BACKGROUND:We reviewed our management strategy and outcome data for all 179 patients with pediatric and/or congenital heart disease who underwent 183 heart transplants from January 1, 2011, to December 31, 2021, and evaluated the impact of elevated panel reactive antibody (PRA). METHODS:High PRA was defined as PRA >10%. Univariate associations with long-term survival were assessed with Cox proportional hazards models. Impact of high PRA on survival was estimated with multivariable models. RESULTS:PRA >10% was present in 60 of 183 transplants (32.8%), who were more likely to have prior cardiac surgery, higher number of prior cardiac operations, prior sternotomy, prior heart transplant, and positive crossmatch (24 of 60 [40.0%] vs 11 of 123 [8.9%], P < .0001). Univariate associations with long-term survival include acquired heart disease vs congenital or retransplant (hazard ratio [HR], 0.18; 95% CI, 0.053-0.593; P = .005), prior cardiac surgery (HR, 5.6; 95% CI, 1.32-23.75; P = .020), number of prior cardiac operations (HR, 1.3 for each additional surgery; 95% CI, 1.12-1.50; P = .0004), single ventricle (HR, 2.4; 95% CI, 1.05-5.48; P = .038), and preoperative renal dysfunction (HR, 3.4; 95% CI, 1.43-7.49; P = .002). In multivariate analysis, high PRA does not impact survival when controlling for each of the factors shown in univariable analysis to be associated with long-term survival. The Kaplan-Meier method provided the following survival estimates at 1 year (95% CI) and 5 years (95% CI) after cardiac transplantation: All patients, 93.6% (89.9%-97.3%) and 85.8% (80.0%-92.1%); PRA <10%, 96.6% (93.4%-99.9%) and 86.7% (79.6%-94.3%); and PRA >10%, 86.7% (78.0%-96.4%) and 83.8% (74.0%-95.0%). Despite high PRA being associated with higher mortality at 1 year (14.9% vs 3.8%, P = .035), no significant difference exists in Kaplan-Meier overall survival at 5 years posttransplant in patients with and without high PRA (log-rank P = .4). CONCLUSIONS:In our cohort, 5-year survival in patients with high PRA (PRA >10%) is similar to that in patients without high PRA (PRA <10%), despite the presence of more risk factors in those with high PRA. Individualized immunomodulatory strategies can potentially mitigate the risk of high PRA.

Introduction: Aortic stenosis (AS) is common, with >= moderate severity ~10% above age 75. Despite new therapies, many with AS go undiagnosed due to lack of echo availability and untreated due to improper interpretation. To expand AS diagnosis, we developed an artificial intelligence (AI) algorithm to characterize AS from routine B-mode echo exams without Doppler (AutoAS). Methods: 80,000 de-identified clinical echoes were assembled spanning none, mild, moderate, and severe AS. About 30,000 of these were used to train a convolutional neural network (CNN) using labels derived from a cluster analysis of maximal jet velocity, mean AS gradient, and aortic valve area (AVA). Once labeled, we extracted all available B-mode clips from parasternal long-axis, short axis at aortic level, and apical 5-chamber views, irrespective of image quality. A spatiotemporal CNN was trained to return a probability distribution for none/mild/moderate/severe AS. To assess performance of the model, a hold-out test set of echoes uniformly distributed over patient sex and AS severity was used. Three Level 3 echo trained cardiologists blindly read the complete Doppler echoes and agreed to call AS severity by AVA (< 1 cm2, severe; 1.0-1.5 cm2, moderate; > 1.5 cm2 but restricted, mild; no restriction, none). Results were also dichotomized into none/mild and moderate/severe AS. Results: 40 cases comprised this initial test set. Consistency among the readers was outstanding, with κ = 0.95. The table shows the confusion matrix between AutoAS and panel reads, with excellent accuracy (κ = 0.90). Dichotomous results were also outstanding with sensitivity to detect moderate/severe AS of 91% and specificity of 94%. Conclusions: AI can identify AS from 3 B-mode views and characterize AS severity with accuracy highly congruent to an expert panel using full Doppler data. This may allow AS to be detected in low-resource and screening settings. Further assessment with a larger hold-out test set is planned.

BACKGROUND/OBJECTIVE:Older adults are at risk for tooth loss and compromised nutritional status. Our objective was to conduct a systematic review and meta-analysis to answer the following question: Among adults aged ≥60 y living in developed countries, what are the associations between tooth loss and nutritional status as assessed by a validated nutrition screening or assessment tool?METHODS:PRISMA guidelines were followed. PubMed, Scopus, CINAHL, Web of Science, and MEDLINE were searched for studies published in English between 2009 and 2019 that met inclusion criteria. Data extracted included study and participant characteristics, dentition, and nutritional status. Risk of bias was assessed with a modified Newcastle-Ottawa Scale. Random effects meta-analysis was used.RESULTS:Of the 588 unduplicated articles identified, 78 were reviewed in full text, and 7 met inclusion criteria. Six studies were combined for a meta-analysis, which revealed that individuals who were completely edentulous or who lacked functional dentition had a 21% increased likelihood of being at risk of malnutrition or being malnourished, as compared with those who were dentulous or had functionally adequate dentition (risk ratio, 1.21; 95% CI, 1.11 to 1.32; I2 = 70%). Whether the article statistically adjusted for medical history explained most of the heterogeneity in the pooled effect.CONCLUSIONS AND IMPLICATIONS:Findings suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Use of validated tools to assess risk of malnutrition in older adults with tooth loss is important to promote early intervention and referral to optimize nutrition and oral health status. Findings were limited by heterogeneity, risk of bias, and overall quality of the studies reviewed. Cohort studies that adjust for known confounders and use consistent approaches to assess tooth loss and nutritional status are needed.KNOWLEDGE TRANSFER STATEMENT:The results of this study suggest that older adults with tooth loss are at greater risk of malnutrition than those with functionally adequate dentition. Screening of this population for malnutrition by health care professionals, including dentists and dietitians, may result in corresponding referrals to optimize nutrition and oral health status. Further research is needed with consistent approaches to assess tooth loss and nutritional status.

Importance:Artificial intelligence (AI) has been applied to analysis of medical imaging in recent years, but AI to guide the acquisition of ultrasonography images is a novel area of investigation. A novel deep-learning (DL) algorithm, trained on more than 5 million examples of the outcome of ultrasonographic probe movement on image quality, can provide real-time prescriptive guidance for novice operators to obtain limited diagnostic transthoracic echocardiographic images. Objective:To test whether novice users could obtain 10-view transthoracic echocardiographic studies of diagnostic quality using this DL-based software. Design, Setting, and Participants:This prospective, multicenter diagnostic study was conducted in 2 academic hospitals. A cohort of 8 nurses who had not previously conducted echocardiograms was recruited and trained with AI. Each nurse scanned 30 patients aged at least 18 years who were scheduled to undergo a clinically indicated echocardiogram at Northwestern Memorial Hospital or Minneapolis Heart Institute between March and May 2019. These scans were compared with those of sonographers using the same echocardiographic hardware but without AI guidance. Interventions:Each patient underwent paired limited echocardiograms: one from a nurse without prior echocardiography experience using the DL algorithm and the other from a sonographer without the DL algorithm. Five level 3-trained echocardiographers independently and blindly evaluated each acquisition. Main Outcomes and Measures:Four primary end points were sequentially assessed: qualitative judgement about left ventricular size and function, right ventricular size, and the presence of a pericardial effusion. Secondary end points included 6 other clinical parameters and comparison of scans by nurses vs sonographers. Results:A total of 240 patients (mean [SD] age, 61 [16] years old; 139 men [57.9%]; 79 [32.9%] with body mass indexes >30) completed the study. Eight nurses each scanned 30 patients using the DL algorithm, producing studies judged to be of diagnostic quality for left ventricular size, function, and pericardial effusion in 237 of 240 cases (98.8%) and right ventricular size in 222 of 240 cases (92.5%). For the secondary end points, nurse and sonographer scans were not significantly different for most parameters. Conclusions and Relevance:This DL algorithm allows novices without experience in ultrasonography to obtain diagnostic transthoracic echocardiographic studies for evaluation of left ventricular size and function, right ventricular size, and presence of a nontrivial pericardial effusion, expanding the reach of echocardiography to clinical settings in which immediate interrogation of anatomy and cardiac function is needed and settings with limited resources.

We sought to assess the impact of diastolic dysfunction (DD) grade, as per the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines, on survival of patients with severe aortic stenosis (AS) who underwent transcatheter aortic valve implantation (TAVI). We included consecutive patients with severe AS who underwent TAVI in our institution. DD grading was determined retrospectively according to the 2016 ASE DD guidelines and categorized to grade I-III and indeterminate grade I-II DD. Comparison of 1-year survival according to DD grade was performed by Kaplan-Meier analysis, and evaluation of DD at 1 year was performed in a subset of patients. Among 606 TAVI patients, 394 (65%) had sufficient data for DD grading. Seventy-seven (20%) had grade I DD, 191 (48%) had grade II, 60 (15%) had grade III, and 66 (17%) had an indeterminate grade between I and II. Baseline characteristics indicate higher rates of atrial fibrillation, brain natriuretic peptide level, pulmonary artery systolic pressure, and indexed left ventricular mass as DD grade increases (all p ≤0.01). In conclusion, comparison of 1-year survival revealed a higher rate of mortality in patients with grade III DD that remained statistically significant following adjustment in a multivariate Cox proportional hazard model. DD grade after TAVI improved in patients with grades II and III. Severe AS patients with grade III DD have higher risk for 1-year mortality after TAVI compared with milder degrees of DD. Further research is warranted to explore a potential benefit for aortic valve therapy at an earlier stage of the disease process.

Describe the associations between tooth loss and nutrition status in older adults.

Recently a DL algorithm (Caption Guidance, Caption Health) was developed to guide the acquisition of 10 transthoracic echocardiographic (TTE) views by novice users. The DL model was trained using >5,000,000 observations of the impact of transducer location on image orientation and quality. The goal

BACKGROUND:Assessment of left ventricular (LV) filling pressure is among the important components of a comprehensive echocardiographic report. Previous studies noted wide limits of agreement using 2009 American Society of Echocardiography/European Association of Echocardiography guidelines, but reproducibility of 2016 guidelines update in estimating LV filling pressure is unknown.METHODS:Echocardiographic and hemodynamic data were obtained from 50 patients undergoing cardiac catheterization for clinical indications. Clinical and echocardiographic findings but not invasive hemodynamics were provided to 4 groups of observers, including experienced echocardiographers and cardiology fellows. Invasively acquired LV filling pressure was the gold standard.RESULTS:In group I of 8 experienced echocardiographers from the guidelines writing committee, sensitivity for elevated LV filling pressure was 92% for all observers, and specificity was 93±6%. Fleiss κ-value for the agreement in group I was 0.80. In group II of 4 fellows in training, sensitivity was 91±2%, and specificity was 95±2%. Fleiss κ-value for the agreement in group II was 0.94. In group III of 9 experienced echocardiographers who had not participated in drafting the guidelines, sensitivity was 88±5%, and specificity was 91±7%. Fleiss κ-value for the agreement in group III was 0.76. In group IV of 7 other fellows, sensitivity was 91±3%, and specificity was 92±5%. Fleiss κ-value for the agreement in group IV was 0.89.CONCLUSIONS:There is a good level of agreement and accuracy in the estimation of LV filling pressure using the American Society of Echocardiography/European Association of Cardiovascular Imaging 2016 recommendations update, irrespective of the experience level of the observer.

Remodeling after transcatheter aortic valve implantation (TAVI) has been well characterized for the left ventricle (LV) but not for the other cardiac chambers. We aimed to describe conventional indices of cardiac remodeling and novel longitudinal strain (LS) in all 4 cardiac chambers post-TAVI and to explore gender remodeling disparities. Consecutive patients with significant aortic stenosis who underwent TAVI were included if echocardiograms in sinus rhythm before and 1-year postprocedure were available. Speckle tracking analysis was performed retrospectively to evaluate size and function of the 4 cardiac chambers. Baseline and 1-year data were compared. From a total of 612 patients who underwent TAVI, 213 were included in this study (82 +/- 9 years old, 42% men). Although no significant size or function changes were seen for right cardiac chambers at follow-up, significant improvements were seen for ejection fraction (EF) and LS in both the LV and left atrium (LA) (p < 0.05 for both). The absolute percentage of LV and LA function improvement was higher for LS than for EF (p < 0.05). Women had smaller LV and right ventricular (RV) size, whereas parameters of LV and RV function were higher. All 1-year remodeling parameters were similar for men and women. Conventional LV remodeling parameters (LV mass) failed to improve 1 year after TAVI. However, novel strain-derived parameters of size and function showed remodeling of left chambers but not of RV or right atrium. The degree of LV and LA remodeling by LS is almost twice that of EF. Remodeling was similar for both genders. (C) 2019 Elsevier Inc. All rights reserved.

In this issue of JASE, in a well-written and thoughtful article, Park et al. 1 Park J.Y. Foley T.A. Bonnischsen C.R. Maurer M.J. Goergen K.M. Nkomo V.T. et al. Transthoracic echocardiography versus computed tomography for ascending aortic measurements in patients with bicuspid aortic valve. J Am Soc Echocardiogr. 2017; 30: 625-635 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar report on a study in which they retrospectively compared transthoracic echocardiographic and computed tomographic angiographic measurements of the aortic root and ascending aorta in 53 patients with bicuspid aortic valves. These authors evaluated three measurement methods (inner edge to inner edge [I-I], leading edge to leading edge [L-L], and outer edge to outer edge [O-O]), as well as three timing points of these measurements (end-diastole, mid-diastole, and end-systole; Figure 1). This report calls attention to the ongoing controversy and lack of uniformity among both institutions and guidelines as to the “preferred” method(s) for measuring aortic dimensions, 1 Park J.Y. Foley T.A. Bonnischsen C.R. Maurer M.J. Goergen K.M. Nkomo V.T. et al. Transthoracic echocardiography versus computed tomography for ascending aortic measurements in patients with bicuspid aortic valve. J Am Soc Echocardiogr. 2017; 30: 625-635 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar , 2 Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey Jr., D.E. et al. Guidelines for the diagnosis and management of patients with thoracic aortic disease. J Am Coll Cardiol. 2010; 55: e27-e129 Abstract Full Text Full Text PDF PubMed Scopus (1057) Google Scholar , 3 Evangelista A. Flachskampf F. Erbel R. Antonini-Canterin F. Vlachopoulos C. Rocchi G. et al. Echocardiography in aortic diseases: EAE recommendations for clinical practice. Eur J Echocardiogr. 2010; 11: 645-648 Crossref PubMed Scopus (352) Google Scholar , 4 Goldstein S.A. Evangelista A. Abbara S. Arai A. Asch F.M. Badano L.P. et al. Multimodality imaging of diseases of the thoracic aorta in adults: from the American Society of Echocardiography and European Association of Cardiovascular Imaging: endorsed by the Society of Cardiovascular Computed Tomography and Society of Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2015; 28: 119-182 Abstract Full Text Full Text PDF PubMed Scopus (385) Google Scholar , 5 Lang R.M. Badano L.P. Mor-Avi V. Afilalo J. Armstrong A. Ernande L. et al. Recommendations for chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015; 28: 1-39 Abstract Full Text Full Text PDF PubMed Scopus (7072) Google Scholar , 6 Lorenz C.H. The range of normal values of cardiovascular structures in infants, children, and adolescents measured by magnetic resonance imaging. Pediatr. 2000; 21: 37-46 Google Scholar leading to the comparison of “apples to oranges” rather than “apples to apples.”

Echocardiography is the key tool for the diagnosis and evaluation of aortic stenosis. Because clinical decision-making is based on the echocardiographic assessment of its severity, it is essential that standards are adopted to maintain accuracy and consistency across echocardiographic laboratories. Detailed recommendations for the echocardiographic assessment of valve stenosis were published by the European Association of Echocardiography and the American Society of Echocardiography in 2009. In the meantime, numerous new studies on aortic stenosis have been published with particular new insights into the difficult subgroup of low gradient aortic stenosis making an update of recommendations necessary. The document focuses in particular on the optimization of left ventricular outflow tract assessment, low flow, low gradient aortic stenosis with preserved ejection fraction, a new classification of aortic stenosis by gradient, flow and ejection fraction, and a grading algorithm for an integrated and stepwise approach of artic stenosis assessment in clinical practice.

Extracellular nucleotide metabolism controls thrombosis and inflammation and may affect degeneration and calcification of aortic valve prostheses. We evaluated the effect of different decellularization strategies on enzyme activities involved in extracellular nucleotide metabolism. Porcine valves were tested intact or decellularized either by detergent treatment or hypotonic lysis and nuclease digestion. The rates of ATP hydrolysis, AMP hydrolysis, and adenosine deamination were estimated by incubation of aorta or valve leaflet sections with substrates followed by HPLC analysis. We demonstrated relatively high activities of ecto-enzymes on porcine valve as compared to the aortic wall. Hypotonic lysis/nuclease digestion preserved >80 % of ATP and AMP hydrolytic activity but reduced adenosine deamination to <10 %. Detergent decellularization completely removed (<5 %) all these activities. These results demonstrate high intensity of extracellular nucleotide metabolism on valve surface and indicate that various valve decellularization techniques differently affect ecto-enzyme activities that could be important in the development of improved valve prostheses.

Background Right ventricular (RV) dysfunction was shown to be associated with adverse outcomes in a variety of cardiac patients and is considered a risk factor for adverse outcome according to the updated Valve Academic Research Consortium criteria.Objective Our goal was to assess the impact of RV function at baseline on 1-year mortality among patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR).Methods All patients with severe AS treated with TAVR from May 2007 to March 2015 at our center were included in the present study, and baseline and procedural characteristics were recorded for each patient. The patients were categorized according to RV function at baseline as assessed by current guidelines, and a comparison of mortality rates up to 1 year was performed.Results Among 650 patients, 606 had adequate echocardiogram quality and 146 (24%) had RV dysfunction. There were significant differences between the 2 groups, as patients with RV dysfunction were younger (81 +/- 9 vs 84 +/- 7 years, P = .01) and were more likely to be male (65% vs 42%, P < .001). In addition, patients with RV dysfunction had higher rates of prior myocardial infarction (26% vs 16%, P = .02) and atrial fibrillation (51% vs 39%, P = .02). Echocardiographic parameters demonstrated higher rates of left ventricular ejection fraction < 40% (40% vs 18%, P < .001), tricuspid regurgitation above moderate (16% vs 9%, P = .04), and higher pulmonary artery systolic pressure (50 +/- 17 vs 44 +/- 16 mm Hg, P < .001) among patients with severe AS and RV dysfunction compared with patients with normal RV function. Despite the unfavorable cardiac function, patients with severe AS undergoing TAVR have similar functional class (P = .22) and mortality rates at 1 year (27% vs 23%, log-rank P = .45).Conclusions Patients with severe AS and RV dysfunction have similar 1-year mortality and functional class after TAVR to patients with normal RV function. The presence of RV dysfunction does not correlate with outcome in patients with severe AS.

Value-Based Healthcare: Summit 2014 clearly achieved the three goals set forth at the beginning of this document. First, the live event informed and educated attendees through a discussion of the evolving value-based healthcare environment, including a collaborative effort to define the important role of cardiovascular ultrasound in that environment. Second, publication of these Summit proceedings in the Journal of the American Society of Echocardiography will inform a wider audience of the important insights gathered. Third, moving forward, the ASE will continue to build a ‘‘living resource’’ on its website, http://www.asecho.org, for clinicians, researchers, and administrators to use in advocating for the value of cardiovascular ultrasound in the new value-based healthcare environment. The ASE looks forward to incorporating many of the Summit recommendations as it works with its members, legislators, payers, hospital administrators, and researchers to demonstrate and increase the value of cardiovascular ultrasound. All Summit attendees shared in the infectious enthusiasm generated by this proactive approach to ensuring cardiovascular ultrasound’s place as ‘‘The Value Choice’’ in cardiac imaging.

Limited amount of data suggest that patients with aortic stenosis and pulmonary hypertension (PH) who undergo transcatheter aortic valve replacement (TAVR) experience decrease in PH postprocedure. Inconsistent use of systolic pulmonary artery pressure cut-off values in previous studies limits our ability to draw meaningful conclusions regarding the prognostic role of PH in assessment of TAVR candidates. A total of 415 consecutive patients who underwent TAVR were included in the present study. Two groups were compared based on receiver-operating characteristics curve analysis for the best SPAP value to predict outcome, yielding 2 study groups of no/mild PH ( <= 50 mm Hg; n = 172,41%) versus moderate/severe PH (>50 mm Hg; n = 243, 59%). Demographics and co-morbidities were comparable between the 2 groups; however, right-sided cardiac failure (35% vs 19.8%, p = 0.02) and mitral regurgitation (18.4% vs 8.6%, p = 0.007) were more frequent in patients with moderate/severe PH. Procedural characteristics and complications were comparable between the groups. Although there was an early overall decrease in SPAP postprocedure, only 26% of moderate/severe patients with PH experienced a significant decrease in SPAP (>10 mm Hg). The 30-day (14.5% vs 7.4%, p = 0.02) and 1-year mortality (30.8% vs 21%, p = 0.02) was higher in moderate/severe patients with PH. In multivariate analysis, systolic pulmonary artery pressure and chronic lung disease were identified as independent predictors for mortality at 1 year. PH is a frequent co-morbidity in patient's with severe aortic stenosis who underwent TAVR. Significantly elevated pulmonary artery pressures at baseline may serve as a poor prognostic factor when performing preprocedural assessment of the patients. (C) 2015 Elsevier Inc. All rights reserved.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.