transthoracic (TTE) approach. The aims of this study were: (a) to evaluate the feasibility and time required for real-time 3D TTE in a large consecutive cohort of patients with severe DMR in the assessment of MV anatomy; (b) to compare the accuracy of 3D TTE and 2D TOE versus surgical inspection in the recognition and localization of all components of the MV leaflets; (c) to establish the added diagnostic value of 3D colourDoppler examination to pure 3D morphologic evaluation. 149 consecutive patients with severe DMR underwent complete 3D TTE before surgery and 2D TOE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. 3D TTE was feasible in a relatively short time (8 ± 4 min), with good (49%) and optimal (33%) imaging quality in the majority of cases. 3D TTE had significant better overall accuracy compared to 2D TOE (93 and 91%, p < 0.05, respectively). 2D TOE was significantly more specific than 3D TTE in the identification of A3 prolapse (99 vs. 96%). The colourDoppler mode did not improve significantly the accuracy of 3D TTE, albeit it determined a better sensitivity in the detection of A2 prolapse if compared to 2D TOE (95 vs. 85%). 3D TTE with or without colourDoppler is a feasible and useful method in the analysis of MV prolapse; it allows a preoperative and noninvasive description of the pathology as accurate as the 2D TOE.

Feasibility and Accuracy of Automated Software for Transthoracic Three-Dimensional Left Ventricular Volume and Function Analysis: Comparisons with Two-Dimensional Echocardiography, Three-Dimensional Transthoracic Manual Method, and Cardiac Magnetic Resonance Imaging.

BACKGROUND: Recently, a new automated software package (HeartModel) was developed to obtain three-dimensional (3D) left ventricular (LV) volumes using a model-based algorithm (MBA) with a "one-button" simple system and user-adjustable slider. The aims of this study were to verify the feasibility and accuracy of the MBA in comparison with other commonly used imaging techniques in a large unselected population, to evaluate possible accuracy improvements of free operator border adjustments or changes of the slider's default position, and to identify differences in method accuracy related to specific pathologies. METHODS: This prospective study included consecutive 200 patients. LV volumes and ejection fraction were obtained using the MBA and compared with the two-dimensional biplane method, the 3D full-volume (3DFV) modality, and, in 90 of 200 cases, cardiac magnetic resonance (CMR) measurements. To evaluate the optimal position of the slider with respect to the 3DFV and CMR modalities, a set of threefold cross-validation experiments was performed. Optimized and manually corrected LV volumes obtained using the MBA were also tested. Linear correlation and Bland-Altman analysis were used to assess intertechnique agreement. RESULTS: Automatic volumes were feasible in 194 patients (94.5%), with a mean processing time of 29 ± 10 sec. MBA-derived volumes correlated significantly with all evaluated methods, with slight overestimation of two-dimensional biplane and slight underestimation of CMR measurements. Higher correlations were found between MBA and 3DFV measurements, with negligible differences both in volumes (overestimation) and in LV ejection fraction (underestimation), respectively. Optimization of the user-adjustable slider position improved the correlation and markedly reduced the bias between the MBA and 3DFV or CMR. The accuracy of MBA volumes was lower in some pathologies for incorrect definition of LV endocardium. CONCLUSIONS: The MBA is highly feasible, reproducible, and rapid, and it correlates highly with the traditional 3DFV method. It may represent a valid alternative to 3DFV measurement for everyday clinical use.

Right Ventricular Dimensions and Function: Why do we Need a More Accurate and Quantitative Imaging?

The right ventricle plays an important role in the morbidity and mortality of patients presenting with symptoms and signs of cardiopulmonary disease. This cardiac chamber has a unique crescent shape, which adds complexity to the quantification of its size and function. Until recently, little uniformity in echocardiographic imaging of the right heart existed because of a lack of familiarity with various techniques, and the enormous attention directed towards left heart quantification. Three-dimensional (3D) echocardiography, a major technological breakthrough in the field of cardiovascular imaging, provides several advantages over two-dimensional (2D) imaging in the quantitative evaluations of right ventricle because of its independence from any geometrical assumption. In this review, we focus on the contribution of this new modality to the evaluation of right ventricle.

Feasibility and accuracy of three-dimensional transthoracic echocardiography vs. multidetector computed tomography in the evaluation of aortic valve annulus in patient candidates to transcatheter aortic valve implantation.

AIMS: Proper measurement of the aortic annulus (AoA) is crucial for the success of transcatheter aortic valve implantation (TAVI). Transthoracic echocardiography (TTE) is the first step to assess AoA diameter, but a two-dimensional TTE (2DTTE) measurement is no longer accepted as the sole determinant of prosthetic size. The aims of the study were to evaluate feasibility and accuracy of three-dimensional TTE (3DTTE) estimation of AoA dimensions in comparison with multidetector computer tomography (MDCT). METHODS AND RESULTS: We enrolled 100 consecutive patients referred for TAVI. Feasibility of AoA evaluation was 91% for 3DTTE and in 90% for MDCT. In 81 of 100 patients, AoA maximum diameter (max-D), minimum diameter (min-D), and area were measured and compared using 2DTTE, 3DTTE, and MDCT. Image quality of 3DTTE was sufficient in 47, good in 46 and optimal in 7%. High correlations (P < 0.001) were found between MDCT and 3DTTE (max-D: r = 0.89; min-D r = 0.86; area: r = 0.93), and between MDCT and 2DTTE (min-D: r = 0.81; area 0.78). The 3DTTE measurements were found to be highly reproducible on intra- and interobserver variability analyses. Regarding the choice of prosthesis size, agreement between 3DTTE and MDCT was very good (k = 0.84, P < 0.001) while it was poor between 2DTTE and MDCT (k = 0.36, P < 0.001). CONCLUSIONS: 3DTTE may be a valid imaging alternative in patients unsuitable for MDCT during the preoperative evaluation for TAVI. Evaluation of AoA through 3DTTE is feasible, and measurements closely approximate those of MDCT thus improving TTE accuracy in identifying the correct prosthesis size.

Direct closure of an asymptomatic right coronary sinus of Valsalva aneurysm.

A 52-year-old man was referred for evaluation of palpitation. Transthoracic echocardiography revealed an extracardiac aneurysm of the right coronary sinus of Valsalva, and normal anatomy of the aortic valve with no regurgitation. Three-dimensional computed tomography confirmed the aneurysm with a diameter of 21 × 13.7 mm arising from the right coronary sinus of Valsalva under the right coronary artery. Surgical repair was performed without changing the normal anatomy of the aortic valve, preserving the right coronary ostium. Intraoperative and postoperative echocardiography showed complete closure of the aneurysm with normal functioning of the aortic valve.

Randomized trial of predilation versus direct stenting for treatment of carotid artery stenosis.

BACKGROUND: A controversial aspect of carotid artery stenting (CAS) is the placement of a stent with or without predilation. The study was designed to test the hypothesis that direct stenting (DS) was not inferior to CAS with predilation. METHODS: Elective CAS with filter protection was performed in 205 consecutive, unselected patients with carotid artery stenosis (>50% if symptomatic and > or =75% if asymptomatic by Doppler assessment) who were randomly assigned to CAS with predilation (n=100) or direct stenting (DS, n=105). Filter and stent selection were left to the operator's discretion. The study end-point was the angiographic success, defined as < or =30% angiographic residual stenosis after CAS without abnormal angiographic findings in cerebral circulation and without cross-over to predilation in the DS group. RESULTS: At baseline, patient clinical characteristics and stenosis anatomic features did not differ between groups. Angiographic success was 99% and 97%, p=0.33, in predilation and DS, respectively. No cross-over to predilation occurred in the DS group. Procedural time was shorter in DS as compared to predilation (24.3+/-7% versus 19.9+/-6%, p=0.001) and visible debris were more frequently captured in predilation as compared to DS (50% versus 36%, p=0.003). No peri-procedural and 30-day death or major stroke occurred in both groups. Minor stroke and TIA rates were similar in either group (2% versus 0% and 8% versus 5.7%, p=ns, respectively). CONCLUSION: In an unselected, consecutive series of patients submitted to CAS, DS is a feasible technique and is not inferior to CAS with predilation.