Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Project no. RRF-2.3.1-21-2022-00004 (MILAB) has been implemented with the support provided by the European Union. Introduction Cardiopulmonary exercise testing (CPET)-derived peak oxygen uptake (VO2/kg) is a well-established parameter of exercise capacity allowing the quantification of athletic performance. Although VO2/kg is mainly influenced by anthropometric and demographic factors, several studies demonstrated strong associations between resting echocardiography-based measures and VO2/kg. Artificial intelligence could incorporate information from both features, thus enabling a more accurate prediction of exercise capacity in athletes. Aim Accordingly, we aimed to implement a deep-learning (DL) model that uses 2D echocardiography (2DE)-based apical 4-chamber view videos on top of the anthropometric features (age, sex, body surface area [BSA]) to predict VO2/kg and then assess the model’s performance in a large cohort of athletes. Methods We retrospectively identified 422 competitive athletes (15.4±7.3 training hours/week) who underwent resting 2DE evaluation and then CPET to determine VO2/kg (52.7 ± 7.7 mL/kg/min). To predict VO2/kg values, we trained a deep neural network that can process both modalities of the inputs (i.e. 2DE videos and anthropometric data such as age, sex and BSA) simultaneously (Figure 1). We applied 5-fold cross-validation and used mean squared error (MSE), mean absolute error (MAE), and R squared (R2) metrics to measure our model’s performance. Then, we compared the results with linear regression that was trained using only the 3 anthropometric factors (age, gender, BSA). Additionally, after finalization of the DL-based model, we prospectively recruited further 25 competitive athletes with both 2DE and CPET performed to validate our model. Results Using 2DE videos, our DL-based model was able to achieve an accurate prediction of VO2/kg with an MSE of 35.27, MAE of 4.62, and an R2 of 0.393. In comparison, the linear regression model using only anthropometric factors had worse predictive performance in all metrics with an MSE of 40.51, MAE of 4.88, and R2 of 0.303. In addition, we compared the predictive performance of the DL-based and the linear regression models by their respective squared error values using the Wilcoxon test. Our DL-based model had a significantly better performance compared to the linear regression model (Wilcoxon p = 0.006). In the prospective dataset, our DL-based model achieved an MSE of 16.69, MAE of 3.42, and an R2 of 0.169, whereas the linear regression model was inferior with an MSE of 25.43, MAE of 4.51, and an R2 of −0.268. The DL-based model showed a significantly better performance (Wilcoxon p<0.001). Conclusions Using our DL-based approach on our large athlete database, we were able to implement and prospectively validate a model that incorporated 2DE videos to predict VO2/kg more accurately compared to using anthropometric factors alone. DL techniques may advance sports medicine by personalized monitorization of training phases and accurate prediction of athletic performance.
IntroductionDespite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning its prognostic value on long-term mortality. Accordingly, our study aimed to assess both left (LV) and right ventricular (RV) global longitudinal (GLS) and global circumferential strain (GCS) using three-dimensional echocardiography (3DE) to determine their prognostic importance.MethodsThree hundred fifty-seven patients with a wide variety of left-sided cardiac diseases were retrospectively identified (64 ± 15 years, 70% males) who underwent clinically indicated 3DE. LV and RV GLS, and GCS were quantified. To determine the prognostic power of the different patterns of biventricular mechanics, we divided the patient population into four groups. Group 1 consisted of patients with both LV GLS and RV GCS above the respective median values; Group 2 was defined as patients with LV GLS below the median while RV GCS above the median, whereas in Group 3, patients had LV GLS values above the median, while RV GCS was below median. Group 4 was defined as patients with both LV GLS and RV GCS below the median. Patients were followed up for a median of 41 months. The primary endpoint was all-cause mortality.ResultsFifty-five patients (15%) met the primary endpoint. Impaired values of both LV GCS (HR, 1.056 [95% CI, 1.027–1.085], p < 0.001) and RV GCS (1.115 [1.068–1.164], p < 0.001) were associated with increased risk of death by univariable Cox regression. Patients with both LV GLS and RV GCS below the median (Group 4) had a more than 5-fold increased risk of death compared with those in Group 1 (5.089 [2.399–10.793], p < 0.001) and more than 3.5-fold compared with those in Group 2 (3.565 [1.256–10.122], p = 0.017). Interestingly, there was no significant difference in mortality between Group 3 (with LV GLS above the median) and Group 4, but being categorized into Group 3 versus Group 1 still held a more than 3-fold risk (3.099 [1.284–7.484], p = 0.012).DiscussionThe impaired values of both LV and RV GCS are associated with long-term all-cause mortality, emphasizing the importance of assessing biventricular circumferential mechanics. Reduced RV GCS is associated with significantly increased risk of mortality even if LV GLS is preserved.
Global longitudinal strain is a well-established predictive parameter of adverse outcomes in several cardiac diseases, therefore, it is widely used in clinical practice. Despite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning the biventricular circumferential strain phenotypes and their prognostic value on long-term mortality. Accordingly, the aim of our study was to assess both left (LV) and right ventricular (RV) global circumferential strain (GCS) using 3D echocardiography in order to determine the prognostic importance of the deterioration of biventricular circumferential mechanics. Three hundred and sixty-four patients with various established left-sided heart diseases were retrospectively identified (age: 64.8±15.0 years, 69% males) with a median follow-up of 41 months. All patients underwent clinically indicated transthoracic echocardiography and left (LV) and right ventricular (RV) ejection fractions (EF) were measured by 3D analysis. 3D LV and RV GCS were also quantified by dedicated softwares. In order to determine the prognostic power of the different patterns of biventricular circumferential mechanics, we divided the patient population into four groups using the median values of LV and RV GCS (absolute values of 27.1% and 17.9%, respectively). Group 1 consisted of patients with both LV and RV GCS above median values; Group 2 was defined as patients with LV GCS above the median, while RV GCS below the median, whereas in Group 3 patients had LV GCS values below the median, while RV GCS was above median. Group 4 was defined as patients with both LV and RV GCS below the median. The primary endpoint of our study was all-cause mortality. Fifty-five patients (15.1%) met the primary endpoint. The overall patient population showed balanced values of LV and RV EF (49.0±15.7 and 48.2±9.4%, respectively). Comparing the population separated into the above-mentioned four groups based on LV and RV GCS values enabled a detailed risk stratification as shown on the Kaplan-Meier curve (Figure 1.) When comparing Group 1 vs. Group 4, patients who had lower LV and RV GCS values the risk of all-cause mortality was more than 5 times higher than in patients with both LV and RV GCS above the median (HR, 5.240 [95% CI, 2.750–9.985], p<0.001). By comparing Group 2 with Group 3, the associated risks for all-cause mortality did not show a difference (HR, 0.461 [95% CI, 0.178 to 1.194], p=NS) as shown on the Kapan-Meier curve (Figure 2). Based on the different phenotypes of LV and RV GCS, decreased biventricular circumferential shortening was associated with a significantly increased risk of long-term all-cause mortality. Interestingly, decreased RV GCS with maintained LV GCS showed a similar risk of adverse outcomes than decreased LV GCS with maintained RV GCS. Our results emphasize the importance of the assessment of biventricular circumferential mechanics. Funding Acknowledgement Type of funding sources: None.
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