Fully Automated Artificial Intelligence Assessment of Aortic Stenosis by Echocardiography.

BACKGROUND: Aortic stenosis (AS) is a common form of valvular heart disease, present in over 12% of the population age 75 years and above. Transthoracic echocardiography (TTE) is the first line of imaging in the adjudication of AS severity but is time-consuming and requires expert sonographic and interpretation capabilities to yield accurate results. Artificial intelligence (AI) technology has emerged as a useful tool to address these limitations but has not yet been applied in a fully hands-off manner to evaluate AS. Here, we correlate artificial neural network measurements of key hemodynamic AS parameters to experienced human reader assessment. METHODS: Two-dimensional and Doppler echocardiographic images from patients with normal aortic valves and all degrees of AS were analyzed by an artificial neural network (Us2.ai) with no human input to measure key variables in AS assessment. Trained echocardiographers blinded to AI data performed manual measurements of these variables, and correlation analyses were performed. RESULTS: Our cohort included 256 patients with an average age of 67.6 ± 9.5 years. Across all AS severities, AI closely matched human measurement of aortic valve peak velocity (r = 0.97, P < .001), mean pressure gradient (r = 0.94, P < .001), aortic valve area by continuity equation (r = 0.88, P < .001), stroke volume index (r = 0.79, P < .001), left ventricular outflow tract velocity-time integral (r = 0.89, P < .001), aortic valve velocity-time integral (r = 0.96, P < .001), and left ventricular outflow tract diameter (r = 0.76, P < .001). CONCLUSIONS: Artificial neural networks have the capacity to closely mimic human measurement of all relevant parameters in the adjudication of AS severity. Application of this AI technology may minimize interscan variability, improve interpretation and diagnosis of AS, and allow for precise and reproducible identification and management of patients with AS.

Application of a Novel Two-Dimensional Echocardiographic Calcium Quantification Method to Assess All Severities of Aortic Stenosis.

BACKGROUND: Aortic valve (AV) calcification (AVC) is a strong predictor of aortic stenosis (AS) severity. The two-dimensional AVC (2D-AVC) ratio, a gain-independent ratio composed of the average pixel density of the AV and the aortic annulus, has previously shown strong correlations with two-dimensional (2D) echocardiographic hemodynamic parameters for severe AS and AVC by cardiac computed tomography. We hypothesize that the 2D-AVC ratio correlates with hemodynamic parameters in all severities of AS. METHODS: A total of 285 patients with a normal AV (n = 49), aortic sclerosis (n = 75), or mild (n = 38), moderate (n = 72), or severe (n = 51) AS undergoing 2D echocardiography were retrospectively evaluated, and the 2D-AVC ratios were correlated to mean AV gradient, peak AV velocity, AV area, and dimensionless index. The 2D-AVC ratios of various AS severities were compared against each other via area under the curve (AUC) analysis. RESULTS: The 2D-AVC ratio is strongly correlated with mean AV gradient (r = 0.79, P < .0001) and peak AV velocity (r = 0.78, P < .0001). There was moderate correlation with the AV area (r = -0.58, P < .0001) and dimensionless index (r = -0.67, P < .0001) across all AS severities. The 2D-AVC ratio also distinguished nonmoderate AS (mild AS + normal AV) from moderate or greater (moderate + severe) AS (AUC = 0.93) and moderate versus severe AS (AUC = 0.88). CONCLUSION: The 2D-AVC ratio exhibits moderate to strong correlation with 2D echocardiographic hemodynamic parameters across all severities of AS.

Serial Left and Right Ventricular Strain Analysis in Patients Recovered from COVID-19.

BACKGROUND: Strain analysis of transthoracic echocardiography (TTE) is a sensitive tool to detect myocardial dysfunction in those affected by COVID-19. Consideration of preexisting cardiovascular disease is important in detecting changes related to COVID-19. We sought to assess serial TTE changes in patients recovered from COVID-19 compared with baseline, pre-COVID-19 exams, with a focus on left and right ventricular longitudinal strain. METHODS: This retrospective review of serial TTEs in confirmed COVID-19 patients at Mayo Clinic sites included patients who had a TTE within 2 years prior to confirmed COVID-19 diagnosis, and the first available outpatient TTE after diagnosis was used as a comparison. Patients with interval cardiac surgery, procedure, or device placement (n = 9) were excluded. Biventricular strain was retrospectively performed on both echocardiograms. RESULTS: Of 259 individuals, ages 60 ± 16 years, 47% female, and 88% Caucasian, post-COVID-19 TTEs were performed a median of 55 days (interquartile range, 37-92) following diagnosis. No clinically significant TTE changes were noted, although left ventricular ejection fraction was higher (58% vs 57%, P = .049) and tricuspid annulus plane systolic excursion was lower (20 vs 21 mm, P = .046) following COVID-19. Baseline left ventricular global longitudinal strain (LV GLS) and right ventricular free wall strain (RV FWS) were normal (-19.6% and -25.8%, respectively) and similar following COVID-19 (-19.6% and -25.7%, P = .07 and .77, respectively). In the 74 inpatients, no significant change from baseline was seen for LV GLS (-19.4% vs -19.1%, P = .62), RV FWS (-25.5% vs -25.0%, P = .69), or left ventricular ejection fraction (57% vs 57%, P = .71). A significant worsening in strain occurred in 27 patients, 16 (6.8%) of the 237 with LV GLS and 14 (6.0%) of the 235 with RV FWS. Ten (20%) patients reporting new symptoms following COVID-19 had worsened strain, compared with 5 (7%) with persistent/progressive symptoms and 11 (9%) with no new symptoms (P = .04). CONCLUSIONS: While patients with new symptoms following COVID-19 were more likely to have a worsening in absolute strain values, no clinically significant change in TTE parameters was evident in most patients following COVID-19 regardless of symptom status.

Primary angiitis of central nervous system - A challenging diagnosis.

Primary angiitis of the central nervous system is a rare disease characterized by vasculitis of the central nervous system without any systemic involvement. This review aims to provide an insight into the existing stagnancies in the diagnostic approach and management of this disease. The clinical presentation is typically nonspecific, ranging from headaches, altered sensorium, and seizures to recurrent ischemic strokes. The definitive diagnosis can only be ascertained by histopathological studies of tissue obtained from a brain biopsy. While angiography can provide clues to diagnosis, it has often been normal, even in biopsy-proven cases. Primary angiitis of the central nervous system continues to be a diagnostic challenge as little progress has been made over the years in the diagnosis and management strategies. Considering the vast list of mimickers of primary angiitis of the central nervous system and the existence of a significant proportion of imaging-negative and biopsy-negative cases, it becomes imperative to devise universally accepted diagnostic criteria for this disease. Steroids in combination with cyclophosphamide are the agents used to achieve remission. Rituximab can be an alternative. The treatment-related toxicity of cyclophosphamide warrants larger trials for alternative drugs to be studied.

Physical activity is associated with lower pulsatile stress but not carotid stiffness in children.

The cardiovascular disease (CVD) process may begin early in life when accompanied by atherosclerotic risk factors. CVD risk factors in children are associated with stiffening of the large elastic arteries, a reflection of subclinical atherosclerosis. Physical activity is a preventative lifestyle strategy that may benefit arterial stiffness by attenuating the hemodynamic stress on the artery wall. This study examined the relations between physical activity, carotid pulsatile stress, and carotid stiffness in children. One hundred and forty children (9-11 yrs; 50.0% male, 57.9% African-American, 42.10% Caucasian, body mass index (BMI) 20.1 ± 4.7 kg/m2) participated in this study. Physical activity counts were measured using a wrist-worn accelerometer and averaged over 7 days. Carotid artery ß-stiffness and pulse pressure (calibrated to brachial mean and diastolic pressure) were assessed as via ultrasound and tonometry, respectively. Pulsatile stress was calculated as the product of carotid pulse pressure and heart rate. Physical activity counts were correlated with pulsatile stress (r = -0.27), and BMI (r = -0.23), but were unrelated to carotid stiffness. In multivariate models, associations between physical activity counts and pulsatile stress remained (B = -1.3 [95%CI, -2.4, -0.2], ß = -0.20, p < 0.05) after covariate adjustment for age, race, sex, pubertal stage, and BMI. Carotid pulsatile stress was related to regional carotid stiffness (r = 0.45, p < 0.05). These data suggest that higher levels of physical activity at young age are associated with lower hemodynamic stress in the carotid artery. Findings are discussed in the context of an inverse relationship between hemodynamic pulsatile stress and carotid stiffness in children.

Clinical Spectrum of Movement Disorders in Neurology Inpatients in a Tertiary Care Centre.

Background Little data are available on the spectrum of movement disorders in inpatients, particularly those admitted in neurology specialty. This may be related to the fact that patients presenting with movement disorders are usually evaluated from outpatient clinics. Objective The aim of this study is to provide data on the pattern of movement disorders in neurology inpatients. Materials and Methods Patients admitted through emergency department or neurology clinic with complaints of movement abnormalities were recruited in this study from October 2019 to September 2020. Cases were subjected to proforma-based detailed history, examination, and appropriate investigations. Statistical Analysis Descriptive statistics using SPSS 20. Results and Conclusion Bradykinesia with or without tremor was the most common movement disorder (28.3%), followed by ataxia and dystonia (24.5% each) and hemifacial spasm and myoclonus (7.5% each). Chorea, tic disorder, and hemiballismus were also reported. Etiologies included Parkinson disease, Wilson's disease, subacute sclerosing panencephalitis (SSPE), drugs, stroke, spinocerebellar ataxia, Huntington's disease, neuroacanthocytosis, and others. Dystonia represented the most common disorder in the younger age group (44.4%), whereas bradykinesia and/or tremor represented the most common movement disorder in the older age group (46.4%). This study demonstrates the characteristic distribution of movement disorders in neurology inpatients.

Cardiac Abnormalities in COVID-19 and Relationship to Outcome.

OBJECTIVE: To characterize the clinical and transthoracic echocardiographic features and 30-day outcomes of hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: Retrospective cohort study that included consecutive inpatients with COVID-19 infection who underwent clinically indicated transthoracic echocardiography at 10 sites in the Mayo Clinic Health System between March 10 and August 5, 2020. Echocardiography was performed at bedside by cardiac sonographers according to an abbreviated protocol. Echocardiographic results, demographic characteristics, laboratory findings, and clinical outcomes were analyzed. RESULTS: There were 179 patients, aged 59.8±16.9 years and 111 (62%) men; events within 30 days occurred in 70 (39%) patients, including prolonged hospitalization in 43 (24%) and death in 27 (15%). Echocardiographic abnormalities included left ventricular ejection fraction less than 50% in 29 (16%), regional wall motion abnormalities in 26 (15%), and right ventricular systolic pressure (RVSP) of 35 or greater mm Hg in 44 (44%) of 101 in whom it was measured. Myocardial injury, defined as the presence of significant troponin level elevation accompanied by new ventricular dysfunction or electrocardiographic abnormalities, was present in 13 (7%). Prior echocardiography was available in 36 (20%) patients and pre-existing abnormalities were seen in 28 (78%) of these. In a multivariable age-adjusted model, area under the curve of 0.81, prior cardiovascular disease, troponin level, D-dimer level, and RVSP were related to events at 30 days. CONCLUSION: Bedside Doppler assessment of RVSP appears promising for short-term risk stratification in hospitalized patients with COVID-19 infection undergoing clinically indicated echocardiography. Pre-existing echocardiographic abnormalities were common; caution should be exercised in attributing such abnormalities to the COVID-19 infection in this comorbid patient population.