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Background: Primary mitral regurgitation (MR) is a heterogeneous clinical disease requiring integration of echocardiographic parameters using guideline-driven recommendations to identify severe disease., Objectives: The purpose of this preliminary study was to explore novel data-driven approaches to delineate phenotypes of MR severity that benefit from surgery., Methods: The authors used unsupervised and supervised machine learning and explainable artificial intelligence (AI) to integrate 24 echocardiographic parameters in 400 primary MR subjects from France (n = 243; development cohort) and Canada (n = 157; validation cohort) followed up during a median time of 3.2 years (IQR: 1.3-5.3 years) and 6.8 (IQR: 4.0-8.5 years), respectively. The authors compared the phenogroups' incremental prognostic value over conventional MR profiles and for the primary endpoint of all-cause mortality incorporating time-to-mitral valve repair/replacement surgery as a covariate for survival analysis (time-dependent exposure)., Results: High-severity (HS) phenogroups from the French cohort (HS: n = 117; low-severity [LS]: n = 126) and the Canadian cohort (HS: n = 87; LS: n = 70) showed improved event-free survival in surgical HS subjects over nonsurgical subjects (P = 0.047 and P = 0.020, respectively). A similar benefit of surgery was not seen in the LS phenogroup in both cohorts (P = 0.70 and P = 0.50, respectively). Phenogrouping showed incremental prognostic value in conventionally severe or moderate-severe MR subjects (Harrell C statistic improvement; P = 0.480; and categorical net reclassification improvement; P = 0.002). Explainable AI specified how each echocardiographic parameter contributed to phenogroup distribution., Conclusions: Novel data-driven phenogrouping and explainable AI aided in improved integration of echocardiographic data to identify patients with primary MR and improved event-free survival after mitral valve repair/replacement surgery., Competing Interests: Funding Support and Author Disclosures This work was supported by funds from the National Science Foundation (#1920920) and National Institute of General Medical Sciences of the National Institutes of Health (#5U54GM104942-04) and by a research grant (FDN-143225) from the Canadian Institutes of Health Research (CIHR), Ottawa, Ontario, Canada. Mr Bernard is supported by a doctoral scholarship from CIHR. Dr Pibarot holds the Canada Research Chair in Valvular Heart Diseases from CIHR, Ottawa, Ontario, Canada. Dr Pibarot has received funding from Edwards Lifesciences, Medtronic, and Phoenix Cardiac Devices for echocardiography core laboratory analyses with no direct personal compensation. Dr Sengupta is a consultant for Kencor Health, RCE Technologies, and Ultromics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023. Published by Elsevier Inc.)

Background: Pre-procedural chronic kidney disease (CKD) and in-hospital acute kidney injury (AKI) are associated with worse outcomes following transcatheter aortic valve replacement (TAVR). We tested the feasibility of reducing overall AKI by avoiding pre-procedural cardiac CT angiography (CCTA) by using direct 3D-TEE guidance in TAVR patients with known CKD., Methods: An institutional TAVR database was examined from January 2016 to June 2020 to identify 396 patients in whom CCTA sizing was performed and 54 patients with creatinine (Cr) of >1.6 mg/dL in whom direct 3D-TEE, without prior CCTA, was used for TAVR guidance. Baseline demographics, procedural, echocardiographic, and clinical endpoints were compared as defined by the Valve Academic Research Consortium-2 criteria., Results: Baseline demographics and risk factors were similar in both groups other than the creatinine level in CCTA vs. TEE groups (1.33 ± 1.1 vs 1.76 ± 0.7 mg/dL, p = 0.005). Procedural contrast volume was significantly lower in the TEE group compared to the CCTA group. No differences were noted in echocardiographic and clinical endpoints for both groups. Despite higher baseline Cr, patents in the TEE group experienced a similar pattern of changes in Cr compared to the CCTA group, with an overall renal improvement noted at the time of discharge for both groups., Conclusions: In patients with baseline CKD, careful avoidance of large contrast loads associated with CCTA and intra-procedural aortography by using TEE guidance may help reduce AKI following TAVR., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Background: Transesophageal echocardiography (TEE) is the standard imaging modality used to assess the left atrial appendage (LAA) after transcatheter device occlusion. Cardiac computed tomography angiography (CCTA) offers an alternative non-invasive modality in these patients. We aimed to conduct a comparison of the two modalities., Methods: We performed a comprehensive systematic review of the current literature pertaining to CCTA to establish its usefulness during follow-up for patients undergoing LAA device closure. Studies that reported the prevalence of inadequate LAA closure on both CCTA and TEE were further evaluated in a meta-analysis. 19 studies were used in the systematic review, and six studies were used in the meta-analysis., Results: The use of CCTA was associated with a higher likelihood of detecting LAA patency than the use of TEE (OR, 2.79, 95% CI 1.34-5.80, p ​= ​0.006, I 2  ​= ​70.4%). There was no significant difference in the prevalence of peridevice gap ≥5 ​mm (OR, 3.04, 95% CI 0.70-13.17, p ​= ​0.13, I 2  ​= ​0%) between the two modalities. Studies that reported LAA assessment in early and delayed phase techniques detected a 25%-50% higher prevalence of LAA patency on the delayed imaging., Conclusion: CCTA can be used as an alternative to TEE for LAA assessment post occlusion. Standardized CCTA acquisition and interpretation protocols should be developed for clinical practice., Competing Interests: Declaration of competing interest There are no conflicts of interests associated with this manuscript., (Published by Elsevier Inc.)

Objectives: This study sought to explore the spectrum of cardiac abnormalities in student athletes who returned to university campus in July 2020 with uncomplicated coronavirus disease 2019 (COVID-19)., Background: There is limited information on cardiovascular involvement in young individuals with mild or asymptomatic COVID-19., Methods: Screening echocardiograms were performed in 54 consecutive student athletes (mean age 19 years; 85% male) who had positive results of reverse transcription polymerase chain reaction nasal swab testing of the upper respiratory tract or immunoglobulin G antibodies against severe acute respiratory syndrome coronavirus type 2. Sequential cardiac magnetic resonance imaging was performed in 48 (89%) subjects., Results: A total of 16 (30%) athletes were asymptomatic, whereas 36 (66%) and 2 (4%) athletes reported mild and moderate COVID-19 related symptoms, respectively. For the 48 athletes completing both imaging studies, abnormal findings were identified in 27 (56.3%) individuals. This included 19 (39.5%) athletes with pericardial late enhancements with associated pericardial effusion. Of the individuals with pericardial enhancements, 6 (12.5%) had reduced global longitudinal strain and/or an increased native T 1 . One patient showed myocardial enhancement, and reduced left ventricular ejection fraction or reduced global longitudinal strain with or without increased native T 1 values was also identified in an additional 7 (14.6%) individuals. Native T 2 findings were normal in all subjects, and no specific imaging features of myocardial inflammation were identified. Hierarchical clustering of left ventricular regional strain identified 3 unique myopericardial phenotypes that showed significant association with the cardiac magnetic resonance findings (p = 0.03)., Conclusions: More than 1 in 3 previously healthy college athletes recovering from COVID-19 infection showed imaging features of a resolving pericardial inflammation. Although subtle changes in myocardial structure and function were identified, no athlete showed specific imaging features to suggest an ongoing myocarditis. Further studies are needed to understand the clinical implications and long-term evolution of these abnormalities in uncomplicated COVID-19., Competing Interests: Funding Support and Author Disclosures This work is supported in part by funds from the National Science Foundation (NSF: # 1920920) National Institute of General Medical Sciences of the National Institutes of Health (NIH: #5U54GM104942-04). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Science Foundation. Dr. Sengupta has received consulting for HeartSciences, Kencor Health, and Ultromics. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021. Published by Elsevier Inc.)

Background: Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours., Methods: We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes., Results: Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis., Conclusions: Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)