Mankad, Sunil

Abstract Background Left ventricular ejection fraction (LVEF) and diastolic dysfunction (DD) are key prognostic factors in patients with ST-segment elevation myocardial infarction (STEMI). AI-enabled ECG (AI-ECG) has been shown to have excellent agreement with transthoracic echocardiography (TTE) assessment and incremental prognostic value to LVEF. Methods We retrospectively analyzed 1,005 adult acute STEMI patients referred for echocardiography (10/2007–01/2025) who had ECGs within seven days before and after the reference echocardiogram. The ECG closest to the TTE date was designated as the pre-STEMI and post-STEMI ECG, respectively. AI-ECG was used to classify diastolic function grades and grades 2 and 3 were considered as DD. Patients were stratified by LVEF (≤50% vs. >50%) at the time of TTE and the association between AI-ECG-determined DD and 10-year mortality was assessed using Cox regression and Kaplan-Meier curves. Results Among 1,005 patients (mean age 66.4 ± 13.4 years, 29.9% females), AI-ECG-determined DD prior to STEMI was present in 47.9% of patients with LVEF ≤50% and 30.3% of those with preserved LVEF (>50%). DD status remained unchanged post-STEMI in 79.3% of cases, while 10.2% showed worsening diastolic function. Regardless of LVEF, AI-ECG-determined DD prior to STEMI was associated with higher mortality risk (LVEF ≤50%: HR 3.03, 95% CI 2.16–4.24, p < 0.001; LVEF >50%: HR 2.32, 95% CI 1.58–3.41, p < 0.001). Post STEMI AI-ECG-determined DD remained a significant predictor of mortality (LVEF ≤50%: HR 2.54, 95% CI 1.82–3.53, p < 0.001; LVEF >50%: HR 2.43, 95% CI 1.66–3.58, p < 0.001). Echocardiographically determined DD also correlated with higher mortality (LVEF ≤50%: HR 4.91, 95% CI 2.95–8.15, p < 0.001; LVEF >50%: HR 2.72, 95% CI 1.68–4.41, p < 0.001). In patients with LVEF ≤50%, AI-ECG-determined DD remained associated with higher mortality even after adjusting for echocardiographically determined DD (pre-STEMI: HR 1.85, 95% CI 1.23–2.80, p < 0.001; post-STEMI: HR 1.90, 95% CI 1.23–2.91, p < 0.001). Conclusion AI-ECG-determined DD is a significant predictor of mortality in STEMI, independent of LVEF. The presence of normal filling pressure may indicate a better clinical outcome in patients with reduced LVEF patients. These findings underscore the clinical utility of AI-ECG in refining risk stratification beyond conventional LVEF assessment.

Abstract Background Cardiac dysfunction is a common complication in septic population. Though traditionally considered an acute and reversible phenomenon, the true prevalence of reversible cardiac dysfunction and its long-term prognostic implications remain unclear. Purpose Using serial echocardiographic assessments, this study aimed to investigate the prevalence and reversibility of cardiac dysfunction in septic patients, and to determine whether the recovery of cardiac function is associated with improved 5-year mortality. Methods We retrospectively screened 16,041 septic patients who underwent transthoracic echocardiography during their ICU stay. After excluding patients with a history of heart failure, pre-existing cardiac dysfunction, or lacking follow-up echocardiographic assessments post-ICU discharge, 3,112 patients were enrolled for analysis. To assess the reversibility of cardiac dysfunction, paired-sample t-tests were used to evaluate changes in echocardiographic parameters between in-ICU and post-ICU measurements. Furthermore, 5-year mortality were compared among controls and patients with or without recovery of echocardiographic abnormalities. Results Totally 1,604 patients (51.5%) were found to have newly recognized cardiac dysfunction during ICU stay. The mean interval between ICU admission and follow-up echocardiography was 425 days. Most in-ICU echocardiographic abnormalities demonstrated partial recovery over time, with the exception of left atrial volume index (LAVi) and right ventricular fractional area change (RV FAC) (Figure 1). Recovery of left ventricular ejection fraction (LVEF), average E/e', and tricuspid regurgitation (TR) velocity was significantly associated with reduced 5-year mortality (Figure 2). Older age [adjusted hazard ratio (aHR) 0.99, p=0.034], male gender (aHR 0.54, p=0.003), and elevated troponins (aHR 0.87, p=0.006) were negative predictors for LVEF recovery; while older age (aHR 0.099, p=0.043), higher APACHE III scores (aHR 0.99, p=0.018), atrial fibrillation (aHR 0.59, p=0.046), and chronic pulmonary disease (aHR 0.68, p=0.042) were negative predictors for TR velocity recovery. Conclusions Both the presence and recovery of newly recognized echocardiographic abnormalities during ICU stay were significantly associated with long-term mortality. Certain abnormalities, such as increased LAVi, persisted despite resolution of sepsis.Figure 1 Figure 2

Kounis syndrome (KS) is a dangerous and rare acute coronary syndrome elicited in the setting of an allergic, hypersensitivity, or anaphylactic reaction. The syndrome is caused by mast cell activation leading to a release of proinflammatory mediators that can promote coronary vasospasm, atheromatous plaque erosion with rupture, or both. We present the case of a 48-year-old female with a past medical history of type 2 diabetes, hypertension, and chronic kidney disease stage 3 who presented via ambulance with anaphylaxis following an unknown allergen exposure. She was immediately given intramuscular epinephrine with resolution of symptoms, but she continued to have chest discomfort with radiation to her back. Initial EKG showed deep ST depressions in numerous leads (mainly the inferior and anterolateral leads) with ST elevations in leads V1 and aVR, consistent with diffuse subendocardial ischemia (Figure 1). Initial troponin was 2,122 which peaked at 5,328. Coronary angiogram was immediately obtained which showed patent coronary arteries with minimal narrowing of the distal left anterior descending artery. Because of this, cardiac MRI was obtained which showed subendocardial delayed enhancement at the basal and mid left ventricle with associated subendocardial perfusion defects and myocardial edema. These were felt to be in the distributions of the left circumflex and left anterior descending arteries and likely due to vasospasm, so the patient was initiated on diltiazem. Allergy evaluated the patient and felt her symptoms represented KS. They recommended outpatient workup to identify an allergy trigger and discharge with an epinephrine pen. KS is a rare presentation of acute coronary syndrome in the setting of an allergic, hypersensitivity, or anaphylactic reaction. Clinicians must be aware of this phenomenon to be able to promptly diagnose and evaluate these patients as late diagnosis can lead to significant morbidity and mortality.

Abstract There is emerging evidence that the cardiac interatrial septum has an important role as a thromboembolic source for ischemic strokes. There is little consensus on treatment of patients with different cardiac interatrial morphologies or pathologies who have had stroke. In this paper, we summarize the important background, diagnostic, and treatment considerations for this patient population as presented during the Federation of American Societies for Experimental Biology (FASEB) Virtual Catalytic Conference on the Cardiac Interatrial Septum and Stroke Risk, held on December 7, 2022. During this conference, many aspects of the cardiac interatrial septum were discussed. Among these were the embryogenesis of the interatrial septum and development of anatomic variants such as patent foramen ovale and left atrial septal pouch. Also addressed were various mechanisms of injury such as shunting physiologies and the consequences that can result from anatomic variants, as well as imaging considerations in echocardiography, computed tomography, and magnetic resonance imaging. Treatment options including anticoagulation and closure were addressed, as well as an in‐depth discussion on whether the left atrial septal pouch is a stroke risk factor. These issues were discussed and debated by multiple experts from neurology, cardiology, and radiology.

Abstract Background and Aims Bicuspid aortic valve (BAV) is the most common congenital heart anomaly. Lifetime morbidity and whether long-term survival varies according to BAV patient-sub-groups are unknown. This study aimed to assess lifetime morbidity and long-term survival in BAV patients in the community. Methods The authors retrospectively identified all Olmsted County (Minnesota) residents with an echocardiographic diagnosis of BAV from 1 January 1980 to 31 December 2009, including patients with typical valvulo-aortopathy (BAV without accelerated valvulo-aortopathy or associated disorders), and those with complex valvulo-aortopathy (BAV with accelerated valvulo-aortopathy or associated disorders). Results 652 consecutive diagnosed BAV patients [median (IQR) age 37 (22–53) years; 525 (81%) adult and 127 (19%) paediatric] were followed for a median (IQR) of 19.1 (12.9–25.8) years. The total cumulative lifetime morbidity burden (from birth to age 90) was 86% (95% CI 82.5–89.7); cumulative lifetime progression to ≥ moderate aortic stenosis or regurgitation, aortic valve surgery, aortic aneurysm ≥45 mm or z-score ≥3, aorta surgery, infective endocarditis and aortic dissection was 80.3%, 68.5%, 75.4%, 27%, 6% and 1.6%, respectively. Survival of patients with typical valvulo-aortopathy [562 (86%), age 40 (28–55) years, 86% adults] was similar to age-sex-matched Minnesota population (P = .12). Conversely, survival of patients with complex valvulo-aortopathy [90 (14%), age 14 (3–26) years, 57% paediatric] was lower than expected, with a relative excess mortality risk of 2.25 (95% CI 1.21–4.19) (P = .01). Conclusion The BAV condition exhibits a high lifetime morbidity burden where valvulo-aortopathy is close to unavoidable by age 90. The lifetime incidence of infective endocarditis is higher than that of aortic dissection. The most common BAV clinical presentation is the typical valvulo-aortopathy with preserved expected long-term survival, while the complex valvulo-aortopathy presentation incurs higher mortality.

AbstractBackgroundThe predictors and clinical significance of increased Doppler‐derived mean diastolic gradient (MG) following transcatheter edge‐to‐edge mitral valve repair (MVTEER) remain controversial.ObjectiveWe sought to examine baseline correlates of Doppler‐derived increased MG post‐MVTEER and its impact on intermediate‐term outcomes.MethodsPatients undergoing MVTEER were analyzed retrospectively. Post‐MVTEER increased MG was defined as >5 mmHg or aborted clip implantation due to increased MG intraprocedurally. Baseline MG and 3D‐guided mitral valve area (MVA) by planimetry were retrospectively available in 233 and 109 patients.Results243 patients were included; 62 (26%) had MG > 5 mmHg post‐MVTEER or aborted clip insertion, including 7 (11%) that had aborted clip implantation. Mortality occurred in 63 (26%) during a median follow up of 516 days (IQR 211, 1021). Increased post‐MVTEER MG occurred more frequently in females (44% vs. 16%, p < 0.001), those with baseline MVA <4.0 cm2 (71% vs. 16%), baseline MG ≥4 mmHg (61% vs. 20%), or multiple clips implanted (33% vs. 21%, p = 0.04). Increased post‐MVTEER MG was associated with increased subsequent mortality compared to those with normal gradient (HR 1.91 95% CI 1.15–3.18 p = 0.016) as was aborted clip insertion compared to all others (HR 5.23 95% CI 2.06–13.28 p < 0.001).ConclusionsSmaller baseline MVA and increased baseline MG are associated with increased MG post‐MVTEER and patients with a Doppler‐derived post‐MVTEER MG >5 mmHg suffered excess subsequent mortality. In high risk patients considered for MVTEER, identification of those at risk of iatrogenic mitral stenosis with MVTEER is important as they may be optimally treated with alternate surgical or transcatheter therapies.

AbstractBackgroundTranscatheter edge‐to‐edge repair with MitraClip is only approved for treatment of mitral regurgitation but is increasingly used to treat concomitant tricuspid regurgitation (TR) due to its common coexistence and association with poor outcomes. This study aimed to describe the learning curve associated with the challenge of off‐label treatment of concomitant TR.MethodsThis is a retrospective review of initial and consecutive patients who underwent combined edge‐to‐edge repair of mitral and tricuspid valves (TVs) at our institution from August 2017 to October 2019.ResultsRepair of both valves with MitraClip was performed in 22 patients (median age 81.5 years, 32% female). Mean procedure time was 176 ± 47 min; mean fluoroscopy time was 65 ± 24 min. Procedure duration in the first tertile was significantly longer (223 ± 13 min) than in the third tertile (143 ± 23 min, p = .0003). Median number of total clips placed per case was 3; in 15 patients (68%), the anterior and septal leaflets of the TV were clipped. The average changes in mean right atrial (RA) and left atrial (LA) pressures were −1.7 ± 2.5 mmHg (p = .0080) and −3.2 ± 4.6 mmHg (p = .0045), respectively. The average changes in RA and LA V‐wave heights were −3.3 ± 4.0 mmHg (p = .0009) and −8.1 ± 9.9 mmHg (p = .038), respectively. There was a significant trend toward decreasing residual TR over the course of the series (p = .046). At 30 days, survival was 100% and mean NYHA class decreased from 2.8 to 1.8 (p < .0001).ConclusionsCombined edge‐to‐edge tricuspid and mitral valve repair is safe and feasible. With experience, procedure duration and residual TR decreased.

Abstract Background Transcatheter edge-to-edge mitral valve repair (TMVR; MitraClip, Abbott Vascular) is clinically approved for treatment of severe, symptomatic mitral regurgitation (MR) in high or prohibitive surgical risk patients. Iatrogenic mitral stenosis is a known complication of TMVR, but determinants of increased post-procedure mean diastolic gradient are not well defined. Purpose We aimed to investigate the determinants of increased mitral mean diastolic gradient after TMVR. Methods We retrospectively reviewed 59 patients. 2D and 3D TEE data sets acquired before and immediately after procedure were analyzed. 4D Cardio-View and 4D MV-Assessment (TomTec, Germany) were used for the analysis of the 3D volume data set. Quantitative mitral valve analysis was done at the end of systole. Increased mitral mean diastolic gradient after TMVR was correlated with pre-procedure 2D and 3D echocardiographic data. Results 34 patients had primary MR, 25 patients had mixed/secondary MR. Baseline mean mitral diastolic gradient was 2.0 ± 0.9mmHg and increased to 3.9 ± 1.8mmHg post-TMVR and the mean 3D planimetric mitral valve area decreased from 5.3 ± 1.5cm2 to 2.6 ± 1.0cm2. Implantation of multiple clips was performed less frequently in patients with smaller baseline mitral valve area; 8% vs 47% in the lowest quartile vs all others (p = 0.006). 12(20%) of patients had a mean diastolic gradient &gt;5mmHg post-TMVR and 15(25%) of patients had a post-TMVR mitral valve area &lt;2.0 cm2. There was no significant difference in post-procedure heart rate between patients with mean diastolic gradient ≤5mmHg vs &gt;5mmHg (p = 0.08). Patient characteristics according to post-TMVR mean diastolic gradient are shown in the Table. Post-TMVR mean diastolic gradient &gt;5mmHg was more common in patients with increased pre-procedure mean diastolic gradient(p = 0.006), post-TMVR mitral valve area &lt;2.0 cm2(40% vs 14%, p = 0.03), and ≥moderate residual mitral regurgitation(38% vs 11%, p = 0.02). Post-TMVR mitral valve area &lt;2.0cm2 was present in 50% vs 19% of patients with vs without a mean gradient &gt;5mmHg(p = 0.04). Conclusions Elevated post-TMVR mean diastolic gradient is multifactorial and related to mitral stenosis, but residual mitral regurgitation also appears to be an important contributor to increased gradients in some patients. Larger cohorts are likely needed to assess the concurrent impact of mitral annular calcification, leaflet calcification, and other variables on post-TMVR mean gradient. Abstract P1798 Figure. 2D and 3D Echocardiographic Parameters

Abstract Background In patients with hemodynamically-significant chronic aortic valve regurgitation (AR), the prognostic significance of routinely-measured diastolic blood pressure (DBP), resting heart rate (RHR) and physical examination signs of heart failure (HF), is unknown. Purpose To investigate the association of DBP, RHR and HF signs, with all-cause mortality. Methods This retrospective cohort study included all consecutive patients with moderately-severe or severe AR within a tertiary-referral center from 2006–2017. Patients with ≥moderate aortic stenosis and those with ≥moderate mitral stenosis/regurgitation were excluded. Results Of 820 patients (age 59±17 years; 82% men) with DBP 64±13mmHg and RHR 64±12bpm, followed for 5.5±3.5 years, 104 died under medical management and 400 underwent aortic valve surgery (AVS). In multivariable analysis, DBP (adjusted-hazard ratio [HR] 0.82 [0.68–0.98] p=0.031, per 10mmHg increase), RHR (adjusted HR 1.2 [1.01–1.41] p=0.034 per 10bpm increase), and any HF signs (adjusted HR 1.66 [1.04–2.61] p=0.032) were associated with all-cause death independently of demographics, comorbidities, and guideline-derived surgical triggers. Mortality increased in a J-curve fashion for DBP starting at 70 mmHg and peaking at 55 mmHg (Fig A,C), and in a linear fashion for RHR starting at 60bpm (Fig B, D). The association persisted after additional adjustment for medications, presence of hypertension and time-dependent AVS. A clinical score combining DBP, RHR and any HF signs increased the mortality risk-discrimination of demographics and comorbidities from 74% to 79% (p=0.01), and from 79% to 82% after addition of surgical triggers (p=0.04). Figure. Risk of death by DBP and RHR Conclusions In patients with AR, routinely-measured vital signs and physical examination are strongly associated with all-cause mortality; lower DBP, higher RHR and any HF signs are independent predictors of mortality, and provide incremental mortality risk-discriminating value to baseline demographics, comorbidities and guideline-derived surgical triggers. These findings represent a clinical paradigm shift and have guideline implications.

We aimed to assess the role of a short duration multimedia workshop to improve the knowledge and skills in cardiac critical care ultrasonography. Thirty critical care physicians participated in the cardiac critical care ultrasonography workshop. Two weeks prior to hands-on training, a three-hour web-based didactic lecture was provided to learners. Hands-on training consisted of a two-hour examination on models without pathology and a 30-minute debriefing with instructors. Pre- and post-workshop knowledge tests were conducted online using 30 multiple choice questions. Pre- and post-workshop skill tests were video captured for evaluation by two reviewers to whom data were masked. Scores were based on 34 predetermined checklist items including learner performance, instrumentation and adequacy of ultrasound images. Learners’ confidence levels on image acquisition were assessed using a ten-point Likert scale. A short duration multimedia, hands-on workshop improved intensivists’ knowledge, skills and confidence levels on cardiac critical care ultrasonography image acquisition. Further studies are needed to assess the sustainability of observed improvements. This module may be a practical option for the acquisition and maintenance of cardiac critical care ultrasonography knowledge and skills.