Abstract Funding Acknowledgements Type of funding sources: None. Background Patients hospitalized with chest pain frequently undergo stress echocardiography for detecting inducible ischemia, but other cardiac pathology is often noted on rest imaging. The long term significance of these findings is not well studied. We hypothesized that such findings indicative of cardiovascular pathology on the resting portion of a stress echocardiogram have prognostic significance for patients admitted with chest pain. Methods We examined patients admitted with chest pain at an academic tertiary care medical center over a 2-year period who had stress echocardiography as the primary diagnostic test. Patients admitted with heart failure symptoms or syncope or patients referred for presurgical/prerehabilitation clearance were excluded. Resting and stress echocardiograms were evaluated by cardiologists with board-certification in echocardiography, and resting abnormalities were analyzed for any effect on cardiovascular outcomes, assessed over 3 years of follow up. Survival of patients with echocardiographic abnormalities on the resting study (resting wall motion abnormalities) was compared with an age- and sex-matched cohort of admitted chest pain patients without resting abnormalities. Results A total of 587 patients met inclusion criteria, and 198 (34%) had resting echocardiographic abnormalities. The most common abnormality involved the left ventricle. Left ventricular hypertrophy (LVH) was seen in 16% (96), and resting wall abnormalities were seen in 15% (90); among the 90 patients with resting wall motion abnormalities, segmental wall motion abnormality was seen in 57 (9.7% of total sample), and global LV dysfunction was seen in 33 (5.6% of total sample). LVH in the absence of hypertension was found in 5% (28), raising the diagnostic possibility of hypertrophic cardiomyopathy. Moderate or greater left heart valvular abnormalities were found in 3% (18). Abnormal pericardial effusions greater than mild (excluding trivial effusion) were found in 3 patients (0.5%), and pulmonary hypertension was detected in 13 patients (2%). At 3-year follow-up, patients with resting wall motion abnormalities were found to have a higher mortality than an age and sex-matched cohort of chest pain patients without these abnormalities at rest; 85% vs. 97%, p<0.015. Conclusions In patients hospitalized for chest pain, cardiac diagnoses with prognostic significance are often detected on the resting echocardiographic examination. These abnormalities offer insight into outcomes, given their propensity to determine mortality three years post admission, and an opportunity to institute adequate therapy that alters adverse outcomes.

Introduction Plain chest radiograph (CXR) is the most common imaging modality used to evaluate respiratory symptoms. CXR severity scoring has been shown to be an independent predictor of need for hospital admission and intubation and mechanical ventilation (I&MV) in COVID19 patients, but its role in predicting mortality is yet to be explored. Aim We evaluated the predictive value and prognostic utility of CXRs in adult patients with COVID 19 infections. Methods A retrospective analysis of 200 consecutive patients between March 2020 to May 2020 admitted to our tertiary centre with confirmed COVID 19 infection was conducted. Lung fields on CXRs were divided into 6 zones: right and left upper, mid and lower zones. Mild changes were defined as unilateral changes zones 1–3; moderate changes were: bilateral changes zones 2–3; severe changes: changes zones 4–6. CXRs were reviewed and scored independently by 2 reporters: thoracic radiologist and acute medical physician who were blinded to baseline patient characteristics and outcomes. Results 200 patients (median age: 79 (IQR 63–86) years) were included, 108 of which were females and 92 males. 61 (30.5%) died and 139 (69.5%) were discharged. During admission, 19 (9.5%) were admitted to ITU, 2 (1%) to the Non-invasive ventilation (NIV) unit and 179 (89.5%) to COVID Medical wards. Of the 61 patients (median age: 82 (IQR 73–89) years; 27 (44.3%) male, 34 (55.7%) female) who died: 3 (4.9%) were admitted to ITU, 1 (1.6%) to NIV unit and 57 (93.4%) to COVID medical wards; 45 (73.8%) received oxygen up to 15L, 1 (1.6%) received nasal high flow oxygen, 2 (3.3%) received CPAP and 3 (4.9%) received I&MV. CXR changes on admission were not an independent predictor of mortality; no CXR changes (p=0.099), Mild CXR changes (p=0.416), Moderate CXR changes (p=0.283), Severe CXR changes (p=0.994). Severe CXR changes was an independent predictor of I&MV (OR 2.298; 95% CI 1.156–4.566; p=0.018). Conclusion We conclude that a CXR severity score is an effective tool to predict risk for hospital admission and the need for I&MV. Further larger studies will help validate this score by following up repeat CXRs to determine disease trajectory.

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Background: Therapeutic intervention targeted to restrict apoptosis could reduce left ventricle dysfunction.Ergo, noninvasive assessment of apoptosis could be of seminal clinical importance.However, imaging myocardial apoptosis may have differences in feasibility and efficacy when apoptosis is focal (as in the infarct zone) vs. diffuse (as in cardiac allograft rejection).Focal apoptosis imaging using Duramycin can avoid some limitations of Annexin A5 imaging and may be feasible after a major insult like MI, but its comparative efficacy in diffusely distributed apoptosis is unknown.Purpose: To evaluate the feasibility and effectiveness of imaging apoptosis with a novel method [(99mTc) Duramycin], in experimental models of both focal as well as diffuse myocardial insults that cause apoptosis. Methods: 2 models were studied:Protocol A [regional injury after ischemia-reperfusion (IR)] -In an IR injury model in 13 rabbits, 7mCi of 99mTc-labeled Duramycin (n = 10; 4 animals treated with an anti-apoptotic agent-minocycline) or 99mTc-Linear Duramycin (a negative tracer control, n = 3) were intravenously administered 30 minutes after reperfusion.In-vivo mSPECT-mCT imaging was performed 3 hours after reperfusion followed by ex-vivo imaging of the explanted heart, quantitative assessment of tracer uptake and pathological characterization.Protocol B [diffuse apoptosis in cardiac allograft rejection (CAR)] -In a CAR model, 16 mice received abdominal heterotopic cardiac allografts (n= 4 each).Group 1: Balb/c donor to B6 recipient (allogeneic transplant, ALO).Group 2: B6 donor to B6 recipient (syngeneic control transplant, CON).Group 3: Balb/c donor to B6 recipient treated with abatacept (allogeneic transplant and immunosuppressed, IMS).Group 4: Bm12 donor to B6 recipient (sub-allogeneic transplant to test for chronic CAR, CHR).Animals were sacrificed at fixed points (ALO and CON 6-7 days, IMS animals 14-15 days and CHR animals 21 days following transplant).MicroSPECT/CT imaging of the heterotopic transplant was performed in vivo and ex vivo after intravenous Duramycin administration for quantitative uptake.Results: Protocol A -Intense uptake ((%ID/g) of Duramycin was observed in the infarct area (0.751 ± 0.262%) compared to remote area (0.045 ± 0.029%; p < 0.01).Minocycline attenuated apoptosis (0.354 ± 0.0624%; p < 0.01).Protocol B -CAR animals showed intense uptake in ALO (5.8 ± 2.2), followed by CHR (1.8 ± 1.5), then IMS (1.2 ± 0.4), and CON (0.90 ± 0.04) [p< 0.05 for ALO vs. both CON and IMS groups].Rejection was ISHLT Grade 3R in ALO, and Grade 1-2R in IMS / CHR groups.Conclusions Duramycin is similarly effective in imaging apoptotic cell death in localized as well as diffuse myocardial damage and tracks changing levels of apoptosis.Clinical feasibility of apoptosis imaging with a safe PE-seeking antibiotic if proven, might reduce the need for frequent endomyocardial biopsies in patients after cardiac transplant.

BackgroundSoftware‐based beamforming which utilizes delay and standard beamforming is a signal processing technique that temporarily stores data from each probe element to improve specular reflections to improve the image resolution. We compared a software algorithm which uses delay and standard beamforming with delay and sum beamforming in standard, hardware to evaluate endocardial borders and need for echo contrast.MethodsIn this prospective study, eligible participants were ≥18 years of age referred clinically for transthoracic echocardiograms. A limited study consisting of three views (apical 4, apical 3, and apical 2 chamber) was performed with the software‐based beamforming and standard platform. Number and quality of segments visualized were evaluated using a 17‐segment model. Quality of segments was graded as 0 = not visualized, 1 = incompletely visualized, or 2 = completely visualized. Overall quality score for each study (0 = poor, 1 = adequate, 2 = good) was reported. The need for contrast was determined by ASE guidelines.ResultsA total of 101 patients (mean age 61 ± 16 years, males 52%) were enrolled. Mean number of segments visualized in apical 4‐ (6.28 vs 5.65, P < .001), apical 3‐ (6.27 vs 5.54, P < .001), and apical 2‐chamber views (6.26 vs 5.72 P < .001) was higher with the software vs standard platform. The average overall score for image quality was significantly better for the software platform vs standard (1.4 vs 0.9, P =< .001). With the software platform, 23% were judged as requiring contrast as compared with 45% for the standard platform (P < .001).ConclusionsDelay and standard beamforming in software platform identified more segments with better image quality when compared to the standard high‐end platform, decreasing the need for contrast usage.

Background Midwall fibrosis and low stroke volume are independent predictors of mortality in severe aortic stenosis (AS) with preserved LV ejection fraction ( LVEF ). The role of speckle tracking echocardiography ( STE ) to identify latent myopathy pre‐ and post‐ aortic valve replacement ( AVR ) in high risk AS patients with normal LVEF is limited. Methods Demographic, 2D echocardiographic, and STE data were analyzed in patients with severe AS and preserved LVEF who underwent tissue AVR . Velocity vector imaging ( VVI ) was used to assess regional and global peak systolic longitudinal strain ( GLS ). Low flow ( LF ) was defined as an indexed LV stroke volume <35 mL/m 2 . Results Between December 2008 and May 2011, 37 patients (75 ± 9 years, 51% male) had both pre‐ and post‐ AVR echos within 6.6 ± 6.5 months (median = 4 months; range = 2.5–9.5) of surgery. Compared with pre‐ AVR , GLS (−6.9 ± 4.9% vs −11.1 ± 4.1%; P < .001) and strain rate (−0.72 ± 0.3s ‐1 vs −0.87 ± 0.3s ‐1 ; P = .01) improved post‐ AVR . Pre‐ AVR mid‐segments showed a similar myopathy as the basal segments (−9.5 ± 4.3% vs −9.0 ± 4.2%; P = .3). The 16 (43%) LF patients in this study had lower pre‐ and post‐ AVR strain compared to NF patients (GLS Pre‐ AVR : LF vs NF : −5.1 ± 4.1% vs −8.4 ± 4.9% ( P = .04) and GLS Post‐ AVR : LF vs NF : −9.2 ± 3.7% vs −12.5 ± 3.9% ( P = .01)). However, there was no difference in absolute and %change improvement in GLS post‐ AVR ( LF vs NF :∆ −4.2 ± 3.5% vs ∆−4.1 ± 5.3% ( P = .90) and 193 ± 214% vs 143 ± 230% change ( P = .5)). The lowest GLS was seen in LF / HG AS followed by LF / LG , NF / LG and NF / HG AS ; P = .03. Conclusions Latent myopathy is more pronounced in LF AS both pre‐ and post‐ AVR . Our study provides evidence of improvement in myopathy in LF AS despite a persistent worse myopathy compared to NF patients post‐ AVR .

Background: The American Society of Echocardiography (ASE) guidelines suggest the use of several echocardiographic methods to assess mitral regurgitation severity using an integrated approach, without guidance as to the weighting of each parameter. The purpose of this multicenter prospective study was to evaluate the recommended echocardiographic parameters against a reference modality and develop and validate a weighting for each echocardiographic measure of mitral regurgitation severity. Methods: This study included 112 patients who underwent evaluation with echocardiography and magnetic resonance imaging (MRI). Echocardiographic parameters recommended by the ASE were included and compared with MRI-derived regurgitant volume (MRI-RV). Results: Echocardiographic parameters that correlated best with MRI-RV were proximal isovelocity surface area (PISA) radius (r = 0.65, P < .0001), PISA-derived effective regurgitant orifice area (r = 0.65, P < .0001), left ventricular end-diastolic volume (r = 0.56, P < .0001), and PISA-derived regurgitant volume (r = 0.52, P < .0001). In the linear regression models PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet independently predicted MRI-RV. Conclusion: Echocardiographic parameters of mitral regurgitation as recommended by the ASE had moderate correlations with MRI-RV. The best predictors of MRI-RV were PISA-derived effective regurgitant orifice area, PISA-derived regurgitant volume, left ventricular end-diastolic volume, and the presence of a flail leaflet, suggesting that these parameters should be weighted more heavily than other echocardio-graphic parameters in the application of the ASE-recommended integrated approach.

Background: PFO's are prevalent in the population. Guidelines recommend use of echo contrast (EC) in pts with poor acoustic windows (approx. 20% pts). However, EC has been contraindicated in pts with intracardiac R-L shunting. Thus, there is limited information regarding safety of EC in pts with PFO

This review summarizes key imaging studies that were presented in the American Heart Association Scientific Sessions 2016 related to the fields of nuclear cardiology, cardiac computed tomography, cardiac magnetic resonance, and echocardiography. This bird's eye view will inform readers about multiple studies from these different modalities. We hope that this general overview will be useful for those that did not attend the conference as well as to those that did since it is often difficult to get exposure to many abstracts at large meetings. The review, therefore, aims to help readers stay updated on the newest imaging studies presented at the meeting.

Background: Late stent thrombosis in drug eluting stents (DES) is attributed to poor endothelialization of struts. Second generation DES have shown superior safety profile and efficacy in comparison to first generation DES. We conducted a meta-analysis to compare the neointimal coverage patterns between Zotarolimus eluting stents (ZES) and Everolimus eluting stents (EES) using optical coherence tomography (OCT). Methods: We searched online databases for studies comparing the neointimal thickness (NIT), %malapposed strut per stent (MSS) or % uncovered strut per stent (USS) between ZES and EES using OCT. Studies included inte mmeta-analysis, OCT was performed >6 months after stent deployment. A calculation of weighted standardized mean difference (SMD) in NIT, MSS and USS between ZES and EES groups was calculated. Residual maximum likelihood (REML) metaregression was performed on smokers, diabetes mellitus (DM), hypertension, (HTN) dyslipidemia (DLD), and age and sex covariates. Results: A total of 6 studies enrolling 327 patients which met inclusion criteria were included in the meta-analysis. 400 stents including 184 ZES and 216 EES were analyzed by OCT. The median of mean age in years, male sex, smokers, DM, HTN and DLD in the ZES group was 60.7(59.5 - 60.9), 76.7% (71.4 - 77.3), 38.7% (18.2 - 45.8), 36.4% (23.3 - 37.5), 63.6% (60 - 66.6), 66.7% (47.9 - 68.4) versus 62.6(59.8 - 65.3), 63.9% (63.6 - 82.1), 30% (17.2 - 47.2), 31.8% (25 - 36.1), 69.4% (59.1 - 75.9), 70% (48.9 - 70.7) in the EES group respectively. The unweighted median NIT, MSS and USS in the ZES group are 127.5 μm (108.8 - 152.2), 0.7% (0.7 - 0.9), 1.8% (0.2 - 3.5) vs 117.4 μm (108.5 - 128.5), 0.3% (0.2 - 1.3), 2.3% (0.9 - 3.5) in the EES group respectively. The weighted SMD of NIT, MSS and USS in the ZES vs EES groups are -0.22 (95%CI -1.12; 0.67) P = 0.63, -0.51(95% CI -1.78; 0.77), P = 0.44, -1.26 (95%CI -2.83; 0.31). None of the above mentioned covariates accounted for statistical insignificance except age for NIT. As age increases, the SMD increases for NIT and was not significant for MSS and USS. Conclusion: No significant difference was noted in the NIT, MSS and USS between both groups. This suggests that the neointimal coverage patterns are similar in ZES and EES groups.