Comprehensive characterization of cardiac contraction for improved post-infarction risk assessment

This study aims at identifying risk-related patterns of left ventricular contraction dynamics via novel volume transient characterization. A multicenter cohort of AMI survivors (n = 1021) who underwent Cardiac Magnetic Resonance (CMR) after infarction was considered for the study. The clinical endpoint was the 12-month rate of major adverse cardiac events (MACE, n = 73), consisting of all-cause death, reinfarction, and new congestive heart failure. Cardiac function was characterized from CMR in 3 potential directions: by (1) volume temporal transients (i.e. contraction dynamics); (2) feature tracking strain analysis (i.e. bulk tissue peak contraction); and (3) 3D shape analysis (i.e. 3D contraction morphology). A fully automated pipeline was developed to extract conventional and novel artificial-intelligence-derived metrics of cardiac contraction, and their relationship with MACE was investigated. Any of the 3 proposed directions demonstrated its additional prognostic value on top of established CMR indexes, myocardial injury markers, basic characteristics, and cardiovascular risk factors (P < 0.001). The combination of these 3 directions of enhancement towards a final CMR risk model improved MACE prediction by 13% compared to clinical baseline (0.774 (0.771—0.777) vs. 0.683 (0.681—0.685) cross-validated AUC, P < 0.001). The study evidences the contribution of the novel contraction characterization, enabled by a fully automated pipeline, to post-infarction assessment

Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials

Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and – with less certainty – testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required

Head-to-Head Comparison of Different Software Solutions for AVC Quantification Using Contrast-Enhanced MDCT

Aortic valve calcification (AVC) in aortic stenosis patients has diagnostic and prognostic implications. Little is known about the interchangeability of AVC obtained from different multidetector computed tomography (MDCT) software solutions. Contrast-enhanced MDCT data sets of 50 randomly selected aortic stenosis patients were analysed using three different software vendors (3Mensio, CVI42, Syngo.Via). A subset of 10 patients were analysed twice for the estimation of intra-observer variability. Intra- and inter-observer variability were determined using the ICC reliability method, Bland-Altman analysis and coefficients of variation. No differences were revealed between the software solutions in the AVC calculations (3Mensio 941 ± 623, Syngo.Via 948 mm3 ± 655, CVI42 941 ± 637; p = 0.455). The best inter-vendor agreement was found between the CVI42 and the Syngo.Via (ICC 0.997 (CI 0.995–0.998)), followed by the 3Mensio and the CVI42 (ICC 0.996 (CI 0.922–0.998)), and the 3Mensio and the Syngo.Via (ICC 0.992 (CI 0.986–0.995)). There was excellent intra- (3Mensio: ICC 0.999 (0.995–1.000); CVI42: ICC 1.000 (0.999–1.000); Syngo.Via: ICC 0.998 (0.993–1.000)) and inter-observer variability (3Mensio: ICC 1.000 (0.999–1.000); CVI42: ICC 1.000 (1.000–1.000); Syngo.Via: ICC 0.996 (0.985–0.999)) for all software types. Contrast-enhanced MDCT-derived AVC scores are interchangeable between and reproducible within different commercially available software solutions. This is important since sufficient reproducibility, interchangeability and valid results represent prerequisites for accurate TAVR planning and its widespread clinical use

Mitral valve reconstruction by Paneth and pericardial strip plasty by Hetzer in Patients with mitral valve insufficiency

Für die operative Versorgung der Mitralklappeninsuffizienz (MI), der zweithäufigsten Indikation zur operativen Herzklappenversorgung, stehen mit dem Ersatz und der Rekonstruktion (MKR) zwei grundsätzliche Verfahren zu Verfügung. Letztere ist nach aktueller Studienlage wenn möglich zu bevorzugen. Mit der nach Hetzer modifizierten Paneth-Plastik hat ein weiteres Verfahren zur MKR in den Operationssaal Einzug erhalten. Hierbei wird zur Stabilisierung ein unbehandelter autologer Perikardstreifen dem posterioren Klappenanulus aufgenäht. Ziel dieser Arbeit ist es, den postoperativen Verlauf von 104 Patienten, die im Deutschen Herzzentrum Berlin nach dieser Methode durch einen Chirurgen versorgt wurden, zu erfassen und den postoperativen Verlauf auszuwerten. Hierzu wurden die Patienten in die Gruppe mit ischämisch bedingter MI (n=44) und in die Gruppe mit nicht ischämisch bedingter MI (n=60) eingeteilt und diese anschließend untereinander verglichen. Die Auswertung erfolgte im Sinne einer retrospektiven Datenanalyse, wobei besonderes Augenmerk auf die echokardiographisch erhobenen Befunde (u.a. Schweregrad der MI, linksventrikuläre Funktion (LVEF), Diameter des linken Atriums (LA), linksventrikulärer Diameter (LVESD bzw. LVEDD) endsystolisch bzw. enddiastolisch) gelegt wurde. Beachtung fanden zudem weitere Daten aus dem prä-, intra- und postoperativen Verlauf. Die statische Auswertung erfolgte mittels „PASW 18“. Das Durchschnittsalter für das Gesamtkollektiv ist mit 52 Jahren anzugeben, wobei es in der Ischämie Gruppe mit 63 Jahren ±10 über dem in der nicht Ischämie Gruppe mit 44 Jahren ±28 liegt. Bei der Auswertung echokardiographischer Daten zeigte sich in beiden untersuchten Gruppen eine signifikante Abnahme der MI von 2,97 ±0,54 auf 0,34 ±0,56 nach dem 30. postoperativen Tag (POD 30) und auf 0,59 ±0,75 nach dem ersten postoperativen Jahr (POM 12) in der nicht Ischämie Gruppe und in der Ischämie Gruppe von 2,49 ±0,5 auf 0,03 ±0,19 zum Zeitpunkt POD 30 und 0,17 ±0,41 zum Zeitpunkt POM 12. Ebenfalls als signifikant erwies sich die Verkleinerung des LVEDD in beiden Patientengruppen. Ebenso zeigte sich eine Abnahme des LVESD sowie des Durchmessers des LA. Eine Signifikanz konnte jedoch nicht nachgewiesen werden. Die LVEF ist in beiden Gruppen im postoperativen Verlauf signifikant angestiegen. So betrug die LVEF im Mittel präoperativ in der Ischämie Gruppe 30 % und in der nicht Ischämie Gruppe 50 %. Zum Zeitpunkt POM 12 zeigte sich eine LVEF von 45 % in der Ischämie Gruppe gegenüber 58 % in der nicht Ischämie Gruppe. Zudem zeigte sich in der nicht Ischämie Gruppe eine signifikant reduzierte 1- Jahressterblichkeit mit 8% gegenüber 23% in der Ischämie Gruppe. Abschließend gilt es zu konstatieren, dass die nach Hetzer modifizierte Paneth-Plastik sehr gute Ergebnisse im postoperativen Verlauf aufzeigt und bei minimierter Einbringung von Fremdmaterial im Vergleich zu anderen Operationstechniken mehr als nur eine Alternative darstellt.Mitral valve insufficiency is after aortic valve stenosis the second important indication for valve operation. There are two different surgical options: mitral valve reconstruction (MVR) and mitral valve replacement. Several studies have shown that reconstruction has definite advantage over replacement with regard to perioperative mortality and morbidity. There are a lot of different surgical methods for MVR. A young technique is the paneth technique modified by Hetzer: to stabilize the posterior annulus an autologous untreated pericardial strip is used. The postoperative outcome was documented in patients who underwent this operation method. The two subgroups of patients suffered by ischemic mitral insufficiency versus non ischemic mitral insufficiency were evaluated. A retrospective data analysis was done for the first year post operationem. Patients were included who underwent surgery between 1992 and 2009 in the German Heart Institute. Therefore echocardiographic parameters were evaluated according to severity of the MI, diameter of the left atrium and the leftventricular endsystolic (LVESD) and enddiastolic diameter (LVEDD). 104 included Patients were separated into two groups: ischemic mitral valve insufficiency (n=44) and non ischemic mitral valve insufficiency (n=60). Differences between the two groups were analyzed according to the pre-, intra- and postoperative datas. Therefore “PASW 18 Statistic” was used. Data analysis revealed a middle age of 52 years. Patients with ischemic MI were in the middle 63 ± 10 years old and Patients with non ischemic MI were in the middle 44 ± 28 years old. 86% men were in the ischemic MI group and 58% men in the non ischemic group. A significant decrease of the mitral valve insufficiency from 2,97 ± 0,54 to 0,34 ± 0,56 could be shown after the 30th postoperative day and to 0,59 ± 0,75 after the first postoperative year in the non ischemic MI group. A significant reduction of the mitral valve insufficiency occurred also in the ischemic MI group from 2,49 ± 0,5 to 0,03 ± 0,19 30 days after operation and to 0,17 ± 0,41 after the first year post operation. A significant decrease of the LVEDD could be shown in both groups. Otherwise a decrease of the LVESD could be shown, but was not significant. A tendency for the LA decrease was also shown but not significant. The left ventricular ejection fraction (LVEF) increased significantly in both groups. The average for the LVEF was 30% preoperative in the ischemic MI group and 50% in the non ischemic MI group. After one year postoperative an increase to 45% in the ischemic group could be shown towards 58% in the non ischemic MI group. The overall 1-year mortality was 14%, 8% for the non ischemic MI group and 23 % for the ischemic MI group. This was a significant difference. It is to conclude that the Paneth technique modified by Hetzer shows very good results in the postoperative follow up. With the minimal need of foreign material it is more than only an option to other operative methods

Interpretable cardiac anatomy modeling using variational mesh autoencoders

Cardiac anatomy and function vary considerably across the human population with important implications for clinical diagnosis and treatment planning. Consequently, many computer-based approaches have been developed to capture this variability for a wide range of applications, including explainable cardiac disease detection and prediction, dimensionality reduction, cardiac shape analysis, and the generation of virtual heart populations. In this work, we propose a variational mesh autoencoder (mesh VAE) as a novel geometric deep learning approach to model such population-wide variations in cardiac shapes. It embeds multi-scale graph convolutions and mesh pooling layers in a hierarchical VAE framework to enable direct processing of surface mesh representations of the cardiac anatomy in an efficient manner. The proposed mesh VAE achieves low reconstruction errors on a dataset of 3D cardiac meshes from over 1,000 patients with acute myocardial infarction, with mean surface distances between input and reconstructed meshes below the underlying image resolution. We also find that it outperforms a voxelgrid-based deep learning benchmark in terms of both mean surface distance and Hausdorff distance while requiring considerably less memory. Furthermore, we explore the quality and interpretability of the mesh VAE's latent space and showcase its ability to improve the prediction of major adverse cardiac events over a clinical benchmark. Finally, we investigate the method's ability to generate realistic virtual populations of cardiac anatomies and find good alignment between the synthesized and gold standard mesh populations in terms of multiple clinical metrics

Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials

Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and – with less certainty – testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required

Additional file 1 of Cardiovascular magnetic resonance-derived left atrioventricular coupling index and major adverse cardiac events in patients following acute myocardial infarction

Additional file 1: Figure S1. Kaplan–Meier curves for survival analyses in subgroup of low-risk patients. Left atrioventricular coupling index (LACI) and survival in low-risk patients according to left ventricular ejection fraction (LVEF) after acute myocardial infarction. Incidence of MACE (major adverse cardiac events) according to high and low LACI classified according to Youden Index

Improving exercise capacity and quality of life using non-invasive heart failure treatments: evidence from clinical trials

Endpoints of large-scale trials in chronic heart failure have mostly been defined to evaluate treatments with regard to hospitalizations and mortality. However, patients with heart failure are also affected by very severe reductions in exercise capacity and quality of life. We aimed to evaluate the effects of heart failure treatments on these endpoints using available evidence from randomized trials. Interventions with evidence for improvements in exercise capacity include physical exercise, intravenous iron supplementation in patients with iron deficiency, and – with less certainty – testosterone in highly selected patients. Erythropoiesis-stimulating agents have been reported to improve exercise capacity in anaemic patients with heart failure. Sinus rhythm may have some advantage when compared with atrial fibrillation, particularly in patients undergoing pulmonary vein isolation. Studies assessing treatments for heart failure co-morbidities such as sleep-disordered breathing, diabetes mellitus, chronic kidney disease and depression have reported improvements of exercise capacity and quality of life; however, the available data are limited and not always consistent. The available evidence for positive effects of pharmacologic interventions using angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists on exercise capacity and quality of life is limited. Studies with ivabradine and with sacubitril/valsartan suggest beneficial effects at improving quality of life; however, the evidence base is limited in particular for exercise capacity. The data for heart failure with preserved ejection fraction are even less positive, only sacubitril/valsartan and spironolactone have shown some effectiveness at improving quality of life. In conclusion, the evidence for state-of-the-art heart failure treatments with regard to exercise capacity and quality of life is limited and appears not robust enough to permit recommendations for heart failure. The treatment of co-morbidities may be important for these patient-related outcomes. Additional studies on functional capacity and quality of life in heart failure are required

Predictors of lower exercise capacity in patients with cancer

Abstract Maintaining cancer patients’ exercise capacity and therefore patients’ ability to live a self-determined life is of huge importance, but little is known about major determinants. We sought to identify determinants of exercise capacity in patients with a broad spectrum of cancer types, who were already receiving cancer treatment or about to commence such therapy. Exercise capacity was assessed in 253 consecutive patients mostly suffering from advanced cancer using the 6-min walk test (6-MWT). All patients underwent echocardiography, physical examination, resting electrocardiogram, hand grip strength (HGS) measurement, and laboratory assessments. Patients were divided into two groups according to the median distance in the 6-MWT (459 m). Patients with lower exercise capacity were older, had significantly lower HGS and haemoglobin and higher values of high sensitive (hs) Troponin T and NT-proBNP (all p  0.2). Using multivariable logistic regression, we found that the presence of anaemia (odds ratio (OR) 6.172, 95% confidence interval (CI) 1.401–27.201, p = 0.016) as well as an increase in hs Troponin T (OR 3.077, 95% CI 1.202–5.301, p = 0.019) remained independent predictors of impaired exercise capacity. Increasing HGS was associated with a reduced risk of a lower exercise capacity (OR 0.896, 95% CI 0.813–0.987, p = 0.026). Screening patients for elevated hs troponin levels as well as reduced HGS may help to identify patients at risk of lower exercise capacity during cancer treatment