Mitral Annular Plane Systolic Excursion as a Surrogate for Left Ventricular Ejection Fraction

Accuracy of mitral annular plane systolic excursion in diagnosing anthracycline-induced subclinical cardiotoxicity in patients with breast cancer - a retrospective cohort study

BACKGROUND

The mitral annular plane systolic excursion (MAPSE) is used to analyze the left ventricle longitudinal function. However, the accuracy of MAPSE in diagnosing oncological populations is unclear. In this study, we aimed to assess the accuracy of MAPSE in diagnosing subclinical cardiotoxicity in women with breast cancer undergoing anthracycline treatment.

METHODS

This retrospective cohort study included echocardiographic assessments of patients with breast cancer who underwent anthracycline treatment as part of their therapeutic regimen. Assessments were performed before treatment, after administering the first dose of anthracycline, after completing anthracycline treatment, and 6 and 12 months after treatment. Left ventricular ejection fraction was calculated using the modified biplane Simpson method. The performances of MAPSE and global longitudinal strain (GLS) were analyzed using receiver operating characteristic (ROC) curves. Their accuracies were measured using the area under the ROC curves.

RESULTS

Sixty-one patients were included in this study. Of them, 8.2% presented cardiotoxicity 6 months after treatment completion. Patients with cardiotoxicity had lower LVEF (47% vs. 63%; p < 0.001), MAPSE (10.23 mm vs. 12.25 mm; p = 0.012), and LV GLS (16.13% vs. 19.05%; p = 0.005) values than those without. A 12% reduction in the GLS exhibited sensitivity, specificity, and overall accuracy of 80%, 70%, and 78%, respectively. A relative reduction of 15% in MAPSE exhibited a sensitivity, specificity, and accuracy of 80%, 77%, and 81.2%, respectively. An absolute MAPSE reduction of 2 mm exhibited a sensitivity, specificity, and accuracy of 80%, 73.21%, and 81.2%, respectively. No differences were observed between the ROC curves.

CONCLUSION

MAPSE showed similar accuracy to GLS in diagnosing subclinical cardiotoxicity in women with breast cancer undergoing anthracycline treatment.

Association of high-sensitivity troponin T with left ventricular dysfunction in prediabetes

BACKGROUND

Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are an increasingly serious problem worldwide. Tissue Doppler imaging (TDI), a non-invasive technique, may evaluate both systolic and diastolic function during the first phases of cardiovascular disease (CVD). High-sensitivity cardiac troponin T (hs-cTnT) can detect subclinical myocardial injury in asymptomatic prediabetic patients.

AIM

We aimed to investigate the relationship between left ventricular (LV) function and hs-cTnT in prediabetic patients.

METHODS

Between 1 October 2021 and 1 October 2022, we recruited 96 prediabetic and an equal number of age- and gender-matched healthy volunteers prospectively. TDI was used to evaluate both systolic and diastolic functions. Hs-cTnT levels were obtained and compared between groups.

RESULTS

It was found that the values for mitral annular plane systolic excursion (MAPSE), E, the rapid filling wave, E/Em, and the peak annular velocities of systolic excursion in the ejection period (Sm) were all significantly higher in these patients compared to healthy individuals (p < .001). Hs-cTnT was an independent predictor of left ventricular diastolic dysfunction (LVDD) and left ventricular systolic dysfunction (LVSD) (odds ratio [OR] = 2.625, 95% confidence interval [CI] = 1.324-4.308, p < .001, and OR = 1.922, 95% CI = 0.454-3.206, p = .004).

CONCLUSIONS

Prediabetics had higher hs-cTnT levels than controls. We showed that LVSD and LVDD functions were negatively affected in prediabetic patients. Our results proved that hs-cTnT levels may be associated with subclinical LV dysfunction in prediabetes.

Evaluation of subclinical left ventricular myocardial systolic dysfunction in type 2 diabetes mellitus patients with and without diabetes peripheral neuropathy by global myocardial work

AIMS

Speckle-tracking echocardiography can non-invasively estimate myocardial work (MW) to evaluate left ventricular (LV) myocardial systolic function. The present study evaluated whether MW may detect subclinical LV myocardial systolic dysfunction in type 2 diabetes mellitus (T2DM) patients with and without diabetes peripheral neuropathy (DPN).

METHODS

A total of 127 T2DM patients were included in the present study, including 67 T2DM patients with DPN. In addition, 73 sex- and age- matched healthy individuals served as normal controls. The global myocardial work index (GWI), global constructive work (GCW), global waste work (GWW), global positive work (GPW), global negative work (GNW), global work efficiency (GWE) and GCW/GWW were measured and analysed. Furthermore, the differences in MW parameters among normal controls, T2DM patients, and T2DM patients with DPN were analysed. Multiple regression models were built to explore for the independent influencing factors of GWI and GPW values in T2DM patients with DPN. Receiver operating characteristic curve analysis was performed to evaluate the sensitivity and specificity of MW in evaluating subclinical LV myocardial systolic dysfunction in T2DM patients with DPN.

RESULTS

The GWI, GCW and GPW of T2DM patients with DPN were significantly decreased compared with those of T2DM patients and normal controls (P < 0.001) and showed a significant decreasing trend overall (P trend < 0.001). GWE and GCW/GWW were significantly decreased in T2DM patients with DPN compared with normal controls (P < 0.05). Although GWW was not significantly different among the three groups, it showed an increasing trend (Ptrend = 0.033). High-density lipoprotein cholesterol (HDL-C) levels were independent influencing factor for decreased GWI (β = 0.21, P = 0.031) and GPW (β = 0.19, P = 0.043) values in T2DM patients with DPN. The combination of the GWI, GCW, GWE, GPW and GCW /GWW had good sensitivity (62.69%) and specificity (89.04%) when evaluating subclinical LV myocardial systolic dysfunction in T2DM patients with DPN.

CONCLUSIONS

Non-invasive evaluation of LV myocardial work can detect subclinical LV myocardial systolic dysfunction in T2DM patients with and without DPN. DPN has additive deleterious effects on LV myocardial systolic function in T2DM patients. The reduction of HDL-C levels may indicate the occurrence of subclinical LV myocardial systolic dysfunction in T2DM patients with DPN.

Diagnostic Adjunct Techniques in the Assessment of Hypovolemia: A Prospective Pilot Project

INTRODUCTION

Measuring the hypovolemic resuscitation end point remains a critical care challenge. Our project compared clinical hypovolemia (CH) with three diagnostic adjuncts: 1) noninvasive cardiac output monitoring (NICOM), 2) ultrasound (US) static IVC collapsibility (US-IVC), and 3) US dynamic carotid upstroke velocity (US-C). We hypothesized US measures would correlate more closely to CH than NICOM.

METHODS

Adult trauma/surgical intensive care unit patients were prospectively screened for suspected hypovolemia after acute resuscitation, excluding patients with burns, known heart failure, or severe liver/kidney disease. Adjunct measurements were assessed up to twice a day until clinical improvement. Hypovolemia was defined as: 1) NICOM: ≥10% stroke volume variation with passive leg raise, 2) US-IVC: <2.1 cm and >50% collapsibility (nonventilated) or >18% collapsibility (ventilated), 3) US-C: peak systolic velocity increase 15 cm/s with passive leg raise. Previously unknown cardiac dysfunction seen on US was noted. Observation-level data were analyzed with a Cohen's kappa (κ).

RESULTS

44 patients (62% male, median age 60) yielded 65 measures. Positive agreement with CH was 47% for NICOM, 37% for US-IVC and 10% for US-C. None of the three adjuncts correlated with CH (κ -0.045 to 0.029). After adjusting for previously unknown cardiac dysfunction present in 10 patients, no adjuncts correlated with CH (κ -0.036 to 0.031). No technique correlated with any other (κ -0.118 to 0.083).

CONCLUSIONS

None of the adjunct measurements correlated with CH or each other, highlighting that fluid status assessment remains challenging in critical care. US should assess for right ventricular dysfunction prior to resuscitation.

Dobutamine effects on systolic and diastolic left ventricular long-axis excursion and timing - significance for the interpretation of s' and e'

BACKGROUND

Dobutamine effects on the relationships of the peak velocity of left ventricular (LV) long-axis systolic motion (s') with systolic excursion (SExc), systolic duration (SDur) and heart rate, of LV long-axis early diastolic excursion (EDExc) with SExc, and of the peak velocity of LV long-axis early diastolic motion (e') with EDExc, early diastolic duration (EDDur) and isovolumic relaxation time (IVRT') are unknown.

METHODS

Two groups of adult subjects, one young and healthy (n = 10), and one with impaired LV long-axis function (n = 10), were studied, with the aim of identifying consistent findings for the two groups and for the septal and lateral walls. Dobutamine was infused at doses of 5 and 10 µg/kg/min. The relationships between tissue Doppler imaging (TDI) variables acquired before and during dobutamine infusion were analysed using mixed effect multivariate regression modelling.

RESULTS

In both groups, heart rate increased and SDur decreased during dobutamine infusion, and there were independent inverse correlations of SDur with heart rate and dobutamine dose. In contrast, there was no change in EDDur during dobutamine infusion, and no consistent changes in IVRT' independent of heart rate. s' was positively correlated with SExc and inversely correlated with SDur, and there were positive correlations between EDExc and SExc and between e' and EDExc.

CONCLUSION

Dobutamine increases s' due to effects on both systolic excursion and duration and it increases e' due to the associated increases in systolic and early diastolic excursion. A lack of effect on diastolic times does not support the presence of a lusitropic effect of dobutamine.

Assessment of subclinical left ventricular myocardial systolic dysfunction in type 2 diabetes mellitus patients with or without hypertension by global and segmental myocardial work

OBJECTIVE

The research was aimed to evaluate the subclinical left ventricular (LV) myocardial systolic dysfunction in T2DM patients with or without hypertension (HT) by global and segmental myocardial work (MW).

METHODS

A total of 120 T2DM patients (including 60 T2DM patients with HT) and 70 sex- and age- matched normal controls were included. The global and segmental variables of work index (WI), constrictive work (CW), waste work (WW), work efficiency (WE), and CW/WW were analysed by non-invasive pressure-strain loop. Receiver operating characteristic (ROC) analysis was performed for detection the subclinical LV systolic dysfunction in T2DM patients with and without HT.

RESULTS

The global work index (GWI), global CW (GCW), global WE (GWE), and GCW/global WW (GWW) of T2DM and T2DM patients with HT were significantly lower than normal controls (p < 0.05). The WI, CW, WE, and CW/WW of the LV anterior wall in T2DM and T2DM patients with HT were significantly lower when compared with those of the normal controls (p < 0.05). ROC analysis showed that the value of area under the curve (AUC) in combined GWI, GCW, GWE, and GCW/GWW was significantly higher than the AUCs of the individual indices (p < 0.05).

CONCLUSIONS

MW can non-invasively and accurately evaluate subclinical global and segmental LV myocardial systolic dysfunction in T2DM patients with and without HT. Regulating total cholesterol levels and controlling blood pressure in T2DM patients with and without HT might reduce the impairment of LV myocardial systolic function.

Automated estimation of mitral annular plane systolic excursion by artificial intelligence from 3D ultrasound recordings

Perioperative monitoring of cardiac function is beneficial for early detection of cardiovascular complications. The standard of care for cardiac monitoring performed by trained cardiologists and anesthesiologists involves a manual and qualitative evaluation of ultrasound imaging, which is a time-demanding and resource-intensive process with intraobserver- and interobserver variability. In practice, such measures can only be performed a limited number of times during the intervention. To overcome these difficulties, this study presents a robust method for automatic and quantitative monitoring of cardiac function based on 3D transesophageal echocardiography (TEE) B-mode ultrasound recordings of the left ventricle (LV). Such an assessment obtains consistent measurements and can produce a near real-time evaluation of ultrasound imagery. Hence, the presented method is time-saving and results in increased accessibility. The mitral annular plane systolic excursion (MAPSE), characterizing global LV function, is estimated by landmark detection and cardiac view classification of two-dimensional images extracted along the long-axis of the ultrasound volume. MAPSE estimation directly from 3D TEE recordings is beneficial since it removes the need for manual acquisition of cardiac views, hence decreasing the need for interference by physicians. Two convolutional neural networks (CNNs) were trained and tested on acquired ultrasound data of 107 patients, and MAPSE estimates were compared to clinically obtained references in a blinded study including 31 patients. The proposed method for automatic MAPSE estimation had low bias and low variability in comparison to clinical reference measures. The method accomplished a mean difference for MAPSE estimates of (-0.16±1.06) mm. Thus, the results did not show significant systematic errors. The obtained bias and variance of the method were comparable to inter-observer variability of clinically obtained MAPSE measures on 2D TTE echocardiography. The novel pipeline proposed in this study has the potential to enhance cardiac monitoring in perioperative- and intensive care settings.

Decreased diastolic hydraulic forces incrementally associate with survival beyond conventional measures of diastolic dysfunction

Decreased hydraulic forces during diastole contribute to reduced left ventricular (LV) filling and heart failure with preserved ejection fraction. However, their association with diastolic function and patient outcomes are unknown. The aim of this retrospective, cross-sectional study was to determine the mechanistic association between diastolic hydraulic forces, estimated by echocardiography as the atrioventricular area difference (AVAD), and both diastolic function and survival. Patients (n = 5176, median [interquartile range] 5.5 [5.0-6.1] years follow-up, 1213 events) were selected from the National Echo Database Australia (NEDA) based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, and no prior prosthetic valve surgery. NEDA contains echocardiographic and linked national death index mortality outcome data from 1985 to 2019. AVAD was calculated as the cross-sectional area difference between the LV and left atrium. LV diastolic dysfunction was graded according to 2016 guidelines. AVAD was weakly associated with E/e', left atrial volume index, and LVEF (multivariable global R2 = 0.15, p < 0.001), and not associated with e' and peak tricuspid regurgitation velocity. Decreased AVAD was independently associated with poorer survival, and demonstrated improved model discrimination after adjustment for diastolic function grading (C-statistic [95% confidence interval] 0.644 [0.629-0.660] vs 0.606 [0.592-0.621], p < 0.001) and E/e' (0.649 [0.635-0.664] vs 0.634 [0.618-0.649], p < 0.001), respectively. Therefore, decreased hydraulic forces, estimated by AVAD, are weakly associated with diastolic dysfunction and demonstrate an incremental prognostic association with survival beyond conventional measures used to grade diastolic dysfunction.

Normal reference values for mitral annular plane systolic excursion by motion-mode and speckle tracking echocardiography: a prospective, multicentre, population-based study

AIMS

Mitral annular plane systolic excursion (MAPSE) is a simple and reliable index for evaluating left ventricular (LV) systolic function, particularly in patients with poor image quality; however, the lack of reference values limits its widespread use. This study aimed to establish the normal ranges for MAPSE measured using motion-mode (M-mode) and two-dimensional speckle tracking echocardiography (2D-STE) and to explore its principal determinants.

METHODS AND RESULTS

This multicentre, prospective, cross-sectional study included 1952 healthy participants [840 men (43%); age range, 18-80 years] from 55 centres. MAPSE was measured using M-mode echocardiography and 2D-STE. The results showed that women had a higher MAPSE than men and MAPSE decreased with age. The age- and sex-specific reference values for MAPSE were established for these two methods. Multiple linear regression analyses revealed that MAPSE on M-mode echocardiography correlated with age and MAPSE on 2D-STE with age, blood pressure (BP), heart rate, and LV volume. Moreover, MAPSE measured by 2D-STE correlated more strongly with global longitudinal strain compared with that measured using M-mode echocardiography.

CONCLUSION

Normal MAPSE reference values were established based on age and sex. BP, heart rate, and LV volume are potential factors that influence MAPSE and should be considered in clinical practice. Normal values are useful for evaluating LV longitudinal systolic function, especially in patients with poor image quality, and may further facilitate the use of MAPSE in routine assessments.

Mitral annular plane systolic excursion for assessing left ventricular systolic dysfunction in patients with septic shock

Background

Using easy-to-determine bedside measurements, we developed an echocardiographic algorithm for predicting left ventricular ejection fraction (LVEF) and longitudinal strain (LVLS) in patients with septic shock.

Methods

We measured septal and lateral mitral annular plane systolic excursion (MAPSE), septal and lateral mitral S-wave velocity, and the left ventricular longitudinal wall fractional shortening in patients with septic shock. We used a conditional inference tree method to build a stratification algorithm. The left ventricular systolic dysfunction was defined as an LVEF <50%, an LVLS greater than -17%, or both.

Results

We included 71 patients (males: 61%; mean [standard deviation] age: 61 [15] yr). Septal MAPSE (cut-off: 1.2 cm) was the best predictor of left ventricular systolic dysfunction. The level of agreement between the septal MAPSE and the left ventricular systolic dysfunction was 0.525 [0.299-0.751]. A septal MAPSE ≥1.2 cm predicted normal LVEF in 17/18 patients, or 94%. In contrast, a septal MAPSE <1.2 cm predicted left ventricular systolic dysfunction with impaired LVLS in 46/53 patients (87%), although 32/53 (60%) patients had a preserved LVEF.

Conclusions

Septal MAPSE is easily measured at the bedside and might help clinicians to detect left ventricular systolic dysfunction early-especially when myocardial strain measurements are not feasible.

Intra-and inter-observer variability of point of care ultrasound measurements to evaluate hemodynamic parameters in healthy volunteers

BACKGROUND

Point-of-care ultrasound (POCUS) is a valuable tool for assessing the hemodynamic status of acute patients. Even though POCUS often uses a qualitative approach, quantitative measurements have potential advantages in evaluating hemodynamic status. Several quantitative ultrasound parameters can be used to assess the hemodynamic status and cardiac function. However, only limited data on the feasibility and reliability of the quantitative hemodynamic measurements in the point-of-care setting are available. This study investigated the intra- and inter-observer variability of PoCUS measurements of quantitative hemodynamic parameters in healthy volunteers.

METHODS

In this prospective observational study, three sonographers performed three repeated measurements of eight different hemodynamic parameters in healthy subjects. An expert panel of two experienced sonographers evaluated the images' quality. The repeatability (intra-observer variability) was determined by calculating the coefficient of variation (CV) between the separate measurements for each observer. The reproducibility (inter-observer variability) was assessed by determining the intra-class correlation coefficient (ICC).

RESULTS

32 subjects were included in this study, on whom, in total, 1502 images were obtained for analysis. All parameters were in a normal physiological range. Stroke volume (SV), cardiac output (CO), and inferior vena cava diameter (IVC-D) showed high repeatability (CV under 10%) and substantial reproducibility (ICC 0.61-0.80). The other parameters had only moderate repeatability and reproducibility.

CONCLUSIONS

We demonstrated good inter-observer reproducibility and good intra-observer repeatability for CO, SV and IVC-D taken in healthy subjects by emergency care physicians.

Clinical Influence of Handheld Ultrasound, Supported by Automatic Quantification and Telemedicine, in Suspected Heart Failure

Early and correct heart failure (HF) diagnosis is essential to improvement of patient care. We aimed to evaluate the clinical influence of handheld ultrasound device (HUD) examinations by general practitioners (GPs) in patients with suspected HF with or without the use of automatic measurement of left ventricular (LV) ejection fraction (autoEF), mitral annular plane systolic excursion (autoMAPSE) and telemedical support. Five GPs with limited ultrasound experience examined 166 patients with suspected HF (median interquartile range = 70 (63-78) y; mean ± SD EF = 53 ± 10%). They first performed a clinical examination. Second, they added an examination with HUD, automatic quantification tools and, finally, telemedical support by an external cardiologist. At all stages, the GPs considered whether the patients had HF. The final diagnosis was made by one of five cardiologists using medical history and clinical evaluation including a standard echocardiography. Compared with the cardiologists' decision, the GPs correctly classified 54% by clinical evaluation. The proportion increased to 71% after adding HUDs, and to 74 % after telemedical evaluation. Net reclassification improvement was highest for HUD with telemedicine. There was no significant benefit of the automatic tools (p ≥ 0.58). Addition of HUD and telemedicine improved the GPs' diagnostic precision in suspected HF. Automatic LV quantification added no benefit. Refined algorithms and more training may be needed before inexperienced users benefit from automatic quantification of cardiac function by HUDs.

Focused cardiac ultrasound with mitral annular plane systolic excursion (MAPSE) detection of left ventricular dysfunction

OBJECTIVES

Detecting reduced left ventricular ejection fraction (LVEF) by an emergency physician (EP) is an important skill. The subjective ultrasound assessment of LVEF by EPs correlates with comprehensive echocardiogram (CE) results. Mitral annular plane systolic excursion (MAPSE) is an ultrasound measure of vertical movement of the mitral annulus, which correlates to LVEF in the cardiology literature, but has not been studied when measured by an EP. Our objective is to determine whether EP measured MAPSE can accurately predict LVEF <50% on CE.

METHODS

This is a prospective observational single center study using a convenience sample to evaluate the use of a focused cardiac ultrasound (FOCUS) for patients with possible decompensated heart failure. The FOCUS included standard cardiac views to estimate LVEF, MAPSE, and E-point septal separation (EPSS). Abnormal MAPSE was defined as <8 mm and abnormal EPSS as >10 mm. The primary outcome assessed was the ability of an abnormal MAPSE to predict an LVEF <50% on CE. MAPSE also was compared to EP estimated LVEF and EPSS. Inter-rater reliability was determined by two investigators performing independent blinded review.

RESULTS

We enrolled 61 subjects, 24 (39%) had an LVEF <50% on a CE. MAPSE <8 mm had a 42% sensitivity (95% CI 22-63), 89% specificity (95% CI 75-97), and accuracy of 71% for detecting LVEF <50%. MAPSE demonstrated lower sensitivity than EPSS (79% sensitivity [95% CI 58-93], and 76% specificity [95% CI 59-88]) and higher specificity than estimated LVEF (100% sensitivity [95% CI 86-100], 59% specificity [95% CI 42-75]). PPV and NPV for MAPSE was 71% (95% CI 47-88) and 70% (95% CI 62-77) respectively. The ROC for MAPSE <8 mm is 0.79 (95% CI 0.68-0.9). MAPSE measurement interrater reliability was 96%.

CONCLUSIONS

In this exploratory study evaluating MAPSE measurements by EPs, we found the measurement was easy to perform with excellent agreement across users with minimal training. A MAPSE value <8 mm had moderate predictive value for LVEF <50% on CE and was more specific for reduced LVEF than qualitative assessment. MAPSE had high specificity for LVEF <50%. Further studies are needed to validate these results on a larger scale.

Spinal anesthesia does not cause left ventricular dysfunction in patients older than 60 years without cardiovascular disease

BACKGROUND

Elderly patients are undergoing surgery more frequently than ever. In this population, spinal anesthesia, which is known to cause sympathetic blockade associated with arterial vasodilation, is proposed as an excellent option. However, its effects on left ventricular systolic function have not been studied.

OBJECTIVES

To evaluate left ventricular systolic function by transthoracic echocardiography in patients older than 60 years, without prior cardiovascular disease, under spinal anesthesia.

PATIENTS AND METHODS

Prospective observational study with a total of 54 patients older than 60 years without prior cardiovascular disease, in whom, after the completion of subarachnoid anesthesia with hyperbaric 0.5% bupivacaine with sensory block equal to or greater than T10, left ventricular systolic function was measured using MAPSE. In addition, CI-IVC, LVOT-VTI and CO were measured. Values at 5 min after the blockade were compared with those obtained previously.

RESULTS

A 3.3% decrease in MAPSE and a slight decrease in LVOT-VTI and CO were found, with no statistical or clinical significance. 14.8% of the patients presented MAP equal to or less than 60 mmHg. Comparison of echocardiographic changes between hypotensive and non-hypotensive patients was not statistically significant or clinically relevant.

DISCUSSION

Our study shows that spinal anesthesia with anesthetic level T10 or higher in patients older than 60 years without cardiovascular disease is a safe technique since it does not significantly alter echocardiographic parameters measuring left ventricular systolic function.

Echo-Doppler measures of right ventricular systolic function are affected by reduced left ventricular systolic function

BACKGROUND

Objective right ventricular (RV) systolic function assessment is attained using a series of well-described and validated echo-Doppler measurements. However, how left ventricular (LV) systolic function influences these RV functional measurements has not been previously studied. Consequently, we conducted a retrospective proof-of-concept analysis to answer this important question.

METHODS

A total of 100 echocardiographic studies were included and patients were divided into two groups according to their LV ejection fraction (LVEF). The following RV variables were acquired including, tricuspid annular systolic plane excursion (TAPSE), velocity of the systolic motion (TA TDI s'), RV outflow tract velocity time integral (VTI), pulmonary vascular resistance (PVR), and the TAPSE to pulmonary artery systolic pressure (PASP) ratio.

RESULTS

Not only TAPSE, TA DI s', RVOT VTI, PVR, and TAPSE/PASP were all significantly different between patients with normal versus abnormal LVEF; but most importantly, RVOT VTI (p < .0001) was the best discriminatory variable in assessing normal versus abnormal LVEF followed by TAPSE (p = .0001). Using receiver operating characteristic curve analysis, an RVOT VTI value > 11 identified patients with a normal LVEF with a sensitivity of 90% and specificity of 76%.

CONCLUSION

Based on our results, reduced LVEF affects the RV, likely mediated by mechanisms of interventricular dependence. Therefore, RV analysis cannot be performed in isolation as it not only reflects intrinsic RV systolic function but also, is dependent on LV systolic function. In cases of reduced LVEF, additional measures of RV assessment should be used to provide better objective assessments.

The relation of echo-derived lateral MAPSE to left heart functions and biochemical markers in patients with preserved ejection fraction: Short-term prognostic implications

OBJECTIVE

Mitral annular plane systolic excursion (MAPSE) is a simple way to evaluate-left ventricle (LV) function. Our aim was to explain the relationship of MAPSE with LV function and biochemical markers in patients with preserved ejection fraction (EF), and to determine whether it has an effect on prognosis in echocardiography (echo) practice.

METHODS

Consecutive patients referred to the echo laboratory between November 2020 and March 2021 were included in the study. In addition to conventional parameters, MAPSE of the lateral mitral annulus was measured in all patients. Patients were divided into three groups according to lateral MAPSE: low (<12 mm), relatively preserved (12-15 mm), and high (≥15 mm).

RESULTS

A total of 512 patients with preserved EF were included in the study. MAPSE was low in 44 patients (9%), relatively preserved in 231 patients (45%), and high in 237 patients (46%). The mean age was higher in the low group compared to the other two groups (p < 0.001) and the body mass index was increased in the low group compared to the high group (p = 0.010). Atrial fibrillation and hypertension were more common in patients with low MAPSE. The rate of diastolic dysfunction (DD) and all-cause hospitalization were higher in the low and relatively preserved groups than in the high group (p < 0.001, p = 0.002; respectively). The pro-BNP level and mortality rate were higher in the low group compared to the relatively preserved and high groups (p = 0.007, p = 0.005; respectively). MAPSE was identified as independent predictor of hospitalization (OR: 0.284, 95% CI: 0.093-0.862, p = 0.026) via multivariate analysis and independent predictor of in-hospital mortality (HR: 0.002, 95% CI: 0-0.207, p = 0.008).

CONCLUSIONS

Analysis of LV longitudinal function by echo-derived lateral MAPSE when LV ejection fraction is normal provides important information about DD and related heart failure and may predict prognosis in echo practice.

The role of mitral annular plane systolic excursion in prediction of acute blood loss in healthy voluntary blood donors

Aim

The aim of this study is to compare the diameter of the inferior vena cava with mitral annular plane systolic excursion measurement in order to determine the volume loss before and after blood donation in healthy volunteers.

Material and methods

The study was a single-center, prospective, cross-sectional study which included 46 healthy blood donors donating in a tertiary care hospital's blood bank. The inclusion criteria for the study were: volunteers aged 18-65 years, over 50 kg in weight, who met blood donation criteria, with hemoglobin values of >13.5 g/dL for males and >12.5 g/dL for females. After obtaining written consent, the systolic, diastolic, and mean arterial blood pressure along with the pulse rate of the donors were measured in standing and lying positions by the attending physician. Next, inferior vena cava and mitral annular plane systolic excursion measurements were made both pre and post blood donation.

Results

The decrease in both inferior vena cava diameter and mitral annular plane systolic excursion values measured pre and post blood donation was found to be statistically significant (p <0.05). There was no difference between the other variables pre and post blood donation.

Conclusions

Our study revealed that decreased inferior vena cava and mitral annular plane systolic excursion values correlated in determining blood loss post blood donation. Mitral annular plane systolic excursion may be useful to predict blood loss in the early stages of hemorrhagic shock.

Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis

Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography

BACKGROUND

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

Feasibility and Reliability of Automatic Quantitative Analyses of Mitral Annular Plane Systolic Excursion by Handheld Ultrasound Devices: A Pilot Study

OBJECTIVES

Handheld ultrasound devices (HUDs) have previously been limited to grayscale imaging without options for left ventricle (LV) quantification. We aimed to study the feasibility and reliability of automatic measurements of mitral annular plane systolic excursion (MAPSE) by HUDs.

METHODS

An algorithm that automatically measured MAPSE from live grayscale recordings was implemented in a HUD. Twenty patients at a university hospital were examined by either a cardiologist or a sonographer. Standard echocardiography using a high-end scanner was performed. The apical 4-chamber view was recorded 4 times by both echocardiography and the HUD. MAPSE was measured by M-mode and color tissue Doppler (cTD) during echocardiography and automatically by the HUD.

RESULTS

The automatic method underestimated mean MAPSE ± SD versus M-mode (9.6 ± 2.2 versus 10.9 ± 2.6 mm; difference, 1.2 ± 1.4 mm, P < .005). The difference between the automatic and cTD measurements was not significant (0.8 ± 1.8 mm; P = .073). The intraclass correlation coefficients (ICCs) between automatic and M-mode measurements was 0.85, and 0.81 for cTD measurements. There was good agreement between the methods, and the intra- and inter-rater ICCs were excellent for all methods (≥0.86).

CONCLUSIONS

In this novel study evaluating automatic quantification of LV longitudinal function by HUD, we showed the high feasibility and reliability of the method. Compared to M-mode imaging, the automatic method underestimated MAPSE by 8% to 10%, but the difference with cTD imaging was nonsignificant. We conclude that this study's method for automatic quantitative assessment of LV function can be integrated in HUDs.

Prognostic value of left ventricular mitral annular longitudinal displacement obtained by tissue Doppler imaging in patients with heart failure with reduced ejection fraction

Background

Tissue Doppler imaging (TDI) can be used to measure the mitral annular longitudinal displacement (LD) during systole. However, the prognostic utility of global and regional LD in patients with heart failure with reduced ejection fraction (HFrEF) is unknown.

Methods

Echocardiographic examinations from 907 patients with HFrEF were analysed obtaining conventional echocardiographic measurements. Regional LD was obtained from colour TDI projections in six mitral annular regions and global LD was calculated as an average.

Results

Mean age was 67 years, 26.9% were women and mean left ventricular ejection fraction was 27%. During a median follow-up period of 40 months, 150 (16.5 %) patients died. The risk of dying increased with decreasing tertile of global LD and was approximately five times higher for patients in the lowest tertile compared with the highest (1. tertile vs 3. tertile, HR 4.9, 95% CI: 3.0 to 7.9, p<0.001).

Global LD was a significant independent predictor of mortality after adjusting for age, gender, body mass index, pacemaker, heart rate, atrial fibrillation, diabetes and conventional echocardiographic measures and global longitudinal strain: HR 1.16 (95% CI: 1.00 to 1.34, p=0.044) per 1 mm decrease.

For regional measures, inferior LD was also a significant independent predictor in the multivariable model: HR 1.16 (95% CI: 1.04 to 1.29, p=0.006) and adding inferior LD to the conventional measures yielded a significant increase in Harrell’s C-statistic (95% CI: 0.75 to 0.78, p=0.009).

Conclusion

In patients with HFrEF, global and inferior LD are independent predictors of all-cause mortality. Furthermore, inferior LD proved to be a significant prognosticator when compared with all the conventional echocardiographic parameters.

Evidence of subtle left ventricular systolic dysfunction in cryptogenic stroke in the young

INTRODUCTION

Ischemic stroke in young patients often remains cryptogenic, that is, no underlying reason can be found. Some of these strokes may originate in the heart. Left ventricular (LV) dynamic volumetry and strain analysis are relatively new and promising methods for evaluating LV function.

METHODS

In this pilot study, we recruited 30 young (18-50 years) patients with cryptogenic ischemic stroke and 30 age- and sex-matched controls from the SECRETO study (NCT01934725). The LV systolic function was assessed by LV volumetry (ejection fraction, peak emptying rate, and time to peak emptying rate). The longitudinal systolic function was assessed by speckle tracking strain and strain rate imaging, and by tissue velocity imaging derived MAD (mitral annular displacement) and septal S'.

RESULTS

Stroke patients had less vigorous global longitudinal strain (median -18.9, interquartile range 3.3), compared to healthy controls (median -20.0, interquartile range 2.8), P = .010. There was no statistically significant differences in septal S', MAD, global longitudinal strain rate, or dynamic volumetry-derived parameters between the two groups.

CONCLUSIONS

Young cryptogenic stroke patients have subtly altered systolic function compared to healthy controls, found merely with longitudinal strain analysis. This infers that the heart may play a role in the pathogenesis of cryptogenic ischemic stroke.

Transseptal direct complete annuloplasty: early experience

Annuloplasty is a fundamental component of surgical mitral valve repair, and is employed in nearly 100% of repair operations for both primary and secondary mitral regurgitation (SMR). Developing transcatheter techniques to replicate surgical annuloplasty has been the focus of significant innovation and development in recent years. Since many patients are not offered surgery due to high perceived surgical risk, transcatheter approaches will provide new treatment options. In this manuscript, we review technologies which allow transseptal and transcatheter mitral valve (MV) annuloplasty.

Echocardiographic evaluation of left ventricular systolic function by the M-mode lateral mitral annular plane systolic excursion in patients with Duchenne muscular dystrophy age 0-21 years

BACKGROUND AND AIMS

Duchenne muscular dystrophy (DMD) results in cardiac fibrosis and dysfunction. These patients frequently have poor image quality. Mitral annular plane systolic excursion (MAPSE) is a reproducible and reliable method for determining function and can be a valuable tool in patients with poor images. Our study was performed to evaluate the feasibility of MAPSE and compare it to shortening fraction (SF) in patients with DMD.

METHODS

Lateral M-mode MAPSE was obtained on all echocardiograms performed on DMD patients aged 0 to 21 years between October 2013 and April 2015. Retrospectively, interobserver and intraobserver variability was determined for these measurements and each measurement was compared to patient characteristics and measured values of SF.

RESULTS

There was good interobserver (r 2 = .66, P = .0081) correlation. Seventeen of 59 echocardiograms (29%) had abnormal SF while 32 (54%) echocardiograms had an abnormal M-mode lateral MAPSE Z-score. There was no significant association between lateral MAPSE Z-score and SF. Age at the time of echocardiogram and time from diagnosis to echocardiogram both had a significant negative correlation with lateral MAPSE.

CONCLUSIONS

Lateral M-mode MAPSE measurements are reproducible in young patients with Duchenne muscular dystrophy. M-mode lateral MAPSE may worsen over length of time with Duchenne muscular dystrophy. Further studies are necessary to provide absolute conclusions, but this study shows that lateral M-mode MAPSE may be a valuable additional tool at routine echocardiogram in these patients.

The relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions, hepatic and cardiac iron siderosis among Egyptian children and young adults with β-thalassaemia major and sickle cell disease: a cross-sectional study

Background: Cardiac, hepatic and pancreatic T2* measured by magnetic resonance imaging (MRI) has been proven to be an accurate and non-invasive method for measuring iron overload in iron overload conditions. There is accumulating evidence that pancreatic iron can predict cardiac iron in young children because the pancreas loads earlier than the heart. The aim of our study was to assess the relationships between pancreatic T2* values and pancreatic iron loading with cardiac dysfunctions and liver and cardiac iron among patients with β-thalassaemia major (βTM) and sickle cell disease (SCD).

Methods: 40 βTM and 20 transfusion-dependant SCD patients were included along with 60 healthy age and sex-matched controls. Echocardiography and Tissue Doppler Imaging were performed for all subjects as well as the control group.  Hepatic, cardiac and pancreatic iron overload in cases were assessed by MRI T2*.

Results:  The mean age of our patients was 13.7 years with mean frequency of transfusion/year 12. Mean cardiac T2* was 32.9 ms and mean myocardial iron concentration was 0.7 mg/g; One patient had cardiac iron overload of moderate severity. Mean pancreatic T2* was 22.3 ms with 20 patients having mild pancreatic iron overload.

Pancreatic T2* correlated positively peak late diastolic velocity at septal mitral annulus (r=0.269, p=0.038), peak early diastolic velocity at tricuspid annulus (r=0.430, p=0.001) and mitral annular plane systolic excursion (r=0.326, p=0.01); and negatively with end systolic pulmonary artery pressure (r=-0.343, p=0.007) and main pulmonary artery diameter (MPA) (r=-0.259, p=0.046). We couldn’t test the predictability of pancreatic T2* in relation to cardiac T2* as only one patient had cardiac T2*<20 ms.

Conclusion: There was a relationship between pancreatic iron siderosis with cardiac dysfunction in multi-transfused patients with βTM and SCD. No direct relation between pancreatic iron and cardiac siderosis was detected.

Assessing left ventricular systolic function in children with a history of Kawasaki disease

BACKGROUND

The incidence of Kawasaki disease (KD) is increasing. Indeed, KD has become the most common cause of acquired heart disease in children. Previous studies have well summarized the acute phase left ventricular (LV) systolic dysfunction using speckle tracking echocardiography (STE); however, changes in LV systolic function after long-term follow-up remain unclear.

METHODS

One hundred children with a history of KD, but without coronary artery aneurysms, were enrolled. These children were divided into two subgroups based on the presence or absence of coronary artery dilatation (CAD). The duration of follow-up was > 7 years. The control group consisted of 51 healthy children. The LV myocardial strain were measured by two- and three-dimensional STE.

RESULTS

Two-dimensional STE not only revealed that LV longitudinal strain decreased in part of segments in both KD groups, but also showed that global strain decreased in the KD group with CAD compared to the controls (P < 0.05). Global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and global area strain (GAS) were obtained by 3D STE. Compared to the controls, GLS and GAS decreased in both KD groups (P < 0.05). GCS and GRS decreased in the KD group with CAD, but was unchanged in the KD group without CAD (P < 0.05).

CONCLUSIONS

LV systolic dysfunction in children with KD and CAD was more severe than KD children without CAD compared to healthy children. This dysfunction can be assessed by LV regional and global myocardial strain using two- and three-dimensional STE.

Correlation Between Echocardiographic and Hemodynamic Variables in Cardiothoracic Intensive Care Unit

OBJECTIVES

The echocardiographic indices have not been validated in critically ill population. The authors investigated the correlation between some echocardiographic and hemodynamic parameters.

DESIGN

Prospective, spontaneous, noninterventional observational study.

SETTING

Adult cardiothoracic intensive care unit, single center (Royal Brompton Hospital, London, United Kingdom).

PARTICIPANTS

Consecutive adult patients admitted to the cardiothoracic intensive care unit for severe respiratory failure, primary cardiocirculatory failure, and post-aortic surgery.

INTERVENTIONS

Clinical hemodynamic parameters (stroke volume [SV], cardiac output [CO], mean arterial pressure [MAP], and cardiac power index [CPI]) and echocardiographic indices of ventricular function (left ventricular total isovolumic time [t-IVT], mitral annular plane systolic excursion [MAPSE], and left ventricular fraction [LVEF]) were evaluated offline.

MEASUREMENTS AND MAIN RESULTS

The study comprised 117 patients (age 57.2 ± 19; 60.6% male). The t-IVT showed an inverse correlation with SV, CO, MAP, and CPI (r -67%; -38%; -45%; -51%, respectively). MAPSE exhibited a positive correlation with SV, CO, MAP, and CPI (r 43%; 44%; 34%; 31%, respectively). LVEF did not show any correlation. In the multivariate analysis the association between t-IVT and hemodynamics was confirmed for SV, CO, MAP, and CPI, with the highest partial correlation between t-IVT and MAP (R = -58%).

CONCLUSIONS

MAPSE and t-IVT are 2 reproducible and reliable echocardiographic indices of systolic function and ventricular efficacy associated with hemodynamic variables in cardiothoracic critically ill patients, whereas LVEF did not show any correlation.

[Usefulness and reliability of point of care ultrasound in Family Medicine: Focused cardiac and lung ultrasound]

The family doctor incorporates clinical ultrasound as an exploration and diagnosis technique in his care activity, the same way as the rest of the specialists. His generalist role makes him a potential user of all possible applications of this technique, which can provide a high impact on his ability to manage, focus and solve a large number of clinical situations. In this article we focus on assessing the usefulness and reliability of clinical ultrasound performed by the family doctor in their most novel aspects such as focused cardiac ultrasound and lung ultrasound.

Mitral Annular Plane Systolic Excursion as a predictor of Left Ventricular Ejection Fraction in mechanically ventilated patients

Introduction

The accurate measurement of Left Ventricular Ejection Fraction (LVEF) requires high-quality images and echocardiography expertise. Critically ill patients can present challenges in obtaining good acoustic windows for ultrasound, particularly for ICU trainees early in their ultrasound learning. Mitral Annular Plane Systolic Excursion (MAPSE), a simple measurement, may be useful in this context to estimate LV systolic function.

Materials and Methods

All adult patients admitted to the Alfred ICU between August 2012 and February 2013 who were on mechanical ventilation and needed an echocardiography examination were eligible to be included in the study. An ICU trainee in their first year of echocardiography training performed MAPSE measurements. An advanced echocardiographer classified LV systolic function into normal, mild, moderate or severe categories based on the visual estimation of LVEF. The relationship between the MAPSE measurements and the range of LV systolic function was assessed.

Results

Amongst 39 patients, the mean (SD) age was 55 (18.6) years, 20 (50%) were males, 36 (90%) were in sinus rhythm, 19 (48%) were on vasopressors, 12 (30%) were on inotropes and 23 (58%) were on mandatory mode mechanical ventilation. The mean (SD) MAPSE was 12.2 (5.28) mm. 28 (70%) of the patients had normal or mildly reduced LVEF. The ROC analysis showed that a MAPSE cut-off point of ≥12.5 mm diagnosed normal or mildly reduced LVEF with 82.14% sensitivity and 91.67% specificity. The area under ROC curve was 0.91 (95% CI 0.82-1.00).

Conclusion

MAPSE is useful as a surrogate for LVEF in mechanically ventilated patients. In early critical care echocardiography training, a novice learner can perform MAPSE easily, accurately, and find it helpful for assessment of LVEF.

Modeling left ventricular dynamics using a switched system approach based on a modified atrioventricular piston unit

The contribution of the longitudinal atrioventricular plane displacement to ventricular pumping has drawn more and more attentions. In this paper, differential equations of the left ventricle (LV) are derived via the atrioventricular piston concept. The contribution of left ventricular radial function to blood flow was converted to an equivalent coefficient. A systemic circulatory model incorporating the modified atrioventricular piston unit was developed on a switched system form by adding some state-dependent switching planes. Simulation results prove that the end-systolic pressure volume relationship of the model with a changing systemic arterial resistance is approximately linear and insensitive to perturbations in afterload. Then the LV model was validated using a data fitting method. A pressure-volume loop from a patient undergoing routine diagnostic cardiac catheterization with LV angiography was used as measurements. Model parameters and the trapezoidal profile of contraction forces were adjusted by a trial method. The root mean squared error between the measured and estimated LV pressure is 2.99 mmHg. The LV compliance is 0.34 ml/mmHg. The ratio between left ventricular and left atrial cross-section is 1.8. Therefore, parameter values used in the modified LV model match physiological data. The model can reproduce the realistic pressure-flow relationship in the LV chamber.

Mitral Annular Plane Systolic Excursion: A Simple, Reliable Echocardiographic Parameter to Detect Left Ventricular Systolic Dysfunction in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting with Transesophageal Echocardiography

OBJECTIVES

This study's objective was to test the hypothesis that transesophageal echocardiography (TEE)-based mitral annular plane systolic excursion (MAPSE) measurement is useful in perioperative settings to detect left ventricular (LV) systolic dysfunction in patients undergoing off-pump coronary artery bypass grafting (OPCAB).

DESIGN

Retrospective observational study.

SETTING

Tertiary-care level hospitals.

PARTICIPANTS

The study comprised 116 patients undergoing OPCAB to obtain cutoffs of MAPSE to detect LV dysfunction. These cutoffs were validated in another 105 patients from 2 other institutions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In 116 patients who had undergone OPCAB during the study period with TEE monitoring, MAPSE was measured post hoc at the lateral and septal mitral (and average) annulus using the software tool M.mode.ify (http://www.ultrasoundoftheweek.com/M.mode.ify). Receiver operating curves were constructed to obtain cutoff values of MAPSE at the lateral and septal (and average) annulus of the mitral valve to predict LV systolic dysfunction, which was defined by an ejection fraction <52% for men and <54% for women as measured using the biplane method of disks. These cutoff values then were validated in another 105 patients. LV systolic dysfunction was present in 43% patients. Youden's index values of 9mm for lateral MPASE (area under the receiver operating curve [AUC] 0.93 [confidence interval {CI} 0.87-0.97]; p < 0.0001); 7mm for septal MAPSE (AUC 0.87 [CI 0.79-0.92]; p < 0.0001); and 9mm for average MAPSE (AUC 0.92 [CI 0.86-0.96]; p < 0.0001) were obtained. These cutoffs were statistically significant in the validation cohort (p < 0.0001) with an AUC of 0.84 (CI 0.75-0.90), sensitivity of 86.2%, specificity of 80.8%, positive predictive value of 84.8%, and negative predictive value of 82.6%.

CONCLUSIONS

MAPSE is a simple, rapid, and reliable method to detect LV dysfunction using TEE in patients undergoing OPCAB. Its use as screening tool for LV dysfunction is recommended.

Association of High-Sensitivity Troponin T With Left Ventricular Dysfunction in Ankylosing Spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a systemic inflammatory disease, and cardiac dysfunction has not been clearly described clinically. High-sensitivity cardiac troponin T (hs-cTnT) is a noninvasive marker for subclinical myocardial injury.

OBJECTIVE

In this study, we aimed to investigate any relationship between hs-cTnT and left ventricular (LV) function evaluated via tissue Doppler imaging in AS patients with no known cardiac risk factor.

METHODS

Our study used a cross-sectional case protocol design and was conducted between January 2016 and June 2016. In total, 40 AS patients (17 females and 23 males) were age and sex matched with healthy volunteers (20 females and 20 males) and enlisted for this study. Detailed transthoracic echocardiography was performed, and tissue Doppler imaging was used to assess systolic and diastolic functions. High-sensitivity cardiac troponin T levels were measured and compared between 2 groups.

RESULTS

Compared with control subjects, AS patients had lower early (Em)/late (Am) diastolic myocardial velocities, mitral annular plane systolic excursion, and end-diastolic distance from the mitral annulus to the LV apex. Conversely, they had greater systolic myocardial velocity (Sm), isovolumetric relaxation time, and displacement index (p < 0.001, for all). Higher hs-cTnT levels were measured in AS patients (0.45 ± 0.22 vs. 1.11 ± 0.27, p < 0.001), and multivariate logistic regression analyses revealed that hs-cTnT was an independent predictor of LV diastolic dysfunction in AS patients.

CONCLUSIONS

These data show that AS patients had impaired LV functions and increased hs-cTnT levels. Tissue Doppler imaging may be a useful tool for detection of early functional LV abnormalities, and hs-cTnT may be valuable biomarker of diastolic LV dysfunction in AS patients.

[Focused echocardiography in acute medicine]

Focused echocardiography has become increasingly important for bedside diagnostics in acute medicine. Focused echocardiography can detect various cardiac pathologies, such as pericardial effusion, left ventricular dysfunction, right heart strain, relevant heart valve defects and dissection of the ascending aorta. Echocardiographic findings should be interpreted in the clinical context.

Mitral Annular Plane Systolic Excursion as a Predictor of Mortality in Children With Septic Shock

OBJECTIVES

Myocardial dysfunction is well recognized in severe sepsis and septic shock. Echocardiography provides rapid, noninvasive, and bedside evaluation of cardiac function in patients with hemodynamic instability. Mitral annular plane systolic excursion is an M-mode-derived echocardiographic variable used to assess longitudinal left ventricular systolic function. No data are available about the uses of mitral annular plane systolic excursion in children with septic shock. Therefore, we aimed to assess the prognostic significance of mitral annular plane systolic excursion in children with septic shock and to correlate it with the most commonly used measures of left ventricular systolic function and myocardial injury.

DESIGN

A prospective cohort study.

SETTING

The study carried out at the PICU of Menoufia University Hospital in the period from March 2015 to September 2016.

PATIENTS

We serially enrolled 50 children with septic shock.

INTERVENTIONS

Complete diagnostic workup was performed for each patient including calculation of Pediatric Risk of Mortality III score. Transthoracic echocardiography was done to obtain mitral annular plane systolic excursion and the left ventricular ejection fraction measurement within 24 hours of inclusion then repeated on third and fifth days. Patients were followed up until hospital discharge or death. The predictive power of mitral annular plane systolic excursion was determined using the receiver operating characteristic curve.

MEASUREMENTS AND MAIN RESULTS

Mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors (p < 0.001). Receiver operating characteristic curve analysis showed an area under the curve of 0.892 for mitral annular plane systolic excursion on day 1. The cut-off point was 7.9 mm with 82.76% sensitivity and 80.95% specificity. Furthermore, follow-up of the patient's systolic function showed that mitral annular plane systolic excursion was significantly lower in nonsurvivors compared with survivors on days of follow-up, whereas left ventricular ejection fraction was not significantly different between survivors and nonsurvivors at any day. Mitral annular plane systolic excursion was positively correlated with left ventricular ejection fraction (p = 0.044) and duration of hospital stay (p < 0.001) and negatively correlated with Pediatric Risk of Mortality III score (p < 0.001) and cardiac troponin I level (p < 0.001).

CONCLUSIONS

Measurement of mitral annular plane systolic excursion at admission added a prognostic value in septic shock children. Compared with the left ventricular ejection fraction, longitudinal systolic function might be more sensitive in the detection of myocardial dysfunction in critically ill children and should receive more attention.

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

Arterial hypertension and atrial fibrillation: standard and advanced echocardiography from diagnosis to prognostication

: Structural changes in left and right cardiac chambers that occur in arterial hypertension (AH) may lead to an increased risk of atrial fibrillation. Considering that AH is currently the most common cardiovascular disease in the general population, it represents a major risk factor for atrial fibrillation development. This review explores the complex relationship between atrial fibrillation and AH, starting from its pathophysiological basis. It focuses on the role of echocardiography in the management of hypertensive and atrial fibrillation patients, with emphasis on what should be evaluated about left ventricular remodeling, diastolic and systolic function, left atrial (LA) size and function and right ventricular deformation in patients with AH.

Noninvasive Cardiac Imaging and the Prediction of Heart Failure Progression in Preclinical Stage A/B Subjects

Heart failure (HF) continues to grow as a cause of morbidity and mortality in our community and presents a significant public health problem, predominantly in individuals ≥65 years of age. Early intervention in asymptomatic HF subjects (Stage A/B) at risk of progression to symptomatic HF (Stage C/D) may provide an opportunity to halt this epidemic. The ability of cardiac imaging to assess cardiac structure and function permits early identification of those at increased risk of developing symptomatic HF. Systolic, diastolic, and structural left ventricular parameters each predict symptomatic HF, but no single parameter has sufficient sensitivity for screening to identify individuals with Stage A/B HF who are at increased risk of disease progression. Transthoracic echocardiography (TTE) has the advantage over other imaging modalities in being able to measure systolic, diastolic, and structural left ventricular parameters, and it identified at least 1 abnormal parameter in >50% of individuals with Stage A/B HF ≥65 years of age. Moreover, identification of at least 1 abnormality according to TTE in individuals with Stage A/B HF ≥65 years of age had 72% to 82% sensitivity for detection of those who subsequently developed symptomatic HF. Therefore, a case can be made for cardiac imaging by using TTE for community-dwelling populations with Stage A/B HF ≥65 years of age to identify those with increased risk of symptomatic HF who can be offered preventative therapies. Further studies are required to determine the best strategy for identifying the risk of symptomatic HF in younger individuals.

Value of mitral annular plane systolic excursion in the assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization

Background

Mitral annular plane systolic excursion (MAPSE) is an M-mode derived echocardiographic marker of left ventricular longitudinal function, the aim of this study is to evaluate the value of MAPSE in assessment of contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.

Methods

The study included 50 patients with ischemic cardiomyopathy with ejection fraction (EF) ≤35%, the patients presented to echocardiography laboratory for dobutamine stress echocardiography (DSE) to assess viability and contractile reserve before revascularization, patients with primary valvular disease, and those with significant mitral annular calcifications were excluded from the study. A low dose DSE was done to all patients using standardized incremental infusions of 5, 10, and 20 μg/kg/min and the following parameters were measured at both baseline and peak dose, (EF, wall motion score index(WMSI) and MAPSE). Contractile reserve was measured as the difference between the low dose and baseline values of the EF and WMSI.

Results

The study included 50 patients aged 55.08 ± 7.15 years, 94% were males, the DSE protocol was complete in all patients without serious side effects. A total of eight hundred segments were analyzed, at baseline 65% were dysfunctional including 31.2% hypokinetic, 28.8% were akinetic, and 5% were dyskinetic. At low dose study 70% of the dysfunctional myocardium showed viability, EF increased significantly from 30.84 ± 4.56 to 42.24 ± 8.15%, p < 0.001, the WMSI reduced significantly from 1.92 ± 0.33 to 1.47 ± 0.39, and MAPSE increased significantly from 1.02 ± 0.23 to 1.30 ± 0.30 mm. MAPSE showed a significant positive correlation with EF at both baseline and low dose study (r = 0.283, p = 0.046 & r = 0.348, p = 0.013) respectively and a significant negative correlation with WMSI at both baseline and low dose study (r = −0.3, p = 0.034 & r = −0.409, p = 0.003), respectively. By ROC curve analysis we found that Δ MAPSE ≥2 mm can predict contractile reserve at Δ EF >10% (AUC = 0.6, sensitivity 67.86, specificity 59.09), and Δ MAPSE ≥1.8 mm can predict contractile reserve at ΔWMSI ≤0.20 (AUC = 0.61, sensitivity 65.5, specificity 75.6).

Conclusions

MAPSE is a rapid simple quantitative echocardiographic method that can asses contractile reserve in patients with ischemic cardiomyopathy before cardiac revascularization.

Echocardiographic Applications of M-Mode Ultrasonography in Anesthesiology and Critical Care

Proficiency in echocardiography and lung ultrasound has become essential for anesthesiologists and critical care physicians. Nonetheless, comprehensive echocardiography measurements often are time-consuming and technically challenging, and conventional 2-dimensional images do not permit evaluation of specific conditions (eg, systolic anterior motion of the mitral valve, pneumothorax), which have important clinical implications in the perioperative setting. M-mode (motion-based) ultrasonographic imaging, however, provides the most reliable temporal resolution in ultrasonography. Hence, M-mode can provide clinically relevant information in echocardiography and lung ultrasound-driven approaches for diagnosis, monitoring, and interventional procedures performed by anesthesiologists and intensivists. Although M-mode is feasible, this imaging modality progressively has been abandoned in echocardiography and is often underutilized in lung ultrasound. This article aims to comprehensively illustrate contemporary applications of M-mode ultrasonography in the anesthesia and critical care medicine practice. Information presented for each clinical application will include image acquisition and interpretation, evidence-based clinical implications in the critically ill and surgical patient, and limitations. The present article focuses on echocardiography and reviews left ventricular function (mitral annular plane systolic excursion, E-point septal separation, fractional shortening, and transmitral propagation velocity); right ventricular function (tricuspid annular plane systolic excursion, subcostal echocardiographic assessment of tricuspid annulus kick, outflow tract fractional shortening, ventricular septal motion, wall thickness, and outflow tract obstruction); volume status and responsiveness (inferior vena cava and superior vena cava diameter and respiratory variability [collapsibility and distensibility indexes]); cardiac tamponade; systolic anterior motion of the mitral valve; and aortic dissection.

Intraobserver and interobserver reproducibility of M-mode and B-mode acquired mitral annular plane systolic excursion (MAPSE) and its dependency on echocardiographic image quality in children

BACKGROUND

Mitral annular plane systolic excursion (MAPSE) is an increasingly used echocardiography technique to assess left ventricular (LV) function. However, reproducibility and dependence on echocardiographic image quality for MAPSE in pediatric patients have not been studied to date.

METHODS

We analyzed 284 transthoracic echocardiograms performed on consecutive normotensive children without structural heart disease (mean age 12.6±3.1 years, 50.4% female). B-mode and M-mode derived MAPSE measurements were performed and analyzed regarding inter- and intraobserver reliability and the influence of echocardiographic image quality.

RESULTS

Overall, MAPSE measurements were highly reproducible with only minor bias. Both inter- and intraobserver reliability were significantly better for M-mode derived MAPSE (p<0.001). Echocardiographic image quality did not significantly influence M-mode MAPSE reproducibility (p>0.235). In contrast, B-mode lateral MAPSE was significantly better reproducible in optimal image quality (-0.07±1.04) when compared to suboptimal echocardiographic images (0.42±1.59, p<0.001). Moreover, poor quality images yielded significantly lower M-mode MAPSE values (14.3±2 mm) than near-optimal (15.2±1.9 mm, p<0.001) or optimal images (15.1±2.2 mm, p = 0.006).

CONCLUSION

Echocardiographic image quality essentially has a negligible effect on MAPSE reproducibility and measurements. Consequently, MAPSE is a robust echocardiographic parameter with convincing reproducibility for the assessment of LV function in children-even in patients with substandard imaging conditions.

Is mitral annular ascent useful in studying left ventricular function through left atrio-ventricular interactions?

Background

The mitral annulus (MA) is a crucial structure that is in constant motion throughout the cardiac cycle. The main purpose of this study was to determine if M-mode evaluation of the longitudinal motion of the MA could be useful to examine atrio-ventricular interactions.

Methods

Echocardiographic data obtained from 150 patients (mean age 56 ± 16; 82 males) from the University of Cincinnati College of Medicine was evaluated to examine if any relationship exists between MA motion and measures of atrio-ventricular interactions.

Results

Even though left atrial size, left ventricular (LV) mass index, LV ejection fraction (LVEF) and degree of LV diastolic dysfunction (LVDD) were significant echocardiographic variables affecting MA motion; LVEF and the degree of LVDD were the main determinants of MA excursion during systole (MAPSE) and after atrial contraction (MAa). Our results confirm the surrogate value of MAPSE with regards to LVEF and also show that the extent of MA excursion during systole is the main determinant of MAa. The effect of LV diastolic function applies more strongly to MAPSE than to MAa. However, the maximal MAa amplitude varies in accordance to the type of LVDD.

Conclusions

We have shown for the first time that M-mode interrogation of the MA longitudinal motion appears useful to assess atrio-ventricular interactions. Since LV systolic and diastolic functions are so closely related; additional studies are now required to examine how this longitudinal measure correlates with known circumferential rotational data obtained with other imaging modalities.

Are Measures of Left Ventricular Longitudinal Shortening Affected by Left Atrial Enlargement?

BACKGROUND

Even though left atrial (LA) size and function are intimately related to left ventricular (LV) diastolic dysfunction, the role of LA with regard to LV systolic function is less clear. Consequently, we examined the potential association that might exist between measures of longitudinal LV systolic shortening and LA dilation using LA volume index (LAVI).

METHODS

In this retrospective analysis, data from 75 echocardiograms (mean age 53 ± 14; range 24 - 89 years; mean body surface area (BSA) 2.0 ± 0.3) were analyzed.

RESULTS

Peak global longitudinal (PGLS) correlated best with LV mass index (LVMI) followed by mitral annular systolic excursion (MAPSE), and age. Similar results were obtained when analyzing the best variables that correlated with LAVI. Finally, MAPSE correlated best with PGLS, then with MA tissue Doppler systolic velocity, BSA, and LAVI in that order. All patients had normal LV ejection fraction (LVEF) and normal sinus rhythm when studied.

CONCLUSIONS

LAVI does not directly affect LV systolic function and longitudinal measures of LV shortening are mainly dependent on LV mass. Additional studies are now required to determine how these associations vary when different degrees of LV dilatation and systolic dysfunction are included in the analysis.

Right ventricular contractile reserve in tetralogy of Fallot patients with pulmonary regurgitation

BACKGROUND

The right ventricular (RV) contractile reserve is a measure of the dynamic function of the RV and is a sensitive indicator of volume load. This can be measured noninvasively using the tricuspid annular plane systolic excursion (TAPSE) during exercise. We studied the RV contractile reserve of patients after tetralogy of Fallot (TOF) repair with varying degree of RV dilation and pulmonary regurgitation (PR), and compared them to a control group.

METHODS

Twenty-six patients who had undergone TOF repair (mean age 29 ± 10 years) were identified and stratified into three group based on the presence and severity of RV dilation and PR. We recruited 13 age- and sex-matched controls with normal cardiac anatomy for comparison. After obtaining a baseline echocardiogram in the resting state, patients underwent exercise testing on a treadmill utilizing Bruce protocol. At maximal voluntary ability during the exercise testing, the patient was immediately laid down on an echocardiography couch, and a peak exercise echocardiogram was obtained.

RESULTS

TOF patients, regardless of RV size and PR severity, had significantly shorter exercise duration (685 vs 802 s, P = .02), lower TAPSE at rest (1.7 vs 2.3 cm, P < 0.001) and at peak exercise (1.6 ± 0.4 vs 2.6 ± 0.5 cm P < .001) when compared to the control group. Patients with RV dilation were more likely to have worse RV contractile reserve but increased TAPSE and tricuspid annular acceleration at rest when compared to patients without RV dilation.

CONCLUSIONS

TOF patients with dilated RV and PR have worse RV function at rest and during exercise, compared to TOF subjects without RV dilation. Long-axis RV contractile reserve as assessed by TAPSE, was lower in TOF subjects versus controls, and was worse in those with significant RV dilation, suggesting a decline in contractile reserve with an increase in RV volume.