Tricuspid valve surgery following septal myectomy in patients with a cardiac implantable electronic deviceCentral MessagePerspective

Background: Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of developing cardiac arrhythmias and have a high prevalence of cardiac implantable electronic device (CIED) use. Tricuspid regurgitation (TR) is a potential complication of device leads and can be severe enough to prompt surgical intervention. Methods: We identified 21 consecutive patients who underwent tricuspid valve (TV) surgery for device lead-induced TR late following septal myectomy (SM) for obstructive HCM. The primary endpoint was long-term all-cause mortality. Results: The median patient age was 63 years (range, 55-71 years), 19 patients (91%) had New York Heart Association class III or IV limitation, and all patients were receiving diuretics for right heart failure. The median interval between device implantation and TV surgery was 4 years (range, 1.5-8.5 years). Eight patients (38%) underwent pacemaker implantation due to complete heart block following SM. Preoperatively, TR was severe in 81% of the patients. The primary mechanism of lead-induced TR was leaflet impingement without adherence (n = 15; 75%). Nine patients (43%) underwent TV replacement, and 12 patients (57%) underwent repair. Only 1 patient died early postoperatively. Patients with lead-induced TR had markedly reduced long-term survival compared to the overall population of patients undergoing SM; 5-year survival was 58%, compared to 96% for the contemporary SM group. Conclusions: Late lead-induced TR is a potential complication of CIEDs in patients with HCM who have undergone SM. Although TV repair and replacement can be done with acceptable early mortality, late patient survival is poor

Tandem deep learning and logistic regression models to optimize hypertrophic cardiomyopathy detection in routine clinical practice

Background: An electrocardiogram (ECG)-based artificial intelligence (AI) algorithm has shown good performance in detecting hypertrophic cardiomyopathy (HCM). However, its application in routine clinical practice may be challenging owing to the low disease prevalence and potentially high false-positive rates. Objective: Identify clinical characteristics associated with true- and false-positive HCM AI-ECG results to improve its clinical application. Methods: We reviewed the records of the 200 patients with highest HCM AI-ECG scores in January 2021 at our institution. Logistic regression was used to create a clinical variable–based “Candidacy for HCM Detection (HCM-DETECT)” score, differentiating true-positive from false-positive AI-ECG results. We validated the HCM-DETECT score in an independent cohort of 200 patients with the highest AI-ECG scores from January 2022. Results: In the 2021 cohort (median age 71 [interquartile range 58–80] years, 48% female), the rates of true-positive, false-positive, and indeterminate AI-ECG results for HCM detection were 36%, 48%, and 16%, respectively. In the 2022 cohort, the rates were 26%, 47%, and 27%, respectively. The HCM-DETECT score included age, coronary artery disease, prior pacemaker, and prior cardiac valve surgery, and had an area under the receiver operating characteristic curve of 0.81 (95% confidence interval 0.73–0.87) for differentiating true- vs false-positive AI results. When the 2022 cohort was limited to HCM detection candidates identified with the HCM-DETECT score, the false-positive AI-ECG rate was reduced from 47% to 13.5%. Conclusion: Application of a clinical score (HCM-DETECT) in tandem with an AI-ECG model improved HCM detection yield, reducing the false-positive rate of AI-ECG more than 3-fold

Ultrasound Enhancing Agents with Transthoracic Echocardiography for Maximal Wall Thickness in Hypertrophic Cardiomyopathy

Objectives: To determine whether ultrasound enhancing agent (UEA) changes maximal wall thickness (WT) in hypertrophic cardiomyopathy (HCM), and if it improves correlation with magnetic resonance imaging (MRI). Patients and Methods: A total of 107 patients with HCM were prospectively enrolled at a single tertiary referral center between July 10, 2014, and August 31, 2017, and underwent transthoracic echocardiography (TTE) with and without UEA and MRI. Maximal WT measurements were compared, and variability among the 3 modalities was evaluated using a simple linear regression analysis and paired t tests and Bland-Altman plots. Interobserver variability for each technique was assessed. Results: Most (63%) of cardiac imagers found UEA helpful in determining maximal WT by TTE, with 49% reporting change in WT. Of 52 patients where UEA changed WT measurement, 32 (62%) reported an increase and 20 (38%) reported a decrease in WT. The UEA did not alter the median discrepancy in WT between MRI and TTE. However, where UEA increased reported WT, the difference between MRI and TTE improved in 79% of cases (P=.001) from 2.0-0.5mm. In those with scar on MRI, UEA improved agreement of WT between TTE and MRI compared with that of TTE without UEA (79% vs 39%; P=.011). Interclass correlation coefficient for WT for TTE without UEA, with UEA, and MRI was 0.84; (95% CI, 0.61-0.92), 0.88; (95%CI, 0.82-0.92), and 0.97; (95%CI, 0.96-0.98), respectively. Conclusion: Although use of UEA did not eliminate differences in WT discrepancy between modalities, the addition of UEA to TTE aided in WT determination and improved correlation with MRI in those with greater WT and in all patients with myocardial scars