Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography

Clinical Utility and Cost of Inpatient Transthoracic Echocardiography Following Acute Ischemic Stroke

Background and Purpose

It is unclear whether it is clinically necessary or cost-effective to routinely obtain a transthoracic echocardiogram (TTE) during inpatient admission for ischemic stroke.

Methods

We assessed consecutive patients presenting with acute ischemic stroke at a comprehensive stroke center from 2015 to 2017 who underwent TTE. We assessed for findings on TTE that would warrant urgent intervention including cardiac thrombus, atrial myxoma, mitral stenosis, valve vegetation, valve dysfunction requiring surgery, and low ejection fraction. Subsequent changes in management included changes in anticoagulation, antibiotics, or valve surgery. We calculated in-hospital resource utilization and associated costs for inpatient TTE using individual direct cost details within a case-costing system.

Results

Of 695 patients admitted with acute ischemic stroke, 516 (74%) had a TTE and were included in our analysis. TTE findings were potentially clinically significant in 30 patients (5.8%) and changed management in 17 patients (3.3%). Inpatient admission was prolonged to expedite TTE in 24 patients, while TTE occurred after discharge in 76 patients. After correcting for the cost of TTE, the mean difference in cost to prolong an admission for TTE was $555.52 (USD), or $16 832 per change in management.

Conclusions

Given the low clinical utility of inpatient TTE after acute ischemic stroke and the costs associated with prolonging admission, discharge from hospital should not be delayed solely to obtain TTE.

Prognostic value of heart failure echocardiography index in HF patients with preserved, mid-ranged and reduced ejection fraction

Background

To investigate the clinical value of heart failure echocardiography index (HFEI) in evaluating the cardiac function and predicting the prognosis of patients with different types of heart failure (HF).

Methods

Four hundred eighty-nine consecutively admitted HF patients were divided into three groups: HF with reduced ejection (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). The baseline characteristics and ultrasound indexes were compared between the three groups. The correlation between HFEI and one-year risk of adverse events was compared by multivariate logistic regression. The clinical value of HFEI and plasma level of NT-proBNP in assessing the prognosis of patients with chronic heart failure (CHF) was analyzed by the receiver operating characteristic (ROC) curve.

Results

HFEI in HFrEF was significantly higher than that in HFmrEF and HFpEF. Multivariate regression analysis indicated that HFEI and plasma level of NT-proBNP were independent risk factors for predicting the short-time prognosis of HF patients. The ROC curve indicated that the HFEI cutoff level of 3.5 and the plasma NT-proBNP level of 3000 pg/ml predicted a poor prognosis of CHF patients with a sensitivity of 64% and a specificity of 75% vs. 68 and 65%.

Conclusion

HFEI can comprehensively evaluate the overall cardiac function of patients with various types of HF, and may prove to be an important index of assessing the prognosis of HF patients.

Prospective long-term follow-up analysis of the cardiovascular system in marathon runners: study design of the Pro-MagIC study

Introduction

Prolonged strenuous exercise training may result in structural, functional and electrical cardiac remodelling, as well as vascular and myocardial injuries. However, the extent to which high-volume, intense exercise is associated with arrhythmias, myocardial fibrosis, coronary heart disease and pathological alterations of the vasculature remains unknown. In addition, there is no clear consensus on the clinical significance of these exercise-induced changes. Previous studies typically used cross-sectional designs and examined exercise-induced cardiovascular changes in small cohorts of athletes for up to 3–7 days of recovery. Long-term longitudinal studies investigating cardiovascular changes induced by prolonged strenuous exercise in large cohorts of athletes are needed to improve scientific understanding in this area.

Methods and analysis

In this prospective observational monocenter study, 277 participants of the Beer, Marathon, Genetics, Inflammation and the Cardiovascular System (Be-MaGIC) study (ClinicalTrials.gov: NCT00933218) will be invited to participate in this 10-year follow-up study. A minimum target sample size of 130 participants will be included in the study. Participating athletes will be examined via the following: anthropometry, resting electrocardiography and echocardiography, blood sampling, retinal vessel diameters, carotid sonography and cardiopulmonary exercise testing, including exercise electrocardiography.

Discussion

This longitudinal study will provide comprehensive data on physiological changes in the cardiovascular system and the development of pathologies after a 10-year period of prolonged and strenuous endurance exercise. Since the participants will have engaged in a wide range of training loads and competitive race events, this study will provide useful risk factor determinants and training load cut-off values. The primary endpoint is the association between the exercise-induced increase in cardiac troponin during the Munich marathon 2009 and the decline in right ventricular ejection fraction over the next 10 years.

Trial registration number

NCT04166903.

Utility of Three-Dimensional Transesophageal Echocardiography for Mitral Annular Sizing in Transcatheter Mitral Valve Replacement Procedures: A Cardiac Computed Tomographic Comparative Study

BACKGROUND

Three-dimensional (3D) transesophageal echocardiographic (TEE) imaging is frequently used as an initial screening tool in the evaluation of patients who are candidates for transcatheter mitral valve replacement (TMVR). However, little is known about the imaging correlation with the gold standard, computed tomographic (CT) imaging. The aims of this study were to test the quantitative differences between these two modalities and to determine the best 3D TEE parameters for TMVR screening.

METHODS

Fifty-seven patients referred to the heart valve clinic for TMVR with prostheses specifically designed for the mitral valve were included. Mitral annular (MA) analyses were performed using commercially available software on 3D TEE and CT imaging.

RESULTS

Three-dimensional TEE imaging was feasible in 52 patients (91%). Although 3D TEE measurements were slightly lower than those obtained on CT imaging, measurements of both projected MA area and perimeter showed excellent correlations, with small differences between the two modalities (r = 0.88 and r = 0.92, respectively, P < .0001). Correlations were significant but lower for MA diameters (r = 0.68-0.72, P < .0001) and mitroaortic angle (r = 0.53, P = .0001). Receiver operating characteristic curve analyses showed that 3D TEE imaging had a good ability to predict TMVR screening success, defined by constructors on the basis of CT measurements, with ranges of 12.9 to 15 cm² for MA area (area under the curve [AUC] = 0.88-0.91, P < .0001), 128 to 139 mm for MA perimeter (AUC = 0.85-0.91, P < .0001), 35 to 39 mm for anteroposterior diameter (AUC = 0.79-0.84, P < .0001), and 37 to 42 mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, P < .0001).

CONCLUSIONS

Three-dimensional TEE measurements of MA dimensions display strong correlations with CT measurements in patients undergoing TMVR screening. Three-dimensional TEE imaging should be proposed as a reasonable alternative to CT imaging in this vulnerable population.

Effect of high-intensity exercise on cerebral, respiratory and peripheral muscle oxygenation of HF and COPD-HF patients

OBJECTIVE

To investigate cerebral oxygenation (Cox) responses as well as respiratory (Res) and active peripheral muscle (Pm) O₂ delivery during high-intensity cycling exercise and contrast responses between patients with coexistent chronic obstructive pulmonary disease (COPD)-heart failure (HF) and HF alone.

METHODS

Cross-sectional study involving 11 COPD-HF and 11 HF patients. On two different days, patients performed maximal incremental cardiopulmonary exercise testing (CPET) and constant load exercise on a cycle ergometer until the limit of tolerance (Tlim). The high-intensity exercise session was 80% of the peak CPET work rate. Relative blood concentrations of oxyhemoglobin ([O₂Hb]), deoxyhemoglobin ([HHb]) of Res, Pm (right vastus lateralis) and Cox (pre-frontal) were measured using near infrared spectroscopy.

RESULTS

We observed a greater decrease in [O₂Hb] at a lower Tlim in COPD-HF when compared to HF (P < 0.05). [HHb] of Res was higher (P < 0.05) and Tlim was lower in COPD-HF vs. HF. Pm and Cox were lower and Tlim was higher in (P < 0.05) HF vs. COPD-HF. In HF, there was a lower ∆[O₂Hb] and higher ∆ [HHb] of Pm when contrasted to Cox observed during exercise, as well as a lower ∆ [O₂Hb] and higher ∆ [HHb] of Res when contrasted with Cox (P < 0.05). However, COPD-HF patients presented with a higher ∆ [HHb] of Res and Pm when contrasted with Cox (P < 0.05).

CONCLUSION

The coexistence of COPD in patients with HF produces negative effects on Cox, greater deoxygenation of the respiratory and peripheral muscles and higher exertional dyspnea, which may help to explain an even lower exercise tolerance in this multimorbidity phenotype.

Left atrial myocardial dysfunction in patients with primary aldosteronism as assessed by speckle-tracking echocardiography

BACKGROUND

We investigated the left atrial myocardial deformation in patients with primary aldosteronism using the speckle-tracking echocardiographic (STE) strain imaging technique.

METHODS

Our study included 107 primary aldosteronism patients [52 aldosterone-producing adenoma (APA) and 55 idiopathic hyperaldosteronism (IHA)] and 50 primary hypertensive patients. We performed conventional echocardiography to measure left atrial volume and ejection fraction, and STE to estimate left atrial myocardial deformation including peak velocity, strain and strain rate and calculate the ratio of E/e' to left atrial strain during left ventricular systole as the left atrial stiffness index.

RESULTS

Patients with APA, compared with those with IHA and primary hypertension had a significantly (P < 0.001) lower serum potassium concentration and higher 24-h urinary aldosterone excretion and plasma aldosterone-to-renin ratio. Patients with APA had a significantly (P < 0.01) larger maximal, precontraction, and minimal left atrial volumes and lower total, active and passive left atrial emptying fractions than those with IHA and primary hypertension. Among the three groups, patients with APA showed lowest left atrial velocity, strain, and strain rate during ventricular systole, early diastole and late diastole (P < 0.05) and highest left atrial stiffness index (P < 0.001). In unadjusted analysis, the left atrial strain, strain rate and stiffness index were significantly (P < 0.05) associated with plasma aldosterone concentration and urinary aldosterone excretion. After adjustment for various confounding factors, these associations remained statistically significant for urinary aldosterone excretion (P < 0.05) but not plasma aldosterone concentration (P ≥ 0.05).

CONCLUSION

Patients with primary aldosteronism, especially APA, had impaired left atrial deformation mechanics and increased left atrial stiffness, providing a promising insight into early detection of subclinical left atrial dysfunction by strain echocardiography.

Radiomics in Echocardiography: Deep Learning and Echocardiographic Analysis

PURPOSE OF REVIEW

Recent development in artificial intelligence (AI) for cardiovascular imaging analysis, involving deep learning, is the start of a new phase in the research field. We review the current state of AI in cardiovascular field and discuss about its potential to improve clinical workflows and accuracy of diagnosis.

RECENT FINDINGS

In the AI cardiovascular imaging field, there are many applications involving efficient image reconstruction, patient triage, and support for clinical decisions. These tools have a role to support repetitive clinical tasks. Although they will be powerful in some situations, these applications may have new potential in the hands of echo cardiologists, assisting but not replacing the human observer. We believe AI has the potential to improve the quality of echocardiography. Someday AI may be incorporated into the daily clinical setting, being an instrumental tool for cardiologists dealing with cardiovascular diseases.

Augmented glycaemic gap is a marker for an increased risk of post-infarct left ventricular systolic dysfunction

BACKGROUND

Left ventricular systolic dysfunction (LVSD) occurs frequently after acute ST-segment elevation myocardial infarction (STEMI). The predisposing factors and underlying mechanism of post-infarct LVSD are not fully understood. The present study mainly investigated the correlation between glycaemic gap, a novel index of stress-induced hyperglycaemia (SIH), and post-infarct LVSD.

METHODS

A total of 274 first STEMI patients were enrolled in this cross-sectional study. Transthoracic echocardiography was performed within 48 h after admission and at 6 months after discharge to obtain left ventricular ejection fraction (LVEF). The change in LVEF was calculated as LVEF at 6 months after discharge minus baseline LVEF. Additionally, post-infarct LVSD was defined as LVEF ≤ 50%. Most importantly, glycaemic gap was calculated as admission blood glucose (ABG) minus the estimated average glucose over the previous 3 months.

RESULTS

In patients without diabetes mellitus (DM), multivariate linear regression analysis revealed that both glycaemic gap (Beta = - 1.214, 95% CI - 1.886 to - 0.541, p < 0.001) and ABG (Beta = - 1.124, 95% CI - 1.795 to - 0.453, p = 0.001) were associated with change in LVEF. In DM patients, only glycaemic gap was still associated with change in LVEF, although this association was not observed in univariate linear regression analysis. Regarding the association between SIH and post-infarct LVSD, multivariate logistic regression analysis revealed that both glycaemic gap (OR = 1.490, 95% CI 1.043 to 2.129, p = 0.028) and ABG (OR = 1.600, 95% CI 1.148 to 2.229, p = 0.005) were associated with an increased risk of having post-infarct LVSD in non-DM patients. However, after multivariate adjustment in DM patients, only glycaemic gap (OR = 1.399, 95% CI 1.021 to 1.919, p = 0.037) remained associated with an increased risk of having post-infarct LVSD. Furthermore, the predictive value of glycaemic gap for post-infarct LVSD was not inferior to ABG in non-DM patients (p = 0.499), and only glycaemic gap, instead of ABG, could significantly predict post-infarct LVSD in DM patients (AUC = 0.688, 95% CI 0.591 to 0.774, p = 0.002).

CONCLUSIONS

Glycaemic gap was strongly associated with a change in LVEF and an increased risk of having post-infarct LVSD in patients following STEMI. In STEMI patients with DM, glycaemic gap could provide more valuable information than ABG in identifying patients at high risk of developing post-infarct LVSD.

Analysis of the relationship between systemic inflammation and diastolic dysfunction in patients with heart failure and rheumatoid arthritis

Aim. To study the relationship of the systemic inflammation with the morphological and functional myocardial parameters in patients with heart failure (HF) due to hypertension and coronary artery disease in combination with rheumatoid arthritis (RA).

Material and methods. The study included 57 women with NYHA class I-II HF. Patients were divided into two comparable groups: group 1 (n=31) — patients with HF and seropositive RA (Steinbrocker X-ray stage I-III); group 2 (n=26) — HF patients without RA.

Results. A comparative analysis of morphological and functional parameters did not reveal significant differences: left ventricular ejection fraction in groups 1 and 2 were 51,06±5,6% and 51,6±6,4%, respectively (p=0,7); the ratio of peak velocity blood flow in early diastole to peak velocity flow in late diastole (E/A) was 0,9±0,1 and 0,8±0,1, respectively (p=0,7). For other echocardiographic parameters, differences were also not detected (p>0,05). Nevertheless, significant regression model was created between the RA activity score (DAS28), rheumatoid factor, and E/A was created: R=0,5; R2 =0,3; F=2,6; p=0,04.

Conclusion. As a result of the study, significant direct moderate correlation of the RA activity score (DAS28) with E/A ratio was revealed in the group of patients with HF and RA. The data obtained may indicate an unfavorable prognosis of HF with an increase in RA activity.

Elevated plasma phenylalanine predicts mortality in critical patients with heart failure

Aims

Previous studies found a relationship between elevated phenylalanine levels and poor cardiovascular outcomes. Potential strategies are available to manipulate phenylalanine metabolism. This study investigated whether increased phenylalanine predicted mortality in critical patients with either acute heart failure (HF) or acute on chronic HF, and its correlation with inflammation and immune cytokines.

Methods and results

This study recruited 152 subjects, including 115 patients with HF admitted for critical conditions and 37 normal controls. We measured left ventricular ejection fraction (LVEF), plasma concentrations of phenylalanine, C‐reactive protein, albumin, pre‐albumin, transferrin, and pro‐inflammatory and immune cytokines. Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and maximal vasoactive–inotropic scores (VIS_max) were calculated. Patients were followed up until death or a maximum of 1 year. The primary endpoint was all‐cause death. Of the 115 patients, 37 (32.2%) were admitted owing to acute HF, and 78 (67.8%) were admitted owing to acute on chronic HF; 64 (55.7%) had ST elevation/non‐ST elevation myocardial infarction. An LVEF measured during the hospitalization of <40%, 40–50%, and ≥50% was noted in 51 (44.3%), 15 (13.1%), and 49 (42.6%) patients, respectively. During 1 year follow‐up, 51 (44.3%) patients died. Death was associated with higher APACHE II, SOFA, and VIS_max scores; higher levels of C‐reactive protein and phenylalanine; higher incidence of atrial fibrillation and use of inotropic agents; lower cholesterol, albumin, pre‐albumin, and transferrin levels; and significant changes in pro‐inflammatory and immune cytokines. Phenylalanine levels demonstrated an area under the receiver operating characteristic curve of 0.80 for mortality, with an optimal cut‐off value set at 112 μM. Phenylalanine ≥ 112 μM was associated with a higher mortality rate than was phenylalanine < 112 μM (80.5% vs. 24.3%, P < 0.001) [hazard ratio = 5.07 (2.83–9.05), P < 0.001]. The Kaplan–Meier curves revealed that phenylalanine ≥ 112 μM was associated with a lower accumulative survival rate (log rank = 36.9, P < 0.001). Higher phenylalanine levels were correlated with higher APACHE II and SOFA scores, higher C‐reactive protein levels and incidence of using inotropic agents, and changes in cytokines suggestive of immunosuppression, but lower levels of pre‐albumin and transferrin. Further multivariable analysis showed that phenylalanine ≥ 112 μM predicted death over 1 year independently of age, APACHE II and SOFA scores, atrial fibrillation, C‐reactive protein, cholesterol, pre‐albumin, transferrin, and interleukin‐8 and interleukin‐10.

Conclusions

Elevated phenylalanine levels predicted mortality in critical patients, phenotypically predominantly presenting with HF, independently of traditional prognostic factors and cytokines associated with inflammation and immunity.

Sinus of Valsalva Thrombosis Detected on Computed Tomography after Transcatheter Aortic Valve Replacement

BACKGROUND AND OBJECTIVES

Leaflet thrombosis after transcatheter aortic valve replacement (TAVR) has been reported recently, whereas thrombus formation in sinus of Valsalva has yet to be fully evaluated. This study describes clinical and cardiac computed tomography (CT) findings of patients with sinus of Valsalva thrombosis.

METHODS

Between March 2011 and Aug 2019, 192 patients underwent cardiac CT after TAVR. After a retrospective review of CT images, 9 patients (82 years, male:female=2:7) who had sinus of Valsalva thrombosis identified by cardiac CT were selected for this study. Patient demographics, interval between TAVR and cardiac CT scan, location and CT attenuation of sinus of Valsalva thrombosis, and presence of concurrent leaflet thrombosis were evaluated.

RESULTS

The median interval between TAVR and cardiac CT was 11 days. Sinus of Valsalva thrombosis was frequently detected in the non-coronary sinus (89%, 8/9), and predominantly located in the bottom of the sinus extending upward towards the sinotubular junction. Three patients had concomitant leaflet thrombosis, and 3 patients had subclinical embolic stroke noted on brain magnetic resonance imaging. All patients had been prescribed aspirin and clopidogrel after TAVR for at least 6 months without anticoagulants.

CONCLUSIONS

Cardiac CT after TAVR can detect sinus of Valsalva thrombosis, and attention should be paid to this potential source of subsequent systemic embolization.

Quantitative [18F]florbetapir PET/CT may identify lung involvement in patients with systemic AL amyloidosis

PURPOSE

The clinical diagnosis of pulmonary involvement in individuals with systemic AL amyloidosis remains challenging. [18F]florbetapir imaging has previously identified AL amyloid deposits in the heart and extra-cardiac organs. The aim of this study is to determine quantitative [18F]florbetapir pulmonary kinetics to identify pulmonary involvement in individuals with systemic AL amyloidosis.

METHODS

We prospectively enrolled 58 subjects with biopsy-proven AL amyloidosis and 9 control subjects (5 without amyloidosis and 4 with ATTR cardiac amyloidosis). Pulmonary [18F]florbetapir uptake was evaluated visually and quantified as distribution volume of specific binding (Vs) derived from compartmental analysis and simpler semiquantitative metrics of maximum standardized uptake values (SUVmax), retention index (RI), and target-to-blood ratio (TBR).

RESULTS

On visual analysis, pulmonary tracer uptake was absent in most AL subjects (40/58, 69%); 12% (7/58) of AL subjects demonstrated intense bilateral homogeneous tracer uptake. In this group, compared to the control group, Vs (median Vs 30-fold higher, 9.79 vs. 0.26, p < 0.001), TBR (median TBR 12.0 vs. 1.71, p < 0.001), and RI (median RI 0.310 vs. 0.033, p < 0.001) were substantially higher. Notably, the AL group without visually apparent pulmonary [18F]florbetapir uptake also demonstrated a > 3-fold higher Vs compared to the control group (median 0.99 vs. 0.26, p < 0.001). Vs was independently related to left ventricular SUVmax, a marker of cardiac AL deposition, but not to ejection fraction, a marker of cardiac dysfunction. Also, intense [18F]florbetapir lung uptake was not related to [11C]acetate lung uptake, suggesting that intense [18F]florbetapir lung uptake represents AL amyloidosis rather than heart failure.

CONCLUSIONS

[18F]florbetapir PET/CT offers the potential to noninvasively identify pulmonary AL amyloidosis, and its clinical relevance warrants further study.

Importance of Nonlongitudinal Motion Components in Right Ventricular Function: Three-Dimensional Echocardiographic Study in Healthy Volunteers

BACKGROUND

Global right ventricular (RV) function is determined by the interplay of different motion components related to the myofiber architecture, and the relative importance of these components is still not thoroughly characterized. The aims of this study were to quantify the relative contributions of longitudinal, radial, and anteroposterior motion components to global RV function and to examine their determining factors in a large cohort of healthy volunteers using three-dimensional echocardiography.

METHODS

Three hundred healthy adults with a balanced age range and an equal sex distribution were investigated at two centers. A three-dimensional mesh model of the right ventricle was generated, and its motion was decomposed along the three anatomically relevant axes. Multiplicative relative contributions were measured by dividing the ejection fraction (EF) values generated by shortening in the longitudinal, radial, and anteroposterior directions by global RV EF (longitudinal EF index [LEFi], radial EF index [REFi], and anteroposterior EF index, respectively). The circumferential contribution was defined as shortening in the radial and anteroposterior directions, omitting only longitudinal shortening.

RESULTS

Circumferential EF index was markedly higher compared with LEFi (79 ± 7% vs 47 ± 9%, P < .001). LEFi (47 ± 9%) and anteroposterior EF index (49 ± 7%) were found to be similar in the pooled population, whereas REFi (44 ± 10%) was lower (P < .001). In younger individuals (20-39 years of age), the relative contribution of longitudinal shortening was significantly higher compared with the radial component; however, in the older age groups, LEFi and REFi were comparable. Age, body surface area, heart rate, and RV end-diastolic volume were independent predictors of LEFi and REFi, but all with opposite effects on the two motion directions.

CONCLUSIONS

In contrast to the traditional viewpoint, the contributions of the radial and anteroposterior motion directions may be of comparable significance with that of longitudinal shortening in determining global RV function. Standard parameters referring only to longitudinal shortening of the right ventricle may be inadequate to characterize RV function thoroughly.

Rare Congenital Obstruction of the Inferior Vena Cava Diagnosed by Intraoperative Transesophageal Echocardiography

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Idiopathic IVC obstructions are rare and unlikely to be detected by routine testing.

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They can be aberrant membranes, stenoses, or malformed Eustachian valves.

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IVC obstructions may be a cause of congestive hepatopathy.

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IVC obstructions are more likely detected by complete TEE than standard TTE.

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Complete and systematic intraoperative TEE is valuable for cardiac surgery.

Estimation of Stroke Volume and Aortic Valve Area in Patients with Aortic Stenosis: A Comparison of Echocardiography versus Cardiovascular Magnetic Resonance

BACKGROUND

In aortic stenosis, accurate measurement of left ventricular stroke volume (SV) is essential for the calculation of aortic valve area (AVA) and the assessment of flow status. Current American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines suggest that measurements of left ventricular outflow tract diameter (LVOTd) at different levels (at the annulus vs 5 or 10 mm below) yield similar measures of SV and AVA. The aim of this study was to assess the effect of the location of LVOTd measurement on the accuracy of SV and AVA measured on transthoracic echocardiography (TTE) compared with cardiovascular magnetic resonance (CMR).

METHODS

One hundred six patients with aortic stenosis underwent both TTE and CMR. SV was estimated on TTE using the continuity equation with LVOTd measurements at four locations: at the annulus and 2, 5, and 10 mm below annulus. SV was also determined on CMR using phase contrast acquired in the aorta (SV_CMR-PC), and a hybrid AVA_CMR-PC was calculated by dividing SV_CMR-PC by the transthoracic echocardiographic Doppler aortic velocity-time integral. Comparison between methods was made using Bland-Altman analysis.

RESULTS

Compared with the referent method of phase-contrast CMR for the estimation of SV_CMR-PC and AVA_CMR-PC (SV_CMR-PC 83 ± 16 mL, AVA_CMR-PC 1.27 ± 0.35 cm²), the best agreement was obtained by measuring LVOTd at the annulus or 2 mm below (P = NS), whereas measuring 5 and 10 mm below the annulus resulted in significant underestimation of SV and AVA by up to 15.9 ± 17.3 mL and 0.24 ± 0.28 cm², respectively (P < .01 for all). Accuracy for classification of low flow was best at the annulus (86%) and 2 mm below (82%), whereas measuring 5 and 10 mm below the annulus significantly underperformed (69% and 61%, respectively, P < .001).

CONCLUSIONS

Measuring LVOTd at the annulus or very close to it provides the most accurate measures of SV and AVA, whereas measuring LVOTd 5 or 10 mm below significantly underestimates these parameters and leads to significant overestimation of the severity of aortic stenosis and prevalence of low-flow status.

Impact of inferior caval valve implantation on severity of tricuspid regurgitation and right heart function

AIMS

Severe tricuspid regurgitation (TR) is a common finding in heart failure patients and associated with increased mortality. New interventional therapeutic options are needed as many heart failure patients are unfit for surgery. The TRICAVAL study compared valve implantation into the inferior vena cava (CAVI) with optimal medical therapy (OMT) in patients with severe TR. Here, we report details on the impact of CAVI on TR severity as well as right heart function and morphology.

METHODS AND RESULTS

We randomized 28 patients with severe TR to CAVI (n = 14) with transfemoral implantation of an Edwards Sapien XT valve into the inferior vena cava or OMT (n = 14). Inclusion and exclusion criteria were based on anatomical and clinical parameters. Echocardiographic measurements were performed at baseline, at the first postoperative day and one, three, and twelve months after randomization. As proof of concept of an effective sealing of the inferior vena cava, we detected a significant decrease in systolic hepatic vein reflux volume (11.0 [6.2-21.9] mL vs 3.5 [0.6-8.5] mL, P = .016) and hepatic vein diameter (11.5 [10.0-14.8] mm vs 10.0 [9.3-11.8] mm, P = .034) at thirty-day follow-up. However, CAVI had no significant impact on TR, cardiac function, and morphology.

CONCLUSIONS

Caval valve implantation significantly reduced systolic reflux into the hepatic veins but was not associated with an improvement in cardiac function, morphology, or TR severity.

Left ventricular systolic dyssynchrony in patients with Kawasaki disease: a real-time three-dimensional echocardiography study

The left ventricular (LV) systolic dyssynchrony index (SDI) is an important prognostic indicator for many cardiovascular diseases; however, the characteristics of the SDI in patients with Kawasaki disease (KD) are unknown. In this study, we aimed to identify and quantify the SDI using real-time three-dimensional echocardiography (RT3DE) in KD patients during different phases. In addition, we intended to explore whether the SDI is associated with systolic dysfunction. Seventy consecutive KD patients and seventy age- and sex-matched controls were enrolled. The SDIs (percent of cardiac cycle) of 16 segments (16-SDI%) and 12 segments (12-SDI%) were calculated based on the defined standard deviation of each segment time from end diastole to the minimal systolic volume according to the 17-segment model (apex excluded). In the acute phase, the 16-SDI% and 12-SDI% were significantly higher in KD patients than in controls (4.40 ± 0.14 vs. 1.98 ± 0.12, P = 0.000; 3.55 ± 1.21 vs. 1.67 ± 0.93, P = 0.009, respectively), and patients with coronary artery aneurysm (CAA) exhibited higher 16-SDI% (P = 0.021) and 12-SDI% (P = 0.034) than patients without CAA. In the convalescent phase, patients with CAA still had higher 16-SDI% (P = 0.002) and 12-SDI% (P = 0.031) than controls, while the SDI in patients without CAA recovered to normal. The 16-SDI% was negatively correlated with the LV ejection fraction obtained from RT3DE (r = - 0.845, P = 0.000). Mechanical dyssynchrony is prevalent in KD patients during the acute phase and transient in patients without CAA, while patients with CAA still have impaired synchrony even in the convalescent phase. LV systolic dysfunction is associated with increased dyssynchrony. RT3DE is a valuable modality for identifying and quantifying dyssynchrony in KD patients.

Artificial Intelligence and Echocardiography: A Primer for Cardiac Sonographers

Artificial intelligence (AI) is emerging as a key component in diagnostic medical imaging, including echocardiography. AI with deep learning has already been used with automated view labeling, measurements, and interpretation. As the development and use of AI in echocardiography increase, potential concerns may be raised by cardiac sonographers and the profession. This report, from a sonographer's perspective, focuses on defining AI, the basics of the technology, identifying some current applications of AI, and how the use of AI may improve patient care in the future.

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AI will have a strong role in echocardiography.

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AI will guide image acquisition and optimization.

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AI for image analysis may aid in interpretation.

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AI is a tool that will not replace sonographers but will help them be more efficient.

Exploring human trainability: Design and rationale of Studies of Twin Responses to Understand Exercise as a Therapy (STRUETH) study

Background

Exercise confers myriad health benefits and physical inactivity is a modifiable risk factor for many non-communicable chronic diseases. However, individual responsiveness to guideline-based exercise programs is idiosyncratic for health and fitness outcomes. It is not known whether the response of individuals to distinct exercise modalities tend to be concordant or whether there is a genetic contribution to variation in exercise responsiveness.

Methods/design

Healthy, young adult (16-40yrs) monozygotic (MZ) and dizygotic (DZ) twin pairs were recruited and randomly assigned to 3 months of endurance or resistance exercise training. Twin pairs trained together. After 3 months of training in their randomly assigned mode, a washout period of 3 months was observed before twin pairs crossed over to complete 3 months of the alternate exercise intervention. Measures of cardiac morphology and function, cerebrovascular function, cognitive performance, peripheral artery function, biochemistry, blood pressure, body composition, skeletal muscle strength and cardiopulmonary fitness were collected before and after each exercise intervention (i.e. at weeks 0, 12, 24 and 36).

Discussion

We adopted exercise modalities that produce distinct haemodynamic and physiological stimuli for physiological adaptation and recruited MZ and DZ twin pairs to address questions such as; do individuals exhibit concordant responses to distinct exercise modalities? and what is the genetic contribution to adaptation resulting from distinct training modalities? The results of this study will provide insight into the genetic and environmental contribution to exercise response to distinct modes of training, with implications for determining the optimal approaches to exercise prescription.

Two-Dimensional and Three-Dimensional Transthoracic Echocardiography as Predictive and Prognostic Indicators of All-Cause Mortality in Heart Failure with Reduced Ejection Fraction in Patients with Ischemic Heart Disease

Background

This study aimed to compare the predictive role of two-dimensional transthoracic echocardiography (2D-TTE) and three-dimensional transthoracic echocardiography (3D-TTE) on in-hospital all-cause mortality in patients with heart failure and reduced ejection fraction (HFrEF) due to ischemic heart disease (IHD).

Material/Methods

Patients (N-224) with HFrEF due to IHD who had a left ventricular ejection fraction (LVEF) <40% on admission when measured by 2D-TTE and 3D-TTE were studied and divided into survival and mortality groups. Baseline demographic and clinical characteristics were compared.

Results

Compared with the survival group (n=142), patients who died during hospitalization (n=82) were more commonly older (67.3 vs. 62.6 years), female (48.8% vs. 38.7%), with diabetes mellitus (51.2% vs. 32.4%), chronic kidney disease (48.8% vs. 32.4%), intravenous inotropes (85.4% vs. 76.1%), and intravenous vasodilators (70.7% vs. 61.3%). Regression model analysis for all-cause mortality identified significant associations with age, diabetes mellitus, myocardial infarction (MI), intravenous inotropes, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and LVEF following 2D-TTE. Age, diabetes mellitus, prior MI, the use of intravenous inotropes, NT-proBNP, LVEF, and left ventricular end-diastolic volume (LVEDV) index following 3D-TTE were significantly associated with all-cause mortality. Modeling of 2D-TTE parameters showed that the concordance statistic (C-index) increased significantly after including the LVEF, from 0.72 to 0.77 and from 0.72 to 0.80, respectively. Modeling of 3D-TTE parameters showed that the C-index increased significantly after including the LVEDV index (from 0.80 to 0.76).

Conclusions

In patients with HFrEF due to IHD, 3D-TTE was a better predictor than 2D-TTE of in-hospital all-cause mortality.

"Pure" severe aortic stenosis without concomitant valvular heart diseases: echocardiographic and pathophysiological features

Purpose

In echocardiography the severity of aortic stenosis (AS) is defined by effective orifice area (EOA), mean pressure gradient (mPG_AV) and transvalvular flow velocity (maxV_AV). The hypothesis of the present study was to confirm the pathophysiological presence of combined left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with “pure” severe AS.

Methods and Results

Patients (n = 306) with asymptomatic (n = 133) and symptomatic (n = 173) “pure” severe AS (mean age 78 ± 9.5 years) defined by indexed EOA < 0.6 cm² were enrolled between 2014 and 2016. AS patients were divided into 4 subgroups according to mPG_AV and indexed left ventricular stroke volume: low flow (LF) low gradient (LG)-AS (n = 133), normal flow (NF) LG-AS (n = 91), LF high gradient (HG)-AS (n = 21) and NFHG-AS (n = 61). Patients with “pure” severe AS showed mean mPG_AV of 31.7 ± 9.1 mmHg and mean maxV_AV of 3.8 ± 0.6 m/s. Only 131 of 306 patients (43%) exhibited mPG_AV > 40 mmHg and maxV_AV > 4 m/s documenting incongruencies of the AS severity assessment by Doppler echocardiography. LVH was documented in 81%, DD in 76% and PAH in 80% of AS patients. 54% of “pure” AS patients exhibited all three alterations. Ranges of mPG_AV and maxV_AV were higher in patients with all three alterations compared to patients with less than three. 224 (73%) patients presented LG-conditions and 82 (27%) HG-conditions. LVH was predominant in NF-AS (p = 0.014) and PAH in LFHG-AS (p = 0.014). Patients’ treatment was retrospectively assessed (surgery: n = 100, TAVI: n = 48, optimal medical treatment: n = 156).

Conclusion

In patients with “pure” AS according to current guidelines the presence of combined LVH, DD and PAH as accepted pathophysiological sequelae of severe AS cannot be confirmed. Probably, the detection of these secondary cardiac alterations might improve the diagnostic algorithm to avoid overestimation of AS severity.

Early Surgery versus Watchful Waiting in Patients with Moderate Aortic Stenosis and Left Ventricular Systolic Dysfunction

Background and Objectives

Severe aortic stenosis (AS) with left ventricular systolic dysfunction (LVSD) is a class I indication for aortic valve replacement (AVR) but this recommendation is not well established in those at the stage of moderate AS. We investigate the clinical impact of AVR among patients with moderate AS and LVSD.

Methods

From 2001 to 2017, we consecutively identified patients with moderate AS and LVSD, defined as aortic valve area 1.0–1.5 cm² and left ventricular ejection fraction <50%. The primary outcome was all-cause death. The outcomes were compared between those who underwent early surgical AVR (within 2 years of index echocardiography) at the stage of moderate AS versus those who were followed medically without AVR at the outpatient clinic.

Results

Among 255 patients (70.1±11.3 years, male 62%), 37 patients received early AVR. The early AVR group was younger than the medical observation group (63.1±7.9 vs. 71.3±11.4) with a lower prevalence of hypertension and chronic kidney disease. During a median 1.8-year follow up, 121 patients (47.5%) died, and the early AVR group showed a significantly lower all-cause death rate than the medical observation group (5.03PY vs. 18.80PY, p<0.001). After multivariable Cox-proportional hazard regression adjusting for age, sex, comorbidities, and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of death (hazard ratio, 0.43; 95% confidence interval 0.20–0.91; p=0.028).

Conclusions

In patients with moderate AS and LVSD, AVR reduces the risk of all-cause death. A prospective randomized trial is warranted to confirm our findings.

Impact of the left anterior descending artery wrapping around the left ventricular apex on cardiac mechanics in patients with normal coronary angiography

Background

We examined the impact of left anterior descending (LAD) wrapping on left ventricular (LV) mechanics in patients with normal coronary angiography. Seventy-one patients with evidence of normal coronary angiography (LAD wrapping: n = 52, 73%) and LAD non-wrapping (n = 19, 27%) were included in the study. Using 2D-strain imaging, we measured LV longitudinal and circumferential (circ) strain (ε_sys), systolic strain rate (SR_sys), early (SR_e) and atrial (SR_a) diastolic SR, LV electromechanical dyssynchrony (TTP-SD), and LV twist and torsion in study groups.

Results

No significant difference in age, gender, body surface area (BSA), or ejection fraction (EF%) between groups. LAD-wrapping group showed higher deceleration time (DT) (P < 0.0001), global longitudinal ε_sys % (P < 0.02), circ SR_a at the basal segments (P < .02), circ SR_sys and SR_e, and SR_a (P < 0.0001) at the apical segments and apical rotation compared with the non-wrapped group. LV twist was correlated negatively with LV electromechanical dyssynchrony (r = .25, P < 0.03) and positively with longitudinal ε_sys (r = .47, P < .0001), circ ε_sys% (r = .55, P < .0001), circ SR_sys (r = .23, P < .05), and circ SR_e (r = .55, P < .0001). Using multivariate regression analysis, DT: OR 0.932, CI 0.877–0.991, and P < 0.02 and circ at atrial diastole (SR_a): OR 0.000, CI .000–.271, and P < 0.03 were independent predictors of LAD wrapping around LV apex.

Conclusion

Wrapped LAD is associated with better myocardial relaxation and rotational mechanics in patients with normal coronary angiography. This could explain the worse prognosis in such population when LAD occlusion acutely emerges.

The Year in Perioperative Echocardiography: Selected Highlights From 2019

This article is the fourth of an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board, for the opportunity to continue this series. In most cases, these were research articles that were targeted at the perioperative echocardiography diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, these articles targetted the use of perioperative echocardiography in general.

Establishment of adult right ventricle failure in ovine using a graded, animal-specific pulmonary artery constriction model

BACKGROUND

Right ventricle failure (RVF) is associated with serious cardiac and pulmonary diseases that contribute significantly to the morbidity and mortality of patients. Currently, the mechanisms of RVF are not fully understood and it is partly due to the lack of large animal models in adult RVF. In this study, we aim to establish a model of RVF in adult ovine and examine the structure and function relations in the RV.

METHODS

RV pressure overload was induced in adult male sheep by revised pulmonary artery constriction (PAC). Briefly, an adjustable hydraulic occluder was placed around the main pulmonary artery trunk. Then, repeated saline injection was performed at weeks 0, 1, and 4, where the amount of saline was determined in an animal-specific manner. Healthy, age-matched male sheep were used as additional controls. Echocardiography was performed bi-weekly and on week 11 post-PAC, hemodynamic and biological measurements were obtained.

RESULTS

This PAC methodology resulted in a marked increase in RV systolic pressure and decreases in stroke volume and tricuspid annular plane systolic excursion, indicating signs of RVF. Significant increases in RV chamber size, wall thickness, and Fulton's index were observed. Cardiomyocyte hypertrophy and collagen accumulation (particularly type III collagen) were evident, and these structural changes were correlated with RV dysfunction.

CONCLUSION

In summary, the animal-specific, repeated PAC provided a robust approach to induce adult RVF, and this ovine model will offer a useful tool to study the progression and treatment of adult RVF that is translatable to human diseases.

Bedside Focused Cardiac Ultrasound in COVID-19 from the Wuhan Epicenter: The Role of Cardiac Point-of-Care Ultrasound, Limited Transthoracic Echocardiography, and Critical Care Echocardiography

BACKGROUND

Three cases of the application of focused cardiac ultrasound in patients with coronavirus disease 2019 are presented.

METHODS

Cardiac point-of-care ultrasound, limited transthoracic echocardiography, and critical care echocardiography were applied in cases of heart failure, pulmonary embolism, and myocarditis with thrombus respectively.

RESULTS

The impact on patient management and the global context of each presentation are discussed.

CONCLUSIONS

Focused cardiac point-of-care ultrasound played an important, front-line role in the bedside management of patients during the COVID-19 pandemic in Wuhan, China.

Left ventricular cavity obliteration: Mechanism of the intracavitary gradient and differentiation from hypertrophic obstructive cardiomyopathy

Background

Controversy surrounds the cause of the pressure gradient in patients with hypertrophic obstructive cardiomyopathy (HOCM). Left ventricular cavity obliteration (LVCO) was first described as the cause of the gradient but subsequently systolic anterior motion (SAM) of the mitral valve has been established as the cause. Nevertheless, the two gradients, though different in origin and significance, share similar characteristics. They both have a similar “dagger” profile, are obtained from the cardiac apex, are associated with a hyperdynamic left ventricle, and the gradients are worsened by Valsalva. The distinction has clinical relevance, because treating the intracavitary gradient (ICG) of LVCO as if it were a SAM‐associated gradient associated with HOCM would be inappropriate and possibly harmful.

Materials and Methods

To clarify the cause and characteristics of the ICG in patients with LVCO in patients without HOCM, we assessed the extent and duration of cavity obliteration, and for differentiation, we compared the spectral profiles with patients with HOCM and severe aortic stenosis (AS).

Results

Higher ICG is associated with a greater extent and more prolonged apposition of LV walls, and smaller left ventricular cavity size.

The spectral profile of patients with AS, HOCM, and LVCO is differentiated by the peak/mean gradient ratios of 2 or less, 2–3, and 3 or greater, respectively, in >90% of patients. Most patients with LVCO without HOCM or severe LVH have an ICG < 36 mm Hg.

Conclusion

The magnitude of ICG is quantitatively associated with the extent and duration of LVCO. Spectral profiles of severe AS, HOCM, and LVCO can be differentiated by the peak/mean gradient ratio.

Hepatic venous Doppler assessment can anticipate simplified pulmonary embolism severity index and right ventricle dysfunction in patients with acute pulmonary embolism

PURPOSE

Acute pulmonary embolism (APE) is a life-threating cardiothoracic thromboembolic emergency in which right ventricle dysfunction (RVD) is a major concern. In the present study, we examined the hepatic veins (HVs) blood flow with pulsed-wave spectral Doppler ultrasonography to determine its relationship with the simplified pulmonary embolism severity index (sPESI) and the patient's RVD status.

METHODS

We divided the 243 patients who met the inclusion criteria into two groups based on both their sPESI scores and their RVD status. Transthoracic echocardiography was performed to evaluate the RVD and the HVs within 1 hour after patient admission. The liver was evaluated using subcostal and intercostal echocardiographic windows in grayscale B-mode, and HVs were assessed using color and spectral Doppler assessment though the same echocardiographic windows.

RESULT

A cut-off value of the systolic reverse flow velocity-time integral (SrVTI) = 2.2 cm carried a sensitivity and specificity of 84.29% and 74.89%, respectively, for the prediction of sPESI ≥ 1. A SrVTI cut-off value of 2.1 cm yielded a sensitivity and specificity of 83.03% and 73.91%, respectively, for the prediction of RVD.

CONCLUSION

HV Doppler assessment could be a useful method for anticipating the sPESI and the presence of RVD in patients with APE. In addition, it may provide information regarding the hemodynamic impact of APE.

Do sporting activities and using protein supplements change the frontal QRS-T angle?

BACKGROUND

The aim of this study was to investigate whether the frontal QRS-T angle was different between the athletes and normal healthy people.

METHODS

The study included 122 healthy athletes (the mean age was 29.7±7.7 years, of them, were 73.8% male) and a control group consisted of 60 healthy people (the mean age was 29.8±7.8 years, 26% of them were male). Then, the athletes were divided into two groups as who used protein supplements (PS) and those who did not. In the 12-lead ECG, heart rate (HR), P, QRS, QT, corrected QT (QTc) duration, QT and corrected QT dispersion (QTD, QTcD), the sum of V1 or V2S amplitude and V5 or V6R amplitude (V1/2S+V5/6R), frontal QRS-T angle were calculated.

RESULTS

There was no significant difference between the athletes and control groups regarding age, gender, smoking, body mass index, systolic blood pressure (SBP) and diastolic blood pressure (DBP), echocardiographic features, P, PR duration, P, QRS, T axis, QTD and QTcD (P>0.05).HR and QTc were significantly lower (P<0.05) and QRS, QT duration was longer in athletes group (P<0.001). The V1/2S+V5/6R and frontal QRS-T angle values were higher in the athlete's group (P<0.001). There was no significant difference between PS users and non PS users regarding demographic characteristics, duration of sports years, SBP and DBP (P>0.05). However, male gender was dominant in the PS users group (P=0.018). The P axis, PR and QRS duration were longer in the PS users group (P<0.05).It was found that the T axis was negatively correlated (r=-0.431,P<0.001) but the QRS axis was positively correlated (r=0.395,P<0.001) with frontal QRS-T angle.

CONCLUSIONS

The frontal QRS-T angle, was found to be wider in athletes compared to normal healthy participants. However, there was no significant difference between who used PS and those who did not.

Immediate and 24-h post-marathon cardiac troponin T is associated with relative exercise intensity

PURPOSE

We aimed at exploring whether cardiopulmonary fitness, echocardiographic measures and relative exercise intensity were associated with high-sensitivity cardiac troponin T (hs-TNT) rise and normalization following a marathon.

METHODS

Nighty-eight participants (83 men, 15 women; 38.72 ± 3.63 years) were subjected to echocardiographic assessment and a cardiopulmonary exercise test (CPET) before the race. hs-TNT was measured before, immediately after and at 24, 48, 96, 144 and 192 h post-race. Speed and mean heart rate (HR) during the race were relativized to CPET values: peak speed (%V_VMAX), peak HR (HR_%MAX), speed and HR at the second ventilatory threshold (HR_%VT2 and %V_VT2).

RESULTS

Hs-TNT increased from pre- to post-race (5.74 ± 5.29 vs. 50.4 ± 57.04 ng/L; p < 0.001), seeing values above the Upper Reference Limit (URL) in 95% of the participants. At 24 h post-race, 39% of the runners still exceeded the URL (High hs-TNT group). hs-TNT rise was correlated with marathon speed %V_VT2 (r = 0.22; p = 0.042), mean HR_%VT2 (r = 0.30; p = 0.007), and mean HR_%MAX (r = 0.32; p = 0.004). Moreover, the High hs-TNT group performed the marathon at a higher Speed %V_VT2 (88.21 ± 6.53 vs. 83.49 ± 6.54%; p = 0.002) and Speed %V_VMAX (72 ± 4.25 vs. 69.40 ± 5.53%; p = 0.009). hs-TNT showed no significant associations with cardiopulmonary fitness and echocardiographic measures, except for a slight correlation with left ventricular end systolic diameter (r = 0.26; p = 0.018).

CONCLUSION

Post-race hs-TNT was above the URL in barely all runners. Magnitude of hs-TNT rise was correlated with exercise mean HR; whereas, its normalization kept relationship with marathon relative speed.

The Efficacy of Contrast Transthoracic Echocardiography and Contrast Transcranial Doppler for the Detection of Patent Foramen Ovale Related to Cryptogenic Stroke

Background

Patent foramen ovale (PFO) has been linked to the pathophysiology of cryptogenic stroke. Contrast transesophageal echocardiography (cTEE) is the current gold standard for PFO diagnosis, but it has the disadvantage of being semi-invasive and does not exempt from risks. As a diagnostic test, the efficacy of contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) is controversial. This study is aimed at investigating the efficacy of cTTE and cTCD versus cTEE in PFO detection, exploring a more cost-effective and reliable method for the diagnosis of PFO related to cryptogenic stroke.

Methods

From August 2019 to January 2020, a total of 213 patients with suspected PFO were included in our study. All patients underwent cTEE, cTCD, and cTTE examinations. cTTE3 was named for using a cutoff of 3 beats to detect PFO during cTTE, and cTTE5 represented a cutoff of 5 beats. A cutoff of cTCD grade III was named cTCD III. A cutoff of grade IV was named cTCD IV. cTTE3+cTCD IV was used for the combination of a cutoff of 3 beats during cTTE with grade IV of cTCD. cTTE5+cTCD III combined a cutoff of 5 beats during cTTE with cTCD grade III. Taking cTEE as the gold standard, we compared the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate for PFO detection among the above methods.

Results

A total of 161 of 213 (76%) patients had PFO confirmed by cTEE. With the spontaneous Valsalva maneuver, the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTTE3 in PFO diagnosis were 60%, 90%, 44%, and 10%, respectively, and those for cTTE5 were 76%, 78%, 31% and 22%, respectively. The sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTCD III were 80%, 71%, 29%, and 29%, respectively, while those for cTCD IV were 55%, 90%, 49%, and 10%, respectively. When cTTE and cTCD were combined to diagnose PFO, the specificity and misdiagnosis rate were significantly improved, especially cTTE3+cTCD IV, with 100% specificity and a misdiagnosis rate of 0.

Conclusion

cTTE or cTCD can be used for preliminary PFO related to cryptogenic stroke findings. The combination of the two methods can improve the specificity of PFO diagnosis, especially using the cutoff of cTTE3+cTCD IV.

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

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Echocardiography services have been interrupted by the COVID pandemic.

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Services are being gradually reintroduced as healthcare facilities reopen.

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Operational, workflow and prioritization considerations are suggested.

Troponins and Natriuretic Peptides in Cardio-Oncology Patients-Data From the ECoR Registry

BACKGROUND

The long-term survival of cancer patients has significantly improved over the past years. Despite their therapeutic efficacy, various cancer therapies are associated with cardiotoxicity. Therefore, timely detection of cardiotoxic adverse events is crucial. However, the clinical assessment of myocardial damage caused by cancer therapy remains difficult.

METHODS

This retrospective study was performed to evaluate the diagnostic value of cardiac troponin I (cTnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) for monitoring cancer therapy-induced cardiomyopathy. A total of 485 cancer patients referred to our cardio-oncology unit between July 2018 and January 2020 were selected from our Essen Cardio-oncology Registry (ECoR). We included patients with all types of cancer. Plasma concentrations of cTnI and NT-proBNP were measured by radioimmunoassay, and two-dimensional left ventricular ejection fraction (2D-LVEF), diastolic function, and global longitudinal strain (GLS) were measured by transthoracic echocardiography. In 116 patients, assessment was conducted before the induction of cancer therapy and during a short-term follow-up period; n = 42 of these were treated for malignant melanoma, and n = 42 with serial measurements were under treatment for breast cancer.

RESULTS

In cross-sectional data, elevated NT-proBNP was associated with reduced LVEF and pathological GLS in the total cohort. A total of 116 patients had serial LVEF and biomarker measurements, and changes in NT-proBNP and troponin correlated with changes in LVEF during follow-up investigations. Similar to the total cohort, a subgroup of patients treated for malignant melanoma showed a correlation between the change in cTnI and the change in LVEF. In a subgroup analysis of patients undergoing breast cancer therapy, a correlation between the change in NT-proBNP and the change in LVEF could be detected. Thirty patients presented with chemotherapy-induced cardiomyopathy, defined as a significant LVEF decrease (> 10%) to a value below 50%. The number of patients with increased cTnI and NT-proBNP was significantly higher in patients with chemotherapy-induced cardiomyopathy than in patients without cardiotoxicity. Patients with positive cTnI and NT-proBNP were more likely to have a history of coronary heart disease, atrial fibrillation, and arterial hypertension.

CONCLUSION

Our data suggest that cardiac biomarkers play an important role in the detection of cancer therapy-induced cardiotoxicity. Larger systematic assessment in prospective cohorts is mandatory.

Associations between Cardiac Magnetic Resonance T1 Mapping Parameters and Ventricular Arrhythmia in Patients with Chagas Disease

Chronic Chagas disease can progress to myocardial involvement with intense fibrosis, which may predispose patients to sudden cardiac death through ventricular arrhythmia. The associations of myocardial fibrosis detected by cardiac magnetic resonance (CMR) parameters with non-sustained ventricular tachycardia (NSVT) were evaluated. This cross-sectional study included patients in early stages of Chagas disease (n = 47) and a control group (n = 15). Patients underwent cardiac evaluation, including CMR examination. Myocardial fibrosis assessment by CMR with measurement of late gadolinium enhancement (LGE), native T1, and extracellular volume (ECV) was performed. There was an increase in myocardial fibrosis CMR parameters and ventricular arrhythmias among different stages of Chagas disease, combined with a decrease in the left ventricular ejection fraction (LVEF) by CMR and also in the right ventricular systolic function by S' wave on tissue Doppler. Fibrosis mass and ECV were associated with the Rassi score, ventricular extrasystole, and E/e' ratio in a logistic regression model adjusted for age and gender. The ECV maintained an association with the presence of NSVT, even after adjustments for fibrosis mass and LVEF assessed by CMR. The receiver-operating characteristic area under the curve for global ECV (0.85; 95% CI: 0.71-0.99) and NSVT was greater than that for fibrosis mass (0.75; 95% CI: 0.54-0.96), although this difference was not statistically significant. Extracellular volume could be an early marker of increased risk of ventricular arrhythmia in Chagas disease, presenting an independent association with NSVT in the initial stages of chronic Chagas cardiomyopathy, even after adjustment for fibrosis mass and LVEF.

Tablet-Based Limited Echocardiography to Reduce Sonographer Scan and Decontamination Time during the COVID-19 Pandemic

Background

Limited assessments with handheld ultrasound have found meaningful clinical use in the care of acutely ill patients. However, there are limited data on incorporating handheld-based limited echocardiography into the echocardiography laboratory. The purpose of this study was to assess the efficacy of limited handheld tablet echocardiography as an alternative to traditional echocardiography during the coronavirus disease 2019 (COVID-19) pandemic as a means to limit exposure while providing essential clinical information.

Methods

Ninety consecutive inpatients with known or suspected COVID-19 were scanned according to laboratory COVID-19 guidelines using a limited 11- to 20-clip protocol on a tablet sonograph. The primary assessment was length of study time. Comparison data were drawn from comprehensive echocardiographic examinations ordered on intensive care patients not under COVID-19 precautions.

Results

Over a 36-day time period, a total of 91 requests were deemed to be appropriate for echocardiography on patients with suspected or confirmed COVID-19 (average age, 67 years; 64% men; mean body mass index, 32 kg/m²). Of these, 90 (99%) examinations were performed using a handheld device, and all were deemed diagnostic and provided sufficient information for the clinical care team. Sonographer scan time decreased from an average of 24 ± 6.8 min on a traditional platform to 5.4 ± 1.9 min on a tablet.

Conclusions

Limited handheld echocardiography can be successfully implemented in the echocardiography laboratory for screening of COVID-19-related cardiac conditions. The protocol performed with handheld tablet ultrasound provides adequate diagnostic information of major cardiac complications of COVID-19 while decreasing sonographer contact and simplifying decontamination.

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Handheld ultrasound is an effective alternative in patients with COVID-19.

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A majority of handheld studies are sufficient to guide management in these patients.

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Study time is markedly reduced (79% less), thereby reducing sonographer exposure.

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A contrast agent can be used to enhance image fidelity when necessary.

New Imaging Parameters to Predict Sudden Cardiac Death in Chagas Disease

Chronic Chagas' cardiomyopathy is the most severe and frequent manifestation of Chagas disease, and has a high social and economic burden. New imaging modalities, such as strain echocardiography, nuclear medicine, computed tomography and cardiac magnetic resonance imaging, may detect the presence of myocardial fibrosis, inflammation or sympathetic denervation, three conditions associated with risk of sudden death, providing additional diagnostic and/or prognostic information. Unfortunately, despite its high mortality, there is no clear recommendation for early cardioverter-defibrillator implantation in patients with Chagas heart disease in the current guidelines. Ideally, the risk of sudden cardiac death may be evaluated in earlier stages of the disease using new image methods to allow the implementation of primary preventive strategies.

Right Ventricular Global Longitudinal Strain and Outcomes in Heart Failure with Preserved Ejection Fraction

BACKGROUND

Right ventricular (RV) strain has emerged as an accurate tool for RV function assessment and is a powerful predictor of survival in patients with heart failure with reduced ejection fraction. However, its prognostic impact in patients with heart failure with preserved ejection fraction (HFpEF) remains unclear. The aim of this study was to compare the prognostic value of RV global longitudinal strain (RVGLS) by two-dimensional speckle-tracking echocardiographic (STE) imaging in patients with HFpEF against conventional RV function parameters.

METHODS

Patients with HFpEF were prospectively recruited, and 149 of 183 (81%) with analyzable STE RVGLS images constituted the final study population (mean age, 78 ± 9 years; 61% women), compared with 28 control subjects of similar age and sex. All control subjects and 120 patients also underwent cardiac magnetic resonance imaging. Patients were followed up for a primary end point of all-cause mortality and first heart failure hospitalization, and Cox regression analysis was performed.

RESULTS

Mean STE RVGLS was significantly altered in patients with HFpEF compared with control subjects (-21.7 ± 4.9% vs -25.9 ± 4.2%, P < .001). STE RVGLS correlated well with RV ejection fraction by cardiac magnetic resonance (r = -0.617, P < .001). Twenty-eight patients with HFpEF (19%) had impaired STE RVGLS (>-17.5%). During a mean follow-up period of 30 ± 9 months, 91 patients with HFpEF (62%) reached the primary end point. A baseline model was created using independent predictors of the primary end point: New York Heart Association functional class III or IV, hemoglobin level, estimated glomerular filtration rate, and the presence of moderate or severe tricuspid regurgitation. Impaired STE RVGLS provided significant additional prognostic value over this model (χ² to enter = 7.85, P = .005). Impaired tricuspid annular plane systolic excursion and fractional area change, however, did not.

CONCLUSIONS

In patients with HFpEF, impaired RVGLS has strong prognostic value. STE RVGLS should be considered for systematic evaluation of RV function to identify patients at high risk for adverse events.

COVID-US: A simplified approach to cardiopulmonary ultrasound in suspected and confirmed COVID-19 patients in surge crisis

The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has placed an unprecedented challenge on healthcare systems across the globe. Rapid assessment of the cardiorespiratory function to monitor disease progression and guide treatment is essential. Therefore, we have designed the COVID-US: a simplified cardiopulmonary ultrasound approach to use in suspected and confirmed COVID-19 patients, to aid front-line health workers in their decision-making in a surge crisis.

Longitudinal Reference Ranges for Tricuspid Annular Plane Systolic Excursion and Mitral Annular Plane Systolic Excursion in Normally Grown Fetuses

OBJECTIVES

The aim of this study was to construct reference ranges for fetal tricuspid annular plane systolic excursion (TAPSE) and mitral annular plane systolic excursion (MAPSE) using conventional M-mode ultrasound (US) in the second half of pregnancy.

METHODS

Participants underwent US scans every 4 weeks from 18 weeks' gestation until delivery. The TAPSE and MAPSE were measured by conventional M-mode US at each examination. The relationships between TAPSE and MAPSE and gestational age and estimated fetal weight were modeled by Bayesian mixed effects linear regression.

RESULTS

Positive linear relationships were observed between both MAPSE and TAPSE and gestational age and estimated fetal weight. Reference centiles for TAPSE and MAPSE were developed.

CONCLUSIONS

This simple technique is a useful tool for assessing cardiac function and could be used for quantitative assessments of fetal cardiac function, particularly in high-risk pregnancies such as those complicated by maternal diabetes.

Sex Differences in the Association of Cumulative Body Mass Index from Early Adulthood to Middle Age and Left Atrial Remodeling Evaluated by Three-Dimensional Echocardiography: The Coronary Artery Risk Development in Young Adults Study

Background:

The relationship between long-term obesity and left atrial (LA) structure and function is not entirely understood. We examined the association of cumulative body mass index (cBMI) with LA remodeling using three-dimensional (3D) speckle-tracking echocardiography (STE).

Methods:

The Coronary Artery Risk Development in Young Adults (CARDIA) study is a community-based cohort of black and white, men and women, ages 18–30 years at baseline in 1985–86 from four U.S. centers. This study included 2,144 participants who had satisfactory image quality and body mass index measurements during the entire follow-up period. The 3D STE-derived LA parameters were maximum, minimum, and pretrial contraction volumes; total, passive, and active emptying fraction; maximum systolic longitudinal strain; and early and late diastolic longitudinal strain rates. Multivariable linear regression analyses stratified by sex assessed the relationship between cBMI and 3D STE-derived LA parameters, adjusting for demographics and traditional cardiovascular.

Results:

The mean age of the cohort was 55 ± 3.6 years; 54.8% were women, and 46.5% were black. There were statistically significant additive sex interactions for the association between cBMI and LA minimum contraction value, maximum systolic longitudinal strain, and early and late diastolic longitudinal strain rates. In the fully adjusted model, greater cBMI was associated with lower magnitude LA longitudinal deformation (maximum systolic longitudinal strain and early and late diastolic longitudinal strain rates) in men and with higher LA emptying fraction in women. In addition, greater cBMI was associated with higher LA phasic volumes indices in both men and women.

Conclusions:

This study showed that while greater cBMI from early adulthood throughout middle age was associated with higher LA volumes in both genders, differences were found for LA function, with lower longitudinal deformation in men and higher reservoir and active LA function in women. (J Am Soc Echocardiogr 2020;33:878–87.)