Developing an Echocardiography-Based, Automatic Deep Learning Framework for the Differentiation of Increased Left Ventricular Wall Thickness Etiologies.

AIMS: Increased left ventricular (LV) wall thickness is frequently encountered in transthoracic echocardiography (TTE). While accurate and early diagnosis is clinically important, given the differences in available therapeutic options and prognosis, an extensive workup is often required to establish the diagnosis. We propose the first echo-based, automated deep learning model with a fusion architecture to facilitate the evaluation and diagnosis of increased left ventricular (LV) wall thickness. METHODS AND RESULTS: Patients with an established diagnosis of increased LV wall thickness (hypertrophic cardiomyopathy (HCM), cardiac amyloidosis (CA), and hypertensive heart disease (HTN)/others) between 1/2015 and 11/2019 at Mayo Clinic Arizona were identified. The cohort was divided into 80%/10%/10% for training, validation, and testing sets, respectively. Six baseline TTE views were used to optimize a pre-trained InceptionResnetV2 model. Each model output was used to train a meta-learner under a fusion architecture. Model performance was assessed by multiclass area under the receiver operating characteristic curve (AUROC). A total of 586 patients were used for the final analysis (194 HCM, 201 CA, and 191 HTN/others). The mean age was 55.0 years, and 57.8% were male. Among the individual view-dependent models, the apical 4-chamber model had the best performance (AUROC: HCM: 0.94, CA: 0.73, and HTN/other: 0.87). The final fusion model outperformed all the view-dependent models (AUROC: HCM: 0.93, CA: 0.90, and HTN/other: 0.92). CONCLUSION: The echo-based InceptionResnetV2 fusion model can accurately classify the main etiologies of increased LV wall thickness and can facilitate the process of diagnosis and workup.

Cardiac Troponin T and Right Ventricular Systolic Pressure Predict Cardiovascular and Mortality Risk in Kidney Transplant Candidates.

BACKGROUND: Patients presenting for kidney transplant (KTx) evaluation are subject to high rates of mortality and cardiovascular (CV) events pre- and post-KTx. CV and mortality risk assessment is needed. METHODS: We evaluated cardiac troponin T (cTnT) as a predictor of CV events and mortality in a racially diverse cohort with significant CV disease burden presenting for KTx evaluation. Right ventricular systolic pressure (RVSP) was also assessed in predicting these outcomes. The population consisted of 561 patients presenting for KTx evaluation from 2011 to 2013 at Mayo Clinic, Arizona. A cutoff value for cTnT and RVSP that was most associated with CV events or mortality was derived. Multivariate Cox regression analysis was used to assess cTnT, RVSP, traditional, and other risk factors for the outcomes of interest. RESULTS: Mean age was 53.5 ± 13.7 years and the median follow-up after KTx evaluation was 48.0 months. The cohort was 70.6% (n = 392) White, 11.4% (n = 63) Black, 8.5% (n = 47) Native American, and 3.1% (n = 17) Asian. Preexisting CV disease at the time of evaluation was prevalent in 24.4% (n = 137) of patients. During follow-up, 66.3% (n = 372) received a KTx and 21.9% (n = 123) had a composite event (16.8% death, 6.6 % CV events). It was found that 70.7% (n = 87) of events occurred in patients who were not transplanted; 53.5% (n = 300) had an elevated cTnT (≥0.01 ng/mL, median 0.02 ng/mL) and 84.1% (n = 344) of patients with RVSP data had an elevated RVSP (>25 mm Hg). Time to event analysis identified a cTnT ≥0.036 ng/mL and RVSP ≥31 mm Hg to be best predictive of CV events and mortality. Smoking, CV disease, hypoalbuminemia, RVSP, and cTnT independently predicted CV events and mortality. CONCLUSION: Elevated cTnT and RVSP were independently predictive of CV events and mortality in the cohort. Clinicians should consider the value of RVSP and cTnT as markers of CV risk in KTx evaluation.

Monster Lung Cavity in a Heart Transplant Recipient.

Invasive mucormycosis infections occur in less than 1% of recipients of orthotopic heart transplants. Given the angioinvasive nature of these infections, the mortality rate is high. Little literature exists regarding the presentation and management of these infections. We present a case of a patient who developed an infection after orthotopic heart transplant, describe the successful multidisciplinary management surrounding his care, and review the available literature regarding mucormycosis infections in heart transplant recipients.

Left ventricular assist devices: physiologic assessment using echocardiography for management and optimization.

Left ventricular assist devices (LVAD) are being deployed increasingly in patients with severe left ventricular dysfunction and medically refractory congestive heart failure of any etiology. The United States Food and Drug Administration (FDA) recently approved the use of the Thoratec Heartmate II (Thoratec Corporation, Pleasanton, CA, USA) for outpatient use. Echocardiography is fundamental during each stage of patient management, pre-LVAD placement, during LVAD placement, for postoperative LVAD optimization and long-term follow-up. We present a pragmatic and systematic echocardiographic approach that serves as a guide for the management of left ventricular assist devices.

Successive circulatory support stages: a triple bridge to recovery from fulminant myocarditis.

Fulminant myocarditis with rapid onset of symptoms and hemodynamic compromise is a rare indication for mechanical support. Because of the potentially reversible nature of this illness, advanced mechanical circulatory support is warranted to achieve recovery or as a bridge to transplantation. Circulatory device options currently available allow for a phased implementation of support modalities in a manner that reduces costs and patient risk. We present a patient with fulminant myocarditis where extracorporeal membrane oxygenation (ECMO) support escalated to short-term Levitronix CentriMag (Levitronix, Waltham, MA) biventricular assist devices (BiVADs). These in turn were exchanged, without major surgery, to long-term paracorporeal VADs (Thoratec, Pleasanton, CA). After rehabilitation and nearly total recovery, the patient was weaned from mechanical circulatory support after 104 cumulative days.

Simultaneous heart and kidney transplantation after bridging with the CardioWest total artificial heart.

End-stage renal failure is often considered a relative contraindication for total artificial heart implantation due to the increased risk of mortality after transplantation. We report the successful treatment of a patient having heart and renal failure with the CardioWest (SynCardia Inc, Tucson, AZ) total artificial heart for bridge-to-cardiac transplantation of a heart and kidney.

Treating heart failure and dyspnea in a 78-year-old man with surgical correction of pectus excavatum.

Reports documenting the cardiopulmonary significance of pectus excavatum are limited, and there remains a lack of consensus as to whether surgical repair can improve function. We present a case of pectus excavatum deformity and heart failure. Surgical repair was performed with significant improvement of performance and heart function.